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Smokeless tobacco is defined as any product containing tobacco that is placed in the mouth or nose and not burned . The smokeless tobacco products used most often in England are the paan quid with tobacco (PQT), gutkha and khaini . These products contain the core ingredients of tobacco leaf or processed tobacco (zarda), slaked lime as an alkalinity regulator and areca nut, which has itself been classified by the International Agency for Research on Cancer (IARC) as carcinogenic .
England is a member of the European Union (EU) and is required to follow its tobacco regulation requirements . These regulations distinguish between ‘tobacco products’ (whether smoked or chewed) and ‘tobacco for oral use’, which is sucked. Swedish snus is considered a tobacco ‘for oral use’ and is sold only in Sweden and other non-EU Scandinavian countries. As a tobacco ‘product’ the use of smokeless tobacco in England is allowed, although largely restricted to South Asians from the Indian, Pakistani and especially Bangladeshi communities, which together make up 4.5% of the population . More members of the UK resident Pakistani and Bangladeshi communities suffer poor health than the general population, as almost two-thirds of these communities live in low-income households .
Smokeless tobacco products used by these communities in England are widely available, despite not meeting the current EU regulatory requirements for tobacco products , most particularly with respect to ingredient disclosure, pack identification codes and health warnings. It is widely recognized that these smokeless tobacco products have adverse effects on health with a specific increased risk of oral cancer, especially among South Asian women , and tobacco dependency . Oral pain is also commonly reported following a cessation attempt, suggesting that chewing smokeless tobacco acts to mask symptoms of oral disease .
Current English practice guidelines suggest that relevant health professionals, particularly dentists, should ask about smokeless tobacco use in their South Asian patients, update the patient's notes and advise of potential health risks. Dentists should examine smokeless tobacco users' mouths for any potentially malignant change. Specialist smoking cessation services should provide counselling for smokeless tobacco use where there is a demand . English National Health Service (NHS) Stop Smoking Service (SSS) guidance recommends the use of behavioural support (BS) alone in helping smokeless tobacco users to quit, excluding nicotine replacement therapy (NRT) use. Providing any NHS SSS quit support for smokeless tobacco users has been a discretionary activity and outcomes are excluded from target monitoring .
There is no evidence that pharmacotherapy assists cessation of South Asian smokeless tobacco. A Cochrane Review  reported eight trials of NRT used as an aid to smokeless tobacco cessation which were of varying effectiveness in assisting successful cessation [odds ratio (OR) = 1.14, 95% confidence interval (CI): 0.91, 1.42]. In addition, none of these studies examined NRT use in English South Asian communities. Behavioural interventions with an oral examination or telephone follow-up were therefore recommended. However, the included trials reported a low prevalence of withdrawal symptoms and NRT-related adverse events. NRT patch and gum use was observed to reduce withdrawal symptoms both in range and intensity compared to placebo. NRT-related adverse events were reported as minimal, more likely to be heartburn or gastroesophageal reflux if lozenges were used [13-19].
A higher proportion of the general population have quit smoking successfully compared to the proportion of English resident Bangladeshi women who have quit smokeless tobacco use successfully . There are two reports of a specialist outreach service [the Bangladeshi Stop Tobacco Project (BSTP)] using NRT to support smokeless tobacco cessation activity with Bangladeshi women resident in Tower Hamlets, England [21, 22]. The most recent of these reports demonstrated that those using NRT in addition to BS to support their quit attempt were nearly five times more likely to report continuous abstinence over 4 weeks. Participants recruited in the community were nearly twice as likely to report continuous abstinence over 4 weeks as those recruited from health clinics. A third significant variable predicting successful self-reported cessation was a relatively superior socio-economic position. These two reports provided no data on the quitting process, such as withdrawal symptoms, adverse events or participant satisfaction. A third study has compared the outcomes of an outreach project for Pakistani and Bangladeshi male smokers with the standard NHS SSS . The potential to increase cessation attempts and a small increase in the number of 4-week abstinent smokers was reported. No significant differences in participant satisfaction between either the outreach intervention or standard programme were identified.
The aim of this study was to evaluate the process and outcomes of smokeless tobacco cessation in three English NHS SSS settings with communities of South Asian origin, with particular emphasis upon client withdrawal symptoms, NRT-related adverse events and satisfaction. It was hypothesized that South Asian smokeless tobacco users would be more likely to make a successful cessation attempt if they were recruited using an outreach clinic model, had access to NRT to support their cessation attempt, had lower levels of withdrawal symptoms and NRT-related adverse events and that successful cessation would result in positive satisfaction levels. The primary outcome was self-reported continuous abstinence from smokeless tobacco use during the cessation attempt.