Non-compliant packaging and illicit smokeless tobacco in Bangladesh, India and Pakistan: findings of a pack analysis

INTRODUCTION

Illicit smokeless tobacco (ST) trade has seldom been documented despite ST use in at least 127 countries across the world. Based on non-compliance with packaging regulations, we report the proportion of illicit ST products from samples on sale in Bangladesh, India and Pakistan where 85% of global ST users reside.

METHODS

We purchased unique ST products from tobacco sellers in two purposively selected administrative areas (division/district) in each of the three countries. The criteria to determine illicit ST products were based on country-specific legal requirements for ST packaging and labelling. These requirements included: 'market retail price disclosure', 'sale statement disclosure', 'pictorial health warning (PHW) pertinence', 'appropriate textual health warning' and 'using misleading descriptors (MDs)'. Non-compliance with even one of the legal requirements was considered to render the ST product illicit.

RESULTS

Almost all ST products bought in Bangladesh and India were non-compliant with the local packaging requirements and hence potentially illicit, all products in Pakistan lacked desirable features. The most common feature missing was health warnings: 84% packs in Bangladesh, 93% in India, and 100% in Pakistan either did not have PHW or their sizes were too small. In Bangladesh, 61% packs carried MDs. In India and Pakistan, the proportions of such packs were 32% and 42%, respectively.

CONCLUSIONS

Weak and poorly enforced ST control policies may be slowing the progress of tobacco control in South Asia. Standardised regulations are required for packaging and labelling ST. Improving compliance and reducing sale of cheap illicit products may require business licensing and market surveillance.

Multicomponent Behavioural Intervention during Pregnancy to Reduce Home Exposure to Second-Hand Smoke: A Pilot Randomised Controlled Trial in Bangladesh and India

BACKGROUND

Pregnant women exposed to second-hand smoke (SHS) are at increased risk of poor birth outcomes. We piloted multicomponent behavioural intervention and trial methods in Bangalore, India, and Comilla, Bangladesh.

METHODS

A pilot individual randomised controlled trial with economic and process evaluation components was conducted. Non-tobacco-using pregnant women exposed to SHS were recruited from clinics and randomly allocated to intervention or control (educational leaflet) arms. The process evaluation captured feedback on the trial methods and intervention components. The economic component piloted a service use questionnaire. The primary outcome was saliva cotinine 3 months post-intervention.

RESULTS

Most pregnant women and many husbands engaged with the intervention and rated the components highly, although the cotinine report elicited some anxiety. Forty-eight (Comilla) and fifty-four (Bangalore) women were recruited. The retention at 3 months was 100% (Comilla) and 78% (Bangalore). Primary outcome data were available for 98% (Comilla) and 77% (Bangalore).

CONCLUSIONS

The multicomponent behavioural intervention was feasible to deliver and was acceptable to the interventionists, pregnant women, and husbands. With the intervention, it was possible to recruit, randomise, and retain pregnant women in Bangladesh and India. The cotinine data will inform sample size calculations for a future definitive trial.

The diversity in tobacco use among women of reproductive age (15-49 years) in Pakistan: A secondary analysis of a Multiple Indicator Cluster Survey (MICS) 2016-2018

INTRODUCTION

Tobacco use in women of reproductive age group(15-49 years) may contribute to poor maternal and child health outcomes. We estimated the prevalence of smokeless tobacco (ST), cigarette, and waterpipe use among these women in Pakistan and explored associations with socio-economic differences and birthweights after recent childbirths (past 2 years).

METHODS

We used the Multiple Indicator Cluster Surveys(MICS) datasets from three provinces in Pakistan. Prevalence was generated for current use of tobacco among women with recent childbirth(WWRC) and without recent childbirth(WWoRC). We further compared socio-economic status and birthweights between tobacco users and non-users.

RESULTS

The prevalence of current ST use was 1·4% and 2·5%, and waterpipe smoking was 1·2% and 1·8%, in WWRC and WWoRC, respectively. ST use varied across Pakistan's provinces by 13 percentage points in WWRC and WWoRC while waterpipe smoking by 10 and 15 percentage points, respectively. The odds of using any form of tobacco were significantly lower with higher levels of education or wealth index. Compared to children born to mothers who did not use tobacco, the birthweight of children born to mothers who smoked waterpipe was on average 0.83kg (95%CI -1·6 to -0·1) lower whereas it was 0·33kg (95%CI -0·9 to 0·3) higher for ST users.

CONCLUSIONS

Tobacco use among women of reproductive age in Pakistan varied significantly based on province and tobacco type. Waterpipe smoking was associated with a reduction in birth weight. Raising awareness of the harms of tobacco use among women of reproductive age and targeting interventions in high-burden regions of Pakistan should be prioritised.

IMPLICATIONS

The prevalence of current smokeless tobacco use and waterpipe smoking varied significantly in Pakistan (~13 and ~15 percentage points, respectively) among women of reproductive age, and there seems to be little change in tobacco use behaviour around pregnancy and early motherhood. The study highlights a need to better understand the prevalence of tobacco use in Pakistan, and further contextual research is warranted to understand the reasons for such high tobacco use in certain areas. This information highlights the need for improving current tobacco control interventions and policies, including measures that could help reduce its use and prevent its uptake. Furthermore, compared to children born to mothers who did not use any form of tobacco, we found a statistically significant difference (830 grams) in birthweight for babies born to mothers who at the time of the interview smoked waterpipe and a non-statistically significant difference of about 330 grams for children born to mothers who at the time of the interview used smokeless tobacco. In addition to our findings, some literature suggests the association of waterpipe smoking with low birth weight. A possible explanation could be the exposure to smoke that contains toxicants from the tobacco product itself in addition to the burning of charcoal, which is required when using waterpipe. Waterpipe smoking also results in high exposures of carbon monoxide and polycyclic aromatic hydrocarbons, which are known to be carcinogenic and teratogenic. In terms of smokeless tobacco use, further research is warranted to understand its impact on birth outcomes through longitudinal studies accounting for diverse products, its constituents and the amount of consumption.

Effect of smoke-free policies in military settings on tobacco smoke exposure and smoking behaviour: a systematic review

INTRODUCTION

Smoke-free legislation has been instrumental in reducing secondhand smoke (SHS) exposure in public places. However, the evidence of the impact of institutional smoke-free policies in settings such as healthcare and defence is weaker. Specifically, the literature on the effect of smoke-free policies in military settings has not yet been synthesised.

METHODS

This review aimed to identify, critically appraise and synthesise the available evidence to evaluate the effect of defence smoke-free policies on SHS exposure. Eight electronic databases (eg, EMBASE, MEDLINE) were searched from inception to June 2020. We included English-language studies on smoke-free policies introduced in a defence setting, assessing their impact on SHS exposure (primary outcome) and healthcare utilisation, smoking behaviours and defence efficiency (secondary outcomes). Risk of bias was assessed using ROBINS-I. Synthesis without meta-analysis was conducted using vote counting of direction of effect.

RESULTS

The search retrieved 4503 citations of which eight met inclusion criteria; two controlled and six uncontrolled before-and-after studies. The evidence, although low-quality, from one study indicated reduced SHS exposure following the introduction of a defence smoke-free policy. For secondary outcomes the review found mixed results, with the quit rate being the one outcome favouring smoke-free policies. The cumulative confidence of evidence is uncertain and therefore reliable conclusions cannot be drawn from these studies.

CONCLUSIONS

A research gap exists for high-quality studies on the impact of defence smoke-free policies which should use comparators and, if possible, randomisation. Policy-makers should introduce institutional smoke-free policies in defence settings within an evaluative framework to generate such evidence.

Is Tobacco Use Associated With Risk of Recurrence and Mortality Among People With TB?: A Systematic Review and Meta-Analysis

BACKGROUND

Associations between tobacco use and poor TB treatment outcomes are well documented. However, for important outcomes such as TB recurrence or relapse and mortality during treatment, as well as for associations with smokeless tobacco (ST), the evidence is not summarized systematically.

RESEARCH QUESTION

Is tobacco use associated with risk of poor treatment outcomes among people with TB?

STUDY DESIGN AND METHODS

The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature databases were searched on November 22, 2021. Epidemiologic studies reporting associations between tobacco use and at least one TB treatment outcome were eligible. Independent double-screening, extractions, and quality assessments were undertaken. Random effects meta-analyses were conducted for the two primary review outcomes (TB recurrence or relapse and mortality during treatment), and heterogeneity was explored using subgroups. Other outcomes were synthesized narratively.

RESULTS

Our searches identified 1,249 records, of which 28 were included in the meta-analyses. Based on 15 studies, higher risk of TB recurrence or relapse was found with ever using tobacco vs never using tobacco (risk ratio [RR], 1.78; 95% CI, 1.31-2.43; I2 = 85%), current tobacco use vs no tobacco use (RR, 1.95; 95% CI, 1.59-2.40; I2 = 72%), and former tobacco use vs never using tobacco (RR, 1.84; 95% CI, 1.21-2.80; I2 = 4%); heterogeneity arose from differences in study quality, design, and participant characteristics. Thirty-eight studies were identified for mortality, of which 13 reported mortality during treatment. Ever tobacco use (RR, 1.55; 95% CI, 1.32-1.81; I2 = 0%) and current tobacco use (RR, 1.51; 95% CI, 1.09-2.10; I2 = 87%) significantly increased the likelihood of mortality during treatment among people with TB compared with never using tobacco and not currently using tobacco, respectively; heterogeneity was explained largely by differences in study design. Almost all studies in the meta-analyses scored high or moderate on quality assessments. Narrative synthesis showed that tobacco use was a risk factor for other unfavorable TB treatment outcomes, as previously documented. Evidence on ST was limited, but identified studies suggested an increased risk for poor outcomes with its use compared with not using it.

INTERPRETATION

Tobacco use significantly increases the risk of TB recurrence or relapse and mortality during treatment among people with TB, highlighting the need to address tobacco use to improve TB outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42017060821; URL: https://www.crd.york.ac.uk/prospero/.

Tobacco use in people with severe mental illness: Findings from a multi-country survey of mental health institutions in South Asia

INTRODUCTION

People with severe mental illness (SMI) tend to die early due to cardiovascular and respiratory diseases, which may be linked to tobacco use. There is limited information on tobacco use in people with SMI in low- and middle-income countries where most tobacco users reside. We present novel data on tobacco use in people with SMI and their access to tobacco cessation advice in South Asia.

METHODS

We conducted a multi-country survey of adults with SMI attending mental health facilities in Bangladesh, India, and Pakistan. Using data collected with a standardized WHO STEPS survey tool, we estimated the prevalence and distribution of tobacco use and assessed receipt of tobacco cessation advice.

RESULTS

We recruited 3874 participants with SMI; 46.8% and 15.0% of men and women consumed tobacco, respectively. Smoking prevalence in men varied by country (Bangladesh 42.8%, India 20.1% and Pakistan 31.7%); <4% of women reported smoking in each country. Smokeless tobacco use in men also varied by country (Bangladesh 16.2%, India 18.2% and Pakistan 40.8%); for women, it was higher in Bangladesh (19.1%), but similar in India (9.9%) and Pakistan (9.1%). Just over a third of tobacco users (38.4%) had received advice to quit tobacco. Among smokers, 29.1% (n=244) made at least one quit attempt in the past year. There was strong evidence for the association between tobacco use and the severity of depression (OR=1.29; 95% CI: 1.12-1.48) and anxiety (OR=1.29; 95% CI: 1.12-1.49).

CONCLUSIONS

As observed in high-income countries, we found higher tobacco use in people with SMI, particularly in men compared with rates reported for the general population in South Asia. Tobacco cessation support within mental health services offers an opportunity to close the gap in life expectancy between SMI and the general population.

STUDY REGISTRATION

ISRCTN88485933; https://doi.org/10.1186/ISRCTN88485933 39.

Children Learning About Secondhand Smoke (CLASS III): a protocol for a cluster randomised controlled trial of a school-based smoke-free intervention in Bangladesh and Pakistan

INTRODUCTION

Secondhand smoke (SHS) exposure is a major cause of premature death and disease, especially among children. Children in economically developing countries are particularly affected as smoke-free laws are typically only partially implemented and private homes and cars remain a key source of SHS exposure. Currently, firm conclusions cannot be drawn from the available evidence on the effectiveness of non-legislative interventions designed to protect children from SHS exposure. Following the success of two feasibility studies and a pilot trial, we plan to evaluate a school-based approach to protect children from SHS exposure in Bangladesh and Pakistan-countries with a strong commitment to smoke-free environments but with high levels of SHS exposure in children. We will conduct a two-arm cluster randomised controlled trial in Bangladesh and Pakistan to assess the effectiveness and cost effectiveness of a school-based smoke-free intervention (SFI) in reducing children's exposure to SHS and the frequency and severity of respiratory symptoms.

METHODS AND ANALYSIS

We plan to recruit 68 randomly selected schools from two cities-Dhaka in Bangladesh and Karachi in Pakistan. From each school, we will recruit approximately 40 students in a year (9-12 years old) with a total of 2720 children. Half of the schools will be randomly allocated to the intervention arm receiving SFI and the other half will receive usual education. Salivary cotinine concentration-a highly sensitive and specific biomarker of SHS exposure-is the primary outcome, which will be measured at month 3 post-randomisation. Secondary outcomes will include frequency and severity of respiratory symptoms, healthcare contacts, school absenteeism, smoking uptake and quality of life. Embedded economic and process evaluations will also be conducted.

ETHICS AND DISSEMINATION

The trial has received ethics approval from the Research Governance Committee at the University of York. Approvals have also been obtained from Bangladesh Medical Research Council and Pakistan Health Research Council. If SFI is found effective, we will use a variety of channels to share our findings with both academic and non-academic audiences. We will work with the education departments in Bangladesh and Pakistan and advocate for including SFI within the curriculum.

TRIAL REGISTRATION NUMBER

ISRCTN28878365.

Correction: Addressing TB multimorbidity in policy and practice: An exploratory survey of TB providers in 27 high-TB burden countries

[This corrects the article DOI: 10.1371/journal.pgph.0001205.].

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention

INTRODUCTION

The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial.

METHODS

We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation.

RESULTS

Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries.

CONCLUSIONS

This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums.

TRIAL REGISTRATION

ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

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.

Prevalence of physical health conditions and health risk behaviours in people with severe mental illness in South Asia: multi-country cross-sectional survey

BACKGROUND

People with severe mental illness (SMI) die earlier than the general population, primarily because of physical disorders.

AIMS

We estimated the prevalence of physical health conditions, health risk behaviours, access to healthcare and health risk modification advice in people with SMI in Bangladesh, India and Pakistan, and compared results with the general population.

METHOD

We conducted a cross-sectional survey in adults with SMI attending mental hospitals in Bangladesh, India and Pakistan. Data were collected on non-communicable diseases, their risk factors, health risk behaviours, treatments, health risk modification advice, common mental disorders, health-related quality of life and infectious diseases. We performed a descriptive analysis and compared our findings with the general population in the World Health Organization (WHO) 'STEPwise Approach to Surveillance of NCDs' reports.

RESULTS

We recruited 3989 participants with SMI, of which 11% had diabetes, 23.3% had hypertension or high blood pressure and 46.3% had overweight or obesity. We found that 70.8% of participants with diabetes, high blood pressure and hypercholesterolemia were previously undiagnosed; of those diagnosed, only around half were receiving treatment. A total of 47% of men and 14% of women used tobacco; 45.6% and 89.1% of participants did not meet WHO recommendations for physical activity and fruit and vegetable intake, respectively. Compared with the general population, people with SMI were more likely to have diabetes, hypercholesterolemia and overweight or obesity, and less likely to receive tobacco cessation and weight management advice.

CONCLUSIONS

We found significant gaps in detection, prevention and treatment of non-communicable diseases and their risk factors in people with SMI.

FCTC 2030 - a programme to accelerate the implementation of WHO Framework Convention for Tobacco Control in low- and middle-income countries: A mixed-methods evaluation

BACKGROUND

FCTC 2030 Programme (2017-2021) was launched to accelerate WHO Framework Convention on Tobacco Control (FCTC) implementation in 15 low- and middle-income countries (LMICs). We evaluated the Programme in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion and Sponsorship (TAPS) bans; International and Regional Cooperation.

METHODS

Following a mixed-methods design, we surveyed (Jun-Sept 2020) FCTC focal persons in 14 of the 15 countries, to understand the Programme's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial=1, technical=1, or both=2) and progress (none=1, some=2, partial=3, or strong=4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings.

RESULTS

FCTC 2030 offered substantial financial and technical inputs, responsive to country-needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r=0.61 for Taxation (p<0.05) to r=0.91 for Smoke-Free Policies (p<0.001). The interviews indicated that the Programme provided timely and relevant evidence and created opportunities for influencing tobacco control debates.

CONCLUSIONS

The FCTC 2030 Programme might have led to variable but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation.

IMPLICATIONS

What this study adds: In many low- and middle-income countries (LMICs), WHO Framework Convention for Tobacco Control (WHO FCTC) policies are not in place; and even when enshrined in law, they are poorly enforced.It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies is likely to lead to progress in tobacco control.

Common assumptions in tobacco control that may not hold true for South-East Asia

Tobacco is a threat to public health in South-East Asia and its control should be a priority. However, many common assumptions about tobacco control may not hold true for the region and can misdirect policy. The substantial health risks associated with smokeless tobacco have been largely misunderstood and neglected. The syndemic association between tuberculosis and tobacco has also been overlooked. Similarly, less attention has been paid to address second-hand smoke exposure of pregnant women to indoor smoking (caused predominantly by men). On the other hand, our poor understanding of the diverse tobacco supply chain has been blocking progress in tobacco control. Finally, the rising popularity of electronic cigarettes has thrown new challenges; many governments, concerned for its youth, have banned such products. We argue for a nuanced approach to tobacco control in South-East Asia. We also encourage a wider debate in public health, where other established assumptions may be hampering progress.

Depression, Anxiety, and Cigarette Smoking Among Patients with Tuberculosis

Smoking adversely affects tuberculosis (TB) outcomes and may be associated with depression and anxiety among people diagnosed with TB in Botswana. We conducted a cross-sectional study among patients newly diagnosed with TB in Gaborone, Botswana, evaluating factors associated with self-reported cigarette smoking. We performed Poisson regression analyses with robust variance to examine whether depressive and anxiety symptoms were associated with smoking. Among 180 participants with TB enrolled from primary health clinics, depressive symptoms were reported in 47 (26.1%) participants and anxiety symptoms were reported in 85 (47.2%) participants. Overall, 45 (25.0%) participants reported current smoking. Depressive symptoms were associated with a higher prevalence of smoking (adjusted prevalence ratio [aPR]: 2.04; 95% confidence interval [CI]: 1.29-3.25) in the adjusted analysis. The association between anxiety symptoms and smoking did not reach statistical significance (aPR: 1.26; 95% CI: 0.77-2.05). Future studies should further investigate these associations when addressing TB care.

Awareness, perceptions of and compliance with tobacco control policies among naswar vendors in Khyber Pakhtunkhwa Pakistan

INTRODUCTION

Regulatory compliance in the retail environment is integral to the success of tobacco control. We assessed compliance among naswar (smokeless tobacco product widely used in South Asia) vendors with tobacco control laws. We also assessed their awareness of tobacco-related harms and policies and perceived effect of policies on their sales.

METHODS

We surveyed 286 naswar vendors in three districts of the Khyber Pakhtunkhwa province of Pakistan. We recruited general and specialty vendors from urban and rural areas through multistage cluster sampling. Compliance was measured for promotion, sale to/by minors and tax paid on naswar. We used logistic regression analyses for assessing the association between the outcome variables (awareness of tobacco harms and laws, perceptions about the effect of policies on business and compliance with laws) and their predictors.

RESULTS

Most vendors (70%) were aware of tobacco-related harms of naswar. Although educated vendors were more aware of tobacco control policies, the greatest awareness was for a ban on sales to/by minors (21% overall). The majority of vendors (76%) violated this policy (measured by self-report), and violations were more common among rural than urban vendors (OR 2.27, 95% CI 1.05 to 4.96). Most vendors (71%) violated a ban on promotion of naswar. Vendors perceived tax increases and sales ban to/by minors as most detrimental for business.

CONCLUSIONS

There was poor awareness and compliance among naswar vendors in Pakistan with tobacco control laws. This study finds potential areas for policy interventions that can reduce urban/rural disparities in implementation of and compliance with tobacco control laws.

Oral Cancer Risk Assessment for Different Types of Smokeless Tobacco Products Sold Worldwide: A Review of Reviews and Meta-analyses

Smokeless tobacco (SLT) use is a significant cause of lip and oral cavity cancers. Globally, oral cancer prevalence is strongly linked to the types of tobacco products used, their chemical composition, and their pattern of use. Except snus, all SLT products sold in different World Health Organization regions are strongly associated with oral cancer incidence. Shammah showed the highest association OR with 95% confidence intervals (CI; OR, 38.74; 95% CI, 19.50-76.96), followed by oral snuff (OR, 11.80; 95% CI, 8.45-16.49), gutkha (OR, 8.67; 95% CI, 3.59-20.93), tobacco with betel quid (OR, 7.74; 95% CI, 5.38-11.13), toombak (OR, 4.72; 95% CI, 2.88-7.73), and unspecified chewing tobacco (OR, 4.72; 95% CI, 3.13-7.11). Most SLT products containing high levels of carcinogenic tobacco-specific nitrosamines (TSNA) exhibit a high risk of oral cancer. There is an urgent need to frame and implement international policies for oral cancer prevention through legal control of the TSNA levels in all SLT product types.

PREVENTION RELEVANCE

Most smokeless tobacco products sold worldwide, mainly shammah, toombak, gutkha, betel quid with tobacco, and dry snuff, are associated with a high risk of oral cancer. A high concentration of tobacco-specific nitrosamines in smokeless tobacco products is the major causative factor for oral cancer development.

"Everything the hujur tells is very educative but if I cannot apply those in my own life then there is no meaning": a mixed-methods process evaluation of a smoke-free homes intervention in Bangladesh

BACKGROUND

Second-hand smoke exposure from tobacco significantly contributes to morbidity and mortality worldwide. A cluster RCT in Bangladesh compared a community-based smoke-free home (SFH) intervention delivered in mosques, with or without indoor air quality (IAQ) feedback to households to no intervention. Neither was effective nor cost-effective compared to no intervention using an objective measure of second-hand smoke. This paper presents the process evaluation embedded within the trial and seeks to understand this.

METHODS

A mixed method process evaluation comprising interviews with 30 household leads and six imams (prayer leader in mosque), brief questionnaire completed by 900 household leads (75% response), fidelity assessment of intervention delivery in six (20%) mosques and research team records. Data were triangulated using meta-themes informed by three process evaluation functions: implementation, mechanisms of impact and context.

RESULTS

IMPLEMENTATION: Frequency of SFH intervention delivery was judged moderate to good. However there were mixed levels of intervention fidelity and poor reach. Linked Ayahs (verses of the Qur'an) with health messages targeting SHS attitudes were most often fully implemented and had greatest reach (along with those targeting social norms). Frequency and reach of the IAQ feedback were good.

MECHANISMS OF IMPACT

Both interventions had good acceptability. However, views on usefulness of the interventions in creating a SFH were mixed. Individual drivers to behaviour change were new SFH knowledge with corresponding positive attitudes, social norms and intentions. Individual barriers were a lack of self-efficacy and plans.

CONTEXT

Social context drivers to SFH intervention implementation in mosques were in place and important. No context barriers to implementation were reported. Social context drivers to SHS behaviour change were children's requests. Barriers were women's reluctance to ask men to smoke outside alongside general reluctance to request this of visitors. (Not) having somewhere to smoke outside was a physical context (barrier) and driver.

CONCLUSIONS

Despite detailed development and adaption work with relevant stakeholders, the SFH intervention and IAQ feedback became educational interventions that were motivational but insufficient to overcome significant context barriers to reduce objectively measured SHS exposure in the home. Future interventions could usefully incorporate practical support for SFH behaviour change. Moreover, embedding these into community wide strategies that include practical cessation support and enforcement of SFH legislation is needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49975452.

Prevalence and risks of tuberculosis multimorbidity in low-income and middle-income countries: a meta-review

OBJECTIVES

Co-occurrence of tuberculosis (TB) with other chronic conditions (TB multimorbidity) increases complexity of management and adversely affects health outcomes. We aimed to map the prevalence of the co-occurrence of one or more chronic conditions in people with TB and associated health risks by systematically reviewing previously published systematic reviews.

DESIGN

Systematic review of systematic reviews (meta-review).

SETTING

Low-income and middle-income countries (LMICs).

PAPERS

We searched in Medline, Embase, PsycINFO, Social Sciences Citation Index, Science Citation Index, Emerging Sources Citation Index and Conference Proceedings Citation Index, and the WHO Global Index Medicus from inception to 23 October 2020, contacted authors and reviewed reference lists. Pairs of independent reviewers screened titles, abstracts and full texts, extracted data and assessed the included reviews' quality (AMSTAR2). We included systematic reviews reporting data for people in LMICs with TB multimorbidity and synthesised them narratively. We excluded reviews focused on children or specific subgroups (eg, incarcerated people).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence or risk of TB multimorbidity (primary); any measure of burden of disease (secondary).

RESULTS

From the 7557 search results, 54 were included, representing >6 296 000 people with TB. We found that the most prevalent conditions in people with TB were depression (45.19%, 95% CI: 38.04% to 52.55%, 25 studies, 4903 participants, I²=96.28%, high quality), HIV (31.81%, 95% CI: 27.83% to 36.07%, 68 studies, 62 696 participants, I²=98%, high quality) and diabetes mellitus (17.7%, 95% CI: 15.1% to 20.0.5%, 48 studies, 48,036 participants, I²=98.3%, critically low quality).

CONCLUSIONS

We identified several chronic conditions that co-occur in a significant proportion of people with TB. Although limited by varying quality and gaps in the literature, this first meta-review of TB multimorbidity highlights the magnitude of additional ill health burden due to chronic conditions on people with TB.

PROSPERO REGISTRATION NUMBER

CRD42020209012.

Illicit cigarette trade in the cities of Pakistan: comparing findings between the consumer and waste recycle store surveys

BACKGROUND

Concerns about the magnitude of illicit cigarette trade have prevented the Government of Pakistan from increasing tobacco taxes. We estimated the proportion of illicit cigarettes sold in Pakistani cities. Moreover, we compared two methods for collecting cigarette packs and investigated if the illicit cigarette trade equates to tax evasion.

METHOD

We analysed cigarette packs collected from 10 cities of Pakistan using two methods: consumer survey based on a two-stage random sampling strategy to recruit adult smokers and photograph their cigarette packs and waste recycle store survey to purchase used cigarette packs. Cigarettes were considered illicit if any one of the following was absent from their packs: text and pictorial health warning, underage sale prohibition warning, retail price and manufacturer's name. From the consumer survey, we also estimated the proportion of smokers who purchased loose cigarettes (illegal) and packs below the minimum retail price. Taxation officers (n=4) were consulted to assess their level of confidence in judging tax evasion using the above criteria.

RESULTS

Out of 2416 cigarette packs in the consumer survey, 454 (17.8%; 95% CI 15.4% to 20.2%) were illicit. Similarly, out of 6213 packs from waste recycle shops, 1046 (16.8%; 95% CI 15.9% to 17.7%) were illicit; the difference was not statistically significant (p=0.473). Among consumers, 29.5% bought loose cigarettes and 13.8% paid less than the minimum retail price. The taxation officers considered the manufacturer's name and retail price on cigarette packs as the most relevant criteria to detect tax evasion.

CONCLUSIONS

One in six cigarette packs consumed in Pakistan could be illicit. These figures are far less than those propagated by the tobacco industry. Collecting packs from waste recycle stores is an efficient and valid method to estimate illicit cigarette trade.

Cost-utility of cytisine for smoking cessation over and above behavioural support in people with newly diagnosed pulmonary tuberculosis: an economic evaluation of a multicentre randomised controlled trial

OBJECTIVES

To assess the cost-effectiveness of cytisine over and above brief behavioural support (BS) for smoking cessation among patients who are newly diagnosed with pulmonary tuberculosis (TB) in low-income and middle-income countries.

DESIGN

An incremental cost-utility analysis was undertaken alongside a 12-month, double-blind, two-arm, individually randomised controlled trial from a public/voluntary healthcare sector perspective with the primary endpoint at 6 months post randomisation.

SETTING

Seventeen subdistrict hospitals in Bangladesh and 15 secondary care hospitals in Pakistan.

PARTICIPANTS

Adults (aged ≥18 years in Bangladesh and ≥15 years in Pakistan) with pulmonary TB diagnosed within the last 4 weeks who smoked tobacco daily (n=2472).

INTERVENTIONS

Two brief BS sessions with a trained TB health worker were offered to all participants. Participants in the intervention arm (n=1239) were given cytisine (25-day course) while those in the control arm (n=1233) were given placebo. No significant difference was found between arms in 6-month abstinence.

PRIMARY AND SECONDARY OUTCOME MEASURES

Costs of cytisine and BS sessions were estimated based on research team records. TB treatment costs were estimated based on TB registry records. Additional smoking cessation and healthcare costs and EQ-5D-5L data were collected at baseline, 6-month and 12-month follow-ups. Costs were presented in purchasing power parity (PPP) adjusted US dollars (US$). Quality-adjusted life years (QALYs) were derived from the EQ-5D-5L. Incremental total costs and incremental QALYs were estimated using regressions adjusting for respective baseline values and other baseline covariates. Uncertainty was assessed using bootstrapping.

RESULTS

Mean total costs were PPP US$57.74 (95% CI 49.40 to 83.36) higher in the cytisine arm than in the placebo arm while the mean QALYs were -0.001 (95% CI -0.004 to 0.002) lower over 6 months. The cytisine arm was dominated by the placebo arm.

CONCLUSIONS

Cytisine plus BS for smoking cessation among patients with TB was not cost-effective compared with placebo plus BS.

TRIAL REGISTRATION NUMBER

ISRCTN43811467.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial

BACKGROUND

Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries.

METHODS

We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data.

DISCUSSION

The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use.

TRIAL REGISTRATION

ISRCTN identifier 65109397.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATION

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

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach

Introduction

Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers’ exposure to SHS in the home via faith-based messages.

Methods

The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF.

Results

It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated.

Conclusion

The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01100-5.

"If I don't smoke shisha, I won't be able to sleep": lived experiences of high school students in Ethiopia

Background

Shisha smoking predisposes the users to cardiovascular diseases, cancer, and infections, such as tuberculosis, hepatitis, and herpes. In Ethiopia, there is little data on the adolescents' shisha smoking experience. This study aimed to explore the lived experience of high school students and inform ongoing and future prevention and control interventions.

Methods

This study was conducted in Addis Ababa and Adama cities in Ethiopia. Twenty-five secondary school students aged 15-22 years who had shisha smoking experience participated in this study. A topic guide was used to facilitate the in-depth interviews (IDIs) and a digital audio recorder recorded the interviews. Interviews varied between 40-90 minutes and were conducted in private open-air spaces where only the interviewee and researcher were present. Each transcript was coded using Atlas.ti version 8 software. The analytical approach was iterative, with interview transcripts analyzed at the time of coding and re-analyzed after a preliminary result was drafted to search for additional themes.

Results

Students described two key factors that influenced their decision to initiate shisha smoking: peer influence and perceiving it as a means to release stress. After initiating shisha use students maintained the behaviour because of: peer influence, khat chewing, enjoyment of shisha smoking, having prolonged leisure time, and accessibility to shisha. Students regretted the impact shisha use had on their lives, such as conflict with their families, poor academic performance, and spending money on shisha smoking. Female students were also concerned about reproductive health risks related to shisha use.

Conclusions

Peer influence played a major role both in initiating and maintaining shisha use. However, students admitted concern over the impact of shisha smoking on academic performance and their relationship with their families. Since shisha use is associated with khat chewing; shisha smoking control programs cannot be successful without controlling khat. Especially young girls had worries about their reproductive health risks associated with shisha use. This suggests that targeted awareness raising programs highlighting the dangers of shisha use for both health and safety; especially for young women is required.

Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study

BACKGROUND

Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes.

METHODS

We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis.

RESULTS

Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14-20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes.

CONCLUSIONS

System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

INTRODUCTION

There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS

We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION

The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Corrigendum to: Addressing tobacco smoking and drinking to improve TB treatment outcomes, in South Africa: a feasibility study of the ProLife program

Alcohol and tobacco use may lead to negative treatment outcomes in tuberculosis (TB) patients, and even more so if they are HIV-infected. We developed and tested the feasibility of a complex behavioral intervention (ProLife) delivered by lay health workers (LHWs) to improve treatment outcomes in TB patients who smoke tobacco and/or drink alcohol, at nine clinics in South Africa. The intervention comprised three brief motivational interviewing (MI) sessions augmented with a short message service (SMS) program, targeting as appropriate: tobacco smoking, harmful or hazardous drinking and medication adherence. Patients received SMSs twice a week. We measured recruitment and retention rates and assessed fidelity to the MI technique (MI Treatment Integrity 4.1 tool). Finally, we explored LHWs’ and patients’ experiences through interviews and semistructured questionnaires, respectively. We screened 137 TB patients and identified 14 smokers, 13 alcohol drinkers, and 18 patients with both behaviors. Participants’ mean age was 39.8 years, and 82.2% were men. The fidelity assessments pointed to the LHWs’ successful application of key MI skills, but failure to reach MI competency thresholds. Nevertheless, most patients rated the MI sessions as helpful, ascribed positive attributes to their counselors, and reported behavioral changes. SMSs were perceived as reinforcing but difficult language and technical delivery problems were identified as problems. The LHWs’ interview responses suggested that they (a) grasped the basic MI spirit but failed to understand specific MI techniques due to insufficient training practice; (b) perceived ProLife as having benefitted the patients (as well as themselves); (c) viewed the SMSs favorably; but (d) considered limited space and privacy at the clinics as key challenges. The ProLife program targeting multiple risk behaviors in TB patients is acceptable but LHW training protocol, and changes in wording and delivery of SMS are necessary to improve the intervention.

Trial registration: ISRCTN14213432

Smokeless Tobacco in Uganda: Perceptions among Tobacco Control Stakeholders

The use and sale of smokeless tobacco (SLT) is prohibited in Uganda under the Tobacco Control Act (TCA), 2015. Nonetheless, SLT products remain available, and there are limited and inconsistent data on SLT users. Additionally, the perceptions of tobacco control stakeholders on SLT are unknown, making it difficult to determine barriers to enforcing the ban. This study examined perceptions of tobacco control stakeholders regarding SLT in Uganda. Qualitative semi-structured interviews were conducted with stakeholders who were purposively selected from ministries, semi-autonomous government agencies and Civil Society Organizations. Interviews explored knowledge, attitudes, perceptions of SLT appeal, and user demographics. Data were analysed using Nvivo V.12 software. Participants demonstrated a general lack of awareness of SLT product types and the extent of their use. They believed SLT use was increasing among females and minors and was as harmful to health and the economy as smoking. SLT products were thought to be cheaper than cigarettes and to appeal to minors. Discreet use was thought to help users overcome the cultural aversion towards tobacco use among women and youth in Uganda. There is an urgent need to strengthen the implementation of the SLT ban whilst also increasing efforts to reduce tobacco smoking.

Protocol for a feasibility study of longitudinal surveys to assess the impact of policies on tobacco use among school-going adolescents in South Asia

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world’s 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among school going adolescents to evaluate existing tobacco control policies on tobacco uptake and use, and a feasibility study for that prospective, observational cohort study.

Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To evaluate if the questionnaire can assess tobacco uptake and use, and their potential predictors.

Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among students of grade 6-8, one year apart. At each time point, data on tobacco uptake and potential predictors will be collected from students via self-administered questionnaires that were designed for the longitudinal study. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers.

Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.

Development of a core outcome set for multimorbidity trials in low/middle-income countries (COSMOS): study protocol

INTRODUCTION

'Multimorbidity' describes the presence of two or more long-term conditions, which can include communicable, non-communicable diseases, and mental disorders. The rising global burden from multimorbidity is well documented, but trial evidence for effective interventions in low-/middle-income countries (LMICs) is limited. Selection of appropriate outcomes is fundamental to trial design to ensure cross-study comparability, but there is currently no agreement on a core outcome set (COS) to include in trials investigating multimorbidity specifically in LMICs. Our aim is to develop international consensus on two COSs for trials of interventions to prevent and treat multimorbidity in LMIC settings.

METHODS AND ANALYSIS

Following methods recommended by the Core Outcome Measures in Effectiveness Trials initiative, the development of these two COSs will occur in parallel in three stages: (1) generation of a long list of potential outcomes for inclusion; (2) two-round online Delphi surveys and (3) consensus meetings. First, to generate an initial list of outcomes, we will conduct a systematic review of multimorbidity intervention and prevention trials and interviews with people living with multimorbidity and their caregivers in LMICs. Outcomes will be classified using an outcome taxonomy. Two-round Delphi surveys will be used to elicit importance scores for these outcomes from people living with multimorbidity, caregivers, healthcare professionals, policy makers and researchers in LMICs. Finally, consensus meetings including all of these stakeholders will be held to agree outcomes for inclusion in the two COSs.

ETHICS AND DISSEMINATION

The study has been approved by the Research Governance Committee of the Department of Health Sciences, University of York, UK (HSRGC/2020/409/D:COSMOS). Each participating country/research group will obtain local ethics board approval. Informed consent will be obtained from all participants. We will disseminate findings through peer-reviewed open access publications, and presentations at global conferences selected to reach a wide range of LMIC stakeholders.

PROSPERO REGISTATION NUMBER

CRD42020197293.

Effect of a brief motivational interview and text message intervention targeting tobacco smoking, alcohol use and medication adherence to improve tuberculosis treatment outcomes in adult patients with tuberculosis: a multicentre, randomised controlled trial of the ProLife programme in South Africa

OBJECTIVE

To investigate the effectiveness of a complex behavioural intervention, ProLife, on tuberculosis (TB) treatment success, medication adherence, alcohol use and tobacco smoking.

DESIGN

Multicentre, individual, randomised controlled trial where participants were assigned (1:1) to the ProLife intervention or usual care.

SETTING

27 primary care clinics in South Africa.

PARTICIPANTS

574 adults starting treatment for drug-sensitive pulmonary TB who smoked tobacco or reported harmful/hazardous alcohol use.

INTERVENTIONS

The intervention, delivered by lay health workers (LHWs), consisted of three brief motivational interviewing (MI) sessions, augmented with short message service (SMS) messages, targeting medication adherence, alcohol use and tobacco smoking.

OUTCOME MEASURES

The primary outcome was successful versus unsuccessful TB treatment at 6-9 months, from TB records. Secondary outcomes were biochemically confirmed sustained smoking cessation, reduction in the Alcohol Use Disorder Identification Test (AUDIT) score, improved TB and antiretroviral therapy (ART) adherence and ART initiation, each measured at 3 and 6 months by questionnaires; and cure rates in patients who had bacteriology-confirmed TB at baseline, from TB records.

RESULTS

Between 15 November 2018 and 31 August 2019, 574 participants were randomised to receive either the intervention (n=283) or usual care (n=291). TB treatment success rates did not differ significantly between intervention (67.8%) and control (70.1%; OR 0.9, 95% CI 0.64% to 1.27%). There was no evidence of an effect at 3 and 6 months, respectively, on continuous smoking abstinence (OR 0.65, 95% CI 0.37 to 1.14; OR 0.76, 95% CI 0.35 to 1.63), TB medication adherence (OR 1.22, 95% CI 0.52 to 2.87; OR 0.89, 95% CI 0.26 to 3.07), taking ART (OR 0.79, 95% CI 0.38 to 1.65; OR 2.05, 95% CI 0.80 to 5.27) or AUDIT scores (mean score difference 0.55, 95% CI -1.01 to 2.11; -0.04, 95% CI -2.0 to 1.91) and adjusting for baseline values. Cure rates were not significantly higher (OR 1.16, 95% CI 0.83 to 1.63).

CONCLUSIONS

Simultaneous targeting of multiple health risk behaviours with MI and SMS using LHWs may not be an effective approach to improve TB outcomes.

TRIAL REGISTRATION NUMBER

ISRCTN62728852.

The effectiveness of behaviour change interventions delivered by non-dental health workers in promoting children’s oral health: A systematic review and meta-analysis

Objectives

Dental caries is the most common preventable childhood condition. Non-dental professionals and health workers are often well placed to support parents in adopting positive oral health behaviours for their children. The aim of this study was to determine the effectiveness of behaviour change interventions and their individual component behaviour change techniques (BCTs), that were delivered by non-dental professionals and health workers.

Methods

A systematic search of Ovid MEDLINE, PubMed, CINAHL, Cochrane Library, Web of Science, TRoPHI and PROQUEST from inception until March 2021 was conducted. Randomised controlled trials and quasi-experimental studies for improving oral health outcomes in children were included. Quality assessment was carried out using Cochrane Risk of Bias tool and ROBINS-I tool. Publication bias was assessed using funnel plots and Egger’s regression intercept. Effect sizes were estimated as standardised mean difference (SMD) and odds ratio/risk ratio for proportions. Meta-analyses were performed for studies reporting mean decayed, missing, filled surfaces (dmfs) and mean decayed, missing, filled, teeth (dmft) indices. Behaviour change technique coding was performed using behaviour change technique taxonomy v1 (BCTTv1).

Results

Out of the 9,101 records retrieved, 36 studies were included with 28 showing a significant effect either in clinical and/or behavioural/knowledge outcomes. Most studies (n = 21) were of poor methodological quality. The pooled SMD for caries experience showed statistically significant result for caries prevention at surface level -0.15 (95% CI -0.25, -0.04) and at the tooth level -0.24 (95% CI -0.42, -0.07). In 28 effective interventions, 27 individual BCTs were identified and the most frequently used were: “Instructions on how to perform the behaviour” and “Information about health consequences”.

Conclusion

There is low quality of evidence suggesting non-dental professionals and health workers may help improve oral health outcomes for children. To confirm these findings, further high-quality studies incorporating a variety of BCTs in their interventions for adoption of good oral health behaviours are needed.

Attitudes of smokers towards tobacco control policies: findings from the Studying Tobacco users of Pakistan (STOP) survey

BACKGROUND

Public attitude is a political driver in successful implementation of tobacco control policies. We assessed support for a range of tobacco control policies among smokers in Pakistan.

METHODS

We conducted a household survey among adult smokers in 10 cities of Pakistan, using a two-stage random sampling strategy to select households and Kish grid method to select one smoker per household. Attitudes were measured using a five-point ordinal scale on four policy statements: a complete ban on tobacco sale within 10 years; raising the legal age to buy tobacco from 18 to 21; increasing tobacco taxes to fund healthcare and a ban on smoking in cars with minors.

RESULTS

6014 participants were interviewed between September 2019 and March 2020. Most participants demonstrated strong support for all policy statements: a ban on smoking in cars with minors (86.5%); a complete ban on tobacco sale within 10 years (82.1%); raising the legal age to buy tobacco (77.9%) and increasing tobacco taxes (68.1%). Smokers' support for tobacco control policies increased with age but decreased with higher educational attainment and heaviness of smoking.

CONCLUSIONS

There is strong support among smokers in Pakistan to strengthen tobacco control. Given this, policy-makers should strongly consider strengthening existing national policies on tobacco control.

Addressing TB multimorbidity in policy and practice: An exploratory survey of TB providers in 27 high-TB burden countries

In people with TB, co-existence of long-term conditions (e.g., depression, diabetes and HIV) and risk factors (e.g.,alcohol misuse, malnutrition, and smoking) are associated with increased mortality and poor treatment outcomes including delayed recovery, TB treatment failure and relapse. However, it is unclear as to what extent these comorbidities are addressed in TB policy and practice. Between August and October 2021, we conducted an online cross-sectional survey in high-TB burden countries. We recruited a purposive sample of TB health workers, managers, policy makers, advisors and advocates from these countries. The survey enquired about the extent to which various comorbid conditions are: (a) mentioned in TB policies, plans, and guidelines; (b) screened, diagnosed, treated or referred to specialist services by TB healthcare workers. We summarised using descriptive analysis. Of the 1100 potential respondents contacted in 33 countries, 543 responded but only 446 (41%) from 27 countries provided sufficient data for inclusion in the study. We found no notable differences between these providing insufficient data and those completing the survey. HIV, diabetes mellitus, depression and tobacco and alcohol use disorders were identified as the most common and concerning comorbid conditions in TB. HIV was screened for and managed by TB services in most countries. Screening for diabetes and/or tobacco and alcohol use disorders was offered by almost half of all TB services but only a few offered relevant treatments. Depression was rarely screened for, almost never treated, and only infrequently referred to specialist services. Most respondents felt confident in screening/diagnosing these comorbid conditions but not in treating these conditions. With the exception of HIV, chronic comorbid conditions are only partially screened for and rarely managed within TB services. Mental health conditions are for the most part neglected. Given their adverse impact on TB outcomes, integrating screening and management of these comorbidities within TB programmes offers a significant opportunity to meet TB targets, address non-communicable diseases and improve patient well-being.

Effect of quitting smoking on health outcomes during treatment for tuberculosis: secondary analysis of the TB & Tobacco Trial

BACKGROUND

Despite treatment, patients with tuberculosis (TB) who smoke have poorer outcomes compared with non-smokers. It is unknown, however, if quitting smoking during the 6 months of TB treatment improves TB outcomes.

METHODS

The TB & Tobacco Trial was a double-blind, placebo-controlled randomised trial of cytisine for smoking cessation in 2472 patients with pulmonary TB in Bangladesh and Pakistan. In a secondary analysis, we investigated the hypothesis that smoking cessation improves health outcomes in patients during the TB treatment course. The outcomes included an eight-point TB clinical score, sputum conversion rates, chest X-ray grades, quality of life (EQ-5D-5L), TB cure plus treatment completion rates and relapse rates. These were compared between those who stopped smoking and those who did not, using regression analysis.

RESULTS

We analysed the data of 2273 (92%) trial participants. Overall, 25% (577/2273) of participants stopped smoking. Compared with non-quitters, those who quit had better TB cure plus treatment completion rates (91% vs 80%, p<0.001) and lower TB relapse rates (6% vs 14%, p<0.001). Among quitters, a higher sputum conversion rate at week 9 (91% vs 87%, p=0.036), lower mean TB clinical scores (-0.20 points, 95% CI -0.31 to -0.08, p=0.001) and slightly better quality of life (mean EQ-5D-5L 0.86 vs 0.85, p=0.015) at 6 months were also observed. These differences, except quality of life, remained statistically significant after adjusting for baseline values, trial arm and TB treatment adherence rates.

CONCLUSION

Patients with TB who stop smoking may have better outcomes than those who don't. Health professionals should support patients in stopping smoking.

What factors are associated with waterpipe smoking cessation? A secondary data analysis

INTRODUCTION

Waterpipe smoking is gaining popularity and becoming a major global public health concern. An understanding of factors that predict waterpipe smoking cessation is necessary for targeting tobacco control efforts.

METHODS

This is a secondary data analysis of a randomised controlled-trial comparing the efficacy of varenicline against placebo in helping waterpipe smokers to quit. A total of 510 adult daily waterpipe smokers were recruited to the trial in 2016. Logistic regression models were applied to assess factors (i.e., demographic, environmental, behavioural, and physiological) associated with primary outcome (waterpipe smoking cessation) and secondary outcomes (waterpipe cessation alongside abstinence from cigarette and short-term and long-term waterpipe smoking cessation). Cessation was defined as 7-day point prevalence abstinence from smoking reported at 5,12, and/or 25 weeks follow ups.

RESULTS

Over a period of six months, 189 (39.2%) participants abstained from waterpipe smoking for at least one week. Being male (adjusted odds ratio (aOR):2.99 (95%CI:1.47-6.08)), dual smoker (waterpipe and cigarettes) (aOR:2.98 (95%CI:1.87-4.74)), more withdrawal symptoms measured by the Mood and Physical Symptoms Scale (aOR:1.08 (95%CI:1.02-1.13)), less nicotine dependency measured by Lebanon Waterpipe Dependency Scale (aOR:0.90 (95%CI:0.85-0.96)), having history of quit attempt (aOR:2.14 (95%CI:1.16-3.96)), smoking restriction in the house (aOR:2.69 (95%CI:1.01-7.14)), and not sharing waterpipe with others (aOR:2.72 (95%CI:1.31-5.66)) predicted waterpipe smoking cessation.

CONCLUSIONS

In addition to nicotine dependency, social factors such as home restrictions on smoking, and not sharing waterpipe were identified as predictors of waterpipe smoking cessation. To help waterpipe smokers quit, social environment may be just as or even more important than well-known physical and psychological factors.

IMPLICATIONS

A range of factors, predominantly social factors play a significant role in facilitating or deterring waterpipe smokers from quitting smoking. Our findings suggest that interventions that focus on social as well as physical/psychological factors may encourage waterpipe smokers in achieving abstinence.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Supply Chain Actors' Willingness to Switch the Business of Smokeless Tobacco: A Mixed-Methods Study on Naswar Business in Pakistan

INTRODUCTION

Provision of alternate livelihoods to smokeless tobacco (SLT) supply chain (SC) actors can help in curtailing SLT business and its consumption. We explored the reasons for SC actors' engagement in Naswar (SLT used in South Asia) business and their willingness to switch to other alternatives.

AIMS AND METHODS

We conducted an equal-status concurrent mixed-methods study in four districts of Khyber Pakhtunkhwa province of Pakistan. We surveyed 286 general points of sale (GPOS) and exclusive Naswar (EN) vendors through multistage cluster sampling. Additionally, we interviewed 15 tobacco farmers interpretively, being distinct from other SC actors. We assessed the association between vendors' willingness to switch and their awareness about tobacco-harms, profit margin, Naswar as a family business, length of business, education level, and shop type using logistic regression. Qualitative data assessed the farmer's viable alternatives to switch and were analyzed using deductive-inductive thematic analysis.

RESULTS

Product demand-77% and profit margins-75% were the main drivers for selling SLT by EN vendors. Half of the GPOS and 25% EN vendors expressed willingness to stop Naswar's sale. Vendors aware of tobacco-harms were more willing to switch, but less likely to switch if Naswar was perceived to bring "good profit." Farmers were mainly cultivating tobacco because of profitability, family-run farm, and perceived land-suitability for tobacco. Lack of government support was main constraint for farmers looking to switch.

CONCLUSIONS

A considerable portion of Naswar SC actors in Pakistan are willing to switch to viable alternatives, with profitability of alternatives, support from authorities, and social obligations as key considerations in doing so.

IMPLICATIONS

This study highlights that good profit margins in the Naswar business, lack of awareness of tobacco-related health harms, and absence of the government's support are key detriments to switching to alternative businesses among Naswar SC actors in Pakistan. These findings are the first to come out in the context of both Pakistan and Naswar product, making a case for policy interventions focusing on tax increases, awareness campaigns about tobacco-harms, and a proactive role by the government to provide support for the security of livelihoods to those tobacco SC actors who want to switch to other alternatives.

Association between age at first reported e-cigarette use and subsequent regular e-cigarette, ever cigarette and regular cigarette use

BACKGROUND AND AIMS

Association of electronic cigarette use and subsequent smoking has received considerable attention, although age of first use has not. This study tested differences in regular (e-cigarettes, cigarettes) and ever (cigarettes) use between e-cigarette user groups: early versus never users, late versus never users, early versus late users and effects of controlling for covariates.

DESIGN

Prospective study with 12- and 24-month follow-up of e-cigarette/cigarette ever/regular use with data from an intervention.

SETTING

Forty-five schools in England (Staffordshire and Yorkshire).

PARTICIPANTS

Never smokers (3289 13-14-year-olds) who were part of a cluster randomized controlled trial.

MEASUREMENTS

The sample was divided into groups of e-cigarette users: early users (at 13-14 years), late users (at 14-15 years) and never users (at 13-14 and 14-15 years). Dependent variables were self-reported regular e-cigarette and cigarette use and ever cigarette use at 15-16 years. Covariates were assessed.

FINDINGS

Early and late users compared with never users were significantly more likely to be regular e-cigarette users [early: odds ratio (OR) = 9.42, 95% confidence interval (CI) = 5.38, 16.49, P < 0.001; late: OR = 6.89, 95% CI = 4.11, 11.54, P < 0.001], ever cigarette users (early: OR = 7.96, 95% CI = 6.02, 10.53, P < 0.001; late: OR = 5.13, 95% CI = 3.85, 6.84, P < 0.001) and regular cigarette users (early: OR = 7.80, 95% CI = 3.99, 15.27, P < 0.001; late: OR = 4.34, 95% CI = 1.93, 9.77, P < 0.001) at age 15-16 years. Late users compared with early users had significantly lower rates of ever use of cigarettes at 15-16 years (OR = 0.48, 95% CI = 0.35, 0.66, P < 0.001), although this difference was non-significant at 12 months after first use of e-cigarettes (OR = 0.89, 95% CI = 0.64, 1.25, P = 0.498). Controlling for covariates did not change the findings.

CONCLUSIONS

Adolescents in England who report using e-cigarettes at age 13-14 years have higher rates of subsequently initiating cigarette use than adolescents who report using e-cigarettes at age 14-15 years, a difference that may be attributable to a longer period of time to initiate cigarette use in former group.

Rural-urban differences in hospitalizations for opioid use-associated infective endocarditis in Kentucky, 2016-2019

PURPOSE

In 2016, the US rate of opioid use-associated infective endocarditis (OUA IE) hospitalizations was 3.86/100,000 for rural and 3.49/100,000 for urban residents. This study estimates the Kentucky OUA IE hospitalization rates, 2016-2019, describing differences in rural-urban residency trends, demographics, relevant comorbidities, and discharge disposition. OUA IE hospitalization rates between counties with and without syringe services programs (SSPs) are also compared.

METHODS

We used Kentucky statewide inpatient discharge records from 2016 to 2019. An OUA IE hospitalization was identified by an infective endocarditis discharge diagnosis in any diagnosis field and a concurrent diagnosis indicating opioid use. Rurality was determined based on the 2013 Rural-Urban Continuum Codes (RUCC).

FINDINGS

Kentucky's rate of OUA IE hospitalizations in 2016 was 8.9/100,000, with no significant variation between rural and urban residents. By 2019, the average rate for urban residents doubled to 17.9/100,000, significantly higher than the rural resident rate, 13.2/100,000. There were no significant rural-urban differences in percentages of those with concurrent diagnoses of HIV (<1%) or HCV (>60%). Counties that established SSPs in 2017-2018 had a 39.4% increase in OUA IE rates from 2016 to 2019, while counties without SSPs had a 79.5% increase.

CONCLUSION

The estimated 2016 Kentucky rates of OUA IE hospitalizations are 2 times higher than reported national rates, highlighting Kentucky as one of the areas most affected by this particular opioid use disorder complication. Despite challenges and barriers to the effectiveness of SSPs as a harm reduction measure, our study suggests a positive effect that should be further investigated.

Tobacco Smoking and Associated Factors Among People Living With HIV in Uganda

INTRODUCTION

The prevalence of smoking among people living with HIV (PLWH) in Uganda is high.

AIMS AND METHODS

We assessed the smoking patterns, behaviors, and associated factors among PLWH in Uganda through a cross-sectional survey. Descriptive statistics were used to describe smoking patterns and behaviors. Logistic regression was used to identify factors associated with current smoking status.

RESULTS

We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) nonsmokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (odds ratio [OR] 6.60 [95% confidence interval, CI = 4.34-10.04]), having at least two smokers among five closest friends (OR 3.97 [95% CI = 2.08-7.59]), living in smoking-permitted households (OR 5.83 [95% CI = 3.32-10.23]), alcohol use (OR 3.96 [95% CI = 2.34-6.71]), a higher perceived stress score (OR 2.23 [95% CI = 1.50-3.34]), and higher health-related quality of life (OR 5.25 [95% CI = 1.18-23.35]). Among smokers, the mean Fagerström Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH's health were low.

CONCLUSIONS

Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores, and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy.

IMPLICATIONS

Future behavioral smoking cessation interventions for PLWH should address co-consumption with alcohol and comorbid mental health conditions that are common among PLWH such as stress. In addition, they should take into account the lack of knowledge among this population of the impact of smoking on their health, and low self-efficacy. Given the relatively low levels of nicotine dependency and high levels of willingness to quit in our sample, smoking cessation interventions, if offered, are likely to support this population in achieving long-term smoking abstinence.