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

Is smokeless tobacco a healthier option in patients with AUD? A follow-up study during treatment

INTRODUCTION

Smoking is negatively related to mental health, but there is a paucity of research on the relationship between the use of smokeless tobacco, such as snus, and mental health outcomes, especially in people with alcohol use disorders (AUD). The aim of the present study was to examine the development of mental distress and quality of life (QoL) among AUD patients in treatment who did or did not use snus.

METHOD

The study included 128 AUD patients (27% female) from three rehabilitation clinics in Eastern Norway who were interviewed at admission, at 6 weeks, and after 6 months. Patients were asked about their mental health-related problems, alcohol, and substance use, QoL, and physical activity. Information about tobacco use was gathered with the questions "Do you smoke cigarettes?" and "Do you use snus?", with follow-up questions "How often?".

RESULT

There were 39 current snus users (31%), of which 20 were also current smokers (dual users). Seventy-five patients (59%) were smokers only, and only 14 (11%) patients were abstainers. Those who used snus only had a lower severity of dependence score than the other groups (p < 0.05). The dual use group reported lower QoL than the no tobacco use group. In a regression model adjusted for sex and age, smokers and dual users, but not users of snus, had higher levels of mental distress and poorer QoL compared to nontobacco users (p < 0.05). There were no differences between tobacco groups at follow-ups.

CONCLUSION

In this study, among AUD patients, snus users reported QoL and mental distress close to that of non-smokers, indicating a lower problem load among snus users compared to smokers.

IMPLICATIONS

Previous studies have shown conflicting results regarding the potential harm reduction effect of snus use among patients with AUD who smoke regarding their tobacco use, quality of life and mental health problems. This study suggests that snus use could also be a viable alternative to smoking for patients with addictions.

Awareness and use of nicotine pouches in a nationwide sample of adults in Poland

INTRODUCTION

Nicotine pouches are a new type of nicotine-containing product that have been marketed in many countries worldwide, generating growing acceptance among consumers. The aim of this study was to assess factors associated with public awareness and use of nicotine pouches among adults in Poland.

METHODS

A cross-sectional survey was conducted with a nationally representative sample of 1080 adults in Poland (February 2024). Awareness of nicotine pouches, history of use, current (past 30-day) use of nicotine pouches, as well as perception of harm was assessed using a purpose-designed questionnaire.

RESULTS

Awareness of nicotine pouches was reported by 24% of the sample, while 9.2% reported ever having used a nicotine pouch product, and 4.3% using a nicotine pouch in the past 30 days. Among all respondents, 60.7% perceived nicotine pouches as harmful as combustible cigarettes, 28.2% perceived nicotine pouches as less harmful, and 11% as more harmful than combustible cigarettes. In multivariable logistic regression model, women (adjusted odds ratio, AOR=1.40; 95% CI: 1.03-1.91; p<0.05), individuals aged <60 years (p<0.05), current tobacco smokers (AOR=2.59; 95% CI: 1.75-3.82; p<0.001), former tobacco smokers (AOR=1.53; 95% CI: 1.01-2.32; p<0.05) and ever users of e-cigarette or heated tobacco (AOR=2.90; 95% CI: 2.07-4.05; p<0.001) were more likely to declare that had ever heard of nicotine pouches. Moreover, individuals aged <60 years (p<0.05), occupationally active individuals (AOR=1.82; 95% CI: 1.01-3.31; p<0.05), current tobacco smokers (AOR=2.71; 95% CI: 1.48-4.97; p<0.01), and ever users of e-cigarette or heated tobacco (AOR=5.29; 95% CI: 2.96-9.44; p<0.001) were more likely to declare ever use of nicotine pouches.

CONCLUSIONS

This study provides the first national data on public awareness and use (ever and current) of nicotine pouches in Poland. Young adults, current smokers, and ever e-cigarette and heated tobacco users are at higher risk of ever use of nicotine pouches, so policy interventions are needed to protect young people from nicotine pouch marketing and nicotine initiation.

Integration of a Tobacco Cessation Program into a Rural Community-Based Maternal and Child Health Program in India: A Stakeholders' Perspective on Task Shifting

INTRODUCTION

According to the Global Adult Tobacco Survey-2, India, 7.5% of pregnant women are tobacco users with a high prevalence of smokeless tobacco use in rural India. Although pregnant women may receive advice to quit tobacco, lack of knowledge on providing cessation support among healthcare workers results in missed opportunities. Community Health Workers (CHWs) play a significant role in maternal and child health (MCH) programs. Thus, task-shifting for providing cessation support by CHWs was planned and the perceptions and attitudes of concerned stakeholders were explored.

AIMS AND METHODS

A pre-implementation qualitative study was conducted in four states of India within existing rural, community-based MCH program settings. Implementation research frameworks were used to develop data collection tools and for inductive and deductive thematic analysis. In-depth interviews were conducted with stakeholders (n = 28) like coordinators, pregnant women, and village functionaries of the government health system. Four focus groups were conducted with female CHWs (n = 24).

RESULTS

Stakeholders intended to adopt the intervention as objectives of the cessation intervention were aligned with the aims of the MCH program. CHWs related to their role in task-shifting and understood the context for implementing the intervention within the MCH program. Pregnant women expressed openness to receiving cessation support from CHWs acting as a facilitator for task-shifting. Barriers anticipated were the additional workload and time required for CHWs to implement the intervention.

CONCLUSIONS

Task-shifting to female CHWs for screening tobacco users, providing brief advice and cessation support within the MCH program was perceived to be acceptable, adoptable, and feasible.

IMPLICATIONS

The study builds insight into the process of developing a grounded approach for the integration of tobacco cessation intervention into a rural, community-based antenatal care setting by task shifting to female CHWs for providing cessation support to pregnant women. The study fills gaps in the literature related to establishing tobacco cessation interventions for pregnant women. The delineated efforts in integration of the intervention and task shifting can be replicated in other developing countries, especially in rural communities within South Asian and Southeast Asian regions having cultural practices, community-based healthcare structures, and tobacco consumption patterns that are comparable to India.

Perspectives of smokers, smokeless tobacco users and cessation practitioners in India: A qualitative study

INTRODUCTION

India is the second largest consumer of tobacco in the world and accounts for 70% of global deaths due to smokeless tobacco (SLT) use.

AIM

The aim of this study is to understand the perspectives of tobacco users (smokers and SLT users) and practitioners in India to inform cessation interventions.

METHOD

Semi-structured in-depth interviews with tobacco users (smoked and smokeless; n=23), and healthcare practitioners (n=13). Perspectives were triangulated using thematic analysis to examine convergence, divergence and complementarity of findings.

RESULTS

We present the results in a socio-ecological framework to highlight reasons for initiation and continuation of tobacco and motives to quit at the individual, interpersonal, occupational, societal and policy levels. SLT is seen as culturally acceptable compared to smoked forms of tobacco. Emotionally framed messages highlighting negative effects of tobacco on loved ones were perceived to be a better motivator than other types of cessation messages.

DISCUSSION

Nuanced differences exist between smokers and SLT user perspectives which have implications for cessation programs. Our findings supplement similar studies with other South Asian populations.

IMPLICATIONS FOR PRACTICE

Our study provides useful insights to tailor cessation interventions to the type of tobacco consumed in order to enhance their acceptability and effectiveness.

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.

The Effects of Nicotine Pouches and E-Cigarettes on Oral Microbes: A Pilot Study

It remains uncertain whether nicotine pouches and electronic cigarettes alter the oral environment and result in a high presence of periodontopathogenic bacteria in saliva, compared to that among cigarette users or non-tobacco users. In this study, saliva samples were collected from respondents using nicotine pouches, electronic cigarettes, and conventional cigarettes, alongside a control group of non-tobacco users. Polymerase chain reaction was used to identify clinical isolates of the following periodontal bacteria: Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, Fusobacterium nucleatum, Fusobacterium periodonticum, Porphyromonas endodontalis, and Rothia mucilaginosa. The presence of some periodontal pathogens was detected in the saliva samples from users of nicotine pouches, electronic cigarettes, and conventional cigarettes but not in samples taken from the control group. Therefore, the initial results of this pilot study suggest that the presence of periodontopathogenic bacteria in the saliva of nicotine pouch and electronic cigarette users could alter the oral microbiome, leading to periodontal diseases. However, further quantitative investigation is needed.

Dementia Prevalence and Onchocerca volvulus Infection among Rural Elderly Persons in the Ntui Health District, Cameroon: A Population-Based Study

Recent research suggests that infection with Onchocerca volvulus induces neurocognitive decline. This study sought to compare the cognitive outcomes of elderly persons based on onchocerciasis infection status and report the overall prevalence of dementia in the rural Ntui Health District in Cameroon. A community-based approach was used to recruit 103 participants aged ≥60 years. Dementia screening was done using the Community Screening Interview for Dementia (CSID) tool with a cut-off value of ≤29.5. O. volvulus infection was determined via microscopic examination of skin snips and serological testing of Ov16 antibodies using rapid diagnostic tests. Overall, the prevalence of dementia was 10.7%. Among the tested individuals, 17.9% (15/84) and 62.1% (41/66) were positive for O. volvulus and Ov16 antibodies, respectively. A multivariable linear regression model of CSID scores found a significant positive association with education level (8.654; 95% CI: 2.0870 to 15.222). However, having a positive skin snip for O. volvulus (-3.399; 95% CI: -6.805 to 0.007) and inhaling tobacco (-5.441; 95% CI: -9.137 to -1.744) tended to lower the CSID scores. Ongoing onchocerciasis transmission in the Ntui Health District may constitute a risk factor for dementia. Strengthening onchocerciasis elimination and adopting healthier lifestyles would contribute to dementia prevention among the elderly residing in endemic communities.

The potential of new nicotine and tobacco products as tools for people who smoke to quit combustible cigarettes - a systematic review of common practices and guidance towards a robust study protocol to measure cessation efficacy

New types of nicotine and tobacco products like electronic cigarettes (ECs), heated tobacco products or nicotine pouches have been discussed as less harmful alternatives to combustible cigarettes and other toxic forms of tobacco products. Their harm reduction potential lay in the efficient transition away from smoking to those new products. Numerous studies addressing the cessation efficacy of ECs have been published with contradictory outcomes. Yet, a comprehensive Cochrane review concluded with high certainty on the cessation efficacy of ECs. This prompted us to perform a review to identify weaknesses in common study designs and to summarize best practices for the study design on the potential of new nicotine products as cessation aids. 120 articles retrieved from Medline were found to be eligible. Most of the studies in the field were interventional trials while observational studies played a minor role in the evaluation of smoking cessation. Efficacy was predominantly assessed for ECs in 77% of the reports while heated tobacco (17%) and non-combustible products (11%) were less frequently investigated up to now. Measures to determine the efficacy were questionnaire-based assessments as well as use documentation/prevalence and abstinence rates. Studies varied largely in their duration and sample size with medians of 3 months and 156.5 participants, respectively.With the help of this review, we identified several weaknesses in the common study designs. One major limitation in longitudinal trials was the lack of compliance measures suited to verify the use status over longer time periods, relying solely on self-reports. Moreover, the motivation of the participants to quit was rarely defined and a profound familiarization period was not taken into account for the majority of the studies. To what extent such weaknesses influence the outcome of the studies was beyond the scope of this review. We encourage researchers to consider the recommendations which resulted from this review in order to determine the abuse liability and cessation efficacy of the products in a more robust manner. Finally, we like to call attention to the missing data for low- and middle-income countries which would require quitting strategies most urgently to combat the tobacco smoking epidemic.

Smartphone application versus written material for smoking reduction and cessation in individuals undergoing low-dose computed tomography (LDCT) screening for lung cancer: a phase II open-label randomised controlled trial

Background

Counseling, nicotine replacement, and other cessation medications have been proven effective in smoking cessation. The wide-scale adoption of smartphones and other mobile devices has opened new possibilities for scalable and personalized smoking cessation approaches. The study investigated whether a smartphone application would be more effective than written material for smoking cessation and reduction in smoking in individuals undergoing low-dose computed tomography (LDCT) screening for lung cancer (NCT05630950).

Methods

This randomized controlled trial enrolled 201 current smokers with marked smoking history (smoked ≥15 cigarettes/day for ≥25 years or smoked ≥10 cigarettes/day for ≥30 years). Participants were stratified by age and pack-years and randomized in 1:1 fashion to the developed smartphone application (experimental arm) or written material (standard of care). All the subjects underwent LDCT screening. Self-reported smoking cessation at three and six months were the primary endpoints of the study. The smoking-related secondary endpoints of the study were the percentage of individuals who had reduced the number of smoked cigarettes/d from the baseline.

Findings

Between Nov 18, 2022, and Apr 14, 2023, 201 patients were screened at Oulu University Hospital, Finland, of whom all were randomly assigned to smartphone application (n = 101) or written cessation material (n = 100); 200 were included in the full analysis set. Study arms were well-balanced for all the studied demographic factors. Subjects randomized to the smartphone application arm had significantly higher rates for self-reported smoking cessation at three (19.8 versus 7.1%; OR 3.175 CI 95% 1.276-7.899) and six months (18.8 versus 7.1%; OR 2.847 CI 95% 1.137-7.128). In the experimental arm, individuals with a frequent use of the application had a higher chance for smoking cessation at three (p < 0.001) and six months (p = 0.003).

Interpretation

The study showed that the developed smartphone application increases the likelihood for smoking cessation in individuals undergoing lung cancer LDCT screening.

Funding

AstraZeneca, Roche, and Cancer Foundation Finland.

To burn or not to burn: similar effects of different types of prenatal tobacco exposure on infant lung function

The first study to describe the harmful effects of snus on the unborn infant provides evidence to help clinicians and mothers collectively to make an informed choice about quitting the use of snus before planning pregnancies https://bit.ly/3vJnBxW.

A Complex Interplay: Navigating the Crossroads of Tobacco Use, Cardiovascular Disease, and the COVID-19 Pandemic: A WHF Policy Brief

The Coronavirus Disease 2019, commonly referred to as COVID-19, is responsible for one of the deadliest pandemics in human history. The direct, indirect and lasting repercussions of the COVID-19 pandemic on individuals and public health, as well as health systems can still be observed, even today. In the midst of the initial chaos, the role of tobacco as a prognostic factor for unfavourable COVID-19 outcomes was largely neglected. As of 2023, numerous studies have confirmed that use of tobacco, a leading risk factor for cardiovascular and other diseases, is strongly associated with increased risks of severe COVID-19 complications (e.g., hospitalisation, ICU admission, need for mechanical ventilation, long COVID, etc.) and deaths from COVID-19. In addition, evidence suggests that COVID-19 directly affects multiple organs beyond the respiratory system, disproportionately impacting individuals with comorbidities. Notably, people living with cardiovascular disease are more prone to experiencing worse outcomes, as COVID-19 often inherently manifests as thrombotic cardiovascular complications. As such, the triad of tobacco, COVID-19 and cardiovascular disease constitutes a dangerous cocktail. The lockdowns and social distancing measures imposed by governments have also had adverse effects on our lifestyles (e.g., shifts in diets, physical activity, tobacco consumption patterns, etc.) and mental well-being, all of which affect cardiovascular health. In particular, vulnerable populations are especially susceptible to tobacco use, cardiovascular disease and the psychological fallout from the pandemic. Therefore, national pandemic responses need to consider health equity as well as the social determinants of health. The pandemic has also had catastrophic impacts on many health systems, bringing some to the brink of collapse. As a result, many health services, such as services for cardiovascular disease or tobacco cessation, were severely disrupted due to fears of transmission and redirection of resources for COVID-19 care. Unfortunately, the return to pre-pandemic levels of cardiovascular disease care activity has stagnated. Nevertheless, digital solutions, such as telemedicine and apps, have flourished, and may help reduce the gaps. Advancing tobacco control was especially challenging due to interference from the tobacco industry. The industry exploited lingering uncertainties to propagate misleading information on tobacco and COVID-19 in order to promote its products. Regrettably, the links between tobacco use and risk of SARS-CoV-2 infection remain inconclusive. However, a robust body of evidence has, since then, demonstrated that tobacco use is associated with more severe COVID-19 illness and complications. Additionally, the tobacco industry also repeatedly attempted to forge partnerships with governments under the guise of corporate social responsibility. The implementation of the WHO Framework Convention on Tobacco Control could address many of the aforementioned challenges and alleviate the burden of tobacco, COVID-19, and cardiovascular disease. In particular, the implementation of Article 5.3 could protect public health policies from the vested interests of the industry. The world can learn from the COVID-19 pandemic to better prepare for future health emergencies of international concern. In light of the impact of tobacco on the COVID-19 pandemic, it is imperative that tobacco control remains a central component in pandemic preparedness and response plans.

Microbial community and functions involved in smokeless tobacco product: a metagenomic approach

Smokeless tobacco products (STPs) are attributed to oral cancer and oral pathologies in their users. STP-associated cancer induction is driven by carcinogenic compounds including tobacco-specific nitrosamines (TSNAs). The TSNAs synthesis could enhanced due to the metabolic activity (nitrate metabolism) of the microbial populations residing in STPs, but identifying microbial functions linked to the TSNAs synthesis remains unexplored. Here, we rendered the first report of shotgun metagenomic sequencing to comprehensively determine the genes of all microorganisms residing in the Indian STPs belonging to two commercial (Moist-snuff and Qiwam) and three loose (Mainpuri Kapoori, Dohra, and Gudakhu) STPs, specifically consumed in India. Further, the level of nicotine, TSNAs, mycotoxins, and toxic metals were determined to relate their presence with microbial activity. The microbial population majorly belongs to bacteria with three dominant phyla including Actinobacteria, Proteobacteria, and Firmicutes. Furthermore, the STP-linked microbiome displayed several functional genes associated with nitrogen metabolism and antibiotic resistance. The chemical analysis revealed that the Mainpuri Kapoori product contained a high concentration of ochratoxins-A whereas TSNAs and Zink (Zn) quantities were high in the Moist-snuff, Mainpuri Kapoori, and Gudakhu products. Hence, our observations will help in attributing the functional potential of STP-associated microbiome and in the implementation of cessation strategies against STPs. KEY POINTS: •Smokeless tobacco contains microbes that can assist TSNA synthesis. •Antibiotic resistance genes present in smokeless tobacco-associated bacteria. •Pathogens in STPs can cause infections in smokeless tobacco users.

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.

The Diversity in Tobacco Use Among Women of Reproductive Age (15-49 Years) in Pakistan: A Secondary Analysis of a Multiple Indicator Cluster Survey 2016-2018

INTRODUCTION

Tobacco use in women of reproductive age group (15-9 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 birth weights after recent childbirths (past 2 years).

AIMS AND METHODS

We used the Multiple Indicator Cluster Surveys 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 birth weights 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 birth weight of children born to mothers who smoked waterpipe was on average 0.83 kg (95% CI -1.6 to -0.1) lower whereas it was 0.33 kg (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 prioritized.

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 behavior 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 g) in birth weight for babies born to mothers who at the time of the interview smoked waterpipe and a non-statistically significant difference of about 330 g 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 to 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.

How do family members influence smokeless tobacco consumption during pregnancy in India? Perspectives of pregnant women

Smokeless tobacco (ST) use in South Asia is culturally ingrained and socially accepted. A better understanding of these sociocultural influences could inform behavioural approaches to prevent ST use. We sought to understand how family members influence pregnant women's behaviour, attitudes, and perceptions towards ST use. Moreover, we captured the influence of community health workers in this context. A qualitative study using a framework analysis was conducted in selected Indian populations. Eight in-depth interviews among pregnant and postpartum women were conducted in Gujarati, the local language, investigating ST use during pregnancy and the influence of family and peers. All transcripts were transcribed verbatim and translated into English and analyzed in NVivo. The social norms and expectations around ST during pregnancy appeared to have shifted away from promoting towards discouraging its use in the past few years. Women described how their spouses and other family members encouraged them to stop using ST during pregnancy, with some women must hide their ST use from their family members. They also received advice on the harms of ST use from community health workers (Accredited Social Health Activist-ASHA workers). Influenced by the advice received from such workers, several women tried to reduce their ST use during pregnancy. Our findings suggest that the acceptability of ST use in pregnancy may be in decline among families in India. Hence, efforts to promote ST prevention during pregnancy are likely to be "pushing against an open door". Furthermore, community health workers appeared to play an influential role in supporting women to abstain from ST use during pregnancy.

Smokeless Tobacco Harbors Bacteria Involved in Biofilm Formation as Well as Salt and Heavy Metal Tolerance Activity

In our previous culture-independent study on smokeless tobacco products, we have observed a strong positive correlation between several bacteria and genes involved in nitrate/nitrite reduction, biofilm formation, and pro-inflammation. Therefore, the present investigation was carried out to analyze the inhabitant bacterial population of the Indian ST products for assessing the health-associated risk attributes using culture-dependent approach. Traditional cultivation approaches recovered several bacterial isolates from commercial ST products on different culture media. A high colony formation unit (CFU) count was observed that ranged from 173 × 104 to 630.4 × 105 per gram of ST products. Of the 74 randomly selected and distinct bacterial isolates, 17 isolates showed a significantly enhanced growth (p-value < 0.05) in the presence of the aqueous tobacco extract. On biochemical characterization, these bacteria were identified as the member of Bacillus, Enterobacter, Micrococcus, Providencia, Serratia, Pantoea, Proteus, and Pseudomonas. Most of these bacteria also exhibited biofilm-forming activity, where eight bacterial isolates were identified for strong biofilm-forming action. 16S rRNA-based molecular characterization of these bacteria identified them as Bacillus subtilis, Bacillus paralicheniformis, Enterobacter sp., Serratia marcescens, Pantoea anthophila, and Enterobacter cloacae. Moreover, these bacteria also exhibited the potential to withstand high salt and heavy metal concentrations. The findings demonstrate that Indian ST products are heavily populated with wide bacterial species exhibiting potential in biofilm formation, heavy metal resistance, and salt tolerance.

An update on the formation in tobacco, toxicity and carcinogenicity of N'-nitrosonornicotine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone

The tobacco-specific nitrosamines N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) are considered 'carcinogenic to humans' by the International Agency for Research on Cancer (IARC) and are believed to be important in the carcinogenic effects of both smokeless tobacco and combusted tobacco products. This short review focuses on the results of recent studies on the formation of NNN and NNK in tobacco, and their carcinogenicity and toxicity in laboratory animals. New mechanistic insights are presented regarding the role of dissimilatory nitrate reductases in certain microorganisms involved in the conversion of nitrate to nitrite that leads to the formation of NNN and NNK during curing and processing of tobacco. Carcinogenicity studies of the enantiomers of the major NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and the enantiomers of NNN are reviewed. Recent toxicity studies of inhaled NNK and co-administration studies of NNK with formaldehyde, acetaldehyde, acrolein and CO2, all of which occur in high concentrations in cigarette smoke, are discussed.

Smokeless tobacco and periodontitis: A systematic review with meta-analysis

AIM

The present systematic review with meta-analysis aimed to investigate the global association between smokeless tobacco (SLT) use and periodontitis, considering significant effect size variation based on the income levels of countries.

METHODS

We searched seven databases to identify studies that assessed the prevalence of periodontitis in adult SLT users compared to non-users. The quality of studies was evaluated using the 10-item risk-of-bias tool, and publication bias was addressed through the trim-and-fill method. Sensitivity analysis utilized the leave-one-out approach. Meta-analysis and meta-regression, stratified by country income, SLT type, and smoking status, employed robust variance estimation.

RESULTS

From an initial pool of 484 studies, 29 studies met the selection criteria and were subjected to qualitative synthesis. Subsequently, data from 19 studies were included in the meta-analysis. SLT users exhibited a nearly threefold greater likelihood of periodontitis compared to non-users (OR = 2.99; 95% CI: 2.10, 4.27; p < .01). The pooled estimate did not vary significantly based on the type of SLT used or concurrent smoking. However, the odds of periodontitis varied according to the economic level of the country; the pooled estimate was higher in high-income countries (OR = 1.69; 95% CI: 1.20, 2.37; p < .01) and even higher in lower-middle-income and lower-income countries (OR = 3.91; 95% CI: 2.66, 5.77; p < .01).

CONCLUSIONS

Smokeless tobacco users have a higher likelihood of developing periodontitis. This study underscores global disparities in the SLT-periodontitis relationship, highlighting the need for targeted interventions, particularly in economically challenged areas where SLT use is largely unregulated.

The potential impact of removing a ban on electronic nicotine delivery systems using the Mexico smoking and vaping model (SAVM)

Objective

To develop the Mexico Smoking and Vaping Model (Mexico SAVM) to estimate cigarette and electronic nicotine delivery systems (ENDS) prevalence and the public health impact of legalizing ENDS use.

Methods

SAVM, a cohort-based discrete-time simulation model, compares two scenarios. The ENDS-Restricted Scenario estimates smoking prevalence and associated mortality outcomes under the current policy of an ENDS ban, using Mexico-specific population projections, death rates, life expectancy, and smoking and e-cigarette prevalence. The ENDS-Unrestricted Scenario projects smoking and vaping prevalence under a hypothetical scenario where ENDS use is allowed. The impact of legalizing ENDS use is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the ENDS-Restricted and Unrestricted scenarios.

Results

Compared to a national ENDS ban, The Mexico SAVM projects that legalizing ENDS use could decrease smoking prevalence by 40.1% in males and 30.9% in females by 2049 compared to continuing the national ENDS ban. This reduction in prevalence would save 2.9 (2.5 males and 0.4 females) million life-years and avert almost 106 (91.0 males and 15.5 females) thousand deaths between 2025 and 2049. Public health gains decline by 43% to 59,748 SVADs averted when the switching rate is reduced by half and by 24.3% (92,806 SVADs averted) with a 25% ENDS risk level from that of cigarettes but increased by 24.3% (121,375 SVADs averted) with the 5% ENDS risk.

Conclusions

Mexico SAVM suggests that greater access to ENDS and a more permissive ENDS regulation, simultaneous with strong cigarette policies, would reduce smoking prevalence and decrease smoking-related mortality. The unanticipated effects of an ENDS ban merit closer scrutiny, with further consideration of how specific ENDS restrictions may maximize public health benefits.

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

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.

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.

Non-compliance with smoke-free law in public places: a systematic review and meta-analysis of global studies

Introduction

Non-compliance with smoke-free law is one of the determinants of untimely mortality and morbidity globally. Various studies have been conducted on non-compliance with smoke-free law in public places in different parts of the world; however, the findings are inconclusive and significantly dispersed. Moreover, there is a lack of internationally representative data, which hinders the evaluation of ongoing international activities towards smoke-free law. Therefore, this meta-analysis aimed to assess the pooled prevalence of non-compliance with smoke-free law in public places.

Methods

International electronic databases, such as PubMed/MEDLINE, Science Direct, Cochrane Library, CINAHL, African Journals Online, HINARI, Semantic Scholar, google and Google Scholar were used to retrieve the relevant articles. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA) guidelines. The Higgs I2 statistics were used to determine the heterogeneity of the reviewed articles. The random-effects model with a 95% confidence interval was carried out to estimate the pooled prevalence of non-compliance.

Results

A total of 23 articles with 25,573,329 study participants were included in this meta-analysis. The overall pooled prevalence of non-compliance with smoke-free law was 48.02% (95% CI: 33.87-62.17). Extreme heterogeneity was observed among the included studies (I2 = 100%; p < 0.000). The highest non-compliance with smoke-free law was noted in hotels (59.4%; 95% CI: 10.5-108.3) followed by homes (56.8%; 95% CI: 33.2-80.4), with statistically significant heterogeneity.

Conclusion

As the prevalence of non-compliance with smoke-free law is high in public places, it calls for urgent intervention. High non-compliance was found in food and drinking establishments and healthcare facilities. In light of these findings, follow-up of tobacco-free legislation and creating awareness that focused on active smokers particularly in food and drinking establishments is recommended.

Short-term exposure to cigarette smoke upregulates cathepsin S and alters expression of tight junction ZO-1

A long-term exposure to cigarette smoke (CS) alters the integrity of airway epithelial barrier, contributes to lung dysfunction, and elicits the expression and activity of lung cathepsin S (CatS), a cysteine protease that participates in the remodeling of connective tissue and cell junctions. Here, we observed that a short-term (4 days) exposure of mice to CS increased the expression and activity of CatS, while the expression level of zonula occludens 1 (ZO-1), an epithelial tight junction protein that stabilizes barrier assembly, was reduced in lung tissue lysates. Present data support that proteolytically active CatS may contribute to the defect of ZO-1 in CS-exposed mice.

16S rDNA-Based Amplicon Analysis Unveiled a Correlation Between the Bacterial Diversity and Antibiotic Resistance Genes of Bacteriome of Commercial Smokeless Tobacco Products

The distribution of bacterial-derived antibiotic resistance genes (ARGs) in smokeless tobacco products is less explored and encourages understanding of the ARG profile of Indian smokeless tobacco products. Therefore, in the present investigation, ten commercial smokeless tobacco products were assessed for their bacterial diversity to understand the correlation between the inhabitant bacteria and predicted ARGs using a 16S rDNA-based metagenome analysis. Overall analysis showed the dominance of two phyla, i.e., Firmicutes (43.07%) and Proteobacteria (8.13%) among the samples, where Bacillus (9.76%), Terribacillus (8.06%), Lysinibacillus (5.8%), Alkalibacterium (5.6%), Oceanobacillus (3.52%), and Dickeya (3.1%) like genera were prevalent among these phyla. The phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt)-based analysis revealed 217 ARGs which were categorized into nine groups. Cationic antimicrobial polypeptides (CAMP, 33.8%), vancomycin (23.4%), penicillin-binding protein (13.8%), multidrug resistance MDR (10%), and β-lactam (9.3%) were among the top five contributors to ARGs. Staphylococcus, Dickeya, Bacillus, Aerococcus, and Alkalibacterium showed their strong and significant correlation (p value < 0.05) with various antibiotic resistance mechanisms. ARGs of different classes (blaTEM, blaSHV, blaCTX, tetX, vanA, aac3-II, mcr-1, intI-1, and intI2) were also successfully amplified in the metagenomes of SMT samples using their specific primers. The prevalence of ARGs in inhabitant bacteria of smokeless tobacco products suggests making steady policies to regulate the hygiene of commercial smokeless tobacco products.

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

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

Evaluation of the effectiveness of the Indian government's policies to strengthen health warning labels on smokeless tobacco products: findings from the 2010-2019 Tobacco Control Project India Surveys

BACKGROUND

Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs.

METHODS

Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010-2011, n=5911), Wave 2 (2012-2013, n=5613) and Wave 3 (2018-2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively.

RESULTS

The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT.

DISCUSSION

There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

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.

Evaluation of Feasibility and Acceptability of a Text-Messaging Intervention for Tobacco Cessation in India

INTRODUCTION

The aim of our study was to assess the feasibility and acceptability of a brief behavioral intervention for tobacco cessation delivered via mobile phone text messaging in India.

AIMS AND METHODS

We conducted an uncontrolled intervention cohort study in adult current users of tobacco. The participants received intervention messages on their mobile phones for eight weeks. We collected qualitative data about participants' perceptions of intervention delivery and receipt, acceptability, and feasibility of the intervention. The outcomes measured at 3 months post-recruitment were self-reported 7- and 28-day point-prevalence abstinence, and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) risk categories for tobacco-low (0-3), moderate (4-26), and high (≥27).

RESULTS

We recruited 26 eligible participants, and 22 completed the outcome assessments. The participants generally perceived the intervention content to be simple to access and useful in facilitating a change in tobacco use. None of the participants indicated that they wanted to discontinue receiving the intervention messages. Some suggestions for enhancing acceptability included supplementing text messaging with more intensive counseling and the use of multimedia content. Eighteen percent of participants reported abstinence in the past 7 and 28 days. A greater proportion of those who used smokeless tobacco were abstinent at follow-up compared to those who smoked (42.9% vs. 6.7%; p = .04).

CONCLUSIONS

If effective, simple and low-cost mobile phone text messaging can be used to deliver interventions for tobacco use, and has the potential to be scaled up so it can be delivered to populations of smokers interested in receiving cessation support.

IMPLICATIONS

Our study is an important step towards the development of a contextually relevant intervention suited for low- and middle-income countries and which is responsive to the needs of both those who use smoked and smokeless tobacco. If found to be effective, our intervention would be a scalable solution to overcome the human resource related barrier to accessing tobacco cessation services in low resource settings.

Heterogeneity of Harmful Constituent Profiles in Smokeless Tobacco Products from Five African Countries

Addictive, toxic, and carcinogenic constituents present in smokeless tobacco (SLT) products are responsible for the harmful effects associated with SLT use. There are limited data on levels of such constituents in SLT products used in Africa, a region with high prevalence of SLT use and the associated morbidity and mortality. Manufactured and custom-made SLT products were purchased from five African countries (South Africa, Uganda, Mauritania, Nigeria, and Zambia) using a standard approach for sample collection, labeling, and storage. Moisture content, pH, total and unprotonated (biologically available) nicotine, five tobacco-specific N-nitrosamines (TSNA), 10 polycyclic aromatic hydrocarbons (PAH), five metals and metalloids (As, Cd, Cr, Ni, and Pb), nitrate, and nitrite were analyzed. A total of 54 samples representing 15 varieties of manufactured SLT products and 13 varieties of custom-made SLT products were purchased and analyzed. In all samples, the total nicotine ranged from 1.6 to 20.5 mg/g product and unprotonated nicotine accounted for 5.3-99.6% of the total nicotine content. The sum of all five TSNA ranged from 1.6 to 100 μg/g product, with significant within-country variations observed across both the manufactured and custom-made varieties. Significant variations were also found for PAH, metals and metalloids, nitrates, and nitrites. This is the most comprehensive report on the chemical profiling of products from African countries. This is also the first study illustrating the variability of harmful constituents within the same types and brands of African SLT. Our findings emphasize the need for consumer education and interventions to reduce SLT use in Africa. The data reported here can be useful to regulators in considering measures to prevent the occurrence of high levels of known toxicants and carcinogens in manufactured products.

Smokeless and combustible tobacco use among 148,944 South Asian adults: a cross-sectional study of South Asia Biobank

INTRODUCTION

Tobacco use, in both smoking and smokeless forms, is highly prevalent among South Asian adults. The aims of the study were twofold: (1) describe patterns of SLT and combustible tobacco product use in four South Asian countries stratified by country and sex, and (2) assess the relationships between SLT and smoking intensity, smoking quit attempts, and smoking cessation among South Asian men.

METHODS

Data were obtained from South Asia Biobank Study, collected between 2018 and 2022 from 148,944 men and women aged 18 years and above, living in Bangladesh, India, Pakistan, or Sri Lanka. Mixed effects multivariable logistic and linear regression were used to quantify the associations of SLT use with quit attempt, cessation, and intensity.

RESULTS

Among the four South Asian countries, Bangladesh has the highest rates of current smoking (39.9% for male, 0.4% for female) and current SLT use (24.7% for male and 23.4% for female). Among male adults, ever SLT use was associated with a higher odds of smoking cessation in Bangladesh (OR, 2.88; 95% CI, 2.65, 3.13), India (OR, 2.02; 95% CI, 1.63, 2.50), and Sri Lanka (OR, 1.36; 95% CI, 1.14, 1.62). Ever SLT use and current SLT use was associated with lower smoking intensity in all countries.

CONCLUSIONS

In this large population-based study of South Asian adults, rates of smoking and SLT use vary widely by country and gender. Men who use SLT products are more likely to abstain from smoking compared with those who do not.

International burden of cancer deaths and years of life lost from cancer attributable to four major risk factors: a population-based study in Brazil, Russia, India, China, South Africa, the United Kingdom, and United States

Background

We provide a comprehensive view of the impact of alcohol consumption, tobacco smoking, excess body weight, and human papillomavirus (HPV) infection on cancer mortality and years of life lost (YLLs) in Brazil, Russia, India, China, South Africa, the United Kingdom (UK), and United States (US).

Methods

We collected population attributable fractions of the four risk factors from global population-based studies and applied these to estimates of cancer deaths in 2020 to obtain potentially preventable cancer deaths and their 95% confidence intervals (CIs). Using life tables, we calculated the number and age-standardised rates of YLLs (ASYR).

Findings

In Brazil, Russia, India, China, South Africa, the UK, and the US in 2020, an estimated 5.9 million (3.3 million-8.6 million) YLLs from cancer were attributable to alcohol consumption, 20.8 million (17.0 million-24.6 million) YLLs to tobacco smoking, 3.1 million (2.4 million-3.8 million) YLLs to excess body weight, and 4.0 million (3.9 million-4.2 million) YLLs to HPV infection. The ASYR from cancer due to alcohol consumption was highest in China (351.4 YLLs per 100,000 population [95% CI 194.5-519.2]) and lowest in the US (113.5 [69.6-157.1]) and India (115.4 [49.7-172.7). For tobacco smoking, China (1159.9 [950.6-1361.8]) had the highest ASYR followed by Russia (996.8 [831.0-1154.5). For excess body weight, Russia and the US had the highest ASYRs (385.1 [280.6-481.2] and 369.4 [299.6-433.6], respectively). The highest ASYR due to HPV infection was in South Africa (457.1 [453.3-462.6]). ASYRs for alcohol consumption and tobacco smoking were higher among men than women, whereas women had higher ASYRs for excess body weight and HPV infection.

Interpretation

Our findings demonstrate the importance of cancer control efforts to reduce the burden of cancer death and YLLs due to modifiable cancer risk factors and promote the use of YLLs to summarise disease burden.

Funding

Cancer Research UK.

Validation of Mobile Messages for an mHealth Intervention for Smokeless Tobacco Cessation in India

BACKGROUND

With the growth in use of mobile messages for behaviour change, the need to incorporate personal needs and cultural characteristics of target users has been promoted. The study aimed to describe the findings of content validation of mobile messages designed to promote smokeless tobacco cessation in primary care.

METHODS

This study used a concurrent mixed-method approach with 13 patients who were tobacco users at urban primary care clinics. The clarity and appeal of 32 messages were rated on a Likert scale from 1 to 10. A mean clarity and appeal score per message was generated. A 5-item discussion guide was used for in-depth interviews and data was analysed using framework analysis.

RESULTS

Participants found the content of the messages useful, and preferred shorter and audio formatted messages. The clarity scores for the messages ranged from 7.9 to 9.4 with an average score of 8.7 (SD 0.5). The appeal scores ranged from 7.3 to 9.2, with an average score of 8.5 (SD 0.6).

CONCLUSIONS

Twenty-six from a total of 32 messages were found appropriate and finalised for use. This methodology can be used when developing contextually relevant mobile message interventions in other low resource settings.

Effects of chewing tobacco on corneal endothelium in patients with diabetes mellitus

OBJECTIVE

To determine the impact of tobacco chewing on corneal endothelial structure in patients with diabetes mellitus (DM).

METHODS

Corneal endothelial parameters (endothelial cell count, ECD; coefficient of variation, CV; hexagonality, Hex, and central corneal thickness, CCT) were analysed in 1234 eyes of 1234 patients using non-contact specular microscopy (EM 4000 Tomey Nishi-Ku, Nagoya, Aichi, Japan). The study group (with a present history of tobacco chewing) comprising of 948 subjects, with 473 having DM was compared with age and gender-matched control group comprising of 286 subjects (139 having DM) with no history of tobacco use in any form.

RESULTS

Tobacco chewers had a significantly reduced ECD (P = 0.024) and Hex (P = 0.009) as compared with non-chewers. Similar results were noted in ECD (P = 0.004) and Hex (P = 0.005) in patients with DM. Tobacco chewers had a significantly decreased ECD values among males, HbA1C ≤ 7.5% and duration of DM ≤ 20 years, and significantly decreased Hex among those with >50 years of age, females, and duration of DM > 20 years. The CV and CCT values were comparable between the study and the control groups. Tobacco chewers showed a significant association of ECD with age, HbA1C, and duration of DM; CV with HbA1C; Hex with age and duration of DM; and CCT with gender, age, HbA1C and duration of DM.

CONCLUSIONS

Tobacco chewing may negatively impact corneal health, especially confounded by additional factors like age and DM. These factors must be accounted for in the pre-operative evaluation of such patients prior to any intra-ocular surgery.

From cultivation to cancer: formation of N-nitrosamines and other carcinogens in smokeless tobacco and their mutagenic implications

Tobacco use is a major cause of preventable morbidity and mortality globally. Tobacco products, including smokeless tobacco (ST), generally contain tobacco-specific N-nitrosamines (TSNAs), such as N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-butanone (NNK), which are potent carcinogens that cause mutations in critical genes in human DNA. This review covers the series of biochemical and chemical transformations, related to TSNAs, leading from tobacco cultivation to cancer initiation. A key aim of this review is to provide a greater understanding of TSNAs: their precursors, the microbial and chemical mechanisms that contribute to their formation in ST, their mutagenicity leading to cancer due to ST use, and potential means of lowering TSNA levels in tobacco products. TSNAs are not present in harvested tobacco but can form due to nitrosating agents reacting with tobacco alkaloids present in tobacco during certain types of curing. TSNAs can also form during or following ST production when certain microorganisms perform nitrate metabolism, with dissimilatory nitrate reductases converting nitrate to nitrite that is then released into tobacco and reacts chemically with tobacco alkaloids. When ST usage occurs, TSNAs are absorbed and metabolized to reactive compounds that form DNA adducts leading to mutations in critical target genes, including the RAS oncogenes and the p53 tumor suppressor gene. DNA repair mechanisms remove most adducts induced by carcinogens, thus preventing many but not all mutations. Lastly, because TSNAs and other agents cause cancer, previously documented strategies for lowering their levels in ST products are discussed, including using tobacco with lower nornicotine levels, pasteurization and other means of eliminating microorganisms, omitting fermentation and fire-curing, refrigerating ST products, and including nitrite scavenging chemicals as ST ingredients.

Latin America and the Caribbean Code Against Cancer 1st Edition: 17 cancer prevention recommendations to the public and to policy-makers (World Code Against Cancer Framework)

Preventable risk factors are responsible of at least 40% of cases and almost 45% of all cancer deaths worldwide. Cancer is already the leading cause of death in almost half of the Latin American and the Caribbean countries constituting a public health problem. Cost-effective measures to reduce exposures through primary prevention and screening of certain types of cancers are critical in the fight against cancer but need to be tailored to the local needs and scenarios. The Latin America and the Caribbean (LAC) Code Against Cancer, 1st edition, consists of 17 evidence-based recommendations for the general public, based on the most recent solid evidence on lifestyle, environmental, occupational, and infectious risk factors, and medical interventions. Each recommendation is accompanied by recommendations for policymakers to guide governments establishing the infrastructure needed to enable the public adopting the recommendations. The LAC Code Against Cancer has been developed in a collaborative effort by a large number of experts from the region, under the umbrella strategy and authoritative methodology of the World Code Against Cancer Framework. The Code is a structured instrument ideal for cancer prevention and control that aims to raise awareness and educate the public, while building capacity and competencies to policymakers, health professionals, stakeholders, to contribute to reduce the burden of cancer in LAC.

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.

The incidence trends of oral cancers worldwide from 1988 to 2012 and the prediction up to 2030

BACKGROUND

This paper aims to analyze the time trend of OCs incidence in 43 countries (1988-2012) and predict the incidence trend of OCs (2012-2030).

METHODS

In the database for Cancer Incidence in Five Continents, the annual data on OCs incidence grouped by age and gender were obtained from 108 cancer registries in 43 countries. The age-standardized incidence rates were calculated, and the Bayesian age-period-cohort model was used to predict the incidence in 2030.

RESULTS

South Asia and Oceania had the highest ASR in 1988 (9.24/100 000) and 2012 (6.74/100 000). It was predicted that India, Thailand, the United Kingdom, the Czech Republic, Austria, and Japan would be the countries with an increased incidence of OCs in 2030.

CONCLUSION

Regional custom is an important factor affecting the incidence of OCs. According to our predictions., it is necessary to control risk factors according to local conditions and enhance screening and education.

Oral Human Papillomavirus Infection among Smokeless Tobacco-using Tribal Women in Mysuru, India

Smokeless tobacco (SLT) is consumed by more than 300 million people worldwide. Studies show high use among Indian indigenous women who are also at high risk for oral cancers. Both human papillomavirus infection (HPV) and SLT have been associated with oral cancer, this study examined the presence of high-risk HPV in oral samples collected from tribal smokeless tobacco users in Mysuru, India. Between June and August 2019, 100 tribal females (50 SLT-users and 50 non-users) from rural Mysuru District, Karnataka, were enrolled in a cross-sectional study. Following informed consent, demographic data and oral samples were collected and processed using a digene HC2 High-Risk HPV DNA test (Qiagen, USA). On average participants were 45.5 (SD: ±6.6) years. Chronic SLT users were mostly married (73%), Hindu (100%), illiterate (62%), and employed (90%). One woman was positive for high-risk HPV infection. Oral HPV infection was low in this sample and this is consistent with the literature from other low and middle-income countries. SLT use is high in this group so interventions to reduce tobacco use are warranted.

Pan-American prevalence of smokeless tobacco use and association with oral potentially malignant disorders and head and neck cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of smokeless tobacco (SLT) use and its association with oral potentially malignant disorders (OPMDs) and head and neck cancer (HNC) in the Pan-American Health Organization (PAHO) region.

STUDY DESIGN

A literature search was conducted across 9 databases and other sources. The eligibility criteria were pediatric (0-18 years old) and adult (19 years and older) populations consuming any type of SLT. Meta-analysis was performed to determine the prevalence of SLT and the association between its use and OPMDs/HNC in the PAHO region; the Grading of Recommendations Assessment, Development, and Evaluation tool was used to verify the certainty of evidence.

RESULTS

Fifty-nine studies from 6 PAHO countries were included, of which 51 were also subjected to quantitative analysis. The pooled SLT prevalence of use was 15% (95%CI: 11.93-18.69) overall, 17% (95%CI: 13.25-22.65) in adults, and 11% (95%CI: 8.54-14.78) in the pediatric population. The highest reported SLT prevalence of use was 33.4% (95%CI: 27.17-39.93) in Venezuela. HNC was positively associated with SLT use (OR = 1.98, 95%CI: 1.54-2.55), with a moderate certainty of evidence. Among OPMDs, only leukoplakia reported a positive association with SLT use (OR = 8.38; 95%CI: 1.05-67.25). However, the quality of the evidence was very low.

CONCLUSION

A high consumption of SLT use, chewing tobacco and snuff, is reported among the adult population residing in the PAHO region with a positive association with the development of oral leukoplakia and HNC.

Social determinants of sex disparities in cancer in Southeast Asia

Sex disparities in cancer exist along the cancer spectrum, ranging from genomic predisposition and behavioral risk factors to access to screening, diagnostics, treatment, and survivorship care. A growing body of research is studying the biological underpinnings of these differences, from cancer risk to tumor biology to treatment response. It is well known, however, that the social determinants of health play a large role across the cancer disease continuum, which encompasses risk, prevention, diagnosis, treatment, survivorship, rehabilitation, and palliative care. Less literature focuses on the gendered disparities that are epidemiologic in nature, especially in Southeast Asia (SEA), a diverse region that is home to nearly 670 million people, where most are lower middle income countries, and where socioeconomic and cultural factors increase cancer risk for women. In this review, we highlight the social drivers of gendered disparities, namely the geographic, environmental, sociocultural, economic, and political forces that contribute to the increased mortality and poorer health outcomes in the region.

Salivary Oxidative Stress and Antioxidant Capacity in Smokeless Tobacco (Naswar) Users

Background

Naswar, a smokeless tobacco product, commonly consumed in Pakistan, is associated with a 10-fold increase in the risk of oral cancer. However, little is known about Naswar's underlying toxicity mechanisms.

Objective

The current study aimed to investigate the effects of Naswar use on oral health and salivary parameters.

Methods

A case-control study was conducted among Naswar users (n=42) and age-matched healthy controls (n=42) in Pakistan in 2019. Participant data were collected using questionnaires. Decayed, missing, and filled teeth (DMFT) scores were computed during clinical examinations. Unstimulated whole saliva was collected to assess salivary flow rate, pH, and salivary total oxidative stress (TOS)/total antioxidant capacity (TAC) using commercially available kits. Participants' oral health parameters were compared between cases and controls using ANOVA.

Results

No significant differences were observed between the two groups in terms of age, oral health, and hygiene practices and mean DMFT score. Mean salivary pH and the salivary flow rate was significantly (p<0.001) higher in Naswar users (7.7 and 0.71 mL/minute, respectively) than in non-users (6.95 and 0.52 mL/minute, respectively). Although TOS and TAC were not significantly different between the groups, Naswar users generally had a higher TOS (51.6±42 µmol/L) and lower TAC (0.55±0.18 mmol/L) than non-users (TOS 45.5±38.2 µmol/L and TAC 0.57±0.17 mmol/L). Correlational analysis also revealed a significant positive correlation between DMFT score and Naswar use duration (r=0.796, p<0.001) and the number of dips/units consumed each day (r=0.515; p<0.001).

Conclusion

Habitual Naswar use is associated with increased salivary flow rate, pH, and TOS, and reduced TAC levels in Pakistani adults compared to non-users. The pro-oxidant changes may contribute toward deleterious effects of Naswar use including oral cancer.

Assessing tobacco use in Swedish young adults from self-report and urinary cotinine: a validation study using the BAMSE birth cohort

OBJECTIVES

Studies on health effects of tobacco often rely on self-reported exposure data, which is subjective and can lead to misclassification. The aim of this study was to describe the prevalence of cigarette smoking, snus and e-cigarette use, as well as to validate self-reported tobacco use among young adults in Sweden.

METHOD

Participants of a population-based Swedish cohort (n=3052), aged 22-25 years, assessed their tobacco use in a web questionnaire. Urinary cotinine was analysed in a subsample of the study population (n=998). The agreement between self-reported tobacco use and urinary cotinine was assessed using Cohen's Kappa coefficient (κ) at a cut-off level of 50 ng/mL.

RESULTS

Patterns of tobacco use differed between men and women. Among men, 20.0% reported daily snus use, 5.8% daily cigarette smoking and 5.6% any e-cigarette use. In contrast, 3.2% of the women reported daily snus use, 9.0% daily cigarette smoking and 2.4% any e-cigarette use. Among the tobacco use categories, daily snus users had the highest levels of cotinine. Of reported non-tobacco users, 3.5% had cotinine levels above the cut-off, compared with 68.0% among both occasional cigarette smokers and snus users, 67.5% among all e-cigarette users and 94.7% and 97.8% among daily cigarette smokers and snus users, respectively. Agreement between self-reported tobacco use and urinary cotinine was classified as strong for daily use of cigarettes (κ=0.824) and snus (κ=0.861), while moderate to weak for occasional smoking (κ=0.618), occasional snus use (κ=0.573) and any e-cigarette use (κ=0.576).

CONCLUSIONS

We found high validity of self-reported tobacco use in our study population, particularly for daily tobacco use. Further, we found that daily snus users were exposed to high levels of cotinine. Together with previous findings, our results indicate good validity of self-reported tobacco use among young adults.

A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: implications for tobacco control in the Southeast Asia region

Background

In Southeast Asia, tobacco use is a major public health threat. Tobacco users in this region may switch between or concurrently use smoked tobacco and smokeless tobacco (SLT), which makes effective tobacco control challenging. This study tracks transitions of use among different product users (cigarettes, bidis, and SLT) in Bangladesh, one of the largest consumers of tobacco in the region, and examines factors related to transitions and cessation.

Methods

Four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey with a cohort sample of 3245 tobacco users were analysed. Generalized Estimating Equations (GEE) models were used to explore the socioeconomic correlates of transitions from the exclusive use of cigarettes, bidis, or SLT to the use of other tobacco products or quitting over time.

Findings

Among exclusive cigarette users, most remained as exclusive cigarette users (68.1%). However, rural smokers were more likely than urban smokers to transition to bidi use (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.29); to SLT use (OR = 2.68, 95% CI = 1.79-4.02) and to quit tobacco (OR = 1.57, 95% CI = 1.06-2.33). Among exclusive bidi users, transitional patterns were more volatile. Fewer than half (43.3%) of the exclusive bidi users maintained their status throughout the waves. Those with higher socio-economic status (SES) were more likely to quit (OR = 4.16, 95% CI = 1.08-13.12) compared to low SES smokers. Exclusive SLT users either continued using SLT or quit with minimal transitions to other products (≤2%). Nevertheless, males were more likely to switch to other tobacco products; younger (OR = 2.94, 95% CI = 1.23-6.90 vs. older), more educated (OR = 1.55, 95% CI = 1.77-3.12 vs. less educated), and urban SLT users (OR = 0.52, 95% CI = 0.30-0.86 for rural vs. urban users) were more likely to quit.

Interpretation

Complex transitional patterns were found among different types of tobacco product users over time in Bangladesh. These findings can inform more comprehensive and multi-faceted approaches to tackle diversified tobacco use in Bangladesh and neighbouring countries in the Southeast Asia region with similar tobacco user profiles of smoked tobacco and SLT products.

Funding

This is an unfunded observational study with the use the ITC Bangladesh datasets. The ITC Bangladesh Surveys were supported by grants from the US National Cancer Institute (P01 CA138389), the International Development Research Centre (IDRC Grant 104831-003), and Canadian Institutes of Health Research (MOP-79551, MOP-115016).

Association of Cardiovascular Disease Risk Factors with Exclusive Smokeless Tobacco Use among US Males: Cross-Sectional Analysis of NHANES Data 2003-2018

PURPOSE

To evaluate cardiovascular disease (CVD) risk factors among smokeless tobacco (ST) users. Exclusive ST users were compared to exclusive cigarette smokers and non-tobacco users.

DESIGN

Cross-sectional study.

SAMPLE

Data were used from 16,336 adult males who participated in one of the National Health and Nutrition Examination Surveys (NHANES) from 2003 to 2018.

MEASURES

Biochemically verified tobacco use, CVD risk factors (hypertension, cholesterol levels, BMI categories), physical activity, cotinine concentration, and sociodemographic variables.

ANALYSIS

Weighted analysis of the aggregate data was performed. ST users were compared with cigarette smokers and nontobacco users for their association with CVD risk factors. Associations were examined using univariate and multiple logistic regression with odds ratios (OR) and 95% confidence intervals (CI) reported.

RESULTS

Prevalence of exclusive ST use was 4.4% whereas, exclusive smoking was 22.2%. Among ST users, 36.2% were hypertensive, 24.5% had high cholesterol levels, and most of them were overweight (31.1%) or obese (52.6%). ST users were more likely to have hypertension compared to smokers (aOR = 1.48, 95%CI: 1.12, 1.95) and nontobacco users (aOR = 1.41, 95%CI: 1.09, 1.83) adjusted for other covariates. ST users were twice more likely to be obese than nontobacco users (aOR = 2.18, 95%CI: 1.52, 3.11). ST users had significantly higher cotinine concentration than smokers.

CONCLUSION

Study findings indicate substantial association of ST use among males with hypertension and obesity which are independent risk factors of CVD.

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.

A Comparison of Use Topography and Nicotine Pharmacokinetics Among Loose and Portioned Smokeless Tobacco Users

INTRODUCTION

Moist snuff smokeless tobacco (ST) products are available in the United States in both "loose" and "portioned" (ie, pouched) formats, but no published study to date has clinically evaluated the associations between ST format, use behavior, and nicotine exposure.

AIMS AND METHODS

Participants used their usual brand of ST (loose ST [n = 30] or portioned ST [n = 20]) during an experimental visit wherein use behavior and plasma nicotine pharmacokinetic parameters were measured following single use (first hour of the session) and ad libitum use (remaining 7 h of the session). Participants' ST products were chemically characterized prior to use for pH and nicotine content.

RESULTS

The average amount per use (2.99 vs. 1.52 g; p = .005) and total amount used (11.45 vs. 5.4 g; p = .002) were significantly higher among the loose ST group. Maximum plasma nicotine concentration (Cmax; 33.4 vs. 19.1 ng/ml) and area under the nicotine concentration versus time curve (AUC) were significantly higher for the loose ST group for the first hour (1474.8 vs. 807.2 min* ng/ml; p = .003) and throughout the 8-hour session (15827.9 vs. 8155.3 min* ng/ml; p < .001). Significant associations were observed between free nicotine content and first use Cmax (rs = .488, loose ST group) and AUC0-1 h (rs = 0.448, loose ST group; rs = .441, portioned ST group).

CONCLUSIONS

The loose ST group used more product and had a greater average deposition time per use than the portioned ST group. Nicotine exposure was more strongly associated with free nicotine content than total nicotine content.

IMPLICATIONS

To our knowledge, the current investigation was the first study to date to clinically evaluate the associations between usual-brand smokeless format, use behavior, and nicotine exposure. We observed meaningful differences in use behavior and subsequent nicotine exposure between loose and portioned ST users. Further, we observed that nicotine exposure was more strongly associated with free nicotine content than total nicotine content.

Fungal Community Composition and Function Associated with Loose Smokeless Tobacco Products

Smokeless tobacco products (STPs) contain several microbial communities which are responsible for the formation of carcinogens, like tobacco-specific nitrosamine (TSNAs). A majority of STPs are sold in loose/unpackaged form which can be loaded with a diverse microbial population. Here, the fungal population and mycotoxins level of three popular Indian loose STPs, Dohra, Mainpuri Kapoori (MK), and loose leaf-chewing tobacco (LCT) was examined using metagenomic sequencing of ITS1 DNA segment of the fungal genome and LC-MS/MS, respectively. We observed that Ascomycota was the most abundant phylum and Sterigmatomyces and Pichia were the predominant fungal genera in loose STPs. MK displayed the highest α-diversity being enriched with pathogenic fungi Apiotrichum, Aspergillus, Candida, Fusarium, Trichosporon, and Wallemia. Further, FUNGuild analysis revealed an abundance of saprotrophs in MK, while pathogen-saprotroph-symbiotroph were abundant in Dohra and LCT. The level of a fungal toxin (ochratoxins A) was high in the MK product. This study caution that loose STPs harbor various harmful fungi that can infect their users and deliver fungal toxins or disrupt the oral microbiome of SLT users which can contribute to several oral pathologies.