Evaluation of tobacco dependence measures in South Asian smokeless tobacco users

Sudanese Toombak smokeless tobacco users harbour significantly altered long-term cortisol body production

The Sudanese, in particular its male population, are known to utilise a smokeless tobacco product (Toombak) which is placed in the oral cavity and can be replaced several times a day. Toombak has been shown to harm human health and is highly addictive. The effect on body cortisol response over a retrospective period in users of this product has not been previously explored. In addition, psycho-dependency scores of Toombak users have not been analysed. In this study, 37 male subjects, age 18-45 years were recruited, of which 18 were non-users of Toombak and 19 were Toombak users. One hair sample was collected from each user and non-user of Toombak. Each hair sample (n=37) was placed in a pre-prepared long piece of foil with two labels on either side marked: 'scalp-side' and 'distant-side'. Cortisol was extracted by mincing 10 mg of 'scalp-side' hair, not exceeding 3 cm, with methanol addition, incubation, and sonication. Cortisol was measured using the enzyme-linked immunosorbent assay kit (Enzo Life Sciences, UK). The amount of hair cortisol in the samples was determined using spectrophotometry at wavelength 405 nm measured in pg/ml and visualised with a four parametric logistic curve. Toombak users were further asked to complete the Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco questionnaire (FTND-ST) comprising of six questions. Scores of > 5 indicated a significant dependence, while a score of < 4 marked low to moderate dependence. The mean concentration of hair cortisol in Toombak users (9.7 pg/ml) was significantly lower (p=0.023) compared to non-users (19.4 pg/ml), with total concentrations ranging from 2.1 to 55.6 pg/ml. FTND-ST scores ranged from 4 to 9, with high levels of psycho-dependency (score > 5) and nicotine tolerance found in 85 % of Toombak users. Cortisol body release in Sudanese smokeless tobacco users was found to be significantly altered. While low cortisol levels do lead to anxiolytic effects, in the long-term, this can allow for increased susceptibility to low cortisol-associated diseases.

Psychometric properties of smokeless tobacco dependence measures: A COSMIN systematic review

BACKGROUND

A comprehensive assessment of the quality of the psychometric properties of smokeless tobacco (SLT) dependence measures is necessary to help researchers and health professionals decide on the most appropriate measure to use when assessing dependence and planning cessation treatment. The aim of this systematic review was to identify and critically appraise measures for assessing dependence on SLT products.

METHODS

The study team searched MEDLINE, CINAHL, PsycINFO, EMBASE and SCOPUS databases. We included English-language studies describing the development or psychometric properties of an SLT dependence measure. Two reviewers independently extracted data and appraised risk of bias using the rigorous Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

Sixteen studies assessing 16 unique measures were eligible for assessment. Eleven studies were conducted in the United States; two in Taiwan and one each in Sweden, Bangladesh, and Guam. Of the sixteen measures, none of the measures was rated as "A" (can be recommended for use) as per COSMIN standards primarily due to limitations in structural validity and internal consistency. Nine measures (FTND-ST, FTQ-ST-9, FTQ-ST-10, OSSTD, BQDS, BQDI, HONC, AUTOS and STDS) were rated as "B": having potential for assessing dependence, although further assessment of psychometric properties is needed. Four measures, MFTND-ST, TDS, GN-STBQ and SSTDS having high quality evidence for an insufficient measurement property were rated as "C" and were not supported for use as per COSMIN standards. The remaining three brief measures HSTI, ST-QFI and STDI (consisting of <3 items) were rated inconclusive due to the inability of assessment of structural validity (minimum 3 items required for factor analysis), which is a prerequisite for assessment of internal consistency per the recommendations by the COSMIN framework.

CONCLUSION

Further validation is required for the current tools that assess dependence on SLT products. Given the concerns related to the structural validity of these tools, a need may also exist to develop new measures for use by clinicians and researchers for assessing dependence on SLT products.

PROSPERO

CRD42018105878.

Development and psychometric evaluation of the Khaini Smokeless Tobacco Dependence Scale

INTRODUCTION

Khaini is a smokeless tobacco (SLT) product commonly used in the South-Asian region. It is the most common smokeless tobacco product used in India, having a prevalence of 11.2% and is used by 104.1 million adults. No scales exist to assess khaini dependence. Existing scales available to assess dependence on smokeless tobacco products are not ideal as these are adapted from cigarette dependence scales and developed for western populations. This study aimed to develop a khaini dependence scale and assess its reliability and validity.

METHODS

Recommended methods for scale development were followed for item development, scale development and scale evaluation. Scale development was guided by a theoretical framework, a review of existing scales and in-depth interviews with 21 khaini users recruited from a tertiary care hospital in Mumbai, India. The process involved the identification of domains for dependence and the development of an item pool. Cognitive interviews and pre-testing were conducted with 20 khaini users to assess content validity. A cross-sectional survey with 323 khaini users was conducted, and Exploratory Factor Analysis (EFA) was used to determine the factor structure of the draft scale. The content validity, criterion validity (by cross-referencing with the cotinine level of users), convergent validity and internal consistency of the new scale were assessed.

RESULTS

The final version of the Khaini SLT Dependence Scale (KSLTDS) had 20 items. EFA indicated an acceptable goodness of fit for a three-factor structure with physical, psychological and sociocultural-behavioral sub-scales. It showed evidence of acceptable criterion validity with cotinine (ρ=0.43, p=0.0002), convergent validity with FTND-ST (ρ=0.51, p<0.0001) and frequency of khaini use (ρ=0.38, p<0.0001). The sub-scales (α=0.87-0.90) showed acceptable internal consistency.

CONCLUSIONS

The psychometric evaluation of the KSLTDS showed preliminary validity and reliability for assessing dependence on khaini, and therefore, it is appropriate for clinical and research purposes. Re-validation studies are required with various khaini user populations.

Predictors of Cigarette Smoking, Smokeless Tobacco Consumption, and Use of both forms in Adolescents in South Asia: A Secondary Analysis of the Global Youth Tobacco Surveys

INTRODUCTION

Tobacco uptake in adolescents is associated with a range of predictors. We examined the predictors of cigarette smoking, smokeless tobacco (ST) consumption, and use of both ST and cigarettes among adolescents in four South Asian countries.

METHODS

We analyzed the Global Youth Tobacco Surveys (GYTS) data for Bangladesh (2013), India (2009), Pakistan (2013), and Sri Lanka (2015), using multinomial regression to examine associations between several predictors and tobacco use.

RESULTS

Data from 23 681 adolescents were analyzed. Overall, 82.8% of the study population were between 13 and 15 years and 52.7% were girls, 2% were cigarette smokers, 6.5% were ST users, and 1.1% used both ST and cigarettes, in the past 30 days. Exposure to smoking in public places was associated with past 30-day smoking (relative risk ratio [RRR] 5.59, 95% confidence intervals [CI] 4.28-7.28), ST use (RRR 2.07, 95% CI 1.84-2.32), and use of both ST and cigarettes (RRR 11.42, 95% CI 7.44-17.54). Exposure to tobacco use in electronic media and being offered free tobacco products were associated with all forms of tobacco use. Shopkeepers' refusal to sell cigarettes protected adolescents from smoking (RRR 0.47, 95% CI 0.36-0.63) and ST use (RRR 0.65, 95% CI 0.45-0.95). However, exposure to antitobacco mass media messages was not protective for any form of tobacco use. Adolescents taught at school about harmful effects of tobacco were less likely to use ST; no evidence of this association was observed for smoking.

CONCLUSION

The associations between tobacco use and protobacco factors were strong, but the associations with antitobacco factors lacked strength and consistency in this study population.

IMPLICATIONS

The predictors of adolescents using different tobacco products, crucial to inform and evaluate tobacco control efforts, are poorly understood. We investigated the associations between several environmental-level factors and cigarette smoking, ST consumption, and use of both forms among adolescents, whereas most of the previous studies focused on individual-level factors. Our study found strong associations between tobacco use and protobacco factors and lack of strength and consistency in associations between antitobacco factors and tobacco use in the study population. Our results indicate that the current tobacco control policies need strengthening to curb the tobacco epidemic in these countries.

Re-visiting serum cotinine concentrations among various types of smokers including cigarette only smokers: some new, previously unreported results

Data (N = 11614) from National Health and Nutrition Examination Survey (NHANES) for 1999-2016 for US adults aged ≥ 20 years were analyzed by fitting regression models to estimate unadjusted and adjusted geometric means (AGM) for several different groups of smokers. Serum cotinine level ≥ 3.3 ng/mL was used to distinguish smokers from nonsmokers. AGMs for cigarette only, cigar only, dual cigarette/cigar, e-cigarette or dual e-cigarette/cigarette, and smokeless tobacco only smokers were estimated to be 152.5, 65.1, 92.5, 146.3, and 272.0 ng/mL, respectively. Males were found to have higher cotinine levels than females for dual cigarette and cigar smokers, but the reverse was observed for smokeless tobacco users. Non-Hispanic blacks had higher AGMs than non-Hispanic whites for cigarette only smokers, but the reverse was observed for dual cigarette and cigar smokers. For the first time, serum cotinine estimates for those self-reported nonsmokers who were classified to be smokers (29.4 ng/mL) and those smokers for whom self-reported data for use of tobacco products were missing were also estimated (113.8 ng/mL).