Tobacco use is the single most important preventable cause of mortality and morbidity in developed countries. However, what is less widely appreciated is that as the overall prevalence of smoking has declined, tobacco use has become an increasingly important driver of health inequalities. For example, the prevalence of smoking in the United Kingdom has declined to around 20%, from a peak of over 50% in the 1950s. However, this masks the fact that most of this decline has occurred in higher income groups, with the prevalence of smoking in lower income groups still close to 40% (ASH, 2013).

Ethnic minority populations are disproportionately affected by chronic diseases, including those caused by smoking (ASH, 2011). For example, in the United States African-Americans have a significantly higher smoking-attributable mortality, and double the potential life years lost, compared with European-Americans. This may be in part due to lower rates of smoking cessation and poorer response to smoking cessation interventions, among ethnic minority groups. In general, different ethnic groups show different patterns of smoking, smoking cessation and treatment response.

Methods

A recent review (Liu et al, 2013) evaluated the studies of smoking cessation programmes adapted to account for specific patterns of smoking, smoking cessation and treatment response in ethnic minority populations (including African-, Chinese- and South Asian-origin populations) residing in Western countries (e.g., the United States, the United Kingdom) where they represent a minority population. The review focused on evidence of the acceptability and effectiveness of these programmes, and the approaches used for adaptation.

Results

In total, 28 studies described in 40 papers were included, all of which were based in the United States. In the majority of cases (23 studies) the interventions were adapted for African-Americans. Most (19 studies) were randomized or controlled clinical trials, and the majority of the remainder (7 studies) used other designs such as cohort or pre-/post- experimental design. The remaining 2 studies were observational. Quality was assessed as strong for 10 studies, moderate for 11 studies and weak or not applicable for the remaining 7 studies.

• A total of 6 studies analysed the acceptability of the adapted interventions and found that these were more acceptable to the target population
• Of the 28 studies, 13 were effective in achieving improved outcomes related to smoking cessation, such as increased number of quit attempts, improved cessation rates, reduction in number of cigarettes smoked and so on
• A number of different adaptations were used in these interventions, including developing materials specifically for the target population, and using materials that reflected the population’s average levels of literacy

Conclusions

This study provides some evidence that adapting smoking cessation interventions to meet the needs of ethnic minority populations may be valuable, and is achievable. The nature of the adaptations can vary, from simply using pictures that reflect the ethnic population targeted, through to developing materials that capture the population’s cultural values. Clearly some approaches will entail more effort than others, but anything which improves the uptake and success of smoking cessation interventions in ethnic minority groups will be valuable.

Limitations

However, there are some limitations to the conclusions that can be drawn from this literature, as the authors note.

• Most importantly, all of the studies were conducted in the United States, and the vast majority on African-Americans. This considerably limits the conclusions we can draw from this review, since we cannot be certain the results will generalise to other populations (although there is also no particular reason to think that they would not generalise).
• Another limitation is that there is no conclusive evidence that adapted interventions are more effective in, for example, promoting cessation. The lack of effectiveness in over half of the studies could be due to a number of factors, such as insufficient intensity of intervention or follow-up support.
• However, it may also be that we simply don’t yet know what dimensions materials should be adapted on, or how adapted materials may be perceived by certain sub-groups (those that identify equally with two cultures, for example). It’s an over-used phrase, but in this case more research really is needed.

Summary

Ultimately, almost any intervention that improves smoking cessation rates, even marginally, is likely to be cost-effective (Stapleton, 2001) because of the enormous health burden associated with smoking. It’s therefore worth considering whether tailored materials should be offered even in the absence of a clear evidence base – in other words, whether we should offer what has been described as a “culturally-competent healthcare system” (Anderson et al, 2003). In an era where materials are often produced in multiple languages to cater for ethnic minority groups (the NHS already offers translator and interpreter services, for example) it seems like a small additional step to tailor these further by including appropriate imagery and, where possible, matching these to different cultural values.

Links

Liu, J.J.,Wabnitz, C., Davidson, E., Bhopal,R.S., White, M., Johnson, M.R.D., Netto, G. & Sheikh, A. (2013). Smoking cessation interventions for ethnic minority groups – a systematic review of adapted interventions. Preventive Medicine, 57, 765-775. doi: 10.1016/j.ypmed.2013.09.014 [PubMed abstract]

ASH. Smoking statistics: who smokes and how much? (PDF) Action on Smoking and Health fact sheet, Oct 2013.

ASH. Tobacco and ethnic minorities (PDF) ASH fact sheet, Sep 2011.

Stapleton J. Cost effectiveness of NHS smoking cessation services (PDF). Sep 2001.

Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J; Task Force on Community Preventive Services. Culturally competent healthcare systems. A systematic review. Am J Prev Med. 2003 Apr;24(3 Suppl):68-79. [PubMed abstract]