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

Perspectives of smokers, smokeless tobacco users and cessation practitioners in India: A qualitative study

INTRODUCTION

India is the second largest consumer of tobacco in the world and accounts for 70% of global deaths due to smokeless tobacco (SLT) use.

AIM

The aim of this study is to understand the perspectives of tobacco users (smokers and SLT users) and practitioners in India to inform cessation interventions.

METHOD

Semi-structured in-depth interviews with tobacco users (smoked and smokeless; n=23), and healthcare practitioners (n=13). Perspectives were triangulated using thematic analysis to examine convergence, divergence and complementarity of findings.

RESULTS

We present the results in a socio-ecological framework to highlight reasons for initiation and continuation of tobacco and motives to quit at the individual, interpersonal, occupational, societal and policy levels. SLT is seen as culturally acceptable compared to smoked forms of tobacco. Emotionally framed messages highlighting negative effects of tobacco on loved ones were perceived to be a better motivator than other types of cessation messages.

DISCUSSION

Nuanced differences exist between smokers and SLT user perspectives which have implications for cessation programs. Our findings supplement similar studies with other South Asian populations.

IMPLICATIONS FOR PRACTICE

Our study provides useful insights to tailor cessation interventions to the type of tobacco consumed in order to enhance their acceptability and effectiveness.

A model to explain smokeless tobacco consumption in adults: A grounded theory study

Introduction

Smokeless tobacco use remains a significant public health concern, necessitating the acquisition of comprehensive and extensive data to effectively address and control its consumption. Understanding the underlying patterns of consumption is crucial for this purpose.

Objective

This study aimed to develop a model that explains smokeless tobacco consumption among adults in the southeastern province of Iran, specifically in the city of Chabahar.

Methods

A qualitative study was conducted using a grounded theory approach with inductive processes. The participants consisted of 30 adults aged 18-64 years from Chabahar City in southeastern Iran. Purposive sampling was used to select participants, and data collection continued until theoretical saturation was achieved. Data analysis followed Strauss and Corbin's perspective, involving four stages: Analyzing Data for Concepts, Analyzing Data for Context, Bringing Process into the Analysis, and Integrating Categories.

Results

The analysis of data yielded three main categories: "starting to use," "continued use," and "cessation attempts," each with their respective subcategories. Additionally, two main categories related to the consequences of smokeless tobacco consumption were identified: "addiction and efforts to overcome addiction," also with their respective subcategories.

Conclusion

The Dependency Cycle Model in Consumption provides a comprehensive understanding of the contextual factors, processes, and consequences associated with smokeless tobacco consumption. This model serves as a valuable tool for researchers aiming to develop effective interventions in the field of smokeless tobacco consumption.

Optimizing Dietary Patterns and Lifestyle to Reduce Atherosclerotic Cardiovascular Risk Among South Asian Individuals

South Asians are at an elevated risk of atherosclerotic cardiovascular disease (ASCVD) when compared with other age-matched subjects of varied ethnicities. The elevated ASCVD risk is multifactorial including a constellation of hypertension, dyslipidemia, metabolic syndrome, overweight/obesity, prediabetes, and type 2 diabetes mellitus. Although traditional ASCVD risk factors remain highly prevalent in South Asians living in the United States, modifiable risk factors of diet, lack of physical activity/increased sedentary time, smoking (of all forms), and excessive alcohol consumption further accelerate the disease process. In this review, we take a deep dive into optimizing lifestyle to reduce the risk of cardiovascular disease in this high-risk ethnic group.

Psychometric properties of Fagerström Tolerance Questionnaire among Turkmen Nass (Naswar) users

BACKGROUND

Smokeless tobacco (SLT) products are gaining popularity around the globe, particularly in Asia, Africa, and the Middle East. Among these products, Nass (aka Naswar) is popular among the Turkmen ethnicity in Iran. Although several studies reported nicotine dependence (ND) among SLT users, psychometric instruments have never been utilized to specifically measure ND among Nass users. Therefore, in this study, we aimed to evaluate the reliability and validity of the Fagerström Tolerance Questionnaire (FTQ) among Turkmen Nass users.

METHODS

A cross-sectional, descriptive study was conducted in June-December 2018 among 411 Turkmen adults who currently (past 30 days) used Nass. Two bilinguals (Persian English) individuals translated and back-translated the FTQ-SLT, which maintained both the questionnaire's accuracy and cultural sensitivity. Construct validity was assessed using exploratory and confirmatory factor analysis.

RESULTS

The mean age and standard deviation for initiating Nass were 22.5 ± 11.81 years. Exploratory and confirmatory factor analysis indicated a single-factor solution with 8-items that captured several important ND components. Using Nass frequently, soon after waking, when sick, and experiencing a craving were some of the main components. Subgroups comparison revealed that higher scores occurred among those who were married, had Nass user(s) in their immediate family, and consumed bulk form of Turkmen Nass directly without using a tissue.

CONCLUSION

Our findings show that the FTQ- SLT is a fairly reliable and valid scale to measure ND among Turkmen Nass users and warrants further testing to accommodate cross-cultural differences in other populations.

Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

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.

Socio-cultural determinants of tobacco consumption: a study of migrant and local workers in a district of Punjab, India

Although the use of tobacco in the state of Punjab is below the national statistics of India, according to Global Adult Tobacco Survey (GATS) 2016 Report, its consumption has increased. Also, what sets it apart from rest of the nation is the cultural as well as the religious taboo associated with tobacco use. The case of Punjab is also peculiar because of the socio demographic profile of the region which has changed since Green Revolution. Having said that, use of tobacco is a social phenomenon and it becomes important to place tobacco use in a social and cultural context. The aim of the study is to explore the socio -cultural determinants of tobacco use within local and migrant groups in a district of Punjab. The tobacco users in the district were divided into groups of local and migrant labourers and focus group discussion was carried out with them. There were various social correlates of tobacco use in the district which saw variations within and across these groups. The socio demographic factors of age, gender, religion and place of residence were related to the use of tobacco and presented similarities and variations across the groups. The study concluded that tobacco prevention and control policies should include cultural interventions to change current traditional practices and social determinants which influence the use of tobacco.

Cardiovascular Risk Management in the South Asian Patient: A Review

South Asians represent a growing percentage of the diverse population in the U.S. and are disproportionately impacted by a greater burden of aggressive and premature cardiovascular disease. There are multiple potential explanations for these findings including a high prevalence of traditional risk factors (particularly diabetes, dyslipidemia, and obesity), a genetic predisposition, and unique lifestyle factors. In this review, we discuss the cardiovascular risk stratification and disease management goals for South Asian adults. We review the pharmacologic and non-pharmacologic interventions studied in this population and discuss the role of specialized clinics and digital outreach to improve care for this vulnerable group of patients.

Understanding cognitive and emotional illness representations of South Asian head and neck cancer survivors: a qualitative study

OBJECTIVES

Head and neck cancer (HNC) constitutes a substantial portion of the cancer burden worldwide, with over 550,000 new cases and over 300,000 deaths annually, with disproportionately high mortality rates in the developing countries. The large majority of HNCs are caused by tobacco use, and synergistic effects of tobacco and alcohol use. Using the Common-Sense Model (CSM) as a framework, this qualitative study sought to understand South Asian HNC survivors' cognitive and emotional representations of their cancer; and to assess if these representations differ by smokeless tobacco (SLT) vs. smoked tobacco use.

DESIGN

In-depth semi-structured interviews, conducted with South Asian HNC survivors (N = 15, 80% participants were immigrants, while 20% came to the United States for treatment) to identify key themes and issues related to HNC experience and SLT vs. smoked tobacco use.

RESULTS

The results of the study provide a deeper understanding of South Asian HNC survivor experiences with receiving a HNC diagnosis, delays in seeking treatment and related medical care, disagreement regarding smoked tobacco/SLT history as potential causes of cancer, strategies to cure the cancer or prevent recurrence, enduring physical and psycho-social consequences of treatment, and emotional impact of the cancer experience. Three key implications emerged: (a) the utility of narratives as a method of eliciting HNC survivor experience to understand patient experiences and concerns; (b) the potential for public health practitioners to harness patients' voices and the power of storytelling for developing campaigns about public awareness of SLT use, providing information and support to SLT users, and encouraging SLT quitting resources; and (c) the importance of providing clear, personalized and culturally sensitive education regarding the risks of SLT use.

CONCLUSIONS

This study underscores the significance of offering tailored tobacco cessation services to South Asian HNC survivors, and to help inform supportive models of care for others.

Automated Solid Phase Extraction and Polarity-Switching Tandem Mass Spectrometry Technique for High Throughput Analysis of Urine Biomarkers for 14 Tobacco-related Compounds

Tobacco use is the leading preventable cause of premature disease and death in the United States. Approximately, 34 million U.S. adults currently smoke cigarettes. We developed a method for automated sample preparation and liquid chromatography-tandem mass spectrometry quantitation of 14 tobacco-related analytes: nicotine (NICF), cotinine (COTF), trans-3'-hydroxycotinine (HCTF), menthol glucuronide (MEG), anabasine (ANBF), anatabine (ANTF), isonicoteine (ISNT), myosmine (MYOS), beta-nicotyrine (BNTR), bupropion (BUPR), cytisine (CYTI), varenicline (VARE), arecaidine (ARD), and arecoline (ARL). The method includes automated solid-phase extraction using customized positive-pressure functions. The preparation scheme has the capacity to process a batch of 96 samples within 4 h with greater than 88% recovery for all analytes. The 14 analytes, separated within 4.15 min using reversed-phase liquid chromatography, were determined using a triple-quadrupole mass spectrometer with atmospheric-pressure chemical ionization and multiple reaction monitoring in negative and positive ionization modes. Wide quantitation ranges, within 1.2-72,000 ng/mL, were established especially for COTF, HCTF, MEG, and NICF to quantify the broad range of biomarker concentrations found in the U.S. population. The method accuracy is above 90% while the overall imprecision is below 7%. Finally, we tested urine samples from 90 smokers and observed detection rates of over 98% for six analytes with urinary HCTF and MEG concentrations ranging from 200-14,100 and 60-57,100 ng/mL, respectively. This high throughput analytical process can prepare and analyze a sample in 9 min and along with the 14-compound analyte panel can be useful for tobacco-exposure studies, in smoking-cessation programs, and for detecting changes in exposure related to tobacco products and their use.

Students' beliefs about smokeless tobacco use in Chabahar city: A qualitative study using focus groups

BACKGROUND

Smokeless tobacco use is a public health problem. This study explored students' beliefs about smokeless tobacco use in Chabahar, Iran.

MATERIALS AND METHODS

The qualitative study was conducted using three Focused Group Discussions among 24 students aged 12-14 years in Chabahar City. Focus Group Guide Morgan was used. Qualitative Content Analysis was used to explore and extract codes and themes. The data analysis process was carried out in accordance with the stages of proposed by Graneheim and Lundman. Guba and Lincoln criteria were used for evaluating research transferability.

RESULTS

Two main themes emerged from the analysis including; beliefs of being useful and harmful. Each of these themes is divided into subthemes with useful or harmful physical and psychological beliefs. Four subthemes included: beliefs of being useful physically, beliefs of being useful psychologically, harmful beliefs physically, and harmful beliefs psychologically.

CONCLUSIONS

One of the more significant findings to emerge from this study is that many students mentioned the benefits of using smokeless tobacco to reduce toothache, relieve headaches, and bad breath. This information can be used to develop targeted interventions aimed at reducing smokeless tobacco consumption. However, more research on this topic needs to be undertaken before the association between kinds of beliefs and smokeless tobacco consumption is more clearly understood.

Current status of periodontitis and its association with tobacco use amongst adult population of Sunsari district, in Nepal

BACKGROUND

Tobacco products are considered significant, but preventable factors related to initiation and progression of periodontal diseases. We assessed the prevalence of periodontitis and evaluated its association with tobacco use and other factors amongst the adult population of Sunsari district in eastern Nepal.

METHODS

A community-based, cross-sectional study was conducted in rural municipalities in the province one of eastern Nepal. A total of 440 adults were interviewed with a set of a pre-tested semi-structured questionnaire. Data on social demographics, adverse oral habits followed by periodontal clinical examination were recorded. Prevalence of periodontitis was assessed by a case definition provided by CDC-AAP. Univariate and multivariate logistic regression analysis was done to measure the association between tobacco use and other factors with periodontitis.

RESULTS

The overall prevalence of periodontitis was found to be 71.6%. Majority (85.4%) of tobacco users had periodontitis and they were significantly associated with the disease and its severity. The study identified age groups, 45-65 years (AOR = 7.58, 95% CI 3.93-14.61), plaque accumulation (AOR = 1.01, 95% CI 1.00-1.02), smoking (AOR = 3.14, 95% CI 1.36-7.27), khaini users (smokeless tobacco, AOR = 2.27, 95% CI 1.12-4.61) and teeth loss (AOR = 2.02, 95% CI 1.21-3.38) as the significant factors associated with periodontitis.

CONCLUSION

The prevalence of periodontitis is high in the surveyed rural adult population. Cigarette smoking along with the use of smokeless tobacco in the form of khaini were identified as significant factors associated with periodontitis.

Smoking cessation interventions in South Asian countries: protocol for scoping review

INTRODUCTION

Unfortunately, like many other health risks, smoking rate has been on the rise in developing countries. Half of current smokers in the world reside in only three countries of Asia that include India. Many smoking cessation interventions that were developed and successfully implemented in the context of developed countries have not been equally successful in South Asia. Hence, there is a dire need of culturally relevant smoking cessation interventions. We propose a scoping review with objectives to explore the extent and nature of interventions for smoking cessation and its associated factors in South Asian Region by systematically reviewing the available published and unpublished literature.

METHODS AND ANALYSIS

The review has been registered in Joanna Briggs Institute (JBI) systematic reviews register and details are given in the Methodology section. The updated framework of JBI for scoping review methodology will be used as guide for conduct of this scoping review. Electronic databases (PubMed, CINAHL plus, Proquest Theses and Dissertations, EBSCO Dentistry and Oral Sciences, and Wiley Cochrane Library), reference lists of selected studies and grey literature will be considered for inclusion in this review. The literature search is anticipated to be carried out in December-January 2020. Initially, two reviewers in consultation with a librarian will develop search syntax followed by search from the selected sources. Consequently, the reviewers will screen all the titles, abstracts and full articles to establish relevance of each study for inclusion. Factors associated with smoking cessation will be coded and categorised applying qualitative content analysis, while interventions extracted from the literature will be described with the stated level of effectiveness.

Perceived Discrimination, Psychological Distress and Cardiovascular Risk in Migrants in Spain

The aim of the present study is to determine the effect of discrimination and psychological distress on the cardiovascular health of immigrants, as well as to analyse potential differences based on age, gender, length of residence in host country and geographic origin. The sample was formed by 1714 immigrants from Africa, Eastern Europe and Latin America. Of the sample, 48.7% were men and 51.3% were women. Most relevant results show that discrimination (t = 4.27; p = 0.000) and psychological distress (t = 4.35; p = 0.000) experienced by immigrants predict their cardiovascular risk. Furthermore, psychological distress mediates the relation between discrimination and risk (t = 4.03; p = 0.000). Significant differences between men and women were found, as well as differences based on ethnicity, although to a lesser extent. Age affects the relation between discrimination, psychological distress and arterial hypertension and hypercholesterolemia. Results are notably relevant for the design of preventive health programmes for immigrants and intervention strategies in order to prevent diseases that may imply cardiovascular risks and seriously affect immigrants' health.

Prevalence and Correlates of Cultural Smokeless Tobacco Products among South Asian Americans in New York City

Despite the high prevalence of smokeless tobacco (SLT) use in South Asia, little is known about the use of cultural smokeless tobacco among South Asians in the United States (US). This study examines the prevalence and correlates of SLT products among South Asians living in New York City (NYC). A total of 602 South Asians living in NYC completed a community health needs and resource assessment and answered questions about the use of SLT. Multivariable logistic regression models were run to examine predictors of SLT use (ever and current use). A total of 28.2% South Asian individuals reported ever use of SLT (35.9% among men and 21.5% among women) and a total of 12.9% reported current use of SLT (16.5% among men and 9.7% among women). Logistic regression models were stratified by sex. Among men, factors associated with ever or current use included: Bangladeshi and Himalayan ethnic subgroup, speaking English very well, attending a religious service a few times a year (ever use only), and current or former cigarette smoking. Among women, factors associated with ever use included: Bangladeshi ethnic subgroup, self-reporting condition of mouth and teeth as fair/poor, and at risk for depression. No factors were significant among women for current use. Overall, prevalence of current and ever use of SLT is high, and important differences exist by sex. Future studies are needed to better understand SLT use patterns in South Asian communities in the US and to inform culturally relevant interventions aiming to decrease overall tobacco use.

The Ominous beginning" Perceptions of Smokeless Tobacco Initiation among the Paniya Tribes of Wayanad: A qualitative Study

BACKGROUND

The prevalence of tobacco chewing, and related oral mucosal lesions is alarmingly high amongst the Paniya tribes of Wayanad. A deeper understanding of their socio-cultural factors, beliefs, attitudes and behaviours would shed greater insights into the indiscriminate use of smokeless tobacco and related products in this community.

METHODS

Ethnography was the theoretical framework adopted with network and convenience sampling. Fifteen in-depth interviews and two focus group discussions were conducted among the key informants from within the tribal colonies of Cheepram and Madikkunnu. The data was audio recorded and converted into verbatim transcripts. Thematic content analysis was done using an inductive approach performed using computer-assisted qualitative data analysis software (NVivo).

RESULTS

This study is suggestive of parental influence and peer pressure as the key factors for smokeless tobacco initiation amongst the adolescent. There was a greater predisposition for women to be chewers of tobacco, particularly after marriage. The key factors influencing initiation of the habit amongst men include peer pressure and availability of tobacco at workplace. The role of contextual factors such as enculturation, marginalization and perceived health benefits also play a substantial role in development of this habit.

CONCLUSION

Targeted strategies for effective tobacco control can be developed through an understanding of the socio-cultural factors leading to initiation of smokeless tobacco use among disadvantaged communities.

Socioeconomic factors associated with tobacco smoking among adult males in Sri Lanka

Background

Tobacco smoking is considered as a major public health issue worldwide. Reduction of tobacco usage has been one of the main government policies in Sri Lanka and the price of cigarettes has been raised several times in the last few years. The purpose of this study was to evaluate the socioeconomic factors associated with tobacco smoking among adult males in Sri Lanka.

Methods

A study was conducted in Gampaha district in Sri Lanka recruiting 365 tobacco smoking people and their spouses. Data regarding tobacco smoking were obtained using an interviewer administrated questionnaire.

Results

Frequency of tobacco smoking was negatively associated with the improvement of educational levels. Employment, monthly income, influence of friends, smoking frequency before price increment, weekly expenditure for smoking, low educational level and the age of first smoking exposure was significantly associated with tobacco smoking among smokers. According to the spouses, smoking frequency before price increment, weekly expenditure of the husbands of smoking and influence of friends, number on smoking friends, spouse’s employment and husband’s monthly income were factors associated with tobacco smoking of their husbands. In addition, smoking at home, at work places and at friend’s houses was significant with the frequency of daily smoking.

Conclusions

Increasing the price of tobacco products has no significant impact on smoking behaviors in Sri Lanka. The need for essential strategies to educate and motivate the smokers to stop smoking is required. Primary care health workers might play a major role in motivating smokers to quit smoking.

Contextual Factors Related to Conventional and Traditional Tobacco Use Among California Asian Indian Immigrants

California's tobacco control program contracted for tobacco use surveillance of Asian Indian Americans to address the paucity of information about tobacco use in this community, given their growing proportion of California's population. This study examined correlates of conventional (CTU) and Asian Indian traditional tobacco use (TTU) in a population-based sample of predominantly immigrant Asian Indian adults residing in California (N = 3228). The analytic sample (n = 2140) was limited to self-identified immigrants from India. Descriptive statistics, bivariate analyses, and multivariate logistic regressions were conducted to examine correlates of tobacco use among Asian Indian immigrants related to their acculturation and religious affiliation. While 65% of the sample had ever used traditional tobacco products (paan masala, gutka, bidis), only 25% had ever used conventional tobacco (cigarettes, cigar, pipe, chewing tobacco, snuff). Less than 5% reported tobacco use in the past 30 days. Rates of ever TTU and CTU were higher among men than women. Ethnic enclave residence was not associated with tobacco use. Impaired mental health was associated with CTU, and number of years spent in the U.S. was positively associated with both CTU and TTU. Individuals affiliated with Sikhism were less likely to use tobacco than individuals affiliated with Hinduism. Few population-based studies in the U.S. address both CTU and TTU use among Asian Indian immigrants. Tobacco use in Asian Indian immigrants may be seriously underestimated if surveillance is limited to conventional tobacco products. Interventions to reduce tobacco use should address mental health issues and consider religious affiliation.

Socio-economic inequalities in secondhand smoke exposure at home in the context of mother-child pairs in Bangladesh

OBJECTIVES

This study aimed to examine socio-economic disparities in mother-child pairs' self-reported and cotinine-measured secondhand smoke (SHS) exposure at home.

STUDY DESIGN

This is a cross-sectional study.

METHODS

This study was conducted in the Rajshahi district of Bangladesh from May to July 2017. A total of 541 mother-child pairs were interviewed for self-reported measured SHS; cotinine-measured saliva test was performed on 263 mothers and 236 children. Mother-child pairs' SHS exposure at home was the outcome of interest.

RESULTS

Overall self-reported prevalence of SHS exposure at home was 49.0%. Self-reported SHS exposure among mothers (50.2%) and children (51.3%) were lower than the prevalence rate of cotinine-measured exposure for mothers (60.5%) and their children (58.9%). Maternal rich bands of wealth were found to be associated with lower likelihood of self-reported (adjusted odds ratio [AOR] = 0.59, 95% confidence interval [CI] = 0.35-0.99) and cotinine-measured SHS exposure among mothers (AOR = 0.17, 95% CI = 0.08-0.37). Maternal rich bands of wealth were also found to be associated with lower likelihood of cotinine-measured SHS exposure among children (AOR = 0.11, 95% CI = 0.07-0.26).

CONCLUSIONS

Socio-economic inequalities exist in exposure to SHS at home. Interventional approaches aimed at reducing SHS at home are urgently needed at public health and healthcare service level, with special focus given to the socioeconomically disadvantaged groups.

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world's population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.

Moving toward a true depiction of tobacco behavior among Asian Indians in California: Prevalence and factors associated with cultural smokeless tobacco product use

BACKGROUND

Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population.

METHODS

California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use.

RESULTS

The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5).

CONCLUSIONS

The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

The experience and influence of social support and social dynamics on cardiovascular disease prevention in migrant Pakistani communities: A qualitative synthesis

OBJECTIVE

The objective of this research was to synthesise qualitative literature about the perceived influence and experience of social support, in relation to cardiovascular disease (CVD) prevention in migrant Pakistani communities.

METHODS

Articles were systematically reviewed, critically appraised, and analysed using an adapted meta-ethnography approach.

RESULTS

Sixteen qualitative studies on health behaviours related to CVD prevention were included.

FINDINGS

include four sub-themes under two substantive thematic areas that focus on: 1) family dynamics and 2) community dynamics influenced by discrimination. For members of the Pakistani community, gendered family dynamics and discrimination from outside and within community networks influenced behaviour change.

CONCLUSION

The authors of the synthesis developed multi-layered, contextualised interpretations of the care needs of an established multi-generational community. Future qualitative studies taking an intersectional approach to interpreting the role of social networks in migrant communities should take into account gender, identity, culture and faith.

PRACTICE IMPLICATIONS

Health care providers should focus on cultural awareness and sensitivity during consultations. In particular, general practitioners can benefit from the insight they gain from patient experiences, allowing for more appropriate recommendations.

Overcoming Challenges in Recruitment of South Asians for Health Disparities Research in the USA

South Asians-individuals with origins in the countries of Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka, and other regions of the subcontinent-are an understudied and at-risk racial/ethnic minority population for disproportionate burden of preventable diseases in the USA. Notwithstanding lack of research disaggregating Asian American subgroups, a key factor in this paucity of data is the lack of participation and engagement of community members in studies which examine distribution and determinants of adverse health outcomes. The purpose of this case study series is to elucidate distinct barriers in recruitment of South Asians in health disparities research within four diverse study designs. These illustrations are followed by a discussion of effective strategies and promising practices to increase and enhance the participation of community members in health-related studies in order to ultimately understand and address disparities among this rapidly growing cultural group in the US systematic collection of data which not only is representative of this understudied population but also elucidates contextual influences on community health and well-being and is pivotal to the reduction and elimination of preventable disparities among South Asians in the USA.

Awareness and Use of South Asian Tobacco Products Among South Asians in New Jersey

South Asians are the third largest Asian group in the US and among the fastest growing racial groups in New Jersey. Tobacco consumption among South Asians is characterized by several smoked and smokeless tobacco products indigenous to the Indian subcontinent. However, there is a paucity of research on tobacco use behaviors among South Asians in the US. The goal of this study was to examine the awareness and use of South Asian tobacco products such as bidis, gutkha, paan, paan masala, and zarda as well as other potentially carcinogenic products such as supari, their context of use, and their cultural significance among South Asians living in the US. Eight focus groups were conducted with South Asian adults living in Central New Jersey. Overall, participants were aware of a wide variety of foreign and American tobacco products with older South Asians identifying a greater variety of indigenous products compared to younger South Asians. Hookah was consistently recognized as popular among the younger generation while products such as paan or paan masala were more commonly identified with elders. Use of tobacco-related products such as paan and supari were described as common at social gatherings or after meals. In addition, light or social users of South Asian tobacco products, including products not consistently defined as tobacco, may not report tobacco use on a survey. Better understanding of the use of these products among South Asians and how some may classify tobacco usage can inform future research and public health interventions in these communities.

Sociodemographic Correlates of Tobacco Consumption in Rural Gujarat, India

Background. The purpose of this study was to examine occupation-, education-, and gender-specific patterns of tobacco use and knowledge of its health effects among 23,953 rural Asian Indians ≥18 years in Gujarat. Methodology. A statewide, community-based, cross-sectional survey was conducted in 26 districts of Gujarat (December 2010-May 2015), using face-to-face interviews by trained community health workers called SEVAKS. Results. Mean age was 39.8 ± 15.2 years. Eighteen percent of respondents used tobacco in various forms. Tobacco consumption was significantly higher among males (32%), 18-34 years' age group (35%), those who were self-employed (72%), and those with elementary education (40%). The prevalence was 11 times higher among males than females (95% CI = 9.78, 13.13). Adjusted ORs for tobacco use showed strong gradient by age and educational level; consumption was lower among the illiterates and higher for older participants (≥55 years). Tobacco consumption also varied by occupation; that is, those who were self-employed and employed for wages were more likely to use tobacco than those who were unemployed. Knowledge of health effects of tobacco lowered the odds of consumption by 30-40%. Conclusions. Effective educational programs should be tailored by gender, to improve knowledge of health risks and dispel myths on perceived benefits of tobacco.

Gutka and Tambaku Paan use among South Asian immigrants: a focus group study

Smokeless tobacco use is prevalent among South Asian immigrants, particularly in the forms of gutka and tambaku paan. In this paper, we examined (a) gutka and tambaku paan initiation and use patterns among South Asian immigrants, and (b) perceptions related to quitting and tobacco control. Six focus groups were conducted with 39 South Asian adult gutka/tambaku paan users, in three different South Asian languages (Gujarati, Bengali, and Urdu). Participants reported easy availability of gutka and tambaku paan in neighborhood stores, and noted several factors that promoted initiation (including social networks, perceived benefits, and curiosity). Due to awareness of low social acceptance of gutka and tambaku paan in the US, some participants discussed changing patterns of use following immigration. Finally, participants proposed roles of various agencies (e.g., doctors'/dentists' role, government-led initiatives) for tobacco control in South Asian immigrant communities. This research provides implications for improving tobacco control efforts in the United States, particularly for South Asian immigrants.

Working to Eliminate Cancer Health Disparities from Tobacco: A Review of the National Cancer Institute's Community Networks Program

INTRODUCTION

In 2005, the National Cancer Institute funded the Community Networks Program (CNP), which aimed to reduce cancer health disparities in minority racial/ethnic and underserved groups through community-based participatory research, education, and training. The purpose of this study was to describe the CNP model and their tobacco-related work in community-based research, education, and training using a tobacco disparities research framework.

METHODS

We conducted a comprehensive review of the CNP tobacco-related activities including publications, published abstracts, research activities, trainee pilot studies, policy-related activities, educational outreach, and reports produced from 2005-2009. Two authors categorized the tobacco-related activities and publications within the framework.

RESULTS

Although there was no mandate to address tobacco, the CNPs produced 103 tobacco-related peer-reviewed publications, which reflects the largest proportion (12%) of all CNP cancer-related publications. Selected publications and research activities were most numerous under the framework areas "Psychosocial Research," "Surveillance," "Epidemiology," and "Treatment of Nicotine Addiction." Thirteen CNPs participated in tobacco control policymaking in mainstream efforts that affected their local community and populations, and 24 CNPs conducted 1147 tobacco-related educational outreach activities. CNP activities that aimed to build research and infrastructure capacity included nine tobacco-related pilot projects representing 16% of all CNP cancer-related pilot projects, and 17 publications acknowledging leveraged partnerships with other organizations, a strategy encouraged by the CNP.

CONCLUSIONS

The CNP is a promising academic-community model for working to eliminate tobacco-related health disparities. Future efforts may address scientific gaps, consider collaboration across groups, assess the extent of operationalizing community-based participatory research, and improve common tracking measures.

Striatal dopamine release regulation by the cholinergic properties of the smokeless tobacco, gutkha

Tobacco products influence striatal dopamine (DA) release primarily through the actions of nicotine, an agonist of nicotinic acetylcholine receptors (nAChR). Gutkha is a smokeless tobacco product that contains not only nicotine, but also includes the habit-forming areca nut and other plant-based constituents that contribute muscarinic acetylcholine receptor (mAChR) agonists and other cholinergic agents. Thus, the net influence of the cholinergic agents in gutkha on striatal DA release is difficult to predict. This study investigated the influence of gutkha extract on evoked DA release in mouse striatal slices using fast-scan cyclic voltammetry. The potency of a given concentration of nicotine in the gutkha extract was found to be significantly lower than that of a comparable concentration of nicotine alone. Atropine, a mAChR antagonist, increased the potency of gutkha-associated nicotine; however, other experiments suggested that this was mediated in part by direct effects of atropine at nAChRs. Overall, these results suggest that the unique constituents of gutkha work together to oppose the influence of gutkha-associated nicotine on evoked striatal DA release.

Use of smokeless tobacco by Indian women aged 18-40 years during pregnancy and reproductive years

Objectives

This paper discusses patterns of daily smokeless tobacco (SLT) use and correlates of poly SLT use among married women aged 18–40 years in a Mumbai slum community with implications for tobacco control.

Methods

Using a mixed methods approach, the study included a structured survey with 409 daily SLT users and in-depth interviews with 42 women. Participants for the survey were selected using a systematic sampling procedure (one woman in every fourth eligible household). Univariate and bivariate analysis, and multiple logistic regressions were conducted to identify demographic and social factors associated with women’s use of poly SLT products. To illustrate survey results, in-depth interviews were analyzed using Atlas ti software.

Results

Sixty-four percent of the women surveyed used only one type of SLT; of these, 30% used mishri, 32% used pan with tobacco and the rest used chewed tobacco (11%), gul (17%) or gutkha (10%). Thirty-six percent used more than one type of SLT. Poly SLT users chewed or rubbed 50% more tobacco as compared to single users (mean consumption of tobacco per day: 9.54 vs. 6.49 grams; p<0.001). Women were more likely to be poly SLT users if they were illiterate as compared to literate (adjusted odds ratio [AOR]=1.67; 95% confidence interval [CI]=1.07-2.71), if they had lived in Mumbai for 10 years or more, versus less than ten years (AOR=1.67, 95% CI=1.03-2.71); and if their husband was a poly SLT user as compared to a non SLT user (AOR=2.78, 95% CI=1.63-4.76). No differences were noted between pregnant and non-pregnant women in SLT consumption patterns.

Conclusions

Tobacco control policies and programs must focus specifically on both social context and use patterns to address SLT use among women of reproductive age with special attention to poly SLT users, an understudied and vulnerable population.

Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

Reigniting tobacco ritual: waterpipe tobacco smoking establishment culture in the United States

INTRODUCTION

Waterpipe tobacco smoking (WTS) is an increasingly prevalent form of tobacco use in the United States. Its appeal may stem from its social, ritualistic, and aesthetic nature. Our aim in this study was to understand WTS as a social ritual with the goal of informing prevention efforts.

METHODS

We conducted a covert observational study consisting of 38 observation sessions in 11 WTS establishments in 3 U.S. cities. Data collection was based on an established conceptual framework describing ritualistic elements of tobacco use. Iterative codebook development and qualitative thematic synthesis were used to analyze data.

RESULTS

Atmospheres ranged from quiet coffee shop to boisterous bar party environments. While some children and older adults were present, the majority of clientele were young adults. Men and women were evenly represented. However, there were 19 occurrences of a male smoking by himself, but no women smoked alone. The vast majority (94%) of the clientele were actively smoking waterpipes. All 83 observed groups manifested at least 1 of the ritual elements of our conceptual framework, while 41 of the 83 observed groups (49%) demonstrated all 4 ritual elements.

CONCLUSIONS

Despite its heterogeneity, WTS is often characterized by 1 or more established elements of a tobacco-related social ritual. It may be valuable for clinical and public health interventions to acknowledge and address the ritualistic elements and social function of WTS.

Disengagement beliefs in South Asian immigrant smokeless tobacco users: A qualitative study

Gutka and tambaku paan (smokeless tobacco products used by South Asian immigrants) are carcinogenic to humans (and perceived as such), yet, one-fourth of South Asian immigrants report current use. This study examined disengagement beliefs that perpetuate gutka/tambaku paan use among South Asians despite awareness of health risks. Six focus groups were conducted with immigrant South Asian adult gutka/tambaku paan users, in Gujarati, Bengali and Urdu languages in New York, USA. Participants included 39 South Asian adults residing in the New York City Metropolitan area, current (a minimum of weekly gutka or tambaku paan use in the last 12 months) or former (regular use prior to past 12 months) gutka or tambaku paan users and self-reported spoken fluency in Gujarati, Urdu or Bengali languages. Participants identified many health risks associated with gutka/tambaku paan use including locked jaw, high blood pressure and cancer. Five themes of disengagement beliefs emerged: (a) skepticism about the gutka/tambaku paan-cancer link, (b) perceived invulnerability to harm, (c) compensatory beliefs, (d) faith-based rationalization and (e) acknowledgment of addiction. To promote smokeless tobacco cessation among South Asians, interventions to counter disengagement beliefs and heighten the discomfort between the dissonant cognitions represent a promising area warranting further attention.

Asian American, Native Hawaiian and Pacific Islander tobacco use patterns

OBJECTIVES

To provide a national depiction of Asian American (AA) and Native Hawaiian/Pacific Islander (NHPI) tobacco use and highlight considerations for targeted interventions.

METHODS

We analyzed data from the 2009-2010 National Adult Tobacco Survey for subgroup differences in prevalence and consumption of various tobacco products.

RESULTS

Use varies considerably by ethnic subgroups for cigarette smoking (including menthol) and other forms of tobacco. Despite being lighter, less frequent, and seemingly less dependent smokers, AANHPIs had similar quit ratios as non-AANHPIs.

CONCLUSIONS

AA and NHPI disparities in tobacco use may be due to underutilization of cessation resources, including those for non-cigarette tobacco products, and lack of availability of culturally-appropriate resources. Community-based and regulatory approaches should be employed to reduce use of all tobacco products, especially among high prevalence subgroups.

The changing face of tobacco use among United States youth

Tobacco use, primarily in the form of cigarettes, is the leading cause of preventable morbidity and mortality in the United States (U.S.). The adverse effects of tobacco use began to be recognized in the 1940's and new hazards of active smoking and secondhand smoke (SHS) exposure from cigarettes continue to be identified to this day. This has led to a sustained and wide-ranging array of highly effective regulatory, public health, and clinical efforts that have been informed by extensive scientific data, resulting in marked decreases in the use of cigarettes. Unfortunately, the dramatic recent decline in cigarette use in the U.S., has been accompanied by an upsurge in adolescent and young adult use of new, non-cigarette tobacco and nicotine-delivery products, commonly referred to as alternative tobacco products (ATPs). Commonly used ATPs include hookah, cigars, smokeless tobacco, and electronic cigarettes. While there have been a number of review articles that focus on adult ATP use, the purpose of this review is to provide an overview of what is, and is not known about emerging ATP use among U.S. adolescents on a national scale; as well as to identify research gaps in knowledge, and discuss future health and policy needs for this growing public health concern. This paper is not meant to systemically review all published survey data, but to present clear depiction of selected ATP usage in youth populations using national survey data.

A conceptual framework for managing modifiable risk factors for cardiovascular diseases in Fiji

AIMS

The current review will look at modifiable lifestyle (physical inactivity, poor nutrition, risky alcohol behavior and cigarette smoking) and cardio-metabolic (obesity, diabetes mellitus, high cholesterol and high blood pressure) cardiovascular disease (CVD) risk factors among Indigenous-Fijian and Indo-Fijian subgroups. A framework for monitoring and managing these risk factors will be presented.

METHODS

National health surveys were identified where available. Electronic databases identified sources for filling missing data. The most relevant data were identified, organized and synthesized.

RESULTS

Compared to Indo-Fijians, Indigenous-Fijians have higher rates of obesity (17% vs 11%) and hypertension (21% vs 16%), but lower rates of diabetes mellitus (12% vs 21%) and high cholesterol (33% vs 39%). Indigenous-Fijians report higher rates of prescribed physical activity (25% vs 21%), but poorer recommended vegetable intake (48% vs 56%), greater risky alcohol behavior (17% vs 15%) and a much greater prevalence of cigarette smoking (45% vs 24%). Both Indigenous-Fijians and Indo-Fijians report a low prevalence of recommended fruit intake (17% vs 15%).

CONCLUSIONS

Fiji is progressing through demographic and epidemiological transitions, including a decline in infectious diseases and improved life expectancy. However, in concert with other developing nations, 'modernization' is accompanied by increased mortality from non-communicable diseases, with CVD being the most prevalent. This transition has been associated with changes to socio-cultural aspects of Fiji, including poor lifestyle choices that may contribute to a cluster of cardio-metabolic conditions which precede CVD.

Culturally Specific Tobacco Use and South Asians in the United States

Over the past two decades, the United States has attracted large South Asian populations, who have imported tobacco products previously unique to the native subcontinent. South Asian cigarette use prevalence is consistently lower than other U.S. Asian subgroups; however, most surveys fail to capture smokeless products accurately. In part because of the pervasive use of popular smokeless cultural products resulting in greater population attributable risk of oral malignancies, many countries outside the United States have developed surveillance systems to capture these products and implemented effective population-level or community-based intervention strategies. This minority population in the United States continues to be “at risk” of suffering from a disproportionate burden of diseases, which are plausibly linked to the use of these products. The primary focus of this article is to provide an exhaustive literature review of tobacco use patterns and existing tobacco control strategies among South Asians in the United States. Framed within the social ecological model, the article suggests that there needs to be more detailed assessment of cultural tobacco products, a concurrent increase in cultural competencies of health care providers and provision of cessation resources outside the clinical setting. At the policy level, future efforts should adequately regulate these products and oversight must include such products in efforts to reduce rates of use. Concurrently, community-based efforts are needed to change social norms related to perceived health benefit and lack of stigma. This will help ensure that appropriately framed messages around use rates and burden of disease are addressed through culturally valued institutions and leaders.