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For Asian men, smoking is second nature and a sign of belonging – but some areas in the UK are more committed than others in providing help for them to quit.
TINA BEXSON reports for the Guardian newspaper
Rufon Uddin is trying to give up smoking. He is finding it very difficult.
One of the biggest obstacles is being out with his friends in Newcastle upon Tyne’s West End where they all live and work. It is also hard because smoking is very much part of being a Bangladeshi man. It’s viewed with a strong sense of social acceptance, social bonding, and tradition.
“It’s very hard when they are all smoking and you are not, you feel apart as though you are missing out,” he says. “It’s also often the only real time when you can smoke properly because once our people get married, we wont smoke at home in front of the wife because she doesn’t like it.”
Nor can he smoke in front of anyone older than him because it is customary for Bangladeshis to never smoke in front of elders. “It’s a respect thing in Bangladeshi society,” Rufon explains. “I don’t smoke in front of my parents, even though my father smokes, and they know I smoke. And if I pass group of lads in their twenties who are smoking they will hide their cigarettes or put them out until I’ve gone past, out of respect for me. But I see lots of white people when they get to 16 smoking in front of their parents with their parents even buying cigarettes for them.”
But he can smoke at work. “95% of us work in an Indian takeaway or restaurant,” he says, “and there are many more opportunities to smoke at work than there are for white people whose day is usually more structured. As long as we go outside we can have a cigarette whenever we need.”
Although he recognises that giving up is ultimately up to the individual, he would like to join a local smoking cessation programme run by Newcastle and Tyne Primary Care Trust (PCT) to give him a head start. But it is only geared towards the white population and fails to acknowledge the different cultural concerns and problems facing smokers from his culture.
This is surprising because according to a survey by the Department of Health smoking is much more common amongst Bangladeshi men (44%) than among white men (27 %). For Bangladeshi men aged 50-74, the rate is a staggering 56%. This has serious health consequences. For example cardiovascular disease (angina, heart attack, stroke, high blood pressure and diabetes) is 60-70% higher amongst Bangladeshi and Pakistani men, than the general population.
These significant differences between whites and South Asian men and women mark a drastic need for culturally sensitive interventions in Newcastle, outlines research recently published in the British Medical Journal (BMJ) from the School of Population and Health Sciences at the University of Newcastle.
Places such as Bradford, Birmingham and Tower Hamlets in London, are already running both successful and advanced interventions such as the campaigns that take place during Ramadam. And since the Department of Health launched the NHS Asian tobacco education campaign in August, local smoking cessation services run by PCTs are increasing in other South Asian communities throughout the UK.
So why not in Newcastle upon Tyne?
Judy Loggie, the manager of smoking cessation services at Newcastle and Tynside PCT, who has only recently took up her post, admits that they should be doing more. “We should be doing all this stuff, but we’re not. We did have Asian smoking cessation workers working on and off for two years, but it wasn’t a programme, it was just how we had responded to Asian needs so far. It’s not enough, and we need to do some more.”
Martin White, Senior Lecturer in Public Health at the University of Newcastle, conducted the BMJ research. He was struck by how “many white middle class professionals within health care will view South Asians as a singular population with the idea that they can develop a ‘one size fits all’ approach to interventions for them.”
“But it’s fundamentally wrong,” he adds. “For example, it doesn’t make sense that what should work for young male Bangladeshis who work anti social hours in the restaurant trade should work for elders sitting at home all day. They are almost different cultural groups.”
Since its almost expected for the elders to smoke, Shazan Uddin, a bilingual community health worker and cardiac rehab nurse for the Westgate Heartbeat project in Newcastle, says that it takes a major health crisis for many of them to give up.
Many of his clients are elderly South Asians with coronary heart disease and diabetes. “Usually they’ve either had a heart attack or are going to have heart bypass surgery before they give up,” he says.
Targeting those who aren’t suffering any ill health effects and who don’t want to give up is very difficult. “They say they’ve smoked all their life and don’t think its doing them any harm, it helps them relax. They’ve always got a way of justifying why they smoke and don’t want to give up”.
The situation isn’t helped by the acute lack of awareness of the serious health risks linked by smoking. DoH figures show that only 27% of Pakistanis and Bangladeshis associate smoking with heart disease.
Religion has little influence because despite tobacco being seen as Haram (not good says God) it is not specifically banned by their Islamic faith as alcohol is. Nor do their wives have much impact. “Their wives do put pressure on them but they say that they as men are the decision makers in Asian families,” says Shazan.
“Up until now there has been very little information available in Bengali advising them on the damage smoking causes and on how to give up. But they need more information but they don’t want any more of those leaflets, most of them don’t like reading anyway.” Because of these reasons, Shazan believes that any culturally sensitive smoking cessation programme would have to include structured group sessions.
Jamal Sarwar, 35, was one of the Bangladeshi advisors working for the PCT. Now he works as a community interpreter in the day and in an Indian restaurant in the evening. He is also a light smoker.
“It is absolutely necessary we have a proper smoking cessation programme in place. When I was working as a smoking cessation advisor we found that we needed a central place where clients could go and see a doctor, a nurse and where they could get advice, nicotine replacement therapy, counselling and join a group. But we did not have that.”
However Martin White acknowledges that there is the possibility of a programme being seen as “intrusive and patronising with people preaching to the Asian community”. “But on the other hand there are many people in the community who do want to give up.”
Jamal agrees. “They would welcome a Bangladeshi smoking cessation programme. There is nothing at the moment and leaving it purely up to will power is very hard. If the programme is geared towards my community then I don’t think it can be patronising at all.”
“Also the elders would only be happy on a programme with their own age group and taken by an adviser of their own age group. The same goes for the younger men who have different pressures and influences such as Indian films where the hero is always smoking. Our people need to feel the comfort of their own people.”
If he ever joined a smoking cessation programme Rufon would want the advisor to understand the pressures of working in an Indian takeaway or restaurant, and know what goes on in his community. “A person from a different culture wouldn’t,” he says, “but a Bangladeshi man would.”
Martin White argues that any future culturally sensitive programme in Newcastle must take on board the differences within the communities themselves if they are going to reach their target population and be effective. “UK investment is urgently needed in culturally sensitive smoking cessation interventions for South Asians that involve the government and national and local health agencies, particularly primary care trusts.” These requirements should be underlined by the Race Relations (Amendment) Act 2000, he adds, which obliges public authorities, including the NHS, to promote racial equality in access to services.
SIDE BAR :
TOWER HAMLETS PCT TOBACCO CESSATION PROGRAMMES FOR SOUTH ASIANS:
Tower Hamlets PCT funds a project serving the Bangladeshi community partnered by Queen Mary University of London and a community organisation, Social Action for Health. It offers a ‘culturally competent service’ that tries to meet the needs of the local community by using bilingual gender specific male and female advisors who are aware of the socio-cultural context of tobacco use and the impact this has on tobacco cessation for the Bangladeshi community.
Although smoking is acceptable amongst Bangladeshi men, in women it is regarded as taboo, and disrespectful. Only 4% of the women smoke. They prefer to chew tobacco in a mixture called Paan especially those aged over 55 and of whom its estimated that 56% chew. Chewing is just as harmful, contributing to coronary heart disease, and cancer of the mouth. “But we don’t want to take anything away from them, it’s traditional within their culture,” says Tobacco Cessation Advisor Shamsia Begum. “They’d have seen their grandparents do it. So our message is ‘enjoy your paan and leave out the tobacco’.”
The advisors try and distinguish what the main causes for the addiction are. For women, its often being in a different country without the freedom they are used to. Smoking is frequently linked to stress.
“So we try and divert the men to an alternative to cigarettes to relieve stress, such as exercise or a hobby,” Shamsia explains. “ It may also be appropriate to refer them on to another service too.”
All materials, including advice pamphlets, contact details and questionnaires, are printed in both English and Bengali. An advisory group made up of smoking cessation advisors and community members meets quarterly to discuss and advise on new developments.
“We work on a locality basis,” says Ray Croucher, Professor of Community Oral Health at Queen Mary University of London, and the project’s joint manager. “We don’t wait for people to contact us – we recruit from the community by being present at, for example, a local food co-op and English language classes.”
Once clients have entered the Tower Hamlets programme they receive one to one counselling, nicotine replacement therapy and weekly advice. “Then we continue to make contact in the community or, if they’d prefer, provide domiciliary visits. Our success rate is around 62%, compared to the national average of 48-50%.”
The approach is “holistic”, he continues, “and sometimes offers guidance on housing and benefits issues or facilitates access to dental care. Through liaison with environmental health officers we’ve also developed a Code of Practice for Retailers – traditional tobacco products imported from South Asia often have inadequate labelling about the health impacts of tobacco use.”
‘Understanding Influences on Smoking in Bangladeshi and Pakistani Adults: A Community Based, Qualitative Study’, by the School of Population and Health Sciences at University of Newcastle, Newcastle upon Tyne, is available at http://bmj.com/cgi/content/full/326/7396/962