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Table 2 Illustrative Quotes

From: Behaviour change intervention for smokeless tobacco cessation: its development, feasibility and fidelity testing in Pakistan and in the UK

ID Quote
BRA004/a A: I, I wouldn’t say I actually believe them, but my mother-in-law did say if you eat paan with tobacco it strengthens your teeth, cos she, her teeth are fine, she got no cavities, they’ve stained a lot, but my mum; when I was small I used to have travel sickness so she used to say, you know, just the beetle nut on its own, cos it dries out your mouth, cos when you feel sick, you know that tangy, liquidy thing you get in your mouth?
Q: Yeah.
A: So when you take that it dries out your mouth so you don’t be sick; and I did used to take it, I can remember, yeah, so.
Q: Yeah. Is that a common belief amongst Bengali communities?
A: Yeah, it is. But they said, you know, if you have, my mother-in-law says if you have, you know, tooth aches or pains in your tooth or gum to chew with tobacco. She’s told me, she, cos I’m, I have very weak gums and she tells me “Oh, you know, the raw tobacco leaf” she says “oh eat with that”. I said “No mum, I can’t eat that cos it’s really, really strong”. Cos with this, it’s not just tobacco, there’s a lot of other things in it like that, so.
Female Client, UK
APK001/a Like, yeah, to grade their readiness. And, OK, so, OK, and with card number one, I don’t think this really represented the type of tobacco they used very well; cos I like, I showed them this card and I was like “Which one do you use?” And they would say “Oh we use gutka, we use naswar”. And then I’d point to gutka in the picture, I’d point to naswar, I’d say “Oh this is naswar and this is gutka”. And they’re like “No, but this isn’t the type we use” and everything. So maybe I, I think maybe this was more oriented towards the England wing of the study where like this is what it looks like over there, whereas over here it doesn’t really look like that… it’s not very all, it’s not all that commercial, like everyone makes their own at home and everything, so it’s not very packaged, very professionally.
Advisor, Pakistan
BRA004/a Yeah, this is, just telling you what’s in it, yeah, that I think they will really take notice of that card, and you know like if you have actual pictures of actual things that can happen; cos in one of the tins that come from Bangladesh recently it’s got the picture, her grandfather gave to her father, it’s literally a man with a picture of cancer in his mouth with a big tumour. Every time I pick it up I just put it down; and she says “Chuck it away, chuck it away”. Cos you know if, if you have pictures like that it literally does make you not want to take that.
Female Client, UK
APK001/b Yes, that was important to a certain extent, where I’d point out that “Oh, you know, once you stop smoking your teeth will look better, you will feel better”. And that one was a factor in certain patients where they, because we’re a population that’s obsessed with the tone of our skin, so they were just obsessed that, oh yeah, we will, like when I wasn’t using tobacco I used to be fairer so I’m gonna become fairer now and my teeth are gonna look better and everything; and then when some of them did stop and they came back for their third session their teeth did look better, they were very proud, proud of that fact, oh look at our teeth, they look so nice and everything. And then there was actually one client that even went and got his cleaned out and everything afterwards; so that was, yes.
Advisor, Pakistan
APK001/c Yes and no, because I feel like the main driving force behind the fact that most of the patients were motivated to quit was because we were motivating them. Like most of the patients were motivated because we talked about, oh OK, so tell me why you wanna quit? So most of them wouldn’t bring up the fact that it causes mouth cancer, they’d be like, oh we, because we’re spending too much money on this and we’re poor and we wanna pay our children’s school fees and everything. So that was why this was so effective, because they weren’t leaving it because they were scared, because I feel like that’s scare factor, and like maybe even as a doctor, like you can only scare patients so much until that becomes redundant and just becomes, OK fine, so maybe this just might happen, so what, you know?
Advisor, Pakistan
LEI002/a For me, I guess you, you know, you’ve got the health one there, that, that’s probably the main important, maybe emphasise a bit more on that and, and what, what are the harmful effects. For example, one of the things that made me go to the dentist is because my teeth discoloured and my gums started to drop as well. So after a lot of use, he’s told me that chances are the gums won’t grow again, but he’s certainly got’em all clean, and thank goodness, I’m grateful that I didn’t have any illness, cos I thought I had an illness on the back of that.
Male Client, UK
ATH002/a This [card10] is a good one, I think, yeah, sometimes when you talk to them you can’t always explain it, but these, these pictures are quite self-explanatory, like people can look at it and understand what other things they can do to, that will help them give up here… These, these are very good ones, these are very good ones. So maybe you can, for women you can think of like, you know, for Muslim or reading Koran or, or like if they’re a bit younger then maybe going to swimming; because they do love swimming, a lot of people love going to swimming; so maybe we can put that.
Advisor, UK
APK001/d Maybe they needed a better idea of what a reward meant, like I felt like I had to pump them a little; like “OK, a present for yourself, like you can get new clothes.” “Oh yeah, we’ll get some.” But then they were just like agreeing with whatever I was saying, and then when I asked them later on they didn’t, they didn’t even understand what I, what I was trying to ask them.
Advisor, Pakistan
ALEE001/a For some people it will be. I think maybe for a lot of Bangladeshi women it’s, not necessarily, cos I, I think they find it hard to know what they would reward themselves with, so, cos they wouldn’t actually go out and buy loads of clothes or; we did talk about maybe having a massage or something like that, I think. I think I suggested possibly because of the, she’s not gonna have the lip staining, maybe buying a lipstick (laughs) or something. But I, I think she found it really difficult to think of a reward; so we didn’t really discuss that, I don’t think.
Advisor, UK
ALEI001/a I think just to give it, them just a couple of weeks; abrupt is usually better in a, in some ways, because there’ll never be a right time or a date for them to stop, but I think just to give them just those two weeks, just to, for them to think about it and absorb everything what we’ve talked about, I think that will give you a result instead of just saying this is it and people don’t really relate to that
Advisor, UK
ATH002/b Only behaviour support might not work because none of us are trained counsellors; even the trained counsellors would find it difficult, with the counselling, to change somebody’s behaviour, and within two, four weeks or eight weeks would not be possible. So I think you do need the, the NRT products, they, they play an important role and a big part, and people think oh it’s like medicine, that might help me; not, it’s not true for everyone but for eighty percent, eighty to ninety percent of our client they go for the NRT support and it does help them and, or sometimes it could be psychological, you know, they think that, OK.
Advisor, UK
ATH001/a I think a lot of clients they tried to give up through will-power and they haven’t succeeded. Obviously because of my previous experience, NRT has been effective and quite a lot of clients they want some form of product to help them stop chewing tobacco because otherwise how the perception is, “if it’s just behavioural support I can just get my friend to support me, I don’t need an advisor”, so I think they just want a combination of maybe NRT and behavioural support.
Advisor, UK
ALEI001/b I think the cards itself are too simple and sometimes you can probably do it in verbal with the client and you don’t really need to show them a picture, I feel, but sometimes it does jog a memory; some things they would say that I’ve, I’ve experienced, they would say I probably haven’t even noticed…. Optional I would say; if it works for some people, fine, but I think you, it shouldn’t be a necessary that you need to use them, yeah.
Advisor, UK
ATH001/b Um I would say maybe a bit of both but I think a lot of clients they’re short for time, so they’re not able to spend that much time with you and, yeah I think the cut down definitely on the resources, make it shorter and maybe, I don’t know, maybe group things together in a nutshell.
Advisor, UK
ALEI001/c I think it was just off-putting using the, the, this resource with the card, for me personally, I think it was too confusing. I think if you got the assessment form done it would be much easier…. For me it isn’t working, it was too complicated. I couldn’t give, I felt I couldn’t give the, the client all that attention that I would normally give. As a smoker, let’s say, we would look at them and while they’re talking we’ll be going through the form and remembering what they’ve said so you’re not duplicating questions as well, so you’re just writing, everything’s on the form, any additional you can write, you know, down. So, you know, it’s like a memory isn’t it then? Maybe we can have the handbook just for ourselves and, but assessment form is really essential.
Advisor, UK
APK001/e So I think that way the resource was great. The only issue that I think the participants had and I think with, and maybe I has as well, with the resources, when we have to ask them to grade, like for example, like oh tell me from 0 to 10 how ready do you think you are to stop smoking this and everything; so the thing was they weren’t quite understanding this grade skill, and I think that’s just an issue with this resource; I think even as a doctor, when we ask patients about like to grade their pain on a pain scale, they face the same issue where they, they automatically just pick 10 or they pick 0, there’s no middle ground in the middle, yes… So I had this issue with one of the participants, the one, he didn’t actually commit to quit, so, all right, he didn’t actually quit, so, but then I was like “Oh how ready are you to stop using tobacco and everything?” And he said “10, 10, 10”. And then at the end of it I was like “OK, so are you ready to stop now?” And he was like “Oh no, I’m not ready to stop”. (Q laughs) …maybe if we had like a reference for each number maybe he would have understood more, maybe he would have told me, oh 4 or 3, 5 or something like that, so yeah.
Advisor, Pakistan
LEI002/b As I say, it’s a first time that I’ve come into something like this; so it’s been helpful that I can actually admit to the fact that I am addicted and I need to do something about it and, as I said, I’m, I’m reliant on, I’m gonna rely on the things that she’s offering me, that it’ll help me in my journey.
Male, Client, UK
APK001/f Yeah the majority of them had quit for like a few days, right, so when they came at this point in time they were experiencing very, very severe withdrawal symptoms, like I mean I’ve seen people in withdrawal but those are very similar. So there is this one theory that I have, and like it’s, this story is based on the information I’ve got from the patients, they say that the tobacco they have, or whatever form they have it in, it’s just not tobacco, there are several other illicit substances involved. So one of the men actually claimed that there was, what he says was (genus?) in it, which I, I think that’s heroin or cocaine in it or something like that, but this is just one person saying this to me. So that was an issue at this point because some of the women who quit, they were just visibly dizzy, like they were just sitting there and they were like this, like I could tell (Q laughs) that they were out of it really, so yeah, like one was just like just not even there, like she was barely comprehending what I was saying, you know, in the end like she actually, we had to actually take a break in the middle of it. “OK, how about you take five and everything, go and take a glass of water.” But they were visibly, visibly, visibly out of it; so they were experiencing very severe withdrawals… Maybe this can be like a potential like confounding factor where we’re gonna have a lot people coming here and who don’t quit. Because if there are other illicit substances involved, because our resource is only for tobacco, you know, and like when it comes to like whatever illicit substance is there like, you know, even if it’s like cocaine, heroin, marijuana like you need other resources there, you know, like maybe you have to give them medication or like they need to go to hospital or something like, but by the end of it, four weeks later it was not a factor I think, like, yeah.
Advisor, Pakistan