Is there any association between use of smokeless tobacco products and coronary heart disease in Bangladesh?

Health effects associated with chewing tobacco: a Burden of Proof study

Chewing tobacco use poses serious health risks; yet it has not received as much attention as other tobacco-related products. This study synthesizes existing evidence regarding the health impacts of chewing tobacco while accounting for various sources of uncertainty. We conducted a systematic review and meta-analysis of chewing tobacco and seven health outcomes, drawing on 103 studies published from 1970 to 2023. We use a Burden of Proof meta-analysis to generate conservative risk estimates and find weak-to-moderate evidence that tobacco chewers have an increased risk of stroke, lip and oral cavity cancer, esophageal cancer, nasopharynx cancer, other pharynx cancer, and laryngeal cancer. We additionally find insufficient evidence of an association between chewing tobacco and ischemic heart disease. Our findings highlight a need for policy makers, researchers, and communities at risk to devote greater attention to chewing tobacco by both advancing tobacco control efforts and investing in strengthening the existing evidence base.

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults

BACKGROUND

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP).

METHODS

We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina.

RESULTS

A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts.

CONCLUSIONS

The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

Genetic and Non-genetic Determinants of Cardiovascular Disease in South Asians

South Asians (SAs), people from the Indian subcontinent (e.g., India, Pakistan, Bangladesh, Sri Lanka, and Nepal) have a higher prevalence of cardiovascular disease (CVD) and suffer from a greater risk of CVD-associated mortality compared to other global populations. These problems are compounded by the alterations in lifestyles due to urbanization and changing cultural, social, economic, and political environments. Current methods of CV risk prediction are based on white populations that under-estimate the CVD risk in SAs. Prospective studies are required to obtain actual CVD morbidity/mortality rates so that comparisons between predicted CVD risk can be made with actual events. Overwhelming data support a strong influence of genetic factors. Genome-Wide Association Studies (GWAS) serve as a starting point for future genetic and functional studies since the mechanisms of action by which these associated loci influence CVD is still unclear. It is difficult to predict the potential implication of these findings in clinical settings. This review provides a systematic assessment of the risk factors, genetics, and environmental causes of CV health disparity in SAs, and highlights progress made in clinical and genomics discoveries in the rapidly evolving field, which has the potential to show clinical relevance in the near future.

Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries

BACKGROUND

Smokeless tobacco (ST) is consumed by more than 300 million people worldwide. The distribution, determinants and health risks of ST differ from that of smoking; hence, there is a need to highlight its distinct health impact. We present the latest estimates of the global burden of disease due to ST use.

METHODS

The ST-related disease burden was estimated for all countries reporting its use among adults. Using systematic searches, we first identified country-specific prevalence of ST use in men and women. We then revised our previously published disease risk estimates for oral, pharyngeal and oesophageal cancers and cardiovascular diseases by updating our systematic reviews and meta-analyses of observational studies. The updated country-specific prevalence of ST and disease risk estimates, including data up to 2019, allowed us to revise the population attributable fraction (PAF) for ST for each country. Finally, we estimated the disease burden attributable to ST for each country as a proportion of the DALYs lost and deaths reported in the 2017 Global Burden of Disease study.

RESULTS

ST use in adults was reported in 127 countries; the highest rates of consumption were in South and Southeast Asia. The risk estimates for cancers were also highest in this region. In 2017, at least 2.5 million DALYs and 90,791 lives were lost across the globe due to oral, pharyngeal and oesophageal cancers that can be attributed to ST. Based on risk estimates obtained from the INTERHEART study, over 6 million DALYs and 258,006 lives were lost from ischaemic heart disease that can be attributed to ST. Three-quarters of the ST-related disease burden was among men. Geographically, > 85% of the ST-related burden was in South and Southeast Asia, India accounting for 70%, Pakistan for 7% and Bangladesh for 5% DALYs lost.

CONCLUSIONS

ST is used across the globe and poses a major public health threat predominantly in South and Southeast Asia. While our disease risk estimates are based on a limited evidence of modest quality, the likely ST-related disease burden is substantial. In high-burden countries, ST use needs to be regulated through comprehensive implementation of the World Health Organization Framework Convention for Tobacco Control.

N, K. S, C. VK, K. ND, C. SK, Maddu N. Smokeless tobacco induced biophysical and biochemical alterations in the plasma, erythrocytes, and platelets of panmasala users: Subsequent biological effects

AIM & BACKGROUND

Smokeless tobacco (SLT) products are extensively consumed throughout the world including India. These products act as the primary addictive agents, due to the presence of nicotine among other tobacco products to humans and animals and its quitting is difficult. Higher the exposure of SLT products more is the toxic effects and alterations in erythrocytes and platelets.

OBJECTIVES

The products of smokeless tobacco could cause increase in the concentrations of oxidants (free radicals), decrease the activities antioxidant enzymes, activate the process of programmed cell death through enhanced expression of inducible nitric oxide synthase. Smokeless tobacco products represent a major modifiable risk factor for the development of redox imbalance through the enhanced production of reactive oxygen species and diminished activities of antioxidant enzymes in plasma, bio-membranes of erythrocytes, and platelets and induction of apoptosis in the blood.

MATERIALS AND METHODS

The protein expression of inducible nitric oxide synthase (iNOS) was studied by western blot and gene expression of apoptotic proteins, tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) was evaluated by RT-PCR technique. Membrane fluidity of erythrocytes and platelets was studied by the fluorescence method.

RESULTS

The results of the present study revealed that significantly elevated levels of iNOS enzyme in plasma, erythrocyte, and platelet membranes of panmasala users. We found that gene expression levels of Bcl2, Bax, IL-6, caspase proteins (Caspase 8, Caspase 10, and Caspase 12) are greater and decreased levels of TNF-α with no significant change in blood of smokeless tobacco users in comparison with normal controls. In addition, there were substantial significantly higher in concentrations of nicotine, cotinine, and epinephrine in the plasma of panmasala users than non-tobacco users. Panmasala can be caused a significant increase in nitroxidative stress marker (LPO, NO, and ONOO-) values and significant decrease in the levels of antioxidant enzymes in erythrocytes and platelets.

CONCLUSION

On the basis of the present study results, it may be concluded that the chronic use of panmasala than any smokeless tobacco products may be a contributory risk factor or may give conclusive idea and has been associated with the expansion of the development of structural and functional alterations in the erythrocyte and platelet membranes induced oxidative damage and apoptosis, possibly further enhanced by nicotine and tobacco-specific N-nitrosamines. SLT exposure had implicated a threat and enormous implications on public health and is required to prove that may not be viewed as a safe alternative to any tobacco products.

Does menopausal status have an effect on body mass index and blood pressure?

Aim of the study was to understand the relationship of menopausal status with BMI and blood pressure. The study area was selected through multistage sampling technique covering six districts of West Bengal, a state located at the eastern part of India. 1400 participants were selected for the study. The participants were divided into four groups on the basis of menopausal status: early and late perimenopausal; early and late postmenopausal. Results shows that menopausal status was significantly associated with Body Mass Index (BMI) and Mean Arterial Pressure (MAP), after controlling the effect of covariates such as participants' age, reproductive behavior, diet and addiction to tobacco use.

Risk of Coronary Heart Disease Among Smokeless Tobacco Users: Results of Systematic Review and Meta-Analysis of Global Data

Background

Use of smokeless tobacco (SLT) products has been linked to multiple adverse effects, especially precancer and cancer of oral cavity. However, the association of SLT use with risk of coronary heart disease (CHD) is shrouded with controversy due to conflicting results in the literature. The present meta-analysis aimed to evaluate the risk of CHD among adult ever-users of SLT products along with sub-group analysis.

Methods

The analysis included studies retrieved from a systematic literature search for published articles assessing risk of CHD with SLT use. Two authors independently extracted risk estimates and study characteristics of the included studies. Summary relative risks were estimated using the random-effect model.

Results

Twenty studies from four WHO regions were included in the analysis. The summary risk of CHD in SLT users was not significantly positive (1.05, 95% CI = 0.96 to 1.15) although a higher risk of fatal CHD was seen (1.10, 95% CI = 1.00 to 1.20). The risk was significant for users in European Region (1.30, 95% CI = 1.14 to 1.47). The results remained unchanged even after strict adjustment for smoking. Product-wise analysis revealed a significant positive association of fatal CHD with snus/snuff use (1.37, 95% CI = 1.14 to 1.61). The SLT-attributable fraction of fatal CHD was calculated to be 0.3%, highest being for European region (5%).

Conclusion

A significant positive association was detected between SLT use and risk of fatal CHD, especially for European users and those consuming snus/snuff. In view of the positive association even after strict adjustment for smoking, these results underscore the need for inclusion of cessation efforts for smokeless tobacco in addition to smoking for control of fatal cardiovascular diseases.

Implications

The present meta-analysis demonstrates a global perspective of association between coronary heart disease (CHD) and use of smokeless tobacco (SLT), especially for fatal cardiac events, even with strict adjustment for smoking. There appears to be some difference in this effect based on the type of SLT product used. These results highlight the independent deleterious effect of SLT products on the outcome of CHD and might help to resolve the long-standing controversy regarding the association of SLT with the risk of CHD. Hence, we propose that in addition to smoking, cessation efforts should be directed towards SLT products as well, for control of cardiovascular diseases.

Tobacco Smoking and Use of Smokeless Tobacco and Their Association with Psychological Distress and Other Factors in a Rural District in Bangladesh: A Cross-Sectional Study

Background

Tobacco smoking and use of smokeless tobacco are the most preventable cause of death in Bangladesh. The prevalence of psychological distress is increasing globally. This paper reports the smoking status and their association with psychological distress and other factors in a rural district, Narail, of Bangladesh.

Materials and Methods

Data were collected from 2425 adults of age 18–90 years. Smoking status along with sociodemographic characteristics and measures of psychological distress using the Kessler 10-item questionnaire were collected using a face-to-face data collection method.

Results

The crude (age-standardized) prevalence of ever smoking was 27.1 (24.3)% that includes current 25.6 (23.7) and smoker 1.5 (0.6)%, and the prevalence of smokeless tobacco (SLT) was 23.5 (13.4)%. The prevalence of ever smoking was the highest in daily labourers (62.9%) and SLT use was the highest in widowed people (47.2%). After adjustment for covariates, no education (odds ratio (OR): 3.78, 95% confidence interval (CI): 1.57–9.07 for females and OR: 2.69, 95% CI: 1.87–3.87 for males) compared to at least secondary level of education and daily labours (OR: 6.66, 95% CI: 1.67–26.6 for females and OR: 5.12, 95% CI: 1.30–20.19 for males) compared to housework were associated with higher prevalence of ever smoking. Any level of psychological distress, such as mild psychological distress, was associated with at least double the prevalence of tobacco smoking in females (OR: 2.12, 95% CI: 1.67–3.83) but not in males (OR: 1.12, 95% CI: 0.80–1.56). Psychological distress was not associated with SLT use.

Conclusions

Prevalence of both smoking and SLT use was high, particularly in daily labourers, people with no education, and females with psychological distress in rural Bangladesh. Appropriate intervention programs should especially target those of low levels of education and laborious occupations for increasing awareness for the cessation of smoking in rural Bangladesh.

Association between iq'mik smokeless tobacco use and cardiometabolic risk profile among Yup'ik Alaska Native people

OBJECTIVE

The traditional lifestyle of Yup'ik Alaska Native people, including a diet abundant in marine-based foods and physical activity, may be cardio-protective. However, iq'mik, a traditional form of smokeless tobacco used by >50% of Yup'ik adults, could increase cardiometabolic (CM) risk. Our objective was to characterize the associations between iq'mik use and biomarkers of CM status (low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], systolic blood pressure [SBP] and diastolic blood pressure [DBP], glycated hemoglobin [HbA1c], fasting blood glucose [FBG], waist circumference [WC], and body mass index [BMI]).

DESIGN

We assessed these associations using data from a cross-sectional sample of Yup'ik adults (n = 874). Current iq'mik use, demographic, and lifestyle data were collected through interviews. Fasting blood samples were collected to measure LDL-C, HDL-C, TG, HbA1c, and FBG. SBP, DBP, WC, and BMI were obtained by physical examination. We characterized the association between current iq'mik use and continuous biomarkers of CM status using multiple approaches, including adjustment for measures of Yup'ik lifestyle and a propensity score.

RESULTS

Based on either adjustment method, current iq'mik use was significantly and positively associated with at least 5% higher HDL-C, and significantly associated but in an inverse direction with multiple biomarkers of CM status including 7% lower TG, 0.05% lower HbA1c, 2% lower FBG, 4% lower WC, and 4% lower BMI. Observed associations for LDL-C, SBP, and DBP varied by adjustment method.

CONCLUSIONS

This inverse association between iq'mik use and cardiometabolic risk status has not been previously reported. Additional research is needed to replicate these findings and explore physiological mechanisms and/or confounding factors.

A systematic review on association between smokeless tobacco & cardiovascular diseases

BACKGROUND & OBJECTIVES

The association of smokeless tobacco (SLT) with cardiovascular diseases has remained controversial due to conflicting reports from various countries. Earlier meta-analyses have shown significantly higher risk of fatal myocardial infarction and stroke in SLT users. However, the risk of hypertension (HTN) with SLT products has not been reviewed earlier. This systematic review was undertaken to summarize the evidence available from global literature on the association of SLT with cardiovascular outcomes - heart disease, stroke and HTN.

METHODS

A systematic literature search was performed in PubMed and Google Scholar since their inception till October 2017 using pre-decided search terms and inclusion/exclusion criteria. Data were extracted from studies included independently by two authors and reviewed.

RESULTS

The review included 50 studies - 23 on heart disease, 14 on stroke and 14 on HTN. Majority of the studies evaluating heart disease or stroke were conducted in the European Region and most of these did not find a significant association between SLT use and either of these outcomes. On the other hand, 70 per cent of the studies on HTN were reported from South-East Asian Region and about half of the studies found a higher risk of HTN in SLT users.

INTERPRETATION & CONCLUSIONS

Current available evidence is insufficient to conclusively support the association of cardiovascular diseases with SLT use due to variability in results and methodological constraints in most of the studies. Region and product-specific well-designed studies are required to provide this evidence to the policymakers. However, advice on cessation of SLT products should be offered to patients presenting with cardiovascular diseases.

Smokeless tobacco consumption and stillbirth: Population-based case-control study in rural Bangladesh

INTRODUCTION AND AIMS

To investigate the association between smokeless tobacco consumption (STC) during pregnancy and risk of stillbirth.

DESIGN AND METHODS

We conducted a population-based case-control study of 253 cases and 759 randomly selected control women in Madaripur, Bangladesh. We conducted a survey of two rural local government areas, including 8082 women, and identified cases based on self-report of a stillbirth outcome of each participant's first pregnancy. All were asked about STC during their first pregnancy and a range of risk markers and known confounders. Demographic and maternal variables associated either with stillbirth or STC were included in logistic regression models.

RESULTS

Of the 241 cases and 757 controls with complete exposure data, 32 cases (13.2%) and 18 controls (2.4%) reported STC during pregnancy [odds ratio 6.28; 95% confidence interval (CI) 3.45, 11.4]. After adjustment for education, household income, age at first pregnancy, vaccination during pregnancy, complications, exposure to arsenic in drinking water, place of delivery and antenatal care, excess risk was attenuated but remained significant [adjusted odds ratio (aOR) 2.87; 95% CI 1.36, 6.08]. There was a dose-effect association, with women who used smokeless tobacco >5 times daily during their first pregnancy at greater risk of having a stillbirth (aOR 5.89; 95% CI 1.70, 20.3) than less frequent users (aOR 1.67; 95% CI 0.65, 4.29). Estimates were robust to extreme assumptions about missing exposure data.

DISCUSSION AND CONCLUSIONS

STC during pregnancy was associated with an increased risk of stillbirth. This finding adds to the urgency of need for smokeless tobacco control strategies to be implemented in South Asia. [Hossain MS, Kypri K, Rahman B,Milton AH. Smokeless tobacco consumption and stillbirth: Population-based case-control study in rural Bangladesh.

Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries

BACKGROUND

Smokeless tobacco is consumed in most countries in the world. In view of its widespread use and increasing awareness of the associated risks, there is a need for a detailed assessment of its impact on health. We present the first global estimates of the burden of disease due to consumption of smokeless tobacco by adults.

METHODS

The burden attributable to smokeless tobacco use in adults was estimated as a proportion of the disability-adjusted life-years (DALYs) lost and deaths reported in the 2010 Global Burden of Disease study. We used the comparative risk assessment method, which evaluates changes in population health that result from modifying a population's exposure to a risk factor. Population exposure was extrapolated from country-specific prevalence of smokeless tobacco consumption, and changes in population health were estimated using disease-specific risk estimates (relative risks/odds ratios) associated with it. Country-specific prevalence estimates were obtained through systematically searching for all relevant studies. Disease-specific risks were estimated by conducting systematic reviews and meta-analyses based on epidemiological studies.

RESULTS

We found adult smokeless tobacco consumption figures for 115 countries and estimated burden of disease figures for 113 of these countries. Our estimates indicate that in 2010, smokeless tobacco use led to 1.7 million DALYs lost and 62,283 deaths due to cancers of mouth, pharynx and oesophagus and, based on data from the benchmark 52 country INTERHEART study, 4.7 million DALYs lost and 204,309 deaths from ischaemic heart disease. Over 85 % of this burden was in South-East Asia.

CONCLUSIONS

Smokeless tobacco results in considerable, potentially preventable, global morbidity and mortality from cancer; estimates in relation to ischaemic heart disease need to be interpreted with more caution, but nonetheless suggest that the likely burden of disease is also substantial. The World Health Organization needs to consider incorporating regulation of smokeless tobacco into its Framework Convention for Tobacco Control.

Prevalence and correlates of smokeless tobacco consumption among married women in rural Bangladesh

Objective

To estimate the prevalence and identify correlates of smokeless tobacco consumption among married rural women with a history of at least one pregnancy in Madaripur, Bangladesh.

Materials and Methods

We conducted a cross-sectional survey using an interviewer administered, pre-tested, semi-structured questionnaire. All women living in the study area, aged 18 years and above with at least one pregnancy in their lifetime, who were on the electoral roll and agreed to participate were included in the study. Information on socio-demographic characteristics and smokeless tobacco consumption was collected. Smokeless tobacco consumption was categorized as ‘Current’, ‘Ever but not current’ and ‘Never’. Associations between smokeless tobacco consumption and the explanatory variables were estimated using simple and multiple binary logistic regression.

Results

8074 women participated (response rate 99.9%). The prevalence of ‘Current consumption’, ‘Ever consumption but not current’, and ‘Never consumption’ was 25%, 44% and 31%, respectively. The mean age at first use was 31.5 years. 87% of current consumers reported using either Shadapata or Hakimpuree Jarda. Current consumption was associated with age, level of education, religion, occupation, being an income earner, marital status, and age at first use of smokeless tobacco. After adjustment for demographic variables, current consumption was associated with being over 25 years of age, a lower level of education, being an income earner, being Muslim, and being divorced, separated or widowed.

Conclusion

The prevalence of smokeless tobacco consumption is high among rural women in Bangladesh and the age of onset is considerably older than that for smoking. Smokeless tobacco consumption is likely to be producing a considerable burden of non-communicable disease in Bangladesh. Smokeless tobacco control strategies should be implemented.

Coronary artery disease in Bangladesh: a review

Coronary artery disease (CAD) is an increasingly important medical and public health problem, and is the leading cause of mortality in Bangladesh. Like other South Asians, Bangladeshis are unduly prone to develop CAD, which is often premature in onset, follows a rapidly progressive course and angiographically more severe. The underlying pathophysiology is poorly understood. Genetic predisposition, high prevalence of metabolic syndrome and conventional risk factors play important role. Lifestyle related factors, including poor dietary habits, excess saturated and trans fat, high salt intake, and low-level physical activity may be important as well. Some novel risk factors, including hypovitaminosis D, arsenic contamination in water and food-stuff, particulate matter air pollution may play unique role. At the advent of the new millennium, we know little about our real situation. Large scale epidemiological, genetic and clinical researches are needed to explore the different aspects of CAD in Bangladesh.

Rose Angina Questionnaire: validation with cardiologists' diagnoses to detect coronary heart disease in Bangladesh

AIM/OBJECTIVES

The study aimed to validate the Rose Angina Questionnaire (RAQ) to detect coronary heart disease (CHD) by comparing with cardiologists' diagnoses in Bangladesh.

METHODS

Patients aged 40-75 years attending to two cardiac hospitals were diagnosed as either CHD positive or CHD negative by cardiologists. The RAQ was used to reclassify them into CHD positive [RAQ] and CHD negative [RAQ].

FINDINGS

There were 302 CHD positive [cardiologists] and 302 CHD negative [cardiologists] individuals. The RAQ reclassified 194 individuals as CHD positive [RAQ] and 409 individuals as CHD negative [RAQ]. Therefore, the RAQ had 53% sensitivity and 89% specificity. There was no difference in sensitivity and specificity during subgroup analyzes by age and gender; the sensitivity was higher among people from lower socio-economic status.

CONCLUSION

The RAQ, having moderate sensitivity but high specificity to detect CHD, can be used to screen individuals at risk of CHD in large-scale epidemiological surveys.

Oral Candida carriage and species prevalence amongst habitual gutka-chewers and non-chewers

Oral Candida colonisation is higher in tobacco smokers as compared to non-smokers; however, it remains unknown whether smokeless tobacco chewers are susceptible to increased oral Candida colonisation. The aim was to determine the oral Candida carriage and species prevalence amongst habitual gutka-chewers and non-chewers in a cohort from Karachi, Pakistan. Forty-five gutka-chewers and 45 non-chewers were included. Information regarding age, sex, duration of gutka-chewing habit, daily frequency of gutka consumption, duration of holding gutka in the mouth, daily frequency of tooth-brushing and tongue brushing was collected using a questionnaire. Oral yeast samples were collected by scraping the dorsum of the tongue and bilateral buccal mucosa with a sterile cotton swab. Identification of yeast species was performed using standard techniques. Tongue lesions were identified and recorded. Unstimulated whole salivary flow rate (UWSFR) was also measured. There was no significant difference in the mean age, UWSFR and oral Candida carriage among gutka-chewers and non-chewers. Individuals were chewing gutka since 4·4 years and were consuming five gutka sachets daily. Candida albicans (C. albicans) was the most common yeast species isolated from 57·8% gutka-chewers and 64.4% non-chewers. In 24.4% gutka-chewers and 22·2% non-chewers, two candidal strains (C. albicans and Candida tropicalis) were isolated. In conclusion, the present results indicated no significant difference in oral Candida carriage in habitual gutka-chewers and non-chewers.

Why Do Bangladeshi People Use Smokeless Tobacco Products?

Despite scientific evidence about the harmful effects of smokeless tobacco (SLT), it is widely used in Bangladesh. This study explored perceptions about health effects of SLT use. Semistructured interviews were conducted with 1812 nonsmoking adults. About 40% of the participants were current SLT users or had used SLT in the past. Family members’ influence was the main factor for initiation. The participants believed that people continued using SLT because of addiction (52%) and as a part of their lifestyle (23%). The majority of participants (77%) did not mention any benefit, but SLT users considered it to be a remedy for toothache ( P < .05). Almost all participants mentioned that SLT was harmful and causes heart disease, cancer, and tuberculosis. Doctors’ advice was the common motivating factor to quit. Health promotion interventions should highlight the adverse effects of SLT use, which outweigh the perceived benefits, and should consider addressing the role of family in SLT initiation and use.