A review of trade practices of smokeless tobacco products in terms of prohibition on sale, manufacturing & importation in Framework Convention on Tobacco Control ratified Parties

Social Determinants and the Prevalence of Paan Masala Use among Adults in India: Results from Global Adult Tobacco Survey, 2016-17

BACKGROUND

Gutkha or Paan masala with tobacco is commonly used smokeless tobacco product in India. Given the restrictions on advertisement and promotion of Gutkha and the necessity of warning labels on tobacco products, the tobacco industry has popularised paan masala without tobacco as a surrogate product. Paan masala itself is harmful for health but remains beyond scope of current tobacco control policies. It was important to understand prevalence and determinants of its use (with or without tobacco).

METHODS

Data from the Global Adult Tobacco Survey (GATS)-2, India was used to estimate prevalence of paan masala use (with or without tobacco) in India. Multi-nominal regression and logistic regression were used to calculate risk ratios and odds ratios.

RESULTS

The prevalence of any form of paan masala was 12.1% among adults in India. Prevalence was higher among males (17.8%) than females (6.0%), aged 25-44 years (14.5%) than those aged 65 years or above (9.0%). Relative risk ratio (RRR) for Paan masala with tobacco was significantly high among those with no formal schooling (RRR:2.00) and among those in poorest wealth quintiles (RRR:1.26). While, RRR were lower for Paan masala use without tobacco among those with no formal schooling (RRR:0.95) and among poorest wealth quintiles (RRR:0.78). Region-wise AOR were highest for North-East (AOR:4.80) and Central regions (AOR:4.76) compared to South India.

CONCLUSION

The prevalence of paan masala use is high in India. Persons belonging to lower socioeconomic status or having no formal schooling have higher risk of consuming paan masala with tobacco. However, persons from higher wealth quintiles or having formal schooling had higher risk of use of paan masala without tobacco. These findings need careful attention of policy makers and law enforcers as it indicates different marketing strategies might have adopted by industry to target these two mutually exclusive population groups.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK National Institute for Health Research.

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

We examined the magnitude of smokeless tobacco (SLT) use in India and identified policy gaps to ascertain the priorities for SLT control in India and other high SLT burden countries in the Southeast Asia region. We reviewed and analysed the legal and policy framework to identify policy gaps, options and priority areas to address the SLT burden in India and lessons thereof. In India, 21.4% adults, including 29.6% of men, 12.8% of women, use SLT while more than 0.35 million Indians die every year due to SLT use. SLT use remains a huge public health concern for other countries in the region as well. Priority areas for SLT control should include: constant monitoring, increasing taxes and price of SLT products, strengthening and strict enforcement of existing laws, integration of SLT cessation with all health and development programmes, banning of advertisement and promotion of SLT, increasing age of access to tobacco up to 21 years, introducing licensing for the sale of SLT, standardising of SLT packaging and preventing SLT industry interference in the implementation of SLT control policies besides a committed multistakeholder approach for effective policy formulation and enforcement. SLT control in India and the other high SLT burden countries, especially in the Southeast Asia region, should focus on strengthening and implementing the above policy priorities.

District-level epidemiology, hot spots and sociodemographic determinants of tobacco use in Indian men and women: analysis of national family health survey-4 (2015-16)

OBJECTIVES

To map district-level tobacco hot spots and understand the Sociodemographic Indices (SDI) influencing tobacco consumption in Indian men and women.

STUDY DESIGN

Cross-sectional study.

METHODS

Tobacco use data from 640 districts of India were extracted from National Family Health Survey-4, carried out from 2015 to 2016 with a sample size of 103,411 men and 699,686 women. Geographic Information System was used to map the tobacco prevalence, and hot spots were identified by spatial statistics (Getis-OrdGi∗). SDI were studied by bivariate analyses and binary logistic regression.

RESULTS

India has two major tobacco hot spots; one comprising the districts of North-Eastern states, excluding Sikkim, and the second cluster is formed by the districts of Central-Eastern states. These hot spots coincide well with demographic determinants: North-East (adjusted odds ratio [aOR] men, 5.74; aOR women, 13.54) and Central India (aOR men, 4.5; aOR women, 3.5) have higher odds of Tobacco consumption. In men, respondents with no education (aOR 2.52; 95% confidence interval [CI]: 2.26-2.81) and Muslims (aOR 3.53; 95% CI: 2.93-4.26) have higher odds of tobacco consumption. The poorest (men aOR, 2.06; 95% CI: 1.87-2.27; women aOR, 3.36: 95% CI: 2.69-4.19) and ST women (aOR 1.89; 95% CI: 1.68-2.13) have higher odds of tobacco consumption.

CONCLUSIONS

We have identified tobacco hot spots and detailed the SDI affecting tobacco use separately in men and women to guide public health policies for targeted intervention of tobacco consumption.

Cigarette and E-Cigarette Use and Smoking Cessation Practices among Physicians in Poland

Physicians play a key role in combating tobacco use. This study aims to evaluate the knowledge, attitude, and behaviors toward smoking cessation and vaping cessation interventions among physicians in Poland; to identify factors shaping physicians’ behaviors toward smoking and vaping cessation interventions; and to assess differences in the tobacco cessation interventions recommended for cigarette smokers and users of electronic cigarettes (e-cigarettes). A questionnaire-based survey was conducted in 2018 among physicians attending mandatory public health training courses delivered at the School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland. The questionnaire included 25 questions related to tobacco product use and smoking cessation interventions. Data were obtained from 423 physicians (64.3% female; mean age 32.0 ± 5.8 years) with response rate of 84.6%. Current cigarette smoking was declared by 7.8% of participants; 1.9% of participants were e-cigarette users and 1.9% used heated tobacco. Smoking cessation interventions were offered more often to patients who smoked cigarettes than those who used e-cigarettes (p < 0.001). Physicians’ behaviors toward smoking cessation and vaping cessation interventions were associated with (p < 0.05) physicians’ smoking status and self-declared knowledge about smoking cessation methods. Among physicians in Poland, discussion of smoking cessation was not common behavior and limited mainly to identification of smoking status.