‘A Taste of Tradition’ Guardian Society Article 2003

Taste of tradition

For Asian men, smoking is second nature and a sign of belonging – but some areas are more committed than others in providing help for them to quit. Tina Bexson reports

Wednesday July 30, 2003
The Guardian

Rufon Uddin is trying to give up smoking – and 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 tough also because smoking is very much part of being a Bangladeshi man. It is 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,” Uddin says. “It’s also often the only real time when you can smoke properly because once our people get married, we won’t 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 never to smoke in front of elders. “It’s a respect thing in Bangladeshi society,” Uddin explains. “I don’t smoke in front of my parents, even though my father smokes, and they know I smoke. And if I pass a group of lads in their 20s 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, and with their parents even buying cigarettes for them.”

He can smoke at work, however. “Ninety-five per cent 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 Uddin recognises that giving up is ultimately down to the individual, he would like to join a local smoking cessation programme run by Newcastle primary care trust (PCT) to give him a head start. But he feels it is geared towards the white population and fails to acknowledge the different cultural concerns and problems facing smokers from his culture.

This may be considered surprising because, according to a survey by the Department of Health (DoH), smoking is much more common among Bangladeshi men (44%) than among white men (27%). For Bangladeshi men aged 50-74, the rate is as high as 56%. There are serious health consequences. Cardiovascular disease (angina, heart attack, stroke, high blood pressure and diabetes) is 60%-70% higher among Bangladeshi and Pakistani men than among the general population.

Research by the school of population and health sciences at the University of Newcastle upon Tyne, published recently in the British Medical Journal (BMJ), suggests there is a drastic need for culturally-sensitive smoking cessation interventions in Newcastle. Comparable places, such as Bradford, Birmingham and Tower Hamlets in east London, are already running successful interventions, such as campaigns that take place during Ramadam. And since the DoH launched an NHS Asian tobacco education campaign in August 2001, local smoking cessation services run by PCTs are growing in other south Asian communities throughout Britain. So why not in Newcastle?

Judy Loggie, manager of Newcastle and North Tyneside’s smoking cessation service (one of the services offered by Newcastle PCT), who has only recently taken up her post, admits that more should be done. “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 Newcastle University, conducted the BMJ research. He was struck by “how many white, middle-class professionals within healthcare 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”.

White adds: “But it’s fundamentally wrong. For example, it doesn’t make sense that what should work for young male Bangladeshis who work antisocial hours in the restaurant trade should work for elders sitting at home all day. They are almost different cultural groups.”

Since it is almost expected for the elders to smoke, Shazan Uddin, a bilingual community health worker and cardiac rehabilitation 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,” Shazan Uddin says. Targeting those who are not suffering any ill-health effects, and who do not want to give up, is very difficult. “They say they’ve smoked all their life and don’t think it’s doing them any harm; it helps them relax.”

The position is not helped by acute lack of awareness of the serious health risks posed by smoking. Health department figures indicate that only 27% of Pakistanis and Bangladeshis associate smoking with heart disease. Religion has little influence because, despite tobacco being seen as “Haram” (immoral or unclean), it is not specifically banned by the Islamic faith, as is alcohol. Nor do women 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 Uddin.

There has been little information available in Bengali on the damage smoking causes and on how to give up, Shazan Uddin maintains. But leaflets are anyway of limited use, he argues, and any culturally-sensitive smoking cessation programme would have to include structured group sessions.

Jamal Sarwar, 35, was one of the Bangladeshi advisers working for the PCT. Now he works as a community interpreter during the day and in an Indian restaurant in the evening. He is himself a light smoker. “It is absolutely necessary we have a proper smoking cessation programme in place,” says Sarwar. “When I was working as a smoking cessation adviser, we found that we needed a central place where clients could go and see a doctor and where they could get advice, nicotine replacement therapy, counselling and join a group. But we did not have that.”

White points out that there is the possibility of a tailored programme being seen as intrusive and patronising, “with people preaching to the Asian community”. However, he adds: “On the other hand, there are many people in the community who do want to give up.”

Sarwar agrees. “They would welcome a Bangladeshi smoking cessation programme,” he says. “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 Uddin would want the adviser to understand the pressures of working in an Indian takeaway or restaurant and to know what goes on in his community. “A person from a different culture wouldn’t,” he says. “But a Bangladeshi man would.”

Custom-led cure

The Tower Hamlets primary care trust in east London funds a smoking cessation project serving the Bangladeshi community. It uses bilingual male and female advisers who are aware of the socio-cultural context of tobacco use and the impact this has on the prospects of cessation.

Although smoking is acceptable among Bangladeshi men, among women it is regarded as a taboo and disrespectful. Only 4% of the women smoke, but they do chew tobacco in paan – a mixture of spices and nuts wrapped in a leaf. It is especially popular among those over 55, of whom an estimated 56% chew.

Chewing tobacco is just as harmful as smoking, contributing to 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 adviser Shamsia Begum. So our message is, ‘Enjoy your paan, but leave out the tobacco.’”

Other partners in the project are Queen Mary University of London and a community organisation, Social Action for Health. Ray Croucher, professor of community oral health at Queen Mary and the project’s joint manager, says: “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.”

Once clients have entered the programme, they receive one-to-one counselling, nicotine replacement therapy and weekly advice. “Then we continue to make contact in the community or provide domiciliary visits,” says Croucher. “Our success rate is around 62%, compared to the national average of 48%-50%.” The approach is “holistic”, he adds, sometimes offering guidance on housing and benefits issues.

· The project’s 24-hour advice line is on 020-7377 8481.