Trends in smokeless tobacco use and attributable mortality and morbidity in the South-East Asia Region: implications for policy

OBJECTIVES

To describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO South-East Asia Region (SEAR), to inform policies for SLT control in the Region.

METHODS

For each SEAR country, we obtained data from Global Adult Tobacco Surveys, WHO STEPwise Approach to NCD Risk Factor Surveillance surveys and Demographic and Health Surveys conducted since 2010 to estimate prevalence of SLT use by country, sex and year. Using data from the World Population Prospects database we estimated the number of users by country. Next, using the results of previous meta-analyses and prevalence results, we estimated the population attributable fractions and attributable mortality and morbidity in terms of annual deaths and disability-adjusted life years lost. We then characterised trends in attributable deaths and disease burden for countries with comparable data.

RESULTS

There were wide differences in SLT use prevalence by country. We estimated that, during 2015-2019, there were 165 803 900 SLT users across SEAR, with 479 466 attributable deaths annually of which India accounted for 79.9% with 383 248. Attributable annual deaths increased in some countries during 2015-2019.

CONCLUSIONS

Annual deaths and disease burden attributable to SLT remain high across SEAR and have only declined modestly in recent years. Effective implementation of all WHO Framework Convention on Tobacco Control measures, addressing both supply-side and demand-side issues, in relation to SLT and areca nut products must be prioritised to ensure reductions in mortality and disease burden are sustained and accelerated.

Prevention of initiation of smokeless tobacco (SLT) consumption among rural children

Background: India Global Youth Tobacco Survey 2019 observed that 8.5% of the young age group (13-15 years) consume tobacco (9.6 % are boys and 7.4 % are girls). No interventional studies among adolescents were conducted before the initiation of the SLT use. Aims & Objectives: To estimate the prevalence of consumption of tobacco and non-tobacco products and to provide school based interventions to bring behavioral changes. Materials and Methods: An interventional study was carried out in Primary Schools. For estimation of the prevalence of tobacco and non tobacco use all the students of 1st to 5th while for the interventions, 4th and 5th standard were selected. Baseline data and change in the behavior at the end of one year was collected. FGD with key informants were also conducted. Descriptive Statistics was conducted. Results: The prevalence of smokeless tobacco consumption and non-tobacco product was found to be 1.3% and 36.5% respectively. After intervention 40.5% students had quit non tobacco products. Findings of FGD suggested that children should not be sent to purchase tobacco products on behalf of their parents. Conclusion: School based intervention and sensitization of the field workers along with knowing their perceptions for the predictors of consumption could be useful.

Areca nut consumption with and without tobacco among the adult population: a nationally representative study from India

OBJECTIVE

Areca nut is one of the most widely consumed substances globally, after nicotine, ethanol and caffeine and classified as carcinogenic to humans. This study examines the disparity and determinants of areca nut consumption with and without tobacco in India.

DESIGN

Nationally representative cross-sectional study.

PARTICIPANTS

We used the nationally representative Global Adult Tobacco Survey 2016-2017. The analytical sample size was 74 037 individual's aged 15 years and above with a response rate of 92.9%.

MEASURES

Current consumption of areca nut without tobacco and with tobacco.

METHOD

We examined determinants of areca nut consumption (without tobacco and with tobacco) using multinomial logistic regression, accounting for the survey design.

RESULTS

About 23.9% (95% CI 23.1 to 24.8) of the adult population consume areca nut, that is, approximately 223.79 million people in India; majority of users (14.2%-95% CI 13.5 to 14.9) consumed areca nut with tobacco. When compared with women, men were more likely to consume areca nut (with tobacco relative risk (RR)=2.02; 95% CI 1.85 to 2.21 and without tobacco RR=1.13; 95% CI 1.07 to 1.20). Age, marital status, education, occupation, caste, religion and region were significantly associated with areca nut consumption. However, the direction and magnitude of association differ with respect to the areca nut consumption with and without tobacco.

CONCLUSION

The ongoing tobacco control efforts would not address the majority of areca nut users until greater attention to areca nut consumption with and without tobacco is reflected in health policies in India.

LifeFirst: Impact of a school-based tobacco and supari cessation intervention among adolescent students in Mumbai, India

INTRODUCTION

The youth are a vulnerable population-group for tobacco-related harms. Schools are an excellent setting for health promotion; yet there is a dearth of school-based cessation interventions, rarely evaluated for their impact. Here, we assess the impact of the LifeFirst program: an ongoing tobacco and supari (areca nut) cessation intervention delivered to students from corporation schools in Mumbai city.

METHODS

We used a prospective quasi-experimental design with an intervention and a control arm embedded within an ongoing LifeFirst program in select schools. We used a difference-in-difference analysis with baseline and end-line surveys to assess the program's impact on students' knowledge about harms, students' refusal skills, and prevalence of tobacco/supari use. We report our work using the TREND statement checklist.

RESULTS

A total of 959 students registered in the LifeFirst program. In our analysis, we included 827 students who completed both the baseline and end-line surveys. Postintervention, we found both tobacco and supari use reduced substantially among the intervention group while tobacco use increased among the control group. The difference-in-difference estimates show a statistically significant reduction of 17.9 and 38.1 percentage points in the intervention group for tobacco and supari use respectively, beyond the reduction in the control group.

CONCLUSIONS

The LifeFirst program was successful in reducing tobacco and supari use among the study participants and protected students in the intervention group against new uptake of tobacco. It helped improve knowledge score and refusal skills among students. Implementation and evaluation of similar school-based programs should be considered as part of a multi-strategy approach to reducing tobacco use among young people.

BactericidalActivity of Crevicular Polymorphonuclear Neutrophils in Chronic Periodontitis Patients and Healthy Subjects under the Influence of Areca Nut Extract: An In Vitro Study

Arecanutchewing is an established risk factor for oral submucous fibrosis (OSMF), but its role in periodontal disease has not yet been defined. Thisstudy aimed to assess the effect of areca nut extracts (ANE) on the bactericidal activity of crevicular polymorphonuclear neutrophils (cPMNs) in healthy subjects and chronic periodontitis (CP) patients. An in vitro study was designed with an equal number of (n = 30) gingival crevicular fluid (GCF) samples collected from CP patients and healthy subjects. Bactericidal activity and hydrogen peroxide (H2O2) assays were performed with the GCF samples pre-treated with extracts of two varieties of areca nut: ripe and tender. Simultaneously, controls were also carried out with Hank’s balanced salt solution (HBSS) and catechin. Independent t-test and one-way analysis of variance (ANOVA), along with post-hoc analysis, were employed for statistical analysis. In both study groups, a significant reduction (p < 0.01)in the bactericidal activity was noted when the samples treated with the ripe areca nut (rANE) were compared with the tender variant (tANE). Similarly, H2O2 levels were significantly reduced (p < 0.001) in the rANE in contrast to tANE for both study groups. The above results were significant within the group but were found to be non-significant between the study groups, except when it was treated with HBSS (p < 0.001). In the present study, it was found that there was a reduction in the bactericidal activity and H2O2 production of cPMNs in both healthy subjects and CP patients in the presence of areca nut extract. Moreover, the effect of rANE on cPMNs was more detrimental than tANE.

Investigating Betel Nut Use, Antecedents and Consequences: A Review of Literature

Background: Betel nut use is a public health issue in the Asia-Pacific region that is often neglected. To control betel nut use, understanding of the adverse effects of betel nut use and evidence-based policies and strategies is necessary. Objectives: This narrative review aims to characterize the current situation on betel nut use at a global level regarding the epidemiology, pharmacology and toxicology, health effects, treatment options, policies and strategies. Methods: We found 139 existing literature published between 1970-2019 on the Web of Science database and other technical documents to collate the most relevant information on betel nut use. Data were categorized into appropriate themes. Results: The literature demonstrates that there is a lack of up to date statistics on betel nut use. There is limited research on the effect of policies and strategies to control betel nut use. Conclusion: Betel nut-chewing countries should focus on understanding which populations chew betel nut and implement appropriate policies, educational and cessation programs to help control betel nut use.