predictors of successful short-term tobacco cessation in uk resident female bangladeshi tobacco...

Predictors of successful short-term tobacco cessationin UK resident female Bangladeshi tobacco chewersadd_3819 1..5

Ray Croucher1, Siddharth Shanbhag1, Manu Dahiya1, Saba Kassim1 & Ann McNeill2

Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of Dentistry, London, UK1 and UK Centre for TobaccoControl Studies, University of Nottingham, Division of Epidemiology and Public Health, Nottingham, UK2

ABSTRACT

Aim To identify predictors of short-term smokeless tobacco cessation in Bangladeshi women resident in theUnited Kingdom. Design Prospective cohort study. Setting A tobacco cessation service offering culturally tailoredsmokeless tobacco cessation support. Participants A total of 419 Bangladeshi women chewing paan with tobacco.Measurements Demographics, tobacco use and dependence and cessation attempt process and outcomes.Findings Client mean age was 48.92 [95% confidence interval (CI) 47.5, 50.34] years and the mean area socialdeprivation score was 3.65 (95% CI 3.33, 3.97). Mean daily smokeless tobacco intakes, as paan, was 9.96 (95% CI9.22, 10.7); 69.8% were recruited from primary care, 78.8% received behavioural support and nicotine replacementtherapy (NRT) and the remainder behavioural support alone. Self-reported 4-week continuous abstinence was 58.3%,predicted by NRT use [odds ratio (OR) = 4.93, 95% CI 2.02, 12.00], community recruitment (OR = 1.84, 95% CI 1.01,3.35) and relatively lower social deprivation (IMD) score (OR = 1.98, 95% CI 1.18, 3.33). Conclusion Bangladeshiwomen in the UK attending clinics to help cessation of paan with tobacco appear to be more likely to be successful inthe short term if they use nicotine replacement therapy, are recruited via the community and have relatively lowerlevels of social deprivation.

Keywords Bangladeshi, smokeless tobacco cessation, women.

Correspondence to: Ray Croucher, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of Dentistry,4 Newark Street, London E1 2AT, UK. E-mail: [email protected] 22 August 2011; initial review completed 17 October 2011; final version accepted 16 January 2012

INTRODUCTION

Smokeless tobacco use in the United Kingdom’s SouthAsian communities is a public health problem. Smokelesstobaccos are purchased easily in the United Kingdom,despite their non-compliance with the legal requirementsfor product labelling [1]. They impact adversely onhealth, particularly oral cancer [2,3]. Paan, commonlychewed, contains areca nuts, slaked lime and catechu towhich tobacco is added, either in cured leaf or processedform [4].

The UK Bangladeshi community suffers multiple dep-rivations [5]. Bangladeshi women have a high prevalenceof chewing paan with tobacco [6,7] and comparativelyfewer successful quit attempts compared to the generalpopulation [5], demonstrating the existence of a healthgradient [8].

Using pharmacotherapy to support cessation attemptsmade by smokeless tobacco chewers lacks effectivenessevidence [9]. A recent Cochrane review [10] included 25trials of approaches to smokeless tobacco cessation. Eightinvolved nicotine replacement therapy (NRT) [11–18].Their results’ generalizability was limited, as participantswere male, aged in their 30s, using North Americanmoist snuff or chewing tobacco. Cessation point preva-lence alone was reported. The review concluded thatbehavioural interventions with oral examinations ortelephone follow-up were more effective.

There is one report of cessation support for UK resi-dent Bangladeshi smokeless tobacco users [19]. Thiscompared a single session of brief advice and encourage-ment against four weekly behavioural advice sessions andaccess to NRT patches. It suggested that the latter inter-vention achieved more successful, although statistically

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RESEARCH REPORT doi:10.1111/j.1360-0443.2012.03819.x

© 2012 The Authors, Addiction © 2012 Society for the Study of Addiction Addiction

non-significant, cessation with respect to 4-weekcotinine-validated abstinence.

This study aimed to identify predictors of successfulsmokeless tobacco cessation in a group of Bangladeshiwomen paan-with-tobacco chewers. It was hypothesized,first, that these smokeless tobacco users would moreprobably make a successful cessation attempt with NRTaccess and, secondly, that there would be a gradientbetween successful and unsuccessful quitters reflectingtheir levels of socio-economic disadvantage.

METHODS

Study design and setting

This prospective cohort study took place in a cessationservice offering smokeless tobacco cessation support.Clients received weekly one-to-one support for up to 12weeks from three trained female outreach communityworkers using culturally tailored support strategies[20,21]. Client NRT use was negotiated individually.

Participants

UK resident Bangladeshi female paan-with-tobaccochewers were recruited between April 2005 and Septem-ber 2009. Those aged under 18 years, unable to giveinformed consent, pregnant, breastfeeding, with serioussystemic illnesses or current smokers were excluded fromthis study.

Variables

A standardized pre-piloted form was used. Data wereextracted by one assistant, blind to the study hypothesis,from client monitoring forms. Duplicate data entry for10% randomly selected records identified no conflicts.Data included demographics (age, area deprivation),tobacco use (frequency, dependence) and cessationattempt process and outcome (NRT prescribing, partici-pant use of NRT types, self-reported abstinence over 4weeks). An index of multiple deprivation (IMD) [22]score was calculated for each participant’s residentialarea. Lower IMD scores indicate higher levels of socio-economic deprivation. Dependence questions wereadapted and scored using current inventories [23,24].Recruitment location was from either primary care,friends and family or at a community centre. Theintervention was either behavioural support alone orbehavioural support and NRT. Continuous unvalidatedabstinence was defined as no tobacco use at all.

Data analysis

Data were analysed using SPSS version 17. Those lostto follow-up were assumed to still chew tobacco.

Frequencies and descriptive statistics for all variableswere performed. Following initial analysis nine variables(participant age, age of starting tobacco use, number ofdaily paan-with-tobacco, dependency score, level of areadeprivation, number of past quit attempts, recruitmentlocation, intervention and type of NRT prescribed) withsignificance values of up to P < 0.20 [25] were enteredinto binary logistic regression modelling, using backwardstepwise elimination and the log-likelihood ratio test,with client quit success as the dependent variable. Thebest-fitting model affecting the odds of client quit successwas sought [26].

Ethics

The investigators were advised by the National ResearchEthics Service that the study was not research and did notrequire Research Ethics Committee review. All partici-pants gave full written consent, confirming that their quitattempt was voluntary.

RESULTS

Of 744 client records, 419 meeting the inclusion criteriawere included in this analysis. Those included andexcluded from the analysis did not differ in mean age(48.9 versus 49.4 years, t = 0.53, P = 0.59) and meanIMD score (3.65 versus 3.16, t = 1.115, P = 0.266).

Demographics

Mean participant age was 48.92 [95% confidence inter-val (CI) = 47.5, 50.34] years and mean IMD score was3.65 (95% CI = 3.33, 3.97).

Tobacco use and dependence

Mean daily paan-with-tobacco chewed was 9.96 (95%CI = 9.22, 10.7) and mean age for starting paan-with-tobacco use was 20.94 (95% CI = 19.76, 22.12) years.Clients who chewed above median (7.50) daily paan moreprobably started their chewing at an earlier age [19.28years (95% CI = 17.71, 20.85) versus 22.52 years (95%CI = 20.79, 24.25) P = 0.007]. Socio-economic depriva-tion (IMD) score was not related to daily paan intake.

The mean dependence score was 5.29 (95%CI = 5.06, 5.51). Those chewing more paan-with-tobacco daily more probably had higher levels of depen-dence (P = 0.005). Dependence scores did not varysignificantly (P > 0.05) by age, age of starting tobacco,IMD score and number of previous quit attempts. Most(53.4%) participants reported making one to five, 29.7%reported none and 16.9% reported making more thanfive previous quit attempts.

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Most (69.8%) participants were recruited throughprimary care, 28% from community centres and 2%through friends and family. More than three-quarters(78.8%) of the participants received NRT and behav-ioural support and the remainder behavioural supportalone. No significant demographic (age: P = 0.806, IMD:P = 0.71), daily paan-with-tobacco (P = 0.129), depen-dency (P = 0.436) or recruitment location (P = 0.208)differences between those using NRT and behaviouralsupport and behavioural support alone were identified.Acute and sublingual NRT (gum, lozenge, microtab andinhalator) was prescribed for 54% of clients comparedwith 30.9% prescribed patch therapy and 15.1% com-bination NRT.

Participant cessation success

More than half (58.3%) of participants reported conti-nuous tobacco cessation over 4 weeks. The mean ageof those abstinent for 4 weeks was significantly higher(P = 0.028) than those not abstinent [50.17 (95%CI = 44.84, 48.98) years versus 46.91 (95% CI = 48.27,52.07) years].

Participants chewing fewer daily paan-with-tobacco,recruited from community centres and who were pre-scribed and used NRT to support their cessation attempt,were significantly more likely to make a successful cessa-tion attempt, while level of dependence, IMD score andnumber of previous cessation attempts were not relatedsignificantly to a successful cessation attempt.

There was no significant difference in the types ofNRT based on cessation outcome. Participants prescribedcombination NRT had a higher mean dependency score(6.14, 95% CI = 5.49, 6.79) (P = 0.001) compared to

participants prescribed patch therapy alone (5.5, 95%CI = 5.09, 5.90) or acute and sublingual forms of NRTalone (4.93, 95% CI = 4.61, 5.25).

Logistic regression modelling (Table 1) demonstratesthat, after age adjustment, participants receiving NRTand behavioural support compared to behaviouralsupport alone (OR = 4.93, 95% CI = 2.02, 12.00)(P = 0.001), who were more probably recruited fromcommunity centres (OR = 1.84, 95% CI = 1.01, 3.35)(P = 0.047) and who had relatively lower socio-economic(IMD) scores (OR = 1.98, 95% CI = 1.18, 3.33) (P =0.001) were significantly more likely to be continuouslyabstinent at 4 weeks. There was no interaction betweendaily paan intake and use of NRT (OR = 1.24, 95%CI = 0.30, 4.98) (P = 0.762).

DISCUSSION

This study investigated predictors of successful smokelesstobacco cessation in clients attending a cessation serviceoffering culturally tailored support to Bangladeshipaan-with-tobacco users.

The results indicate that NRT, offered within culturallytailored support [5], may help these smokeless tobaccousers to make successful quit attempts. The findingreplicates the outcomes of an earlier study of smokelesstobacco cessation in this community [19]. NRT’s effec-tiveness has been demonstrated in smoking cessation[27], but its effectiveness for quitting smokeless tobaccouse has been questioned [9,10]. We argue that our find-ings demonstrate NRT’s relevance, whatever form oftobacco is used. The results also suggest a health gradientin outcome, despite the overall high socio-economic

Table 1 Predictors of short-term continuous abstinence in UK resident female Bangladeshi smokeless tobacco users (n = 309).

Variable Unadjusted OR (95% CI) P-value Adjusted OR (95% CI) P -value

Age – 0.028 1.01 (0.99–1.03) 0.192Number of paan/day 0.004 0.225

�7.5 paan/day 1.0 1.0>7.5 paan/day 0.56 (0.37–0.83) 0.45 (0.12–1.62)

Recruitment location 0.023GP/health centre 1.0 1.0Friends and family 0.68 (0.18–2.61) 0.25 (0.05–1.16) 0.078Community centre 1.86 (1.17–2.96) 1.84 (1.01–3.35) 0.047

Level of deprivation 0.166 0.010�2.7 IMD score 1.0 1.0>2.7 IMD score 1.35 (0.88–2.08) 1.98 (1.17–3.32)

Intervention 0.001 0.001BS alone 1.0 1.0BS + NRT 6.26 (3.67–10.67) 4.93 (2.02–12.00)

CI: confidence interval; IMD: Index of multiple deprivation; BS: behavioural support; OR: odds ratio; GP: general practitioner; NRT: nicotine replacementtherapy.

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deprivation levels. Outreach recruitment and support, acomponent of the service model, also indicated a success-ful quit attempt. This has not been reported previouslyin smokeless tobacco users, although its potential isrecognized in improving other health outcomes [28]. Apost-hoc power analysis indicated that the sample sizewas sufficiently powered to detect a 99% true associationbetween the regression model variables and successfulcessation.

It should be acknowledged that clients were self-selected, with no random allocation to treatment options.The cessation support workers were not blinded to thedifferent treatments negotiated with clients. Short-termself-reported quit success is reported. Confirmation withbiomarkers (salivary cotinine) was not possible, due toresource limitations. Data on client motivation and NRTprescribing compliance was not available.

Further research should investigate the effectivenessand cost-effectiveness of NRT, within a culturally tailoredapproach, using robust study designs. Investigations ofthe acceptability of the cessation process should focus onclient satisfaction with this service model.

In conclusion, NRT use, community recruitment andrelatively lower socio-economic deprivation levels maypredict successful short-term cessation in UK residentBangladeshi women chewing paan-with-tobacco.

Declarations of interests

None.

Acknowledgements

Funding for this study has been received as part of theDepartment of Health’s Tobacco Control InequalitiesConsortium. The Bangladeshi Stop Tobacco Project isfunded by NHS Tower Hamlets.

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