Title: Designing Religiously Informed and Culturally Acceptable Tobacco Cessation Interventions for UK-Based Muslims

Abstract Introduction Globally, tobacco use rates in Muslim communities, particularly among men, are significantly higher than in non-Muslim communities. In the UK, there are also low rates of help seeking among British Muslims who use tobacco. Ramadan could be a “window of opportunity” to support tobacco use behavior change but we lack the voice of British Muslim communities on culturally tailored cessation support. We undertook a public and patient involvement and engagement (PPIE) project to gain views from representatives of these communities. Methods Discussions with fifteen PPIE representatives from, or who worked with, a variety of British Muslim communities identified through gatekeepers, social media and snowballing approaches. Key points and views from PPIE discussions were summarized into broad themes. Results Opportunities and challenges with culturally adapting tobacco cessation support to Ramadan were raised. “Light touch” positive religious messaging connected to tobacco cessation was recommended, and over-emphasizing religion in messaging content to be avoided. Quitting during Ramadan was felt challenging due to fasting, precluding the use of nicotine replacement products or medication, and reinforcing tobacco use as part of fast-breaking routines. Instead, PPIE representatives suggested quitting in advance of Ramadan or promoting cessation afterwards by capitalizing on tobacco reduction achieved during Ramadan. There was support for digital cessation approaches, but it was felt many in their communities would prefer traditional approaches, including interpersonal support and messaging through influential community members. Conclusions “Light touch” culturally tailored tobacco cessation support before or after Ramadan was felt more promising than supporting cessation initiation during Ramadan. Implications Members of British Muslim communities identified challenges with using Ramadan as a “window of opportunity” for tobacco behavior change and favored quitting ahead of time for Ramadan or capitalizing on tobacco behavior change achieved during Ramadan to promote a quit attempt afterwards. Taking a “light touch” approach with religiously tailored messaging could help engage Muslim people who smoke in cessation support. However, avoiding any strong or negatively framed tobacco-related messages linked to religious phrases or imagery is important. This work reinforces the importance of engaging with communities when considering culturally adapting interventions to prevent misdirected adaptions.