Bangladeshi male 14—15 year olds commonly socialize in large gangs of more than 20, both in and out of school. All the male focus groups indicated that smoking cigarettes was the perceived norm for these large gangs.
The influence of social affiliations on smoking was recognized by one smoker who had tried unsuccessfully to give up. He believed a successful outcome was dependent on developing new social affiliations. I dunno, move from here or sommit, go somewhere out to [a relatively rural neighbouring county]. Another boy in Group 16 described how smoking provided a topic of conversation with strangers, and thus facilitated social interaction and getting to know new people.
Smoking to facilitate social affiliations was not always considered an advantage as indicated by a conversation between two non-smokers. Three of the four female groups and all the male groups also had participants who smoked on their own. The other female group Group 03 discussed the need to smoke alone if a young Bangladeshi woman was a regular smoker.
These discussions were confused, such as smoking cigarettes contained calories and could therefore help to put weight on, and consensus was not reached. Nobody indicated that issues surrounding weight were a major reason for smoking or not smoking. Lloyd and Lucas also argue body image concerns are not a major influence on smoking amongst adolescents Lloyd and Lucas, Male Group 16 discussed the relationships between weight control and smoking in relation to others, but indicated that weight control was not an issue for them.
However, smoking and image seemed to be more of an issue for non-smokers and smokers always focused on other people, such as younger people, rather than themselves. Furthermore, the tone of female and male non-smokers and smokers alike was generally disparaging when discussing this issue. Two male groups Groups 15 and 17 were less disparaging about the relationship between image and cigarette lighters.
The themes pertaining to influences which promote non-smoking amongst the Bangladeshi female participants, which are summarized in Table VI and discussed below, were mentioned by the participants within the context of the meanings associated with smoking amongst Bangladeshi females. These meanings as described by the female participants themselves promoted non-smoking. For Bangladeshi males, on the other hand, no major disincentive to smoking was identified, which arose from the meanings associated with smoking.
Thus, the themes pertaining to influences which promote non-smoking amongst the Bangladeshi male participants, which are summarized in Table VI and discussed below, may have been more important to the males than the females even though both genders may have identified common influences.
Parental factors were highlighted by female Groups 01, 02 and 03 as influences which promote non-smoking. All the male groups also discussed parental factors as influences even though the majority of male participants were largely dismissive of parents' ability to influence behaviour. Parental factors included being put off smoking because of its effects on parents' health female Group 01; male Groups 15 and 16 and because participants were scared parents would find out or because they had been caught female Groups 02 and Another said:.
If we smoke we'd be betraying them [parents]. They are proud of us to go to school. If they find out we're smoking…it's a bad idea. Health reasons influenced the decisions of participants in female Groups 01, 02 and One male ex-smoker Group 16 also cited health as an influence but a different non-smoker in the same group disagreed. Female smokers in Group 04 and an ex-smoker in Group 02 also challenged the importance of health as an issue. In contrast, no male smoker challenged this notion.
Indeed, male smokers in Groups 16 and 17 reported that health concerns focusing on heart attacks and cancer had underpinned unsuccessful attempts to give up smoking.
Some participants' decisions were influenced by the unpleasant effects of smoking tobacco such as smell female Groups 01 and 04; male Group 15 and it makes them feel sick female Group 02; male Groups 15 and Female Groups 02 and 04 and male Groups 16 and 17 discussed the influence of expense on non-smoking.
One male smoker Group 15 confirmed the importance of cost and suggested most of his peers were cutting down due to rising costs. Participants in female Groups 01 and 04 believed smoking was not sensible, implying that not smoking was related to making choices. All three male groups highlighted the importance of social affiliations and interactions as factors influencing decisions to never start or stop smoking.
FIRST: …then again I don't go out night times around the streets, I just go to the library or play football sometimes…most people are mixed up they will go around in gangs and all that and they smoke…. One boy in Group 15 stopped smoking because an influential friend decided smoking was a bad idea and persuaded the whole friendship group to stop together.
Lloyd and Lucas also reported that dominant personalities could persuade a whole group of occasional smokers to give up smoking Lloyd and Lucas, The ability to socialize with smokers yet not smoke was discussed by male Groups 15 and Most of my mates are always smoking.
I never get tempted. I walk along with them and they are smoking…they don't really offer they just kid around, you're no fun because they know I don't really want it, which helps also and they won't force me to have one…If they were to like try and force me I wouldn't go with them.
Perhaps these non-smoking Bangladeshi boys felt able to socialize with smokers because their friendships were based on the right to make choices rather than conformity. Michell indicates smoking is not as closely associated with membership of some male friendship groups as it is with female groups Michell, Lloyd and Lucas report that other similarly aged teenagers are more likely than younger people to accommodate a range of behaviours within friendship groups Lloyd and Lucas, Pressure to smoke was discussed by female Groups 03 and 04 but did not focus on participants' own experiences.
In contrast, male non-smokers in Groups 15 and 16 discussed their own experience of pressure to smoke. One participant had some difficulty in resisting pressure. Sometimes I take and sometimes when I don't feel well I say no I don't feel well I don't want it, but most of the time I say no I don't want it.
However, the majority who talked about this issue felt that they could resist if they wanted, e. A different boy in Group 15 argued that resisting pressure appeared to be relatively easy even for younger people. As far as I know little kids yeah, they can stand up to kids and pressure, even if they force them they don't it.
I have seen it. The opinions of the male participants would support this view. One female participant Group 02 believed that taking up table tennis had helped her give up because it prevented her from getting bored.
Male Groups 15 and 16 discussed the influence playing football had on smoking. Smokers and non-smokers reported that boys who played football were less likely to smoke because they had something to occupy them and their time. One smoker said:. Some of your mates don't smoke do they. They go out there and get the ball and kick around with the ball for a while that's how their time goes.
Several smokers from Group 16 noticed that smoking affected their football playing ability and had attempted unsuccessfully to stop because of this.
In the UK, it is illegal to sell tobacco products to people who are under 16 but it is not illegal for under 16 year olds to smoke.
Nevertheless, the illegal nature of smoking influenced both participants in female Group 02 and three participants in male Groups 15 and These adolescents thought they would smoke when they were older and it was legal to buy cigarettes. Only pupils present when the questionnaires were administered were included in the survey. A comparison of the collected sample with the selected sample who did not take part could not be made.
Thus, the collected sample may not represent the population. Furthermore, the representativeness of the sample in terms of ethnicity and gender may not be assessed because the population distribution was unknown. The results may, however, be compared to similarly collected samples. Due to time constraints, relatively few focus groups were conducted and feedback from participants on the preliminary findings was not possible.
Recruitment was totally reliant on key informants. The researchers had no control over focus group size or membership.
Focus group participants did, however, complete a questionnaire which enabled the researchers to exclude people who were not the targeted age and ethnicity from the analysis.
The key informants may have chosen participants who would promote the image of their institution. However, they were all supportive of the project aims and indicated they would guard against this wherever possible. The focus group facilitator was young, white and female, which may have affected the focus group discussions Douglas, She did, however, have extensive experience of working in the locality and made efforts to develop appropriate relationships with participants, particularly in the youth club.
Some focus groups consisted of Bangladeshis while others were composed of Bangladeshis and whites. This may have affected the discussions. Participants also knew each other, which may have encouraged conformity. However, in practice, all the participants appeared relaxed, and comfortably cross-questioned and challenged each other.
There were four female groups and three male groups. Thus, major theme identification required one more female group than male group. In practice no theme raised by two female groups only has been omitted. The focus group discussions were exploratory.
What smoking means to adolescent Bangladeshi girls appears to be different to what it means to adolescent Bangladeshi boys. This difference appears to influence smoking uptake and arises primarily from perceived social norms and cultural values.
The reasons why participants continue to smoke are sometimes similar to the reasons why other participants decide to stop smoking or never smoke, e. A complex picture regarding participants' decisions and smoking is consequently presented.
Lloyd and Lucas, drawing on Beyth-Marom et al. Many of the reasons why Bangladeshi teenagers continue to smoke, stop smoking or never smoke are, however, similar to those identified in studies with largely white adolescents [e. Lloyd and Lucas, ]. The authors believe that adolescents' struggle to develop and drive towards autonomy underpins the reasons why they do and do not smoke, and the complex picture that emerges.
This struggle is influenced by three factors. The second focuses on the need to develop the capacity to reason and the consequent evaluation of behaviour in relation to self and others.
The third focuses on the need to develop the capacity to be able to live life in one's own context. The development of the third factor is hindered by the marginalization that adolescents experience which may be acute amongst Bangladeshis in this study because of their minority status, disadvantaged circumstances and, in the case of the females, their gender.
This study, therefore, highlights the need to tailor smoking prevention interventions to specific populations of Bangladeshi adolescents in order to promote effectiveness. Social norms approaches to adolescent smoking prevention provide adolescents with alternatives to smoking Bruvold, The study findings could inform the planning and development of such approaches which are culturally appropriate for inner city Bangladeshi adolescents.
Initiatives for Bangladeshi boys could focus on increasing the availability and range of options for shared enjoyable endeavour and socializing with a common purpose, which allow them to construct time and prevent them from getting bored. This study highlights the need for additional investigations which examine the meanings other adolescents associate with smoking and which determine whether the gender differences identified in this study are transferable to other adolescents such as other South Asian teenagers living in similar disadvantaged circumstances.
Major response themes pertaining to influences which promote non-smoking. We thank the study participants, the teachers and youth workers. We are grateful to Dave Rogers who facilitated the process, and Dr Rita Jordan for her helpful comments and continued support. Banwell, C. Drug and Alcohol Review , 12 , — Bauman, K. American Journal of Public Health , 84 , — Beyth-Marom, R.
Developmental Psychology , 29 , — Bosanquet, N. Health Policy Unit: Discussion Paper 4. Carden Publications, Chichester. Bruvold, W. American Journal of Public Health , 83 , — Charlton, A. More information. Supplementary notes. Other statistics on the topic. Tobacco Change in the proportion of daily smokers in France , by gender. Tobacco Cigarettes: annual average price of the most sold brand in France Tobacco Share of French aged 18 to 24 years old who are smokers Tobacco Hand-rolled tobacco: average price of a pack in France in euros.
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There are marked ethnic and gender variations in smoking prevalence in the UK. Stopping smoking is especially important in Pakistani and Bangladeshi groups because the incidence of heart disease, stroke and type 2 diabetes is higher than in other population groups [ 2 , 3 ], and stopping smoking would reduce the risk of these diseases by more than a third [ 4 , 5 ].
The UK has a national network of National Health Service NHS smoking cessation services offering interventions proven to be effective in facilitating smoking cessation [ 6 — 10 ]. At the time of planning the trial, South Asian groups i. There might be specific cultural beliefs that deter Bangladeshi and Pakistani smokers from using NHS cessation services.
Qualitative research has shown that Bangladeshi and Pakistani adults were well aware of the dangers of smoking and were motivated to quit, but tended to focus on using willpower and were uncertain about the value of support and cessation medications [ 13 ]. There is no recognised and implemented model that has been shown to challenge these types of beliefs about using the NHS cessation services.
A systematic review reported that interventions to increase service uptake and rates of cessation among disadvantaged groups have shown varying success [ 14 ]. One study found that proactively identifying smokers through primary care practice records and providing these smokers with brief advice and referral to a smoking cessation advisor increased contacts with the services and the number of quit attempts, but did not increase cessation rates [ 15 ].
Two studies included in the review [ 14 ] focused primarily on interventions designed to increase service uptake and cessation in minority ethnic groups [ 16 , 17 ]. One uncontrolled before-after study used social marketing, tailored to cultural beliefs, to highlight the dangers of smoking in Turkish and Kurdish communities in London [ 16 ].
The second study randomised African American communities in the US to a marketing campaign of adverts, posters and outreach aimed at increasing calls to a Cancer Information Service quit line or to control [ 17 ]. We undertook a pilot trial of an intervention designed to offer a culturally tailored, trained community smoking cessation worker model of care. A Cochrane review reported that community lay health workers have been effective in primary care, promoting the uptake of immunisation and for improving outcomes for selected infectious diseases in comparison with usual care [ 18 ].
Only one randomised controlled trial included in the review examined the use of lay workers in encouraging smokers to quit [ 19 ]. In this US study, 22 church communities were randomly allocated to either an intensive intervention involving the use of smoking cessation lay workers or distribution of self-help materials only. The study reported no difference in quit rates, but the intervention communities were more likely to intend to quit in the future.
Similarly, another recent review [ 20 ] that examined the impact of lifestyle advisors on health improvement identified four randomised controlled trials where lay advisors were used to promote smoking cessation [ 21 — 24 ].
Three of these studies found that lay advisor interventions improved quit rates compared to the control [ 22 — 24 ]. One study involved lay health workers delivering home-based smoking cessation programmes, tailored specifically to the cultural beliefs and practices of Latino smokers in the US [ 24 ]. One week abstinence rates were twice as high in the intervention group These include facilitators aiming to improve access to existing mainstream smoking cessation services and the development of parallel home-based specialist services.
Building on these wider insights, we developed and piloted a model of community SSS for Bangladeshi and Pakistani male smokers and their wider communities.
We focused on men because the prevalence of smoking in these ethnic groups is substantially higher than in women [ 1 ]. Also, the stigma of Pakistani and Bangladeshi women smoking [ 25 ] means that these women rarely present for treatment [ 12 ]. We describe here the quantitative outcomes and processes involved in this pilot cluster randomised controlled trial of trained community outreach workers. The aim was to examine whether the intervention led more Pakistani and Bangladeshi men to stop smoking with NHS support compared to standard care.
We also assessed whether the intervention had an impact on the type of treatments chosen, adherence to treatments, attendance at clinic appointments and patient satisfaction with the service. We in addition conducted a longitudinal qualitative study in parallel with the trial to explore the approach outreach workers took when recruiting service users and supporting smoking cessation, and to explore how their role and the intervention changed over time; the results from this qualitative work are reported in detail elsewhere [ 26 , 27 ].
A detailed trial protocol has been published [ 31 ]. It was designed to test the acceptability and feasibility of the intervention and the development of the intervention during the trial was part of the approach [ 26 ].
It was also designed to assess the feasibility and acceptability of the trial methods. It was not designed to provide definitive evidence of efficacy and hence we therefore did not undertake any sample size calculations.
We randomised natural communities to either standard behavioural support and medication available in NHS clinics internal control , or to the same service augmented by community-based outreach workers, aiming to encourage and support male Pakistani and Bangladeshi smokers to quit smoking intervention. We selected these areas to be as widely dispersed as possible, but they were still geographically close and hence it was possible that this would lead to contamination i.
Consequently, we measured the outcome variables in all other Pakistani and Bangladeshi men in other areas of HoB and BEN PCTs external control ; some of these areas were a reasonable distance from the intervention and internal control areas and were judged unlikely to experience contamination.
We used two different approaches to collect our outcome and process data. We obtained anonymised data on all Pakistani and Bangladeshi residents, aged 18 years or over in our intervention, control and external control areas that used an NHS SSS. These data, collected routinely by the NHS SSS, contained information on the service users' age, ethnicity, postcode, quit date and smoking status at four weeks after the quit date. The NHS SSS tried to contact all service users who were abstinent at four-weeks in our intervention, control and external control areas for verification of quit status at three-month and six-month follow-up.
We collected more detailed process data on service use patterns and on satisfaction with the service from a sample of clinics operating in the intervention, control and external control areas. These clinics were chosen because they had treated several Pakistani and Bangladeshi smokers prior to the study.
All participating service providers were given a pack containing a brief procedure guide, information sheets, consent forms, data collection forms and a method to contact the research team.
Pakistani and Bangladeshi smokers aged 18 years or over were asked to participate by their service provider during routine consultation. These data were not anonymised and hence service users gave their consent to give the data. Service providers recorded weekly attendance, choice of treatments and adherence where adherence was defined as good or less than good for each type of treatment.
At three-month follow-up, service users were contacted by NHS SSS to collect information on their experiences of using the service, which was recorded on a patient satisfaction questionnaire developed by the research team. Census lower layer super output areas LSOAs were used as the unit of allocation [ 32 ].
LSOAs are the smallest unit of census geography consisting of households on average. Contiguous LSOAs were aggregated into natural communities i. We created buffer zones around the trial areas to reduce the risk of contamination. The 16 areas were stratified, firstly by the proportion of Pakistani and Bangladeshi residents and secondly, by absolute population size into two further strata. The trial statistician used permuted blocks of four to randomise eight areas to intervention and eight to control.
Despite the stratification for size, the total resident population of the control areas was much larger than in the intervention areas. The managers of the NHS SSS were unhappy to work on the smaller target population; therefore, with the agreement of the Independent Trial Steering Committee, we swapped the intervention and control areas status prior to the intervention starting. Maps of the final areas and their allocation to the two trial arms are published in our trial protocol [ 31 ].
As socio-economic position is a strong predictor of smoking status, mean Index of Multiple Deprivation IMD scores were calculated for each area to rule out potential confounders. Scores are calculated using multiple indices of deprivation within seven domains: income, employment, health and disability, education skills and training, barriers to housing and services, living environment, and crime [ 33 ].
Four male, community based, stop smoking advisors SSAs , known henceforth as 'outreach workers', provided additional support to NHS SSS, which was otherwise similar to that provided in the control areas. Two outreach workers were of Bangladeshi origin and two of Pakistani origin. Between them, they spoke the main relevant languages i.
The outreach workers were paired into two teams of one Bangladeshi and one Pakistani outreach worker in each PCT. Two outreach workers had worked as SSAs prior to the study. Outreach workers had two weeks of training in delivering behavioural support and medication management for smoking cessation, general health promotion, communication skills, and the cultural specific norms of Pakistani and Bangladeshi smokers.
The training involved role-playing the activities in outreach in English and in minority languages. All outreach workers were assessed as competent based on these role-plays by the end of training. The training was delivered by accredited NHS trainers and the research team. The outreach workers and managers met fortnightly initially then monthly during which the diaries and experience of the outreach workers were reviewed and plans made.
The intervention was delivered in two phases, although this was unplanned at the outset. During the first phase, i. November to May , outreach workers concentrated on referring people to existing services that included pharmacies, drop-in clinics, and general practices.
They did this through producing culturally specific advertising e. In direct outreach, the workers set up a stand outside a supermarket, for example, offering to measure exhaled carbon monoxide CO , which naturally led to a conversation about smoking.
Also, outreach workers approached Pakistani and Bangladeshi men either on the street or in workplaces. They enquired about smoking status, and talked about quitting smoking. These discussions were conducted in English or other community languages. Their aim was to refer smokers to the SSS, but literature was left with those who accepted it, even if individuals were not ready to attempt to stop smoking.
Outreach workers kept a copy of referral records and checked on clinic attendance and re-referred if necessary. The management team set a target of 1, referrals to the services in the year of the intervention, but because the actual number of referrals fell far short of this and because many of those referred did not attend for treatment the approach changed.
The second phase ran for six months from June to November and concentrated on outreach workers combining more limited outreach with providing treatment for smokers directly, rather than always referring to NHS services.
The outreach centred on encouraging use of a clinic that the outreach workers provided in non-NHS venues, such as barbers' shops places of meeting for Pakistani and Bangladeshi men , mortgage brokers, taxi bases and bus depots.
Sometimes these clinics were held in the evenings to overcome the problems people working shifts had in attending clinics. The revised targets were for outreach workers to treat a minimum of 10 smokers and achieve five 4-week quitters per month. Further details on the development of the two phases and outreach strategies undertaken are described in our longitudinal qualitative evaluation [ 26 ].
Smokers living in control areas were offered NHS smoking cessation support as normal, which included advertising the availability of treatment through media campaigns. The two primary outcomes assessed in this pilot RCT were rates of uptake of services and abstinence proportions at four weeks, and three and six months defined according to the Russell standard i.
The uptake numerator was defined as the number of Pakistani and Bangladeshi men who set quit dates with the NHS during the intervention year that lived in the intervention and control areas.
The denominator was the estimated number of Bangladeshi and Pakistani smokers in the areas. As the resultant number is an estimate rather than a true denominator, we used a Poisson multilevel model with the log of the estimated number as an offset. The rates of use of the services were estimated having adjusted for the rates of use in those areas in the 12 months prior to the intervention by including the log of these rates as a covariate. The geographical areas randomised were included in the model as a random effect, thereby allowing for the clustering inherent in the design [ 36 ].
The quit proportion was defined as the proportion of people achieving four weeks, three months, or six months prolonged abstinence allowing a standard two week grace period, with a denominator of all those who attended the service and set a quit date.
Self-reporting at four weeks was verified by expired CO less than 10 parts per million [ 37 ].
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