Smokeless tobacco control in India: policy review and lessons for high-burden countries

"The ban is there, but it is not there": perceptions of cigarette users and tobacco vendors regarding ban on the sale of loose cigarettes in India

Introduction

Banning the sales of loose cigarettes is recommended by Article 16 of the World Health Organization - Framework Convention on Tobacco Control. This study aims to understand the perceptions of cigarette users and tobacco vendors regarding such a ban.

Methods

Using a systematic recruitment and interview protocol, we interviewed cigarette users (n = 28) and tobacco vendors (n = 28) from two Indian cities where sales of loose cigarettes were banned (Mumbai) or not banned (Delhi). Separate semi-structured interview guides were used for users and vendors. Interview questions focused on reasons for purchasing loose cigarettes, preference for buying and selling loose vs. packs, thoughts on the necessity of banning loose cigarettes, and the perceived impact of the policy ban for vendors and cigarette users. We performed thematic analysis and used NVivo for organizing transcript coding.

Results

The main reasons users cited for purchasing loose cigarettes were financial constraints, social restrictions (fear of getting caught), and limiting cigarette consumption. In Mumbai, awareness of the existing ban was poor among both users and vendors. Those who were aware did not think the policy had been implemented. Users thought that loose cigarettes promoted smoking initiation and prevented them from quitting. Both users and vendors reported that a ban on loose cigarettes would reduce cigarette consumption and promote quit attempts as it would not be possible for everyone to purchase packs because of financial and social reasons.

Conclusion

Users in both cities reported easy access to and widespread availability of loose cigarettes. Low awareness of the ban in Mumbai suggested inadequate enforcement. A country-wide ban on the sale of loose cigarettes could be highly effective in preventing smoking initiation and promoting quitting.

Determinants of tobacco use among pregnant women in sub-Saharan Africa. A multilevel mixed-effect logistic regression model

INTRODUCTION

Although it is known that maternal tobacco use during pregnancy substantially declined in higher-income countries, information on the magnitude and determinants of tobacco use among pregnant women in sub-Saharan Africa (SSA) remains limited. Establishing evidence on maternal tobacco during pregnancy is crucial for guiding targeted interventions in SSA. This study aimed to determine the overall prevalence of tobacco use and its determinants among pregnant women in SSA countries.

METHODS

The study used data from Demographic and Health Surveys conducted in 33 countries across SSA from 2010 and 2021. Our analysis included a total weighted sample of 40,291 pregnant women. A multilevel logistic regression model was used to identify factors associated with maternal tobacco use during pregnancy. The measure of association between explanatory variables and the outcome was reported using adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

RESULTS

The pooled prevalence of tobacco use among pregnant women in SSA was 1.76% (95% CI: 1.41, 2.12). Our findings showed that pregnant women in the age groups of 25-34 years (AOR 1.44; 95% CI: 1.14, 1.82) and 35+ years (AOR 2.18; 95% CI: 1.68, 2.83) had higher odds of tobacco use during pregnancy. Pregnant women who attained primary education (AOR 0.57; 95% CI: 0.46, 0.70) and secondary or higher education (AOR 0.39; 95% CI: 0.30, 0.53) were associated with lower odds of tobacco use. Similarly, pregnant women who resided in households with a high wealth index (AOR 0.36; 95% CI: 0.55 0.90) and those with media exposure (AOR 0.81; 95% CI: 0.67, 0.99) were less likely to use tobacco during pregnancy.

CONCLUSION

This study revealed that the overall prevalence of maternal tobacco use during pregnancy was relatively low in SSA, but some countries exhibited higher estimates. To address this, it is crucial to implement targeted smoking prevention and cessation strategies, particularly for young pregnant women, those facing socioeconomic disadvantages, and those with lower educational status.

Complementary and Alternative Medicine/Therapy for Tobacco Cessation in India: A Secondary Analysis of GATS-1 and 2

Background

India has nearly 267 million adult tobacco users, with a slowly improving quitting rate. Among the many approaches to quitting the habit, such as counseling, nicotine replacement therapy, nicotine patch or gum, and prescribed allopathic medicines. Complementary and alternative medicine/therapy (CAM), a thousand-year-old practice in India, may also prove to be a potential method in tobacco cessation; however, there is scarce literature on the extent of use of CAM among tobacco users who attempt to quit the habit. Therefore, this study attempts to examine the potential of CAM as a strategy for tobacco control in India.

Material and Methods

We undertook a secondary analysis of the data from both rounds of the Global Adult Tobacco Survey (GATS 2009 and 2016). The dependent variable included in the analysis was the use of traditional medicine as a method for quitting tobacco in three types of users-smokers, smokeless tobacco users, and dual users. The prevalence of CAM use was reported, and Chi-square test was applied to find the factors significantly associated with the use of CAM among tobacco users considering a P value of 0.05 to be statistically significant.

Results

The overall prevalence of traditional medicine use for GATS-1 was observed to be more among dual users (4%), while for GATS-2, it was highest among smokers (3%). For both rounds of the GATS survey, the use of traditional medicine was found to be higher among males, rural residents, users with no education or less than primary education, and the eastern region.

Conclusions

CAM has a promising potential for supporting tobacco cessation provided a concerted effort is undertaken to standardize pharmacopeia and establish robust clinical evidence. In addition, there is a need to create awareness, build the capacity of healthcare providers, and foster academic-industrial research in indigenous Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) systems.

Effects of chewing tobacco on corneal endothelium in patients with diabetes mellitus

OBJECTIVE

To determine the impact of tobacco chewing on corneal endothelial structure in patients with diabetes mellitus (DM).

METHODS

Corneal endothelial parameters (endothelial cell count, ECD; coefficient of variation, CV; hexagonality, Hex, and central corneal thickness, CCT) were analysed in 1234 eyes of 1234 patients using non-contact specular microscopy (EM 4000 Tomey Nishi-Ku, Nagoya, Aichi, Japan). The study group (with a present history of tobacco chewing) comprising of 948 subjects, with 473 having DM was compared with age and gender-matched control group comprising of 286 subjects (139 having DM) with no history of tobacco use in any form.

RESULTS

Tobacco chewers had a significantly reduced ECD (P = 0.024) and Hex (P = 0.009) as compared with non-chewers. Similar results were noted in ECD (P = 0.004) and Hex (P = 0.005) in patients with DM. Tobacco chewers had a significantly decreased ECD values among males, HbA1C ≤ 7.5% and duration of DM ≤ 20 years, and significantly decreased Hex among those with >50 years of age, females, and duration of DM > 20 years. The CV and CCT values were comparable between the study and the control groups. Tobacco chewers showed a significant association of ECD with age, HbA1C, and duration of DM; CV with HbA1C; Hex with age and duration of DM; and CCT with gender, age, HbA1C and duration of DM.

CONCLUSIONS

Tobacco chewing may negatively impact corneal health, especially confounded by additional factors like age and DM. These factors must be accounted for in the pre-operative evaluation of such patients prior to any intra-ocular surgery.

Characterization of physiochemical parameters & their effect on microbial content of smokeless tobacco products marketed in north India

BACKGROUND OBJECTIVES

Smokeless tobacco (SLT) product consumption has profound public health implications for its users. The p H and moisture of SLTs determine the bioavailability of nicotine, the microbial structure dynamics and the amount of microbial conversion of tobacco alkaloids to carcinogenic tobacco-specific nitrosamines. This study aimed to characterize and compare the p H, moisture and alkaloid content of various SLT products.

METHODS

Thirty-seven SLT samples including khaini , snus, moist snuff, gul , pan masala , zarda , Mainpuri kapoori and qiwam were collected from the retail market around the National Capital Region in north India and their p H, moisture, nicotine and alkaloid content were measured. The p H and total nicotine were used to calculate the amount of free nicotine, the readily absorbed form, for each product by applying the Henderson-Hasselbalch equation.

RESULTS

The investigation showed that the SLTs varied drastically in their p H (5.36 to 10.27), moisture content (4.7 to 51.7%) and alkaloid content (0.82 to 35.87 mg/g). The p H and free nicotine levels of a product were found to be positively correlated, and the highest free nicotine content was reported in snus samples. Further, the moisture content was seen to impact the bacterial and fungal diversity in these samples.

INTERPRETATION CONCLUSIONS

Studies to detect the presence of pathogenic microbiological genera as well as potentially toxic constituents are warranted. The use of SLTs as an alternative to cigarette smoking should be discouraged, and cessation programmes must call attention to their detrimental effects and emphasize on benefits of quitting SLT consumption.

Oral health and nicotine dependence in tobacco users visiting a Dental Institution in North India

Objective

The cross-sectional study was intended to evaluate the oral health and nicotine dependence among tobacco users.

Material & Methods

Fagerstorm Test for Nicotine Dependence estimated nicotine dependence and clinically oral examination was performed in recording the dentition status, oral hygiene, gingivitis and periodontal health. Descriptive statistics was computed using mean, percentage and standard deviation. Association was estimated using Independent T Test. Binary logistic regression and multiple regression analysis was used in inferential statistics.

Results

In general, 55.3% had dental caries, followed by 92.6% having gingivitis and 7.4% had clinical attachment loss. Mean DMF was 2.60 (± 3.88) and the subjects mean oral hygiene score was 3.49 (± 1.11). The mean DMF score of tobacco users worsened with increasing age. Current smokers were 1.07 times more predisposed to get dental caries than former smokers and smokeless tobacco chewers had higher odds of 1.060 times to fall susceptible to dental caries than those smoking tobacco. Dependence on tobacco substantially worsened oral hygiene.

Conclusions

Tobacco cessation practices shall be effectively enforced to minimize the burden of nicotine dependence.

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

OBJECTIVE

This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation.

DESIGN

Qualitative semi-structured interviews.

SETTING

Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.

PARTICIPANTS

Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.

RESULTS

The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.

CONCLUSION

Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Changing socioeconomic and geographic gradients in cardiovascular disease risk factors among Indians aged 15-49 years - evidence from nationally representative household surveys

Background

Cardiovascular diseases (CVDs) are the leading cause of death in most low- and middle-income countries (LMICs). CVDs and their metabolic risk factors have historically been concentrated among urban residents with higher socioeconomic status (SES) in LMICs such as India. However, as India develops, it is unclear whether these socioeconomic and geographic gradients will persist or change. Understanding these social dynamics in CVD risk is essential for mitigating the rising burden of CVDs and to reach those with the greatest needs.

Methods

Using nationally representative data with biomarker measurements from the fourth (2015-16) and fifth (2019-21) Indian National Family and Health Surveys, we investigated trends in the prevalence of four CVD risk factors: smoking (self-reported), unhealthy weight (BMI ≥25 kgm2), diabetes (random plasma glucose concentration ≥200 mg/dL or self-reported diabetes), and hypertension (one of: average systolic blood pressure ≥140 mmHg, average diastolic blood pressure ≥90 mmHg, self-reported past diagnosis, or self-reported current antihypertensive medication use) among adults aged 15-49 years. We first described changes at the national level and then trends stratified by place of residence (urban versus rural), geographic region (northern, northeastern, central, eastern, western, southern), regional level of development (Empowered Action Group member state or not), and two measures of socioeconomic status: level of education (no education, primary incomplete, primary complete, secondary incomplete, secondary complete, higher) and wealth (quintiles).

Findings

Unhealthy weight increased among all social and geographic groups but both the absolute and the relative changes were substantially higher among people with low SES (as measured by education or wealth) and in rural areas. For diabetes and hypertension, the prevalence increased for those from disadvantaged groups while staying constant or even decreasing among the wealthier and more educated. In contrast, smoking consumption declined for all social and geographic groups.

Interpretation

In 2015-16, CVD risk factors were higher among more advantaged subpopulations in India. However, between 2015-16 and 2019-21, the prevalence of these risk factors grew more rapidly for less wealthy and less educated subpopulations and those living in rural areas. These trends have resulted in CVD risk becoming far more widespread throughout the population; CVD can no longer be characterized as a wealthy urban phenomenon.

Funding

This work was supported by the Alexander von Humboldt Foundation (grant received by NS); the Stanford Diabetes Research Center [grant received by PG] and the Chan Zuckerberg Biohub [grant received by PG].

Fungal Community Composition and Function Associated with Loose Smokeless Tobacco Products

Smokeless tobacco products (STPs) contain several microbial communities which are responsible for the formation of carcinogens, like tobacco-specific nitrosamine (TSNAs). A majority of STPs are sold in loose/unpackaged form which can be loaded with a diverse microbial population. Here, the fungal population and mycotoxins level of three popular Indian loose STPs, Dohra, Mainpuri Kapoori (MK), and loose leaf-chewing tobacco (LCT) was examined using metagenomic sequencing of ITS1 DNA segment of the fungal genome and LC-MS/MS, respectively. We observed that Ascomycota was the most abundant phylum and Sterigmatomyces and Pichia were the predominant fungal genera in loose STPs. MK displayed the highest α-diversity being enriched with pathogenic fungi Apiotrichum, Aspergillus, Candida, Fusarium, Trichosporon, and Wallemia. Further, FUNGuild analysis revealed an abundance of saprotrophs in MK, while pathogen-saprotroph-symbiotroph were abundant in Dohra and LCT. The level of a fungal toxin (ochratoxins A) was high in the MK product. This study caution that loose STPs harbor various harmful fungi that can infect their users and deliver fungal toxins or disrupt the oral microbiome of SLT users which can contribute to several oral pathologies.

Smokeless tobacco utilization among tribal communities in India: A population-based cross-sectional analysis of the Global Adult Tobacco Survey, 2016–2017

Introduction

Evidence on smokeless tobacco use is scarce among indigenous communities, with the available literature based either on a specific tribe or on a particular region. Therefore, we aimed to estimate the prevalence of smokeless tobacco and assess its correlation among tribal communities in India.

Methods

We utilized data from the Global Adult Tobacco Survey-2 conducted in 2016–2017. A total of 12,854 tribal people aged >15 years were included in this study. The utilization of smokeless tobacco was estimated using the weighted proportion, and its correlates were assessed by multivariable logistic regression reported as an adjusted odds ratio (AOR) with a 95% confidence interval.

Results

The prevalence of smokeless tobacco use was 32%. Participants aged 31–45 years [AOR: 1.66 (1.37–2.00)], who were men [AOR: 2.37 (1.94–1.90)], and who were daily wage/casual laborers [AOR: 5.32 (3.39–8.34)] were observed to have a significant association with smokeless tobacco. Willingness and attempt to quit smokeless tobacco were higher in Eastern India (31.2%) and central India (33.6%), respectively.

Discussion

We observed one-third of the tribal individuals used smokeless tobacco in India. Tobacco control policies should prioritize men, rural residents, and individuals with fewer years of schooling. Culturally appropriate and linguistically tailored messages are required for behavioral change communication.

Social determinants of tobacco use among tribal communities in India: Evidence from the first wave of Longitudinal Ageing Study in India

BACKGROUND

Evidence on tobacco use among indigenous communities is scarce with available literature based either on a specific region or a particular tribe. Considering the large tribal population in India, it is pertinent to generate evidence on tobacco use among this community. Using nationally representative data, we aimed to estimate the prevalence of tobacco use and assess its determinants and regional variations among older tribal adults in India.

METHODS

We analysed data from Longitudinal Ageing Study in India (LASI), wave-1 conducted in 2017-18. A sample of 11,365 tribal individuals aged ≥ 45 years was included in this study. Descriptive statistics was used to assess the prevalence of smokeless tobacco (SLT), smoking, and any form of tobacco use. Separate multivariable regression models were executed to assess the association of various socio-demographic variables with different forms of tobacco use, reported as adjusted odds ratio (AOR) with 95% confidence interval.

RESULTS

The overall prevalence of tobacco use was around 46%, with 19% of smokers and nearly 32% smokeless tobacco (SLT) users. Participants from the lowest MPCE quintile group had a significantly higher risk of consuming (SLT) [AOR: 1.41 (95% CI: 1.04-1.92)]. Alcohol was found to be associated with both smoking [AOR: 2.09 (95% CI: 1.69-2.58)] and (SLT) [AOR: 3.05 (95% CI: 2.54-3.66)]. Relatively higher odds of consuming (SLT) were associated with the eastern region [AOR: 6.21 (95% CI: 3.91-9.88)].

CONCLUSION

This study highlights the high burden of tobacco use and its social determinants among the tribal population in India, which can help tailor anti-tobacco messages for this vulnerable population to make tobacco control programs more effective.

Tobacco Use and Cessation among a Nationally Representative Sample of Men in India, 2019-2021

Tobacco users are exposed to a higher risk of noncommunicable diseases, leading to premature mortality and disability-adjusted life years (DALYs). The future prediction indicates that tobacco-related mortality and morbidity rates will substantially increase in coming years. The study is aimed at assessing the prevalence of tobacco consumption and cessation attempts for different tobacco products among adult men in India. The study utilized information from India's latest National Family Health Survey-5 (NFHS-5) data which was conducted during 2019-21, including 988,713 adult men aged 15 years and above and 93,144 men aged 15-49. Results suggest that 38 percent of men consume tobacco, including 29% in urban and 43% in rural areas. Among the men aged 35-49 years, the odds were significantly higher for consuming any form of tobacco (AOR: 7.36, CI: 6.72-8.05), smoking cigarettes (AOR: 2.56, CI: 2.23-2.94), and smoking bidi (AOR: 7.12, CI: 4.75-8.82) as compared to those aged 15-19. The application of multilevel model indicates that tobacco usages are not evenly distributed. In addition, there is maximum clustering of tobacco usages found around household level factors. Further, 30% of men aged 35-49 years attempted to stop consuming tobacco. Though 27% of men tried to quit tobacco in the last 12 months and 69% of men are exposed to secondhand smoke, 51% of men who received advice for quitting tobacco and visited the hospital in the last 12 months belong to the lowest wealth quintile. These findings prioritize promoting awareness about adverse effects of tobacco use, especially in rural areas, and capacitate them to adopt cessation efforts so that those who want to quit may be successful in their efforts. In addition, the health system's response to the tobacco epidemic in the country should be strengthened by training of service providers to promote cessation efforts through appropriate counselling of all the patients visiting them in the context of tobacco use in any form as key drivers of the increasing burden of noncommunicable diseases (NCDs) in the country.

How does Indian news media report smokeless tobacco control? A content analysis of the gutka ban enforcement

Smokeless tobacco (SLT) products like gutka and paan masala are a growing public health crisis in India. Despite enacting a ban-the highest form of regulation-little is known about implementation progress. The purpose of this study was to look at how enforcement of gutka ban is covered in Indian news media and if media is a reliable source of data. We conducted a content analysis of online news reports (n = 192) from 2011 to 2019. News characteristics such as name and type of publication, language, location, slant and beat coverage, visuals, and administrative focus were quantified. Similarly, news contents were inductively coded to examine dominant themes and the implementation landscape. We found that coverage was initially low but increased after 2016. Overall, news reports were in favor of the ban. Five leading English newspapers covered the majority of the ban enforcement reports. Prominent themes like consumption, health hazards, tobacco control responses, impact on livelihoods, and illicit trade were drawn from the textual analysis as the main arguments in relation to the ban. Gutka is largely seen as an issue of crime reflected by the contents, sources, and frequent use of pictures depicting law enforcement. The interconnected distribution channels of the gutka industry hindered enforcement, highlighting the need to study the complexities of regional and local SLT supply chains.

Prevalence of smokeless tobacco use in India and its association with various occupations: A LASI study

Background

More than two-thirds of deaths in developing countries are due to non-communicable diseases, and tobacco is a leading risk factor. There are numerous different socio-demographic factors that impact on the use of smokeless tobacco, of which occupation is one. The objectives of this study are to find out the overall prevalence of smokeless tobacco use (ever and current use), the pattern of association with various occupations and related variables (current and past workers), and the role of childhood adversity on initiation and use.

Methods

This study used data from the Longitudinal Aging Study in India (LASI) wave 1, a nationally representative cross-sectional study collected in 2017-18. Current and previous users of smokeless tobacco are taken into consideration as the target population. For the data analysis, survey-weighted tools have been applied for descriptive statistics and multivariable logistic regression model. The weighted data analysis has been done using R studio with R version 4.

Results and discussion

From the sample size of 65,561, 38% have used either smoking or smokeless tobacco. Among them, 40% use tobacco in smoke form, 51% use smokeless tobacco, and 9% take both. At the population level, 22.8 and 20.4% are previous and current users of smokeless tobacco, respectively. Type of occupation, type of employer, place of work, kind of business, and workload were found to be significantly associated with smokeless tobacco use. A deaddiction and tobacco quitting policy targeting rural male informal workers should be the focus of the Government.

Outcomes of ST Segment Elevation Myocardial Infarction without Standard Modifiable Cardiovascular Risk Factors - Newer Insights from a Prospective Registry in India

Objectives

Patients with ST elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs; dyslipidaemia, hypertension, diabetes mellitus and smoking) are reported to have a worse clinical outcome compared to those with SMuRFs. However, robust prospective data and low-and middle-income country perspective are lacking. We aimed to study the patients with first STEMI and assess the influence of SMuRFs on clinical outcomes by comparing the patients with and without SMuRFs.

Methods

We included all consecutive STEMI patients without prior coronary artery disease enrolled in the Madras Medical College STEMI Registry from September 2018 to October 2019. We collected baseline clinical characteristics, revascularisation strategies and clinical outcome. We analysed suboptimal self-reported sleep duration as a 5^th extended SMuRF (eSMuRF). Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications and one-year all-cause mortality.

Results

Among 2,379 patients, 605 patients (25.4%) were SMuRF-less. More women were SMuRF-less than men (27.1% vs 22.1%; P = 0.012). SMuRF-less patients were older (57.44 ± 13.95 vs 55.68 ± 11.74; P < 0.001), more often former tobacco users (10.4% vs 5.0%; P < 0.001), with more anterior wall MI (62.6% vs 52.1%; P = 0.032). The primary outcome [in-hospital mortality (10.7% vs 11.3%; P = 0.72)] and secondary outcomes [in-hospital complications (29.1% vs 31.7%; P = 0.23) and one-year all-cause mortality (22.3% vs 22.7%; P = 0.85)] were similar in both groups. Addition of suboptimal self-reported sleep duration as a 5^th eSMuRF yielded similar results.

Conclusions

25% of first STEMI patients were SMuRF-less. Clinical outcomes of patients without SMuRFs were similar to those with SMuRFs. Suboptimal sleep duration did not account for the risk associated with the SMuRF-less status.

Exploring the perceived sociocultural factors in the initiation of smokeless tobacco among adolescents: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to identify and explore the perceived sociocultural factors leading to smokeless tobacco initiation among the adolescent population.

INTRODUCTION

Smokeless tobacco use is associated with oral cancer and premalignant lesions. The initiation of smokeless tobacco often occurs in adolescence, with multiple sociocultural factors facilitating the commencement of this habit. An in-depth understanding of the factors influencing smokeless tobacco uptake can assist policymakers and tobacco-control units in establishing global policies and implementing control strategies to prevent adolescents' taking up smokeless tobacco.

INCLUSION CRITERIA

This review will consider qualitative studies conducted within the last 20 years on adolescent smokeless tobacco users, focusing on sociocultural factors influencing smokeless tobacco initiation. Studies involving cigarette smoking, other alternative forms of smoking, and any form of tobacco cessation intervention will be excluded.

METHODS

A systematic search will be conducted in MEDLINE, Scopus, CINAHL, Embase, PsycINFO, and the Cochrane CENTRAL databases, using a 3-step search process. ProQuest Dissertations and Theses, OAIster, and Google will be searched for unpublished studies. Only studies published from January 2002 until the present and in English will be considered. Study screening, extraction, and critical appraisal will be performed by 2 independent reviewers using the standardized JBI qualitative appraisal and data extraction tools. Data synthesis will involve aggregation of the review findings to generate a set of statements based on similarity of meaning.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021240588.

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.

Smokeless tobacco industry's brand stretching through FM radio: A study from Delhi National Capital Region, India

Smokeless tobacco (SLT) consumption is associated with multiple adverse health effects and mortality, with the highest burden in India. The WHO FCTC has banned tobacco advertisement, promotion and sponsorship via Article 13. Indian laws also prohibit any kind of direct or indirect advertisements in all forms of audio, visual, and print media; brand promotion; and sponsorship of tobacco products. However, the tobacco industry continues to find aggressive marketing ways to advertise their products. This study aims to assess the extent of surrogate advertisement of smokeless tobacco products through frequency modulation (FM) radio stations in the city of Delhi (National Capital Territory of India). In this study, the advertisements broadcasted over FM radio across different channels (private and government owned) in total 162 h were analyzed. The time duration was spread evenly over morning peak hours, off hours, and evening peak hours. It was found that multiple brands including Vimal, Kamla Pasand, and Rajshree have used surrogate advertising to market their brands that are commonly associated with smokeless tobacco products. However, no such advertisement was found to be aired on government-owned FM channels. The total surrogate advertisements broadcasted were over 286 times, where no significant difference was found in distribution among peak and non-peak hours. The study indicated that the tobacco industry is making its way to sell the products through indirect advertisements. The need of the hour is to not only enforce tobacco advertising ban laws in all forms of advertising media but also to strictly regulate smokeless tobacco products.

Predictors of hypertension among current smokeless tobacco users in India; analysis from the fourth round of National Family Health Survey (2015-2016)

Background

Hypertension is a major modifiable risk factor for cardiovascular and cerebrovascular diseases. The association between different risk factors including smoking and hypertension is studied extensively; however, there is a paucity of literature with respect to association between smokeless tobacco use and hypertension in India. In the current study, the relationship between smokeless forms of tobacco use and hypertension is being investigated.

Methodology

This study analyzed the data from fourth round of National Family Health Survey conducted during 2015-2016. Socio-demographic variables such as age, sex, education, wealth index, body mass index, smoked forms of tobacco use, and smokeless forms of tobacco like paan, gutkha, Khaini, etc., presence of co-morbidities were the independent variables. Hypertension was the dependent variable.

Results

It was observed from the present analysis that, smokeless tobacco use is a risk factor for hypertension both in the case of females OR-1.1**(1.08-1.13) as well as males OR-1.07**(1.03-1.1). The other predictors observed were overweight, consumption of alcohol, and diabetes.

Conclusion

It was concluded from the present study, that consumption of smokeless tobacco use acts as an independent risk factor for hypertension.

Scoping Review of Existing Evaluations of Smokeless Tobacco Control Policies: What Is Known About Countries Covered, Level of Jurisdictions, Target Groups Studied, and Instruments Evaluated?

OBJECTIVE

The implementation of smokeless tobacco control policies lags behind those for smoking. This scoping review summarizes the studies that evaluated public policies on smokeless tobacco regulation (SLT) and provides an overview of the jurisdictional level, target groups, and policy instruments.

METHODS

Seven databases were systematically searched for studies reporting on public policies regulating SLT. Two reviewers independently screened all studies. Data extraction was performed using a predefined extraction form. Extraction was replicated for 10% of the identified studies for quality assurance. A narrative synthesis of the included studies was used to analyze and interpret the data. The protocol was published beforehand with the Open Science Foundation (OSF).

RESULTS

Fourty articles comprising 41 studies were included. Most of the studies reported in the articles were conducted in the United States (n = 17) or India (n = 14). Most studies reported outcomes for students (n = 8), retailers/sellers (n = 8), and users/former users (n = 5). The impact of public policies on smokeless tobacco use, in general, was most frequently assessed (n = 9), followed by the impact of taxes (n = 7), product bans (n = 6), sales/advertising bans near educational institutions (n = 4), and health warnings (n = 3) on consumer behavior.

CONCLUSIONS

There are significant gaps in the evaluation of smokeless tobacco regulation studies that need to be filled by further research to understand the observed outcomes. WHO reporting on Framework Convention on Tobacco Control (FCTC) implementation should be linked to studies evaluating smokeless tobacco control measures at all levels of jurisdictions and in countries not members of the WHO FCTC or do not provide data.

IMPLICATION

Large gaps in the evaluation of SLT control policies exist. For some countries, WHO FCTC evaluations are available for different levels of jurisdictions. In countries with a strong federal structure, there is a lack of data beyond the national level to provide a more detailed look at compliance, indirect effects, or implementation gaps. More research is needed at all levels of jurisdictions, which add to the work of the WHO to understand what works for which target group, how the different levels of jurisdiction interact, how the real-world context can be incorporated, and what indirect effects may occur.

Predictors of smokeless tobacco use among the adult population of north-east India during 2009-2017: A decomposition analysis

Background & objectives

Contrary to overall declining trend in smokeless tobacco (SLT) use in India, an increase is observed in north-east (NE) India. This study examined the predictors of daily SLT use by gender and assessed the demographic and socio-economic characteristics that contribute to gender differences in SLT use in NE India.

Methods

Data collected from 15,259 and 13,574 adults in the two rounds of Global Tobacco Adult Survey 1 and 2 for NE India during 2009-2010 and 2016-2017 were analyzed. Relative change, multivariable binary logistic regression and Blinder-Oaxaca decomposition analysis were used for analysis.

Results

The findings suggest that among women in NE India, the daily SLT use significantly increased by 58 per cent between 2009-2010 to 2016-2017. Women residing in Nagaland, Manipur, Mizoram and Tripura were 3.5 and 2.5 times, respectively more likely to be daily SLT users compared to those in Assam. While age, education and wealth were the significant predictors of SLT use in both women and men, increased odds of SLT use were observed with women's type of occupation and the State of residence. The majority of the gender differences in daily SLT use was explained by differences in work status (44%), age (26%), education (14%) and wealth status (9%) between men and women.

Interpretation & conclusions

Increasing prevalence of SLT use amongst women in the NE States necessitates integration of gender-specific messages on harmful effects of SLT in the ongoing tobacco control programmes and development of culturally appropriate community-based interventions for cessation of SLT use.

Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India

INTRODUCTION

Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India.

METHODS

A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression.

RESULTS

Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]).

CONCLUSIONS

The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising.

IMPLICATIONS

The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

Association between smokeless tobacco use and cigarette smoking amount by age

BACKGROUND

The use of smokeless tobacco has increased worldwide among young people. This study aimed to investigate the association between smokeless tobacco use and cigarette smoking amount in adult smoker groups stratified by age.

METHOD

2013-2015 National Health Interview Survey was used. A total of 19,635 subjects were included in our analysis. Propensity score matching was used to adjust for selection and any other bias. Generalized estimating equation was used to analyze the association between smokeless tobacco use and cigarette smoking amount by age.

RESULTS

All 580 smokeless tobacco users were matched to 2,900 non-smokeless tobacco users. Among those who were aged under 30, smokeless tobacco use was positively associated with the number of cigarettes used per day. Smokeless tobacco users who were aged under 30 and tried quitting smoking used more cigarettes than those who did non-smokeless tobacco users.

CONCLUSIONS

The present study revealed that among those who were aged under 30, smokeless tobacco use was positively associated with the number of cigarettes used per day. This study could contribute to understand the behaviors and tendencies of smoking in young adulthood and to establish effective smoking cessation methods for their age.

The progression of the tobacco epidemic in India on the national and regional level, 1998-2016

BACKGROUND

Evidence regarding the progression of the tobacco epidemic remains fragmented in low- and middle-income countries. In India, most of the studies that examined tobacco consumption focused on one time point, on the country as a whole, and on men. Despite important gender differences in tobacco consumption, vast economic and cultural differences exist within India. We, therefore, assessed the progression of the tobacco epidemic in India on both the national and the regional level, by gender.

METHODS

We use information on current tobacco use among Indians aged 15-49 from three rounds of the National Family Health Survey (NFHS) (1998-99, 2005-06, 2015-16) to estimate the age-standardized sex specific smoking and smokeless tobacco prevalence across India and its states.

RESULTS

Age-standardized tobacco use prevalence in India increased between 1998-1999 and 2005-2006, and declined from 2005-2006 to 2015-2016, simultaneously for men and women. There are substantial spatial differences in the progression of the tobacco epidemic in India. While tobacco use declined in the majority of states, we observe high and increasing use for men in the north-eastern states of Manipur, Mizoram and Nagaland, and for women in the western state of Gujarat and north-eastern state of Manipur. We observed even more states with a recent increasing prevalence in either tobacco smoking or smokeless tobacco. Throughout, prevalence of tobacco use has been higher among men than women for all Indian regions, and remained higher than the national average in the north-eastern states.

CONCLUSIONS

Our results suggest that India and the majority of its states experienced a 'compressed tobacco epidemic' in which the prevalence of tobacco consumption increased and decreased simultaneously for women and men over a comparatively short period of time. Despite the overall progress India made in reducing tobacco use, further lowering tobacco consumption remains a public health priority, as the prevalence of smoking and/or smokeless tobacco use remains high in a number of states. We therefore conclude that tobacco regulations should be expanded with the aim of reducing the overall health burden associated with tobacco consumption across India.

"So what if I use tobacco or alcohol? It won't hurt me!" How women perceive substance use: insights from a community study in India

To explore the subjective perceptions of women from rural and urban communities in Bangalore, India, regarding their perspectives about addictive substance use (ASU), and the interventions/support they need to quit use. Based on the data collected, the goal of this study was to develop an intervention that would address the women's needs. Mixed methods were used as follows: (a) door-to-door survey of women (N = 2044) regarding their use of addictive substances, and (b) focus group discussions with the women to explore their perceptions. Interviews were transcribed verbatim, themes and sub-themes identified. More than one-third (32.7%) reported past 3-month ASU, with majority reporting smokeless tobacco products (82.6%). Alcohol use was reported by 17.4%. Four major themes (with sub-themes) were identified from the focus group discussions: (1) Patterns of use (oral tobacco products-kaddipudi, thambaku; alcohol), (2) Reasons for use (to relieve stress and forget problems, tobacco use as a way of life, for postnatal benefits, due to easy availability, to reduce fatigue and pain, indigestion, hunger), (3) Low risk perception related to ASU ("We know how to use tobacco safely", "No real harm from tobacco"), and (4) Issues related to quitting ASU and help-seeking (unwillingness to quit, methods of intervention- "videos, or tablets/injections to help us quit ASU"). The findings highlight challenges involved in the development of effective interventions for women. Additionally, there is a clear need for broader community agencies to address psychological, cultural, and social dimensions.

Tobacco Use Among 1 310 716 Women of Reproductive age (15-49 Years) in 42 Low- and Middle-Income Countries: Secondary Data Analysis From the 2010-2016 Demographic and Health Surveys

INTRODUCTION

Tobacco use among women, especially during pregnancy is a public health concern. There is a need to understand the diverse nature of their tobacco consumption across the globe.

METHODS

We used Demographic and Health Surveys (DHS) data collected between 2010 and 2016 from 42 low- and middle-income countries (LMICs) to estimate the prevalence of smoking, smokeless tobacco, and dual use among pregnant and non-pregnant women of reproductive age (15-49 y). We compared tobacco use between both groups adjusted for age, type of residence, education and combined wealth index, and a subgroup analysis for the South-East Asia Region (SEAR) as the tobacco use in SEAR among women is far more diverse than in other regions primarily due to the popularity of smokeless tobacco use in this region.

RESULTS

Based on the data of 1 310 716 women in 42 LMICs, the prevalence of smoking was 0.69%(95%CI: 0.51-0.90) among pregnant women and 1.09%(95%CI: 0.81-1.42) among non-pregnant women. The prevalence of smokeless tobacco use was 0.56%(95%CI: 0.33-0.84) among pregnant women and 0.78%(95%CI: 0.35-1.37) among non-pregnant women. The relative risk ratios(RRR) for smoking (0.85; 95%CI: 0.67-1.09) and smokeless tobacco use (0.81; 95%CI:0.67-1.00) were not-significantly lower among pregnant women than non-pregnant women and education and wealth index had an inverse relationship with both forms of tobacco. In SEAR, among pregnant women, the prevalence of smoking and smokeless tobacco use was 1.81% and 0.45%, respectively. However, pregnant women were 7%(RRR 1.07; 95%CI:1.02-1.12) more likely to use smokeless tobacco than non-pregnant women.

CONCLUSION

Despite the added risk of foetal harm during pregnancy, there is no evidence that the tobacco consumption between pregnant and non-pregnant women differ in 42 LMICs. A significantly higher use of smokeless tobacco among pregnant women in SEAR is of particular concern and warrants further investigation.

IMPLICATIONS

Tobacco use among women in low- and middle-income countries (LMICs) is lower than high-income countries (HICs), but this may be because LMICs are earlier in the epidemiological transition of tobacco use. If ignored as a public health issue and the tobacco industry continues to market its products to women, the level of tobacco use may rise as it did in HICs. Also, despite low prevalence rates and with no evidence that these differ among pregnant and non-pregnant women, is concerning as tobacco consumption in any form during pregnancy is associated with poor birth outcomes. This suggests a need for raising awareness about the harms of tobacco use among women in LMICs, especially during pregnancy. There is a need to develop preventive and cessation interventions to decrease tobacco use (smoking and smokeless) among women who are from low socio-economic status and less educated, as they bear the greatest burden of tobacco use.

Policy priorities for strengthening smokeless tobacco control in Bangladesh: A mixed-methods analysis

INTRODUCTION

Smokeless tobacco (ST) remains poorly regulated in Bangladesh. This study describes the prevalence and trends of ST use in Bangladesh, presents ST-related disease burden, identifies relevant policy gaps, and highlights key implications for future policy and practice for effective ST control in Bangladesh.

METHODS

We analyzed secondary data from the two rounds (2009 and 2017) of The Global Adult Tobacco Survey, estimated ST-related disease burden, and conducted a review to assess differences in combustible tobacco and ST policies. In addition, we gathered views in a workshop with key stakeholders in the country on gaps in existing tobacco control policies for ST control in Bangladesh and identified policy priorities using an online survey.

RESULTS

Smokeless tobacco use, constituting more than half of all tobacco use in Bangladesh, declined from 27.2% (25.9 million) in 2009 to 20.6% (22 million) in 2017. However, in 2017, at least 16947 lives and 403460 Disability-Adjusted Life Years (DALYs) were lost across Bangladesh due to ST use compared to 12511 deaths and 324020 DALYs lost in 2010. Policy priorities identified for ST control have included: introducing specific taxes and increasing the present ad valorem tax level, increasing the health development surcharge, designing and implementing a tax tracking and tracing system, standardizing ST packaging, integrating ST cessation within existing health systems, comprehensive media campaigns, and licensing of ST manufactures.

CONCLUSIONS

Our analysis shows that compared to combustible tobacco, there remain gaps in implementing and compliance with ST control policies in Bangladesh. Thus, contrary to the decline in ST use and the usual time lag between tobacco exposure and the development of cancers, the ST-related disease burden is still on the rise in Bangladesh. Strengthening ST control at this stage can accelerate this decline and reduce ST related morbidity and mortality.

Evidence on article 5.3 of FCTC (tobacco industry interference in tobacco control activities) in India- a qualitative scoping study

BACKGROUND

The Tobacco Industry (henceforth TI) yearns to portray itself as being "socially responsible" and fights for the decision-making positions; that are it used to deter, delay or dilute tobacco control measures. There is little documented evidence of Tobacco Industry Interference (henceforth TII) from India, the scope of their interference and challenges faced by the experts for effective tobacco control. This research study seeks to cover this significant gap in the literature on the TI of India.

METHODS

A cross-sectional qualitative research design, based upon in-depth interviews (N = 26), was used to explore the key stakeholders' opinions regarding TII in India. The interviews used a set of questions to collect information about the participant's roles and responsibilities in tobacco control, the nature of TII faced by the participants, means of influence by TI, barriers and challenges to tobacco control efforts.

RESULTS

Most of the respondents were engaged in tobacco control, training, advocacy and awareness generation activities for 5-10 years or more. The respondents defined the TI and its scope as per their experience with the help of the power ranking methodology. Most of them perceived TI as 'manufacturers' while others consider them as 'advertisers', 'public relation companies', 'wholesalers', 'vendors', and 'Government firms with TI stocks. The research team identified six significant domains: influencing the policy and administrative decisions, Interference in the implementation of tobacco control laws and activities, false propaganda and hiding the truth, manipulating front action groups (FAG), rampant tobacco advertising and promotion activities and others under which TII activities were classified. Most respondents believed that TI players were interfering in the policy decisions, implementing the tobacco control laws and activities and manipulating the FAG. A detailed taxonomic classification of the TII strategies that emerged from our analysis was linked to article 5.3 of FCTC.

CONCLUSIONS

The study documented a significant level of TII in different domains, with stakeholders acting at various hierarchical levels. Thus providing insight into the tactics of the TI in order to enable stakeholders to anticipate and pre-empt the kinds of alliances the TI may attempt to build; stimulating academicians and researchers to undertake in-depth analysis into various strategies and therefore underscoring the need to ensuring transparency in official interaction with the TI and its representatives.

Invasive oral squamous cell carcinoma induced by concurrent smokeless tobacco and creamy snuff use: A case report

Oral squamous cell carcinomas (OSCC) are caused by chronic tobacco abuse. In this regard, the carcinogenic potential of smoking and smokeless forms of tobacco, including chewing tobacco and moist/dry snuff, has been widely documented. However, the effects of tobacco-containing products such as creamy snuff on oral health have not been widely reported. Here, we report on the clinical presentation of a patient with OSCC induced by concurrent chewing tobacco and creamy snuff use. The development and progression of mucosal carcinogenesis in the context of mixed tobacco use habits is discussed. With the increased availability of newer tobacco-containing products, it is important for clinicians to be aware of these products in the marketplace, including dentifrices and nicotine pouches, and counsel their patients regarding their health risks.