The global impact of tobacco control policies on smokeless tobacco use: a systematic review

BACKGROUND

Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use.

METHODS

In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946).

FINDINGS

14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%).

INTERPRETATION

Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use.

FUNDING

UK National Institute for Health Research.

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy

BACKGROUND

In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST.

METHODS

We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain.

RESULTS

We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations.

CONCLUSION

ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

Concordance of Advertised Cigarette Prices with Purchase Receipts in the United States

OBJECTIVES

Researchers and regulators study the advertised price of tobacco products to evaluate compliance with minimum price policies, tax increases, and geodemographic marketing. However, few studies report reliability of advertised price and none address its concordance with receipt price.

METHODS

In a sample of US tobacco retailers (N=1972), data collectors purchased the leading brand of non-menthol or menthol cigarettes, recorded advertised prices, whether sales tax was included and price was discounted. Intraclass correlation coefficients (ICCs) were computed for the same measures by different observers (reliability), and for receipt and advertised pack price (validity). Discrepancy between receipt and advertised price was modeled as a function of store type and presence of a discount.

RESULTS

Advertised price was assessed reliably (ICCs = 0.74 to 0.87) and concordance with receipt price was near perfect (ICCs = 0.96 to 1.00). Prices were identical in 77.7% of stores for Marlboro and 78.1% for Newport. Differences between receipt and advertised price were related to store type and presence of a discount for Marlboro, but not for Newport.

CONCLUSIONS

Findings validate a common measure of cigarette price in research on minimum price compliance, effects of tax increase and industry marketing.

Surveillance of Tobacco Use Among South Asians in the US: Are We Underestimating Prevalence?

This study employed a randomized split sample survey to assess the accuracy of standard tobacco surveillance measures among South Asians living in the US. 219 South Asian adults completed a web-based survey of "standard" tobacco use questions, as they appear in national surveillance surveys, and half were randomly assigned to also receive questions about South Asian tobacco products. Prevalence of tobacco use was compared by experimental condition, assessed by only the standard questions for the control group (N = 116) and by both standard and South Asian questions for the experimental group (N = 103). Among the experimental group, sensitivity and negative predictive value (NPV) of the standard use definitions were calculated, considering the inclusive definitions as the "gold standard." Prevalence of any tobacco product use was higher among the experimental group, as was prevalence of smokeless tobacco (SLT) use, relative to the control group (34.7 vs. 17.2 % and 21.2 vs. 4.3 %, respectively). 70.6 and 33.3 % of true tobacco users (any product) and SLT users were correctly classified by the respective standard product questions. A majority of gutka, paan with tobacco, and supari with tobacco users (69, 86, and 75 %, respectively) did not otherwise endorse the standard SLT questions. Current tobacco surveillance measures may underestimate the use of tobacco in the South Asian population residing in the US. These results indicate that careful consideration must be given to how tobacco-related questions are presented to minority populations.

Prevalence, pattern and sociodemographic differentials in smokeless tobacco consumption in Bangladesh: evidence from a population-based cross-sectional study in Chakaria

BACKGROUND

The health hazards associated with the use of smokeless tobacco (SLT) are similar to those of smoking. However, unlike smoking, limited initiatives have been taken to control the use of SLT, despite its widespread use in South and Southeast Asian countries including Bangladesh. It is therefore important to examine the prevalence of SLT use and its social determinants for designing appropriate strategies and programmes to control its use.

OBJECTIVE

To investigate the use of SLT in terms of prevalence, pattern and sociodemographic differentials in a rural area of Bangladesh.

DESIGN

Population-based cross-sectional household survey.

SETTING AND PARTICIPANTS

A total of 6178 individuals aged ≥13 years from 1753 households under the Chakaria HDSS area were interviewed during October-November 2011.

METHODS

The current use of SLT, namely sadapatha (dried tobacco leaves) and zarda (industrially processed leaves), was used as the outcome variable. The crude and net associations between the sociodemographic characteristics of respondents and the outcome variables were examined using cross-tabular and multivariable logistic regression analysis, respectively.

RESULTS

23% of the total respondents (men: 27.0%, women: 19.3%) used any form of SLT. Of the respondents, 10.4% used only sadapatha,13.6% used only zarda and 2.2% used both. SLT use was significantly higher among men, older people, illiterate, ever married, day labourers and relatively poorer respondents. The odds of being a sadapatha user were 3.5-fold greater for women than for men and the odds of being a zarda user were 3.6-fold greater for men than for women.

CONCLUSIONS

The prevalence of SLT use was high in the study area and was higher among socioeconomically disadvantaged groups. The limitation of the existing regulatory measures for controlling the use of non-industrial SLT products should be understood and discussion for developing new strategies should be a priority.

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

BACKGROUND

People of South Asian-origin are responsible for more than three-quarters of all the smokeless tobacco (SLT) consumption worldwide; yet there is little evidence on the effect of SLT cessation interventions in this population. South Asians use highly addictive and hazardous SLT products that have a strong socio-cultural dimension. We designed a bespoke behaviour change intervention (BCI) to support South Asians in quitting SLT and then evaluated its feasibility in Pakistan and in the UK.

METHODS

We conducted two literature reviews to identify determinants of SLT use among South Asians and behaviour change techniques (BCTs) likely to modify these, respectively. Iterative consensus development workshops helped in selecting potent BCTs for BCI and designing activities and materials to deliver these. We piloted the BCI in 32 SLT users. All BCI sessions were audiotaped and analysed for adherence to intervention content and the quality of interaction (fidelity index). In-depth interviews with16 participants and five advisors assessed acceptability and feasibility of delivering the BCI, respectively. Quit success was assessed at 6 months by saliva/urine cotinine.

RESULTS

The BCI included 23 activities and an interactive pictorial resource that supported these. Activities included raising awareness of the harms of SLT use and benefits of quitting, boosting clients' motivation and self-efficacy, and developing strategies to manage their triggers, withdrawal symptoms, and relapse should that occur. Betel quid and Guthka were the common forms of SLT used. Pakistani clients were more SLT dependent than those in the UK. Out of 32, four participants had undetectable cotinine at 6 months. Fidelity scores for each site varied between 11.2 and 42.6 for adherence to content - maximum score achievable 44; and between 1.4 and 14 for the quality of interaction - maximum score achievable was 14. Interviews with advisors highlighted the need for additional training on BCTs, integrating nicotine replacement and reducing duration of the pre-quit session. Clients were receptive to health messages but most reported SLT reduction rather than complete cessation.

CONCLUSION

We developed a theory-based BCI that was also acceptable and feasible to deliver with moderate fidelity scores. It now needs to be evaluated in an effectiveness trial.

Before the ban--an exploratory study of a local khat market in East London, U.K

BACKGROUND

Khat is a green leaf with amphetamine-like effects. It is primarily used among people in Africa, the Middle East and in the diaspora communities from these countries. Prior to the prohibition of khat in the UK on 24 June 2014, there was almost no information available on key aspects of the local khat market.

METHODS

A cross-sectional study was conducted in 2012 using snowball sampling, Privileged Access Interviewing and area mapping in order to identify khat sale establishments. Data was collected via face-to-face interviews using mixed methods for data collection. This included information about the establishments selling khat, khat pricing and its use among different ethnic minority groups, in addition to the potential sale of khat to children and risk assessment (e.g., use of pesticides on khat).

RESULTS

Five out of seven sellers identified agreed to participate. Sellers described their khat sale establishments as 'community centres' which included, for example, a restaurant basement. The sellers' history of selling khat ranged between 1-15 years and khat's sale took place between 2pm-10pm. Miraa (e.g., Lara) from Kenya was the most popularly used khat variety, sold in pre-wrapped bundles of approximately 250 g costing £3 each and delivered four days a week. Harari (e.g., Owdi) from Ethiopia was sold in 200 g, 400 g and 1 kg bundles, priced between £5 and £20 and delivered two days a week. The primary benefit of khat use was reported to be social interaction. The customers were predominantly adult males of Somali origin. Most sellers claimed a self-imposed ban on sales to children under 18 years old. Khat bundles had no labelling describing variety or weight and sellers had no knowledge of the use of pesticides on khat and did not advertise the risks associated with khat use.

CONCLUSIONS

Khat selling establishments were businesses that did not adhere to trade standards regulations (e.g., labelling khat bundles). They claimed to provide a community service (facilitating social interaction) to their predominately Somali customers. Without a better understanding of the dynamics of the khat market there is a risk that both health and social needs of the vulnerable populations involved in the market continue to go unaddressed. Future research should track changes in the now illicit khat market in order to evaluate the social and public health implications following the recent changes to the current U.K. regulatory environment regarding khat.

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations

INTRODUCTION

Almost a fifth of the world's tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these.

METHODS

We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations.

RESULTS

We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit.

CONCLUSIONS

Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

A systematic review of store audit methods for assessing tobacco marketing and products at the point of sale

OBJECTIVE

Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesised the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods and measures used to study retail tobacco environments.

METHODS

We systematically searched 11 academic databases for papers indexed on or before 14 March 2012, identifying 2906 papers. Two coders independently reviewed each abstract or full text to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used and measurement properties. We calculated descriptive statistics regarding the use of four P's of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy and sample size.

RESULTS

We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity and audit procedures.

CONCLUSIONS

Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing and resulting health behaviours. Increased emphasis on standardisation and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.

Availability, accessibility and promotion of smokeless tobacco in a low-income area of Mumbai

OBJECTIVE

To examine the role of accessibility, product availability, promotions and social norms promotion, factors contributing to the use of smokeless tobacco (ST) products in a typical low-income community of Mumbai community using Geographic Information System (GIS), observational and interview methodologies and to assess implementation of Cigatettes and other Tobacco Products Act (COTPA) legislation.

RATIONALE

In India, the third largest producer of tobacco in the world, smokeless tobacco products are used by men, women and children. New forms of highly addictive packaged smokeless tobacco products such as gutkha are inexpensive and rates of use are higher in low-income urban communities. These products are known to increase rates of oral cancer and to affect reproductive health and fetal development.

METHODS

The study used a mixed methods approach combining ethnographic and GIS mapping, observation and key informant interviews. Accessibility was defined as density, clustering and distance of residents and schools to tobacco outlets. Observation and interview data with shop owners and community residents produced an archive of products, information on shop histories and income and normative statements.

RESULTS

Spatial analysis showed high density of outlets with variations across subcommunities. All residents can reach tobacco outlets within 30-100 feet of their homes. Normative statements from 55 respondents indicate acceptance of men's, women's and children's use, and selling smokeless tobacco is reported to be an important form of income generation for some households. Multilevel tobacco control and prevention strategies including tobacco education, community norms change, licensing and surveillance and alternative income generation strategies are needed to reduce accessibility and availability of smokeless tobacco use.

Psychological predictors of male smokeless tobacco use initiation and cessation: a 16-year longitudinal study

AIMS

To test whether psychological factors predict male smokeless tobacco (SLT) initiation and cessation longitudinally.

DESIGN

Sixteen-year longitudinal design with 95% retention at year 6 and 82% at year 16.

SETTING

Forty Washington State school districts.

PARTICIPANTS

SLT use data were gathered on a cohort of adolescents (91% Caucasian). For SLT initiation, the sample size was 2468. For SLT cessation, sample sizes were 219 (age 20 outcome) and 192 (age 28 outcome).

MEASUREMENTS

Self-reported psychological measures of parental disobedience ('parent non-compliance'), peer influence ('friend compliance'), rebelliousness and thrill-seeking were taken at ages 12 and 18. SLT use was measured at ages 12, 18, 20 and 28 years.

FINDINGS

For SLT initiation, scoring highly on the following psychological factors at age 12 at least doubled the odds of daily SLT use at age 18 (P < 0.001): friend compliance [odds ratio (OR): 2.56, 95% confidence interval (CI): 1.78-3.68), rebelliousness (OR: 2.16, 95% CI: 1.46-3.19) and thrill-seeking (OR: 2.33, 95% CI: 1.45-3.75). For SLT cessation, none of the psychological factors at age 18 predicted SLT cessation at age 20 or 28 (P value range: 0.06-0.84).

CONCLUSION

Peer influence, rebelliousness, and thrill-seeking appear to predict smokeless tobacco initiation strongly among male youth in the United States.

Point-of-sale tobacco advertising in Beirut, Lebanon following a national advertising ban

Background

The objective of this study was to conduct an audit of point-of-sale (POS) tobacco advertising and assess compliance with an advertising ban in a large district of Beirut, Lebanon.

Methods

The audit was conducted 3 months following the ban on tobacco advertising. Trained students observed all tobacco retail outlets (n = 100) and entered data into a web-based form using iPad® technology. Presence of tobacco advertisements was assessed to determine compliance with the national advertising ban.

Results

Among the 100 tobacco retail outlets, 62% had tobacco advertisements, including 7% with a tobacco brand logo as part of the main exterior store sign.

Conclusions

POS tobacco advertising is widespread in Beirut despite the national advertising ban. These findings point to an urgent need for the enforcement of the advertisement ban with tobacco retail outlets in Lebanon.

Smokeless tobacco cessation in South Asian communities: a multi-centre prospective cohort study

AIM

To evaluate smokeless tobacco cessation in communities of South Asian origin.

DESIGN

Multi-centre prospective cohort study.

SETTING

Three tobacco cessation services offering specialist smokeless tobacco cessation outreach clinic support to South Asians (Bangladeshi, Indian and Pakistani) resident in England.

PARTICIPANTS

A total of 239 South Asian participants seeking to stop smokeless tobacco use between November 2010 and December 2011.

MEASUREMENTS

Socio-demographics, tobacco use and dependence, self-reported abstinence at 4 weeks and satisfaction measures.

FINDINGS

Participants' mean age was 45 [standard deviation (SD) = 13] years, were predominantly female (76%), of Bangladeshi origin (74%), either home carers (53%) or not working (29%). Sixty-three per cent were recruited from community locations, 21% through a clinical contact and 16% through friends and family. Mean daily number of smokeless tobacco intakes was 10 (SD = 7) and the mean dependence score was 4.5 (SD = 1.9). Sixty-three per cent of participants achieved continuous abstinence 4 weeks after quitting. Using nicotine replacement therapy (NRT) versus not using it [OR = 3.47, 95% confidence interval (CI): 1.25, 9.62] and below median (≤ 8) daily smokeless tobacco intakes (OR = 1.91, 95% CI: 1.07, 3.40) predicted successful abstinence.

CONCLUSION

South Asian smokeless tobacco users resident in England accessing services to help them stop appear to have short-term success rates comparable with smokers attending stop-smoking services, with higher success rates being reported by those using nicotine replacement therapy.

Predictors of successful short-term tobacco cessation in UK resident female Bangladeshi tobacco chewers

AIM

  To identify predictors of short-term smokeless tobacco cessation in Bangladeshi women resident in the United Kingdom.

DESIGN

  Prospective cohort study.

SETTING

  A tobacco cessation service offering culturally tailored smokeless tobacco cessation support.

PARTICIPANTS

  A total of 419 Bangladeshi women chewing paan with tobacco.

MEASUREMENTS

  Demographics, tobacco use and dependence and cessation attempt process and outcomes.

FINDINGS

  Client mean age was 48.92 [95% confidence interval (CI) 47.5, 50.34] years and the mean area social deprivation score was 3.65 (95% CI 3.33, 3.97). Mean daily smokeless tobacco intakes, as paan, was 9.96 (95% CI 9.22, 10.7); 69.8% were recruited from primary care, 78.8% received behavioural support and nicotine replacement therapy (NRT) and the remainder behavioural support alone. Self-reported 4-week continuous abstinence was 58.3%, predicted by NRT use [odds ratio (OR) = 4.93, 95% CI 2.02, 12.00], community recruitment (OR = 1.84, 95% CI 1.01, 3.35) and relatively lower social deprivation (IMD) score (OR = 1.98, 95% CI 1.18, 3.33).

CONCLUSION

  Bangladeshi women in the UK attending clinics to help cessation of paan with tobacco appear to be more likely to be successful in the short term if they use nicotine replacement therapy, are recruited via the community and have relatively lower levels of social deprivation.

Factors associated with dental and medical care attendance in UK resident Yemeni khat chewers: a cross sectional study

Background

The chewing of khat leaf with tobacco smoking amongst Yemenis, Somalis and Ethiopians is reported to impact oral and general health. The health status and particularly dental and medical care attendance of UK-khat chewers has not received attention. This study aimed to explore health status and dental and medical attendance and its associated factors in UK permanently resident Yemeni khat chewers.

Methods

A cross- sectional study with a purposively selected sample of 204 khat chewers was conducted. Data were collected through face to face interviews. Data analysis included descriptive, Chi-square tests and binary logistic regressions.

Results

The mean age for this study sample was 44.84 (SD = ±19.70) years and 35% were employed. Forty five percent reported symptomatic medical attendance for self reported health conditions in the last two weeks whilst 44% had symptomatic dental attendance. Higher khat chewing dependency levels associated positively with both symptomatic dental and medical attendance (p = 0.004, OR = 1.14, 95%CI = 1.04-1.25; p = 0.003; OR = 1.16, 95%CI = 1.05-1.29, respectively). Higher social participation levels associated negatively with symptomatic dental attendance (p = 0.034, OR = 0.98, 95%CI = 0.96-0.99) whilst increase in age and self-reported health conditions associated positively with symptomatic medical attendance (p = 0.030, OR = 1.03, 95%CI = 1.01-1.06; p = 0.001, OR = 4.51, 95%CI = 2.02-10.08, respectively).

Conclusions

In this study of khat chewers, a significant proportion reported symptomatic dental and medical attendance. Demographic, psychosocial and self reported general health conditions were associated significantly with dental and medical attendance. Strategies to improve the dental and medical care attendance amongst this group should focus on these and other unexplored underlying factors.

[Prohibición de fumar y sus implicaciones potenciales en cuidados de salud mental. Revisión de la evidencia]

Different publications have described a close relation between tobacco consumption and major psychiatric disorders. A great number of countries have enacted smoking bans in public or working places since the early 2000s; nonetheless, concerns remain over the exemption in some psychiatric settings regarding smoking bans. Admission of smokers to smoke-free units may lead to behavior deterioration, but some recent evidence refutes this argument.

METHODS

Literature review.

RESULTS

One of the earliest smoking bans was a 1.575 Mexican ecclesiastical council ban aimed at smoking prevention in churches. Several recent studies have documented health and economic benefits related to smoking bans. Over 83 countries now have introduced different sorts of regulations. There was no increase in aggression, seclusion or discharge against medical advice, neither increased use of PRN (as needed) medication following the ban. As part of the ban imposition, Nicotine Replacement Therapy- NRT was used by patients. Consistency, coordination and full staff support for the ban were seen as key success factors. Many patients continued smoking after discharge.

CONCLUSIONS

Evidence shows that smoking has no place in psychiatric hospitals or facilities. The introduction of smoking bans in psychiatric settings is possible, but these bans must be conceived only as part of a much larger strategy, necessary to diminish smoking high rates among mental health populations.

Social and cultural influences on tobacco-related health disparities among South Asians in the USA

OBJECTIVE

To explore and understand key cultural contexts of tobacco use among South Asian communities in the USA.

DESIGN

Focus groups, with homogeneous compositions of gender, generational status and length of time in the USA, were conducted in two distinct South Asian ethnic enclaves. Focus group findings were triangulated with observational data regarding the availability of culturally specific tobacco from commercial ethnic outlets and cultural events.

SUBJECTS

Respondents included 88 men and women of South Asian descent, aged 18-65 years, immigrant and native born, representing diversity of religion, socioeconomic status and region of origin, with the use of at least one culturally specific tobacco product in previous 24 months.

RESULTS

A large number of culturally specific products were commonly used by community members. Knowledge of product-specific health risks was lacking or inaccurate. Many culturally specific tobacco products were considered to have beneficial properties. South Asian tobacco items were used to preserve cultural traditions and express ethnic identity in a new dominant culture. The social and cultural values ascribed to use helped distinguish community members from mainstream society and from other minority populations.

CONCLUSIONS

Many cultural factors govern tobacco use among diverse global populations. Especially for migrants with a common regional origin, the role of ethnic identity may strongly influence culturally specific tobacco patterns. Qualitative inquiry helps elucidate such culturally framed behaviour in culturally diverse populations. These cultural contexts should be integrated into research and practice. Understanding multidimensional factors influencing non-traditional tobacco use is essential to ensure that comprehensive tobacco control strategies address tobacco-related disparities.

Availability and use of Naswar: an exploratory study

BACKGROUND

Naswar is a niche smokeless tobacco product from Pakistan. There is little information about its availability and user characteristics.

METHODS

This cross-sectional survey identified outlets selling Naswar in two wards of one London borough and interviewed a purposively recruited sample of 73 Naswar purchasers. Data were analysed using descriptive and chi-square tests (significance, P ≤ 0.05).

RESULTS

Of 65 outlets identified 15 sold Naswar. The purchasers' mean (SD) age was 32 (± 10) years and 63% had completed only secondary education. Naswar consumption was significantly associated with tobacco dependency, whilst starting Naswar use at a younger age, having lower education levels, using Naswar more frequently and being of Pakhtunkhwa origin was associated with high monthly consumption (P ≤ 0.05).

CONCLUSIONS

Naswar was widely available. Naswar purchasers of Pakistani origin were employed and young, but with limited education and little knowledge of Naswar's health impacts. Naswar dependency and consumption was linked to behavioural and socio-demographic factors. Further evidence is needed to support policy development.

Tobacco, nicotine and harm reduction

ISSUES

Tobacco smoking, sustained by nicotine dependence, is a chronic relapsing disorder, which in many cases results in lifelong cigarette use and consequent death of one out of two lifelong smokers from a disease caused by their smoking. Most toxicity due to cigarette smoking is related to the burning process.

APPROACH

Models of harm reduction applied to tobacco suggest that use of non-combustible, less toxic, nicotine-containing products as a substitute for cigarette smoking would reduce the death toll arising from tobacco use. Available options include medicinal nicotine and smokeless tobacco products.

KEY FINDINGS

The potential role of nicotine replacement therapy (NRT) products in a harm reduction strategy is currently severely restricted by strict regulations on dose, safety and potential addictiveness. As a result, NRT products are designed to provide much less nicotine, and deliver it to the brain more slowly, than cigarettes, which are widely accessible and poorly regulated. Smokeless tobacco (snus) has proved to be an acceptable reduced hazard alternative to smoking in Sweden, but supply of snus is illegal elsewhere in the European Union.

IMPLICATIONS

To increase accessibility and reach more smokers, barriers to the use of NRT use need to be removed and more effective NRTs need urgently to be developed. Smokeless tobacco could also play an important role in harm reduction, but current European Union regulations and concerns over exploitation by tobacco companies currently preclude wider use.

CONCLUSION

To improve public health there is an urgent need for an appropriate regulatory framework and regulatory authority at the European level, controlling both tobacco and nicotine products to ensure that the least harmful products are the most accessible.