& Tobacco NicotineNicotine & Tobacco ResearchResearch Advance Access published October 22, 2012
Review
A Systematic Review of Contextual Factors Relating to Smokeless Tobacco Use Among South Asian Users in England Josie Messina, B.A., M.A.,1 Crystal Freeman, B.A., M.P.H., Ph.D.,1 Angie Rees, B.A., M.A., D.P.S.,1 Elizabeth Goyder, M.D., F.F.P.H., M.R.C.G.P.,1 Andrew Hoy, M.Sc.,2 Simon Ellis, B.Sc., M.P.H.,2 & Nicola Ainsworth2 1
University of Sheffield, Section of Public Health, School of Health and Related Research (ScHARR), Sheffield, UK Institute for Health and Clinical Excellence (NICE), Centre for Public Health Excellence, London, UK
2 National
Received March 9, 2012; accepted July 12, 2012
Abstract Introduction: Certain types of smokeless tobacco (ST) are popular among some people of South Asian origin in England; however, little is known about the contextual factors surrounding use in this population. This systematic review explores the factors associated with ST use among people of South Asian origin in England. Methods: An iterative search strategy in targeted databases and grey literature sources was conducted in the summer of 2011. Data extractions and quality assessments were completed and verified by two reviewers, and results were presented as a narrative. Results: A total of 2,968 references were screened by two reviewers who agreed on the inclusion of 14 studies. ST use is more prevalent among older participants who may have started chewing in India; however, the evidence suggests that some younger English-born South Asians are using ST as well. Reasons for chewing included the use of these products in times of stress, boredom or simply to relax. Traditional health messages and prior held beliefs may lead them to chew these products because of misconceptions about their health benefits, since very few people were aware of the health risks. Many expressed a desire to quit, however found it difficult to go without ST. Conclusion: This review examines the complex factors that underpin and influence ST use among South Asians in England with the potential of informing targeted interventions and health policy.
Introduction This review explores the factors associated with smokeless tobacco (ST) use among people of South Asian origin residing in England to uncover the context and cultural practices surrounding ST use. Several areas of England such as Greater
London, West Yorkshire, and West Midlands have a high prevalence of South Asian residents who are regular users of ST (Warnakulasuriya, Sutherland, & Scully, 2005), with many unaware of the health risk associated with its use. ST is defined as any product containing tobacco that is placed in the mouth or nose and not burned. Many of the ST products used in England contain a mix of ingredients including tobacco, slaked lime, areca nut and spices, flavorings and sweeteners (Bedi, 1996). According to a recent report of the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR, 2008), the use of ST products in England is largely restricted to members of Indian, Pakistani, and Bangladeshi communities, which make up 4.5% of the U.K. population—or just over 2 million people. Chewing tobacco is common among the Bangladeshi community with 9% of Bangladeshi men and 6% of Bangladeshi women (Wardle, 2006); however, these numbers may be subject to under-reporting of use (Roth, Aitsi-Selmi, Wardle, & Mindell, 2009). Furthermore, among Bangladeshi women, the use of chewing tobacco is greatest among those aged 35 and over. Among men, there was no difference in the use of chewing tobacco by age (Wardle, 2006). Betel quid (with and without tobacco) is the most commonly used product among South Asians (NHS Health and Social Care Information Centre, Public Health Statistics, 2005). ST is associated with a number of health problems including nicotine addiction (SCENIHR, 2008), mouth and oral cancer (Critchley & Unal, 2003), oral pain (Pau et al., 2003), myocardial infarction, stroke (Boffetta & Straif, 2009), loss in bone density (Quandt, Spangler, Case, Bell, & Belflower, 2005), problems during pregnancy and following childbirth (including stillbirth and lower birth weight) (England et al., 2010; Gupta & Sreevidya, 2004), and late diagnosis of dental problems (West, McNeill, & Raw, 2004). Despite the health risk associated with ST use, many products such as gutkha and pan masala, which are widely used by the South Asian community within England, are virtually
doi:10.1093/ntr/nts193 © The Author 2012. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail:
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Corresponding Author: Josie Messina, B.A., M.A., Section of Public Health, School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK. Telephone: 44 (0) 114-222-0738; Fax: 44 (0) 114-222-0791; E-mail:
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Smokeless tobacco and South Asians unregulated and sold freely (Tobacco Advisory Group of the Royal College of Physician, 2007). Previous reviews of effectiveness of ST-cessation interventions (Ebbert, Montori, Erwin, & Stead, 2009; Ebbert, Montori, Erwin, & Stead, 2011; Ebbert & Fagerstrom, 2012) did not cover contextual aspects; thus a research focus was developed at the start of the review process to investigate the contextual factors of ST use among South Asian populations living in England given the wide-spread use and negative health effects of ST among South Asians.
Methods Search Strategy
Quality Appraisal and Synthesis
Data screening, data extraction, and quality assessments using appropriate checklists (NICE, 2009) was completed by two reviewers with any discrepancies resolved by consensus where the reviewers would meet to discuss assessments. Each study was awarded a quality score of high (++), moderate (+), or poor (–) to reflect the risk of potential bias arising from its design and execution (see Supplementary Data for criteria). This review of ST use among South Asians is presented as a narrative analysis and outlines included study characteristics, main findings, and summarize results in a discussion.
Results Identified Studies and Quality Appraisal
A total of 2,968 records were identified and independently screened by two reviewers who agreed on the inclusion of 14 studies (see Figure 1). Eleven papers were identified from a formalized search while the remaining three papers, which consisted of grey literature and unpublished studies, were identified by the NICE team and subject experts through a formalized evidence call process.
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Included Study Characteristics
All research was set within England with a focus on South Asian communities such as Tower Hamlets (Ahmed et al., 1997; Croucher & Choudhury, 2007; Croucher et al., 2002; Croucher et al., 2007; Longman et al., 2010; Pearson et al., 1999), East London (Prabhu et al., 2001), Harrow (Nathan, 2010), Birmingham (Bedi & Gilthorpe, 1995), and Leicester (Longman et al., 2010; Rees, 2007; Vora et al., 2000). The total number of participants included in the 14 studies was 3,056. Although many papers targeted people of South Asian origin, Bangladeshi populations were well represented in this field of research (Ahmed et al., 1997; Bedi & Gilthorpe, 1995; Croucher & Choudhury, 2007; Croucher et al., 2002; Croucher et al., 2007; Pearson et al., 1999; Prabhu et al., 2001; Summers et al., 1994).
Characteristics of ST Users
Two cross-sectional studies of high quality (++) and seven studies of moderate quality (+) provided data on the characteristics of ST users and are summarized in Table 1. Data suggests a high proportion of study participants were using ST products and these include men, women, and even youth.
Social Acceptability
Two studies of moderate quality (+) examined social acceptability of ST use. According to qualitative research by Croucher and Choudhury (2007), chewing ST was traditionally and culturally more appropriate for females within South Asian communities compared with males. Smoking was not very common among South Asian women and was more socially and culturally appropriate in men, with over a third of the Birmingham-based sample accepting chewing and smoking habits for men (Bedi & Gilthorpe, 1995). Females appeared to be accepting of their own chewing habits, and there was a general consensus that children should not be using betel quid (Bedi & Gilthorpe, 1995).
Age and Location of the Onset of ST and Chewing Products
Four studies of moderate quality (+) reported on the age, location, and onset of ST use. According to a report by the HDA (2000), the use of ST products was more prevalent among older participants; however, younger English-born South Asians are also using ST. The age of first use varied, but as young as pre-teens. This finding is echoed among a mixed gender study of 140 respondents conducted by Ahmed et al. (1997) in the Tower Hamlets community within London indicating that 75%
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This systematic review was commissioned by the National Institute for Health and Clinical Excellence (NICE) in England to support the development of public health guidance on ST-cessation interventions for South Asians (NICE, 2012). An iterative search strategy, which allowed for modifications to the search to be made in phases, was undertaken from July to August 2011 where terms for “smokeless tobacco” and “South Asians” were used in the following databases: Embase, PyscINFO, Medline, Medline in Process, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, HTA Database, NHS EED, Social Science Citation Index, Science Citation Index, ISI Conference Proceedings Citation Index– Science, ISI Conference Proceedings Citation Index Social Science and Humanities, ASSIA, British Nursing Index (see Supplementary Data for search terms). In addition to database searches, citations searching, grey literature sources, reference list checking, and subject experts were consulted. Predetermined inclusion criteria were primary research studies focusing on views or experiences of South Asian ST users living in England.
Nine cross-sectional studies (Ahmed, Rahman, & Hull, 1997; Bedi & Gilthorpe, 1995; Csikar et al., n.d.; Longman, Pritchard, McNeill, Csikar, & Croucher, 2010; Nathan, 2010; Pearson, Croucher, Marcenes, & O’Farrell, 1999; Prabhu, Warnakulasuriya, Gelbier, & Robinson, 2001; Summers, Williams, & Curzon, 1994; Vora, Yeoman, & Hayter, 2000), and two qualitative studies (Croucher & Choudhury, 2007; Health Development Agency (HDA), 2000) were assessed as moderate quality (+) using the NICE quality assessment tools (NICE, 2009). Two cross-sectional studies by Croucher et al. (2002) and Croucher, Islam, and Pau (2007) were graded as high quality (++). A grey literature report (Rees, 2007) was not quality assessed since no appropriate assessment tool existed for reports.
Nicotine & Tobacco Research
Initial Search (n=2968) Rejected at Title and Abstract level (n=2910) Retrieved (n=58) Excluded at Full Paper Stage (n=44) Included Studies (n=14) Figure 1. Paper selection process for smokeless tobacco use in South Asians contextual systematic review.
Predictors of ST Use
Two high-quality (++) studies and three moderate-quality studies (+) provided details on predictors of ST use. According to a cross-sectional survey and interviews with Bangladeshi women in Tower Hamlets by Croucher et al. (2002), women who used ST were significantly older, had used ST for a longer period, were more likely to cite habit as a reason for chewing, and were also more likely to have their first paan after waking. Similarly, a study of first-generation Bangladeshi women found that participants who consumed more paans daily were significantly older, less literate, had fewer years of formal education, and were more likely to believe that ST was a beneficial habit (Summer et al. 1994). Croucher et al. (2007) examined Bangladeshi males who were smokers and/or ST users in Tower Hamlet and found ST users to be older but also found that chewers were more likely to have had no formal education, rate their health as average or poor, have increased chronic illness episodes, and report current oral pain. More specifically, Croucher et al. (2007) found that tobacco chewers had the lowest social capital score, and a high proportion of chewers (83%) had a wife that also used ST. Paan use appeared to be more likely among South Asian females than males who were lighter users (p
