Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment

Conducting tobacco control surveys among schoolchildren in Bangladesh, India and Pakistan: A feasibility study

Most of the world's 300 million smokeless tobacco (ST) users live in South Asia but ST policies for that region are poorly researched, developed and implemented. Longitudinal studies to understand the uptake and use of ST and smoking, and influences on these, such as health promotion strategies, are lacking. We planned to conduct longitudinal surveys among secondary school students in three countries with the highest ST burden: Bangladesh, India and Pakistan to explore ST and smoking uptake, use and health promoting strategies. Before running that longitudinal study, we assessed the feasibility of conducting such a multi country survey using a mixed-methods design. The survey (and feasibility study) was conducted in 24 secondary schools (eight per country, three classes per school). Three data sources, researcher records/fieldnotes, survey data of 1179 students, and interview/focus group discussion data from 24 headteachers, 64 teachers and 76 students, were used to understand the feasibility of three study tasks: 1) selecting, recruiting, and retaining schools and student participants; 2) survey administration; and 3) robustness of the data collection instruments. The datasets were analysed separately and triangulated. Overall, we could select and recruit schools and students using consistent methods across countries although recruitment was challenged by securing higher authority permissions and parental consent. Recommended improvements were for permission/consent processes. Survey administration was generally feasible and acceptable with recommendations for scheduling and researcher-student ratios. Questionnaire completion was 83%-100% across countries, with suggestions to improve readability and understanding, addressing students' queries and questionnaire simplification. Due to COVID-19, we could not conduct follow-up surveys, so were unable to assess school or student retention. In conclusion, incorporating the lessons learnt from this study would improve the feasibility of conducting such a multi-country survey in the future. Reported benefits included increasing tobacco health risks' knowledge with potential for increased tobacco control support.

Levels, Trends and Determinants of Tobacco Quitting Behaviour in India: Findings from Two Consecutive Nationally Representative Surveys

Introduction:

Quitting tobacco use is known to decrease mortality by 90% if successfully achieved before middle age. This analysis was conducted to assess the levels, trends and determinants of tobacco quitting behaviour amongst the Indian population.

Materials and Methods:

This was secondary data analysis of the National Family Health Survey (NFHS)-4 (2015–2016) and NFHS-5 (2019–2020) of India.

Results:

A rising trend (4%) in intention to quit tobacco was observed amongst women, while a decline in intention to quit (0.5%) was observed amongst men from 2015–2016 to 2019–2020. An increase in the quitting was observed amongst women with age, with higher levels of education, being married or widowed/separated/divorced, hypertensives and diabetic patients. Amongst men, a declining trend to quit was observed with increasing level of education amongst the richest and amongst smokers, alcohol users and diabetics. The trends in quitting increased amongst those who were exposed to mass media.

Conclusion:

This study shows an increase in tobacco quitting amongst females and a decline amongst men in the Indian population from 2015–2016 to 2019–2020.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation in Bangladesh, India and Pakistan: A pilot randomized controlled trial

BACKGROUND AND AIMS

Smokeless tobacco (ST) use in South Asia is high, yet interventions to support its cessation are lacking. We tested the feasibility of delivering interventions for ST cessation in South Asia.

DESIGN

We used a 2 × 2 factorial design, pilot randomized controlled trial with a duration of 26 weeks, including baseline and follow-up (6, 12 and 26 weeks) assessments.

SETTING

Two primary health-care facilities each in Dhaka (Bangladesh) and Karachi (Pakistan) and a walk-in cancer screening clinic in Noida (India) took part.

PARTICIPANTS

Adult daily ST users willing to make a quit attempt within 30 days. Of 392 screened, 264 participants [mean age: 35 years, standard deviation = 12.5, 140 (53%) male] were recruited between December 2020 and December 2021; 132 from Bangladesh, 44 from India and 88 from Pakistan.

INTERVENTIONS

Participants were randomized to one of three treatment options [8-week support through nicotine replacement therapy (NRT, n = 66), a behavioural intervention for smokeless tobacco cessation in adults (BISCA, n = 66) or their combination (n = 66)] or the control condition of very brief advice (VBA) to quit (n = 66).

MEASUREMENTS

Recruitment and retention, data completeness and feasibility of intervention delivery were evaluated. Biochemically verified abstinence from tobacco, using salivary cotinine, was measured at 26 weeks.

FINDINGS

Retention rates were 94.7% at 6 weeks, dropping to 89.4% at 26 weeks. Attendance in BISCA pre-quit (100%) and quit sessions (86.3%) was high, but lower in post-quit sessions (65.9%), with variability among countries. Adherence to NRT also varied (45.5% Bangladesh, 90% India). Data completion for key variables exceeded 93% among time-points, except at 26 weeks for questions on nicotine dependence (90%), urges (89%) and saliva samples (62.7%). Among follow-up time-points, self-reported abstinence was generally higher among participants receiving BISCA and/or NRT. At 26 weeks, biochemically verified abstinence was observed among 16 (12.1%) participants receiving BISCA and 13 (9.8%) participants receiving NRT.

CONCLUSIONS

This multi-country pilot randomized controlled trial of tobacco cessation among adult smokeless tobacco users in South Asia demonstrated the ability to recruit and retain participants and report abstinence, suggesting that a future definitive smokeless tobacco cessation trial is viable.

Behavior Change Intervention for Smokeless Tobacco Cessation Delivered Through Dentists in Dental Settings: A Pragmatic Pilot Trial

INTRODUCTION

Evidence on smokeless tobacco (ST) cessation interventions is scarce. The South Asian (SA) region that shares more than 90% of the burden of ST use is grossly underrepresented in research on ST cessation. This study aimed to assess the feasibility of delivering and investigating a behavioral support intervention for ST cessation in dental settings in Pakistan.

METHODS

A multicenter, pilot, two-armed parallel-group, individually randomized control trial, with a 1:1 allocation ratio, was conducted at two dental hospitals. Eligibility criteria included being an ST user seeking dental treatment and not currently accessing cessation support. All participants were provided written self-help ST cessation material. The intervention group also received a dentist-delivered, bespoke behavioral support intervention for ST cessation developed for users of SA origin. Participants were followed up telephonically at 3 and 6 months. Self-reported 6-month abstinence was verified by salivary cotinine. Analysis was descriptive, with 95% confidence intervals presented where appropriate.

RESULTS

One hundred participants were successfully recruited from the selected hospitals. Of these, 78% continued to engage throughout the study duration and provided primary outcome data, whereas 63% completed all hospital visits. The outcome measures were successfully collected. Biochemically verified 6-month abstinence in the intervention and control groups was 10% and 4%.

CONCLUSIONS

It was feasible to deliver and evaluate a dentist-delivered behavioral support intervention for ST cessation in Pakistan. The data suggested that the intervention may improve ST quit rates. The findings of this study will be useful in informing the design of future definitive studies.

IMPLICATIONS

To our knowledge, this is the first pragmatic pilot trial on ST cessation in dental settings in Pakistan and the first trial on dentist-delivered structured behavioral support intervention for ST cessation. It adds to the scarce, trial evidence based on ST cessation interventions. The findings suggest behavioral support intervention for ST cessation may improve quit rates. The trial was conducted in a country with poor ST control measures, where ST products are not taxed, the products are sold openly to and by minors, and the users are offered negligible cessation support. The findings may, therefore, be generalizable to low-middle-income countries, particularly SA countries, with similar policy backgrounds.

Standard smokeless tobacco packaging: potential impact on perceived attractiveness, warning label visibility and harm perceptions among adults in Bangladesh

BACKGROUND

In Bangladesh, smokeless tobacco (SLT) is available in a variety of pack shapes and sizes. Lack of standard packaging could limit compliance with pictorial health warning label (HWL) requirements. We explored Bangladeshi SLT users' and non-users' perceptions of a proposed standard pack shape for gul (tobacco powder) and zordha (chewing tobacco), including the role that HWL placement plays on harm perceptions.

METHODS

We conducted 28 focus groups across three regions of Bangladesh: Dhaka, Sylhet and Khulna. Groups were stratified equally by urban/rural residence, gender and SLT use. Trained facilitators used a standardised guide to discuss perceived attractiveness, noticeability of HWLs and perceived harm of current versus standard packs.

RESULTS

Most groups found bright colours, 'brand owner' portrait imagery, and strong, sturdy pack material of current packs attractive. Many of the same features increased perceived attractiveness of the standard packs. Pictorial HWLs on the standard packs appeared larger and increased the visibility and noticeability of HWLs compared with current packs. Lack of HWLs or limited visibility of HWL due to discolouration contributed to lower levels of perceived harm of the current packs. In contrast, HWL prominence and placement on both sides of the standard pack increased perceived harm of standard packs.

CONCLUSION

The findings suggest a standard shape and size for SLT sold in Bangladesh, coupled with proper implementation of HWLs per the law, could improve HWL noticeability and increase harm perceptions. Additional plain packaging policies that also standardise pack colour may be required to reduce attractive colours and branding.

Self-management of chronic, non-communicable diseases in South Asian settings: A systematic mixed-studies review

Self-management is crucial in mitigating the impacts of a growing non-communicable disease (NCD) burden, particularly in Low and Middle-Income countries. What influences self-management in these settings, however, is poorly understood. We aimed to identify the determinants of self-management in the high NCD region of South Asia and explore how they influence self-management. A systematic mixed-studies review was conducted. Key electronic databases [MEDLINE (1946+), Embase (1974+), PsycInfo (1967+) and CINAHL (EBSCOhost)] in March 2022 (and updated in April 2023) were searched for studies on the self-management of four high-burden NCD groups: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and depression. Study characteristics and quantitative data were extracted using a structured template, and qualitative information was extracted using NVivo. Quality appraisal was done using the Mixed Methods Assessment Tool (MMAT). Quantitative findings were organised using the Commission on Social Determinants of Health (CSDH) framework and synthesised narratively, supported by effect direction plots. Qualitative findings were thematically synthesised. Both were integrated in a mixed synthesis. Forty-four studies (26 quantitative, 16 qualitative and 2 mixed-methods studies) were included, the majority of which were conducted in urban settings and among individuals with diabetes and cardiovascular diseases. Higher age, education, and income (structural determinants), health-related knowledge, social support and self-efficacy (psychosocial determinants), longer illness duration and physical comorbidity (biologic determinants), and the affordability of medicine (health-system determinants) were key determinants of self-management. Qualitative themes highlighted the role of financial adversity and the social and physical environment in shaping self-management.A complex interplay of structural and intermediary social determinants shapes self-management in South Asian settings. Multi-component, whole-systems approaches could boost self-management in these settings. Key areas include empowerment and education of patients and wider community, design and delivery of bespoke behavioural interventions and a stronger emphasis on supporting self-management in healthcare settings.

Smokeless Tobacco Cessation Support in Dental Hospitals in Pakistan: Dentists and Dental Patients' Perspectives on Current Practices, Support Needed, and Opportunities Available

INTRODUCTION

Despite evidence on the effectiveness of tobacco cessation interventions in dental settings, the implementation remains low, especially for smokeless tobacco (ST). The purpose of this study was to develop an understanding of the influences governing the implementation of ST cessation support in dental hospitals.

AIMS AND METHODS

A multicenter qualitative study was conducted at two tertiary-care dental hospitals, in Pakistan. Semi-structured interview guide, guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model, were used to capture the views of dentists (n = 12) and dental patients (n = 12), regarding ST cessation support in dental hospitals. Framework approach was used to thematically analyze the data.

RESULTS

Screening of ST users in routine dental practice was seldom practiced and the cessation support offered was brief advice. Barriers identified by dentists included: Fear of offending and stereotyping patients; lack of knowledge and skills; lack of privacy; lack of belief in the effectiveness of behavioral support; lack of time and workload pressure; ST use amongst dentists; lack of referral systems and; the absence of a mandatory requirement of offering ST cessation support. Facilitators included: Delivering support through junior dentists and the length of interaction between the dentist and the patient. Naswar was the most common ST product used by dental patients. Patients reported receiving negligible cessation support from any healthcare provider.

CONCLUSIONS

A range of influences governing the implementation of ST cessation support in dental hospitals were identified. These findings can inform the implementation of behavioral interventions for ST cessation in dental and other clinical settings, in low and middle-income countries.

IMPLICATIONS

Smokeless tobacco control considerably lags, in comparison to the control of combustible tobacco. This is the first study that qualitatively explores the implementation of ST cessation support in dental settings in Pakistan. Utilizing the "Capability-Opportunity-Motivation-Behavior" model, it provides an in-depth understanding of the inability of dentists in implementing effective behavioral interventions for ST cessation support in routine dental practice. Highlighting the striking discrepancy between the patient's need for and receptivity towards cessation support and the dentists' concerns over their patients' receptivity towards cessation support, it calls for the need for effective implementation strategies to optimize dentist-led tobacco cessation interventions in low-resource settings.

Determinants of initiation, continuation and cessation of smokeless tobacco use among pregnant and lactating women: a qualitative study from low-income communities in urban India

Smokeless tobacco (SLT) consumption increases the risk of cardiovascular diseases and cancer and leads to adverse reproductive health outcomes among women and newborns. This study examines the factors associated with initiation, continuation and cessation of SLT use among women in the reproductive age so as to formulate and include prevention and cessation interventions from its inception. The study was conducted in urban low-income communities in India. Using snowball and purposive sampling techniques, in-depth interviews were conducted with 20 pregnant and 22 lactating women who currently used SLT products. Data were analysed using thematic analysis with the help of QSR NVivo software. Findings revealed that factors such as people influencing usage change with different life stages including pre-marital and post-marital periods. Perceived health benefits, altered taste preferences during pregnancy and social influences were also studied. Women were found to be more aware of the harmful effects of tobacco during pregnancy than during breastfeeding. Social stigma around women consuming tobacco acted as a major driving factor for cessation. Most of the participants were willing to quit but were not aware of any technique or programme for cessation. The findings of the study highlight the need to develop behavioural change intervention tools, which are culturally and locally appropriate and have a gender-sensitive approach. Different socio-cultural factors associated with initiation/cessation at different life stages should also be taken into consideration while developing these tools.

Behaviour change intervention for smokeless tobacco (ST) cessation delivered through dentists within a dental setting: a feasibility study protocol

Objectives/Aim

To adapt a structured behavioural support intervention for smokeless tobacco (ST) cessation and to assess the feasibility and acceptability of delivering the intervention via dentists within dental settings in Pakistan.

Material and methods

The study will have 3 phases: (1) Adapt a previously developed intervention to make it suitable for delivery in a clinical/dental setting through qualitative interviews with dental patients and dentists; (2) A multi-centre, pilot randomised control trial in two teaching dental hospitals in Pakistan. Participants (dental patients) will be randomly assigned to intervention or control group in a 1:1 allocation ratio to receive either a structured behavioural support intervention involving face to face counselling or self-help material plus usual care. Each participant will be in the study for approximately 6 months and the overall study is expected to run for 12 months; (3) An embedded qualitative process evaluation. All trial participants will be followed up at 3 and 6 months to assess self-reported ST use. Outcome measures will include: rates of eligibility, recruitment and retention, randomisation group cross-over rates, the provision of data on ST use behaviour, fidelity to the intervention and qualitative assessment of acceptability and feasibility.

Discussion

Despite the high use of ST in Pakistan, users are offered negligible cessation support. The findings of this multi-centre, mixed-method feasibility study will inform the scope for a larger trial on ST cessation delivered through the existing dental health system.

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.