Behaviour change intervention for smokeless tobacco cessation: its development, feasibility and fidelity testing in Pakistan and in the UK.
People of South Asian-origin are responsible for more than three-quarters of all the smokeless tobacco (SLT) consumption worldwide; yet there is little evidence on the effect of SLT cessation interventions in this population. South Asians use highly addictive and hazardous SLT products that have a strong socio-cultural dimension. We designed a bespoke behaviour change intervention (BCI) to support South Asians in quitting SLT and then evaluated its feasibility in Pakistan and in the UK.



We conducted two literature reviews to identify determinants of SLT use among South Asians and behaviour change techniques (BCTs) likely to modify these, respectively. Iterative consensus development workshops helped in selecting potent BCTs for BCI and designing activities and materials to deliver these. We piloted the BCI in 32 SLT users. All BCI sessions were audiotaped and analysed for adherence to intervention content and the quality of interaction (fidelity index). In-depth interviews with16 participants and five advisors assessed acceptability and feasibility of delivering the BCI, respectively. Quit success was assessed at 6 months by saliva/urine cotinine.



The BCI included 23 activities and an interactive pictorial resource that supported these. Activities included raising awareness of the harms of SLT use and benefits of quitting, boosting clients' motivation and self-efficacy, and developing strategies to manage their triggers, withdrawal symptoms, and relapse should that occur. Betel quid and Guthka were the common forms of SLT used. Pakistani clients were more SLT dependent than those in the UK. Out of 32, four participants had undetectable cotinine at 6 months. Fidelity scores for each site varied between 11.2 and 42.6 for adherence to content - maximum score achievable 44; and between 1.4 and 14 for the quality of interaction - maximum score achievable was 14. Interviews with advisors highlighted the need for additional training on BCTs, integrating nicotine replacement and reducing duration of the pre-quit session. Clients were receptive to health messages but most reported SLT reduction rather than complete cessation.



We developed a theory-based BCI that was also acceptable and feasible to deliver with moderate fidelity scores. It now needs to be evaluated in an effectiveness trial.
Department of Health Sciences, University of York, York, YO10 5DD, UK. Kamran.siddiqi@york.ac.uk.
Kamran
K
Siddiqi
Department of Health Sciences, University of York, York, YO10 5DD, UK.
Omara
O
Dogar
Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
Rukhsana
R
Rashid
Department of Health Sciences, University of York, York, YO10 5DD, UK.
Cath
C
Jackson
School of Psychology, University of Leeds, Leeds, LS2 9JT, UK.
Ian
I
Kellar
Department of Health Sciences, University of York, York, YO10 5DD, UK.
Nancy
N
O'Neill
Department of Medicine, The Aga Khan University, Karachi, Pakistan.
Maryam
M
Hassan
Cameos Consultants, Islamabad, Pakistan.
Furqan
F
Ahmed
Department of Medicine, The Aga Khan University, Karachi, Pakistan.
Muhammad
M
Irfan
Department of Public Health, Leeds City Council, Leeds, LS7 3NB, UK.
Heather
H
Thomson
Department of Medicine, The Aga Khan University, Karachi, Pakistan.
Javaid
J
Khan
D000328:Adult; D044466:Asian People; D001521:Behavior Therapy; D005240:Feasibility Studies; D005260:Female; D015438:Health Behavior; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010154:Pakistan; D010349:Patient Compliance; D020377:Self Efficacy; D020340:Tobacco Use Cessation / Q000523:psychology*; D006113:United Kingdom
Adaptation; Behaviour change; Behavioural support; Cessation; Chewing; Feasibility; Fidelity; Smokeless; South Asian; Tobacco