Trends of Smokeless Tobacco use among Adults (Aged 15-49 Years) in Bangladesh, India and Nepal

Is smokeless tobacco use associated with lower health-related quality of life? A cross-sectional survey among women in Bangladesh

INTRODUCTION

Bangladesh has 22 million adult users of smokeless tobacco (ST). The prevalence among women is higher (24.8%). Health-related quality of life outcome (HRQoL) for ST use is little known. We investigated the association between HRQoL and daily ST use among adult women in Bangladesh.

METHODS

Using multi-stage design, a cross-sectional survey was conducted. Adult women (randomly selected) were surveyed from 4 purposively selected divisions (Dhaka, Chittagong, Khulna and Rangpur). Female ST users and non-users were compared using HRQoL scores. Self-perceived Visual Analogue Scale (EQ-VAS) values and HRQoL scores were modelled to examine their association with ST use.

RESULTS

A total of 2610 women (1149 users and 1461 non-users) were surveyed. The proportion reported any type of problem in all health dimensions was significantly higher among female ST users than non-users (mobility: 43.3% vs 19.5%, self-care: 29.6% vs 11.9%, usual activities: 48.7% vs 21.8%, pain or discomfort: 69.8% vs 40.6%, and anxiety or depression: 61.3% vs 37.5%). The average HRQoL scores were 0.79 (95% CI: 0.78-0.81) and 0.90 (95% CI: 0.89-0.90) for users and non-users, respectively. Moreover, EQ-VAS average values were significantly higher for non-users [80.7 (95% CI: 79.9-81.6) vs 70.27 (95% CI: 69.2-71.2)]. Controlling the sociodemographics, ST use significantly reduced the HRQoL score by an average of 0.15 points. The EQ-VAS values on average decreased by 0.04 points for ST use.

CONCLUSIONS

ST use is significantly associated with the HRQoL of females in Bangladesh. Considering the higher prevalence of ST, especially among women, HRQoL hazards need to be communicated for awareness building.

Patterns of tobacco or nicotine-based product use and their quitting behaviour among adults in India: a latent class analysis

OBJECTIVES

The aims of the study were to identify latent classes of adult tobacco or nicotine-based product users in India, compare their sociodemographic distribution and quitting behaviour and explore the association of quitting behaviour and time to first tobacco use with class membership.

STUDY DESIGN

This was a nationally representative cross-sectional survey.

METHODS

Data from the Global Adult Tobacco Survey 2016-2017 in India, which covered adults aged >15 years, were analysed. Latent class analysis was used to examine patterns of tobacco or nicotine-based product use (cigarette, bidi, cigar, e-cigarette, chewable tobacco and snuff) among current tobacco users. Classes were compared across sociodemographic and tobacco use-related characteristics. Various model fit statistics (Akaike, Bayesian and Sample Size-Adjusted Bayesian Information Criteria, Likelihood Ratio Tests and Entropy) and meaningfulness of the classes were used to select the number of latent classes.

RESULTS

Of 21,857 current tobacco users, five latent classes were extracted: 'poly-tobacco use' (103, 0.5%), 'oral chewable products predominantly' (11,306, 51.7%), 'bidi predominantly' (4965, 22.7%), 'cigarette predominantly' (5318, 24.3%) and 'snuff and chewable products' (165, 0.8%). Significant differences between classes emerged on sociodemographics (age, sex, residence, education, wealth quintile, region). 'Bidi predominantly' class was associated with higher likelihood of quit attempts. Compared with 'cigarette predominantly' class, other classes were significantly associated with time to first tobacco use.

CONCLUSION

We found that people in India could be grouped into five classes based on their tobacco or nicotine-based product use pattern. It may be efficient to tailor messages to different latent classes and address the distinct profiles of these groups of tobacco product users.

The progression of the tobacco epidemic in India on the national and regional level, 1998-2016

BACKGROUND

Evidence regarding the progression of the tobacco epidemic remains fragmented in low- and middle-income countries. In India, most of the studies that examined tobacco consumption focused on one time point, on the country as a whole, and on men. Despite important gender differences in tobacco consumption, vast economic and cultural differences exist within India. We, therefore, assessed the progression of the tobacco epidemic in India on both the national and the regional level, by gender.

METHODS

We use information on current tobacco use among Indians aged 15-49 from three rounds of the National Family Health Survey (NFHS) (1998-99, 2005-06, 2015-16) to estimate the age-standardized sex specific smoking and smokeless tobacco prevalence across India and its states.

RESULTS

Age-standardized tobacco use prevalence in India increased between 1998-1999 and 2005-2006, and declined from 2005-2006 to 2015-2016, simultaneously for men and women. There are substantial spatial differences in the progression of the tobacco epidemic in India. While tobacco use declined in the majority of states, we observe high and increasing use for men in the north-eastern states of Manipur, Mizoram and Nagaland, and for women in the western state of Gujarat and north-eastern state of Manipur. We observed even more states with a recent increasing prevalence in either tobacco smoking or smokeless tobacco. Throughout, prevalence of tobacco use has been higher among men than women for all Indian regions, and remained higher than the national average in the north-eastern states.

CONCLUSIONS

Our results suggest that India and the majority of its states experienced a 'compressed tobacco epidemic' in which the prevalence of tobacco consumption increased and decreased simultaneously for women and men over a comparatively short period of time. Despite the overall progress India made in reducing tobacco use, further lowering tobacco consumption remains a public health priority, as the prevalence of smoking and/or smokeless tobacco use remains high in a number of states. We therefore conclude that tobacco regulations should be expanded with the aim of reducing the overall health burden associated with tobacco consumption across India.

Use of Smokeless Tobacco Before Conception and Its Relationship With Maternal and Fetal Outcomes of Pregnancy in Thatta, Pakistan: Findings From Women First Study

INTRODUCTION

Smokeless tobacco (SLT) consumption during pregnancy has adverse consequences for the mother and fetus. We aimed to investigate the effects of maternal pre-pregnancy SLT consumption on maternal and fetal outcomes in the district of Thatta, Pakistan.

AIMS AND METHODS

We conducted a secondary data analysis of an individual randomized controlled trial of preconception maternal nutrition. Study participants were women of reproductive age (WRA) residing in the district of Thatta, Pakistan. Participants were asked questions regarding the usage of commonly consumed SLT known as gutka (exposure variable). Study outcomes included maternal anemia, miscarriage, preterm births, stillbirths, and low birth weight. We performed a cox-regression analysis by controlling for confounders such as maternal age, education, parity, working status, body mass index, and geographic clusters.

RESULTS

The study revealed that 71.5% of the women reported using gutka, with a higher proportion residing in rural areas as compared with urban areas in the district of Thatta, Pakistan. In the multivariable analysis, we did not find a statistically significant association between gutka usage and anemia [(relative risk, RR: 1.04, 95% confidence interval, CI (0.92 to 1.16)], miscarriage [(RR: 1.08, 95% CI (0.75 to 1.54)], preterm birth [(RR: 1.37, 95% CI (0.64 to 2.93)], stillbirth [(RR: 1.02, 95% CI (0.39 to 2.61)], and low birth weight [(RR: 0.96, 95% CI (0.72 to 1.28)].

CONCLUSIONS

The study did not find an association between gutka usage before pregnancy and adverse maternal and fetal outcomes. In the future, robust epidemiological studies are required to detect true differences with a dose-response relationship between gutka usage both before and during pregnancy and adverse fetomaternal outcomes.

IMPLICATIONS

While most epidemiological studies conducted in Pakistan have focused on smoking and its adverse outcomes among males, none of the studies have measured the burden of SLT among WRA and its associated adverse outcomes. In addition, previously conducted studies have primarily assessed the effect of SLT usage during pregnancy rather than before pregnancy on adverse fetal and maternal outcomes. The current study is unique because it provides an insight into the usage of SLT among WRA before pregnancy and investigates the association between pre-pregnancy SLT usage and its adverse fetomaternal outcomes in rural Pakistan.

Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

METHODS

We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

FINDINGS

In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1·21% [-1·26 to -1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0·94% [-1·72 to -0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

INTERPRETATION

Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Aqueous extract of tobacco induces mitochondrial potential dependent cell death and epithelial-mesenchymal transition in gingival epithelial cells

Smokeless tobacco habits are detrimental to oral health. A correlation between tobacco use and local epithelial tissue damage exists. Yet, the underlying cellular mechanism is not precisely characterized. This study assessed the dose-dependent action of Smokeless tobacco extract on gingival epithelial cells. Gingival tissue was taken from 5 healthy donors. Gingival epithelial cells were isolated by an enzymatic method and cultured up to passage 2. The cultured cells were treated with smokeless tobacco extract at 10%, 25%, 50%, and 75% volume concentration. After 48 h of incubation, MTT assay, Annexin V/PI assay, and DiIC1(5) assay were used to evaluate viability, apoptosis, and mitochondrial potential of the cells. RT-qPCR was used to determine the expression of BAX, BCL2, ECAD, NCAD, and TWIST. The Smokeless tobacco extract reduced cell viability by disrupting the mitochondrial potential and inducing apoptosis. Further, the Smokeless tobacco extract induced a dose-dependent epithelial-mesenchymal-transition in gingival epithelial cells. Apoptotic cellular death caused by tobacco extract on the gingival epithelial system was dependant on the mitochondrial potential of the cell. The results demonstrate that smokeless tobacco causes detrimental metabolic alterations of the periodontium.

Featured application

This study elucidates the mechanism by which Smokeless tobacco products cause cellular damage to the gingival epithelium. The use of Smokeless tobacco products can lead to major cellular and surface changes in the gingiva and its appearance. The consequences of these changes are not limited to oral cancer but also increases a person's risk for dental and periodontal disease.

The Reasons for Using Smokeless Tobacco: A Review

Background:

Smokeless tobacco use is a public health problem in some parts of the world. The major objective of this study was to investigate the reasons and factors of consumption.

Methods:

A content analysis was conducted on articles for the past thirty years (1989–2019). We reviewed and selected 400 abstracts of original articles from PubMed databases by the search strategy, and reviewed one by one. Among these, 45 abstracts were selected, in which the patterns of use, the reasons for using, and the determinants and predictors were described. Eleven papers were selected based on the results and related to the research objectives. The results of these articles were evaluated precisely word by word and phrase by phrase with content analysis method and inductive approach.

Results:

The reasons for the use of smokeless tobacco fell in two main themes: socio-cultural structure; and, beliefs, each contained Sub-themes such as “culture and living conditions”, “laws”, “family and peer relationships”, “beliefs related to psychological” and “beliefs related to physical influences”, “beliefs”, “The role of harm perceptions “.

Conclusion:

There was a difference between beliefs, cultures and social conditions among the people about using of smokeless tobacco and the association of these factors is investigated in future studies. We also suggest for the prevention and control of smokeless tobacco use, cultural norms and beliefs will need to address adequately.

Burden, prevention and control of tobacco consumption in Nepal: a narrative review of existing evidence

Tobacco consumption is one of the major public health problems in the world. Annually, 27 100 premature deaths are attributed to tobacco-related diseases in Nepal. Despite enacting different policies and strategies, the prevalence of tobacco consumption is still high. This study aims to synthesize prevalence, factors associated with its consumption and the policy initiatives for prevention and control in Nepal. This review includes peer-reviewed studies retrieved from two databases (PubMed and EMBASE) and published from 2000 to 2018, and policy initiatives on tobacco prevention and regulations in Nepal. A total of 32 studies and 5 policy documents were reviewed. Findings suggest that tobacco consumption was higher among men, illiterates, older people, people living in rural and mountainous areas and those who initiated smoking as adolescents. Peer pressure and parental/family smoking were major contributing factors for tobacco initiation. Policy analysis showed that low excise tax, weak monitoring mechanisms, poor compliance to bans on the advertisement and promotion of tobacco, smoke-free zones and insufficient programs on tobacco cessation were the major factors behind weak implementation of tobacco-control policies. Hence, targeted and high-risk group tobacco-cessation interventions, increasing taxation and strict policy implementation are crucial for effective tobacco prevention and control in Nepal.

Key Drivers to Implement an Evidence-based Tobacco Control Programme in Schools of India: A Mixed-Methods Study

Background:

Adolescence is an influential stage in students’ lives when lifelong behaviours such as tobacco use are formed. During these years, school teachers are important role models for tobacco control among students. A study was conducted among school personnel and administrators to understand the key drivers for implementing an evidence-based school tobacco control program.

Methodology:

A cross-sectional, mixed-method study was conducted in five districts of Assam, India. The quantitative study was conducted among 565 school personnel across 40 Government-aided schools. Data was collected by means of an anonymous, self-administered questionnaire. Qualitative data was generated from 15 focus group discussions (FGDs) among 146 participants - District Program Officers, Block Education Officers, Cluster Coordinators, Headmasters and Teachers.

Results:

While the prevalence of smoked tobacco was low (3%), the use of smokeless tobacco was higher (40%), and the prevalence of use of areca nut without tobacco (65%) was still higher among school personnel. They were aware of the school policies prohibiting the use of tobacco among students within or outside school buildings or during school-sponsored activities (81%); they had rather limited knowledge about policy for themselves (58%). There was lack of access to training materials about prevention of tobacco use among youth. The FGDs amongst school personnel resulted in several constructive suggestions on tobacco control in schools mainly in training school teachers, monitoring the program and incentives for execution of the program. However, there was a reluctance to implement a smokeless tobacco control programme since many were current users of smokeless tobacco and areca nut.

Conclusion:

Tobacco control policies as well as training school personnel in schools need to improve and further measures must be taken to prohibit use of areca nut, which contains carcinogens. The existing system of the education department can be utilised to implement tobacco control programmes effectively.

Relationship between chewing tobacco, smoking, consuming alcohol and cognitive impairment among older adults in India: a cross-sectional study

BACKGROUND

Physical aging increases the sensitivity to the effects of substance use, elevating the risk for cognitive impairment among older adults. Since studies on the association of substance use with cognitive ability in later years are scant in India, we aimed to explore the factors associated with cognitive impairment especially, alcohol consumption, smoking, and chewing tobacco later in life.

METHODS

The present research used nationally representative data from Building a Knowledge Base on Population Aging in India (BKPAI) that was conducted in 2011, across seven states of India (N=9,453). Sample distribution along with percentage distribution was calculated for cognitive impairment over explanatory variables. For finding the association between cognitive impairment over explanatory variables, binary logistic regression models were estimated.

RESULTS

About 16.5 percent of older adults in rural areas consumed smoked tobacco compared to 11.7 percent in urban areas. Nearly, 23.7 percent of rural older adults consumed smokeless tobacco in comparison to 16 percent in urban areas. Alcohol consumption was high among rural residents (7.9%) than urban counterparts (6.7%). The prevalence of cognitive impairment was 62.8% and 58% among older adults from rural and urban areas respectively. Older adults who smoked tobacco had a 24 percent significantly higher likelihood to have cognitive impairment with reference to older adults who did not smoke [OR: 1.24, CI: 1.02-1.49]. Moreover, older adults who consumed alcohol had a 30 percent significantly higher likelihood to have cognitive impairment [OR: 1.02, 1.65]. It was also found that older adults who had smoked along with consuming alcohol were at risk of worse cognitive outcomes than those who neither smoke nor drink alcohol [OR: 1.56, CI: 1.21-2.00] or consumed either of them unlike consuming smokeless tobacco only.

CONCLUSION

The encouragement of older people to stop smoking and smokeless tobacco use could be considered as part of a strategy to reduce the incidence of cognitive impairment. Further, appropriate measures should be taken for the detection of early stages of cognitive decline in older individuals and efforts should be made to improve the availability and quality of care for dementing older adults.

Disparity between cigarette and smokeless tobacco taxation among various WHO FCTC Parties

INTRODUCTION

Tobacco taxation is the most effective way to prevent and reduce tobacco use. However, all tobacco products are not taxed in the same manner or same rate across countries. Hence, this study aimed to identify the total tobacco tax disparity among countries that are Parties to the WHO FCTC agreement.

METHODS

A cross-sectional study was conducted among the signees of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) treaty. The trends of taxation on cigarettes and smokeless tobacco products were retrieved from WHO FCTC reports published in 2017 and 2018; median tax percentages were then compared based on the economic status of the countries and their corresponding WHO region. Data were analyzed using SPSS version 21.0. A p-value <0.05 was considered statistically significant.

RESULTS

Maximum disparity between cigarette and smokeless tobacco taxation was observed in the South-East Asia region, followed by the Eastern Mediterranean, Western Pacific, and African regions. The disparity was comparatively less in the region of the Americas and the European region (p<0.05).

CONCLUSION

There was variation in tobacco taxation among various FCTC Parties according to the economic status and WHO region of each country.

The impact of information about tobacco-related reproductive vs. general health risks on South Indian women's tobacco use decisions

Smokeless tobacco use among Indian women is increasing despite prevention efforts. Evolutionary theories suggest that reproductive-aged women should be more concerned about immediate threats to reproduction than threats to survival occurring late in life. This study therefore compared an anti-tobacco intervention that emphasized near-term reproductive harms to one involving general harms occurring later in life. Scheduled Tribal women (N = 92) from Karnataka, India participated in this study. At baseline, women reported tobacco use and knowledge of harms, provided a saliva sample to assess use, and randomly viewed either a general harms presentation (GHP) or reproductive harms presentation (RHP). At followup, women reported their use, knowledge of harms and intentions to quit, and provided another saliva sample. At baseline, participants were aware of general harms but not reproductive harms. Both interventions increased knowledge of harms. Women in the RHP condition did not list more harms than women in the GHP condition, however, and the RHP was not more effective in reducing tobacco use than the GHP. In the RHP condition fetal health was particularly salient. In the GHP condition, oral health was highly salient, aligning with the local disease ecology and research on tobacco use and attractiveness.

Prevalence of tobacco use in urban and rural areas of Pakistan; a sub-study from second National Diabetes Survey of Pakistan (NDSP) 2016 - 2017

Objective:

To assess age standardized prevalence of tobacco use in urban and rural areas of Pakistan.

Methods:

This is a sub-study of second National Diabetes Survey of Pakistan (NDSP) 2016-2017. Prevalence of tobacco, ex-tobacco and non-tobacco users was determined in urban/rural areas of four provinces (Punjab, Sindh, Khyber Pakhtunkhwa, and Baluchistan) of Pakistan amongst people aged greater than or equal to 20 years. Information regarding tobacco and non-tobacco users were obtained from second NDSP (2016-2017) predesigned questionnaire. Detailed methodology for demographic, anthropometric and biochemical parameters remained same as reported in second NDSP (2016-2017).

Results:

The age-standardized prevalence of tobacco use in Pakistan was found to be 13.4%. Tobacco use in urban areas was 16.3% and rural areas was 11.7%. Tobacco use in urban and rural males was 26.1% and 24.1%, while in females was 7.7% and 3.1%, respectively. The age-standardized prevalence of ex-tobacco use in Pakistan was found to be 2.3%. Ex-tobacco use in urban areas was 2.6% and rural areas was 2.3%. Similarly, ex-tobacco use in urban and rural males was 4.6% and 4.6%, while in females was 0.7% and 0.5%, respectively. Multinomial logistic regression analysis shows that increasing age does not relate towards addiction of tobacco. Males were found to be 7 times (OR 6.94, 95% CI 5.68-8.49) and urban residents twice (OR 2.09, 95% CI 1.73-2.52) more tobacco users than females and those living in rural areas, respectively. From the likelihood ratio test, all variables were found to be statistically significant except for dysglycemia, dyslipidemia and hypertension.

Conclusion:

The prevalence of tobacco use is high. As a sub paper of a large national survey, this evidence is expected to serve as an important tool to plan larger studies leading in turn to develop strategies for a successful tobacco control program in the country.

Smokeless Tobacco Use is "Replacing" the Smoking Epidemic in the South-East Asia Region

Background

The sustained anti-tobacco campaign initiated in response to the mounting evidence against tobacco smoking has driven tobacco companies and smokers to look for alternative choices, such as smokeless tobacco (SLT) products. If this strategy advances, it could undermine several gains made by the campaign over the years. Our objective was to examine the trends in the prevalence of different tobacco types in three countries (Bangladesh, India, and Nepal) of South-East Asia.

Methods

Data from national surveys were used to estimate the trends of weighted and age-standardized prevalence (along with 95% CI) of different tobacco products. The share of each tobacco type was then calculated as a percentage of total tobacco use for each time point and country.

Results

In all the three countries, smoking prevalence declined (by 6% in Bangladesh, 3% in India, and 7% in Nepal) but SLT use increased (by 3% in Bangladesh, 6% in India, and 4% in Nepal) over the study period. SLT use increased irrespective of whether the total tobacco use increased or decreased. The share of SLT as a percentage of total tobacco use increased from 15% to 19% among Bangladeshi men, from 46% to 61% in India, and from 29% to 41% in Nepal.

Conclusions

In South-East Asia, a clear shift in the product preference from smoking to SLT was noted. Misleading advertising by tobacco companies may be responsible for the increase in the SLT prevalence, which is as harmful as smoking. Countries should strengthen policies to restrict SLT usage and prevent the rise of its use.

Implications

It has been documented that the smoking prevalence has been declining in most countries of the South-East Asia region where effective anti-tobacco laws have been implemented. But, due to a number of factors, the prevalence of smokeless tobacco has been increasing steadily, making the entire anti-tobacco movement less effective in terms of reducing the tobacco-attributable disease burden. In this context, this study has provided a detailed comparative analysis of the prevalence of smokeless tobacco use and smoking in three countries of the SEAR where such data were available. It can be clearly seen that the preference for smoking has shifted towards the smokeless tobacco in all the three study countries. This study recommends that tobacco control interventions should be aligned with the changing dynamics of the tobacco epidemic, and the need of the hour is placing restrictions of smokeless tobacco use so as to drive forward the gains of the anti-tobacco movement.

Association of smokeless tobacco with oral cancer: A review of systematic reviews

INTRODUCTION

Various primary studies and systematic reviews have been conducted to explain the association between smokeless tobacco and oral cancer. This study aims to consolidate and summarize the risk estimates from various systematic reviews with or without meta-analysis to provide the spectrum of estimates on the association between smokeless tobacco use and oral cancer.

METHODS

A comprehensive literature search was done on various databases (PubMed, Google Scholar, IndMED, and TOXLINE) by two of the authors independently. Both qualitative and quantitative data extraction and analysis were performed for the included systematic reviews. Range of risk estimates was obtained and analyzed as quantitative findings due to the limitation of an overview of reviews for the pooled estimates. CASP (Critical Appraisals Skills Programme) and AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) tools were used for the quality assessment of the studies included.

RESULTS

In total, 12 systematic reviews with or without meta-analysis were included in the review. There was a positive and strong association of Smokeless Tobacco (SLT) use with oral cancer irrespective of gender, region, and type of smokeless tobacco. The risk estimate for the South–East Asia Region (SEAR) ranged 4.44–7.90, for Gutkha it was 8.67, while for Paan it ranged 6.3–7.90 and for overall SLT it ranged 1.36–7.90. Risk estimate for females ranged 5.83–14.56.

CONCLUSIONS

The study confirmed the association between SLT use and oral cancer. These findings are of high importance, especially to the South-East Asia Region.

The Poorest of Poor Suffer the Greatest Burden From Smokeless Tobacco Use: A Study From 140 Countries

Background

The full extent of global smokeless tobacco (SLT) use and its association with key demographic factors such as gender, place of residence, and household or country income status is not yet known.

Methods

The global burden of SLT use among adults was estimated using nationally representative data of 140 countries by gender and country income group. Countries were grouped in Group 1 (low and low-middle income countries combined) and Group 2 (upper middle and high income countries combined). The number of male and female SLT users was calculated using prevalence and population estimates of corresponding age groups.

Results

Nearly one in 10 males and one in 20 females used SLT in some form. SLT use prevalence was significantly higher among males (p < .001) and females (p < .001) in Group 1 countries compared with their counterparts in Group 2 countries. However, for both Group 1 (p < .01) and Group 2 (p < .01), males were more likely to use SLT than females. Nearly 91% of a total 356 million adult SLT users resided in Group 1 countries, with 81.6% in countries of WHO South-East Asia region (SEAR). In SEAR and African region, SLT use was higher in rural areas and poorest communities.

Conclusion

The majority of the burden of SLT use is on lower and lower middle income countries with the greatest burden on the poorest segments of the population in these countries.

Implications

This study brings the comprehensive information on epidemiology of SLT use among adults at global level. Ninety percent of SLT burden is in low and low-middle income group of countries and more specifically among the poorest group in such countries. These countries need to have strategies to implement different provisions of the WHO Framework Convention on Tobacco Control. The program in such countries should be targeted towards the poorest communities for effective SLT control.

Smokeless tobacco and public health in Bangladesh

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Widowhood and Alcohol, Tobacco, and Other Drug Use Among Older Adults in India

Objective

We sought to assess how widowhood among older adults in India was associated with alcohol consumption, smoking, and use of chewing tobacco or other drugs.

Method

Data were collected in 2011 from 9,852 adults aged 60 and older from seven regionally diverse states in India. Regression analyses provided estimates of the relationship between widowhood and having smoked cigarettes, consumed alcohol, or used chewed tobacco or other drugs in the past month among men, adjusting for demographic and socioeconomic factors. We also estimated the relationship between widowhood and past-month substance use among women.

Results

Recently widowed men (within 0-4 years) were 1.76 times (95% confidence interval [CI] 1.01-3.09, p < .05) more likely to have consumed alcohol and 1.62 times (95% CI 1.01-2.59, p < .05) more likely to have used chewing tobacco or other drugs as compared with married men. Women widowed for any length of time were 1.37 times (95% CI 1.11-1.69, p < .01) more likely to have used chewing tobacco or other drugs.

Discussion

Interventions aimed at reducing use of chewing tobacco or other drugs among older adults in India should consider focusing on recently widowed men and women widowed for any amount of time.

A nationally representative study on socio-demographic and geographic correlates, and trends in tobacco use in Nepal

Tobacco control still poses an immense challenge for the government of Nepal. Updated knowledge on the current pattern of tobacco use and its associated factors will be helpful for policy makers to curb the tobacco epidemic. This study fills this gap by, (i) exploring demographic, socio-economic and geographic correlates of current tobacco use using a nationally representative sample of 15-49-year adults from Nepal Demographic Health survey 2016, and (ii) examining the prevalence and trends of both smoking and non-smoking forms of tobacco use in a nationally representative sample of 15-49-year adults drawn from three consecutive Demographic Health Surveys (DHS) between 2006 and 2016.Among males, the prevalence of smokeless tobacco use was higher than that of smoking (40.1% and 27.4% respectively), whereas among females smoking was more common than smokeless tobacco use (prevalence of 5.5% and 3.8% respectively). Both smoking and smokeless tobacco use were associated with older age and lower level of education. Among males, those living in urban areas were more likely to consume any form of tobacco. Residents of terai/plains were more likely to use smokeless tobacco. The concentration curves on cumulative proportion of tobacco use ranked by wealth quintiles showed tobacco use to be highest among the lowest socio-economic groups in both males and females in all three survey years. We found a decreasing trend of tobacco smoking and an increasing trend of smokeless tobacco use over the 10-year period. However, the consumption of both forms of tobacco increased in young males during the same period. Proper monitoring of adherence to directives of the anti-tobacco law should be ensured to curb the increasing burden of tobacco use among young males, and a similar effort is needed to sustain the decline in tobacco uses among other population groups in Nepal.

Assessment of Tobacco Consumption and Control in India

Tobacco consumption is a huge public health issue in India and its impact is especially devastating among the poor. Effective tobacco control should be a top priority, both as a health issue and as a method to reduce poverty. Tobacco use is deeply ingrained as a cultural practice and there are a myriad of tobacco types. We reviewed multiple determinants of tobacco consumption including socio-economic status, marriage, population growth, marketing strategies, and price. We also considered the tobacco burden including economic and social costs and adverse health impacts especially those resulting from oral cancer. We then addressed the history of tobacco control legislation in India and challenges in implementation. Tobacco consumption in India is continuing to increase despite tobacco control policy. Needed are more visible and aggressive anti-tobacco campaigns including increased public awareness of tobacco harms and active engagement of worksites and health professionals in promoting tobacco cessation.

Effectiveness of a structured teaching program (STP) on cessation of tobacco chewing, on knowledge and attitude among female hospital housekeeping personnel - a pilot study

AIM

To evaluate the effectiveness of a structured teaching program (STP) on: a) improving knowledge of female hospital housekeeping personnel regarding harmful impact of tobacco chewing and how to quit, and b) fostering an unfavorable attitude toward tobacco chewing.

METHODS

The STP focused on adverse health effects of tobacco chewing, myths and facts, and tobacco cessation. It was administered in regional language to female hospital housekeeping personnel (N=35) over three days. Post-assessments were conducted at 4 weeks following the last session of the STP.

RESULTS

Current tobacco use was reported by 26% of the sample. Tobacco chewers (vs. non-chewers) were more likely to be significantly older, have elementary education, belong to nuclear family, have lesser knowledge regarding harmful effects, and have a more favorable attitude toward the practice of tobacco chewing. At the end of 4 weeks following the STP, participants significantly improved their knowledge regarding the harmful health impact of tobacco chewing and how to quit (p=0.001), and showed a significantly less favorable attitude toward tobacco chewing (p=0.001). Change in participants' knowledge scores was found to be negatively correlated with change in attitude scores, implying that increase in knowledge was associated with less favorable attitude toward tobacco chewing (r=-0.427, p=0.011).

CONCLUSION

Findings provide preliminary evidence for the effectiveness of health education on harmful impact of tobacco chewing and how to quit, delivered through a STP, in improving knowledge and fostering an unfavorable attitude toward tobacco chewing, among female hospital housekeeping personnel.

Prevalence and Factors Associated with Smokeless Tobacco Use, 2014-2016

OBJECTIVES

We aimed to determine whether the prevalence of current use of smokeless tobacco products (STPs) changed during 2014-2016 and examine factors associated with use among adults in the United States (US).

METHODS

Data were obtained from Tobacco Products and Risk Perceptions Surveys of probability samples representative of US adults in 2014, 2015, and 2016. Change over time in current (past 30 day) STP use was examined using pairwise comparisons of proportions and multivariable logistic regression. Associated factors were examined using Rao-Scott χ2 and multivariable logistic regression.

RESULTS

The prevalence of current STP use was higher in 2015 (3.6%) than in 2014 (2.3%, p < .001) and 2016 (2.7%, p = .018) among US adults. In 2016, current STP use was associated with being male, under age 60, currently using hookah or e-cigarettes, and having less than a college degree. Rates of use did not vary by cigarette smoking status, race/ethnicity, income, or metropolitan statistical area (MSA).

CONCLUSIONS

The prevalence of current STP use peaked in 2015. In 2016, current STP use was more prevalent among males and adults with lower education. Continuous monitoring of STP use is needed, particularly non-cigarette tobacco product users.

Non Communicable Disease Risk Factors and their Trends in India

Background: India is a populous country of about 1.3 billion. Non communicable diseases (NCDs) contribute to around 5.87 million (60%) of all deaths in India. Hence, the objectives of this paper are to find baseline information on different NCD risk factors coverage and to determine their trends in India. Methods: For this systematic review, PubMed, Google and different surveillance systems were searched. Of the search results, 41 papers/survey reports were eventually assessed for eligibility. National and state representative data on NCD risk factors (for the major NCDs like cardiovascular diseases, chronic respiratory disease, cancer and diabetes) having World Health Organization(WHO) indicator definitions, covering rural and urban population, were included in the study. Thereafter, state-wise population proportion was added and divided by the total Indian population to determine the percentage of population coverage for each risk factor by the surveys. Also, the old and current data of the periodic surveys were compared to assess prevalence trends. Results: Various national/state level surveys in India include single or multiple risk factors. Nationwide coverage is available for tobacco use, alcohol drinking, raised blood pressure and overweight and obesity. Periodic National Family Health Surveys provide information on selected risk factors during 2005-16 among adults aged 15-49 years. An overall significant increase was noted in overweight and obesity while decline was noted in tobacco and alcohol use during the same period. From GATS 1 (2009-10) to 2 (2016-17) also, the prevalence of tobacco consumption decreased in India. Conclusion: India has a much delayed response on NCD risk factors surveillance and information of the same are sporadic and incomplete. In order to increase information comprehensiveness, standard WHO NCD risk factors questions must be incorporated in the ongoing surveys. India should also plan for cost and time effective NCD surveillance system.

Psychology of tobacco use: Are anti-tobacco policies encouraging the use of smokeless tobacco? A cross-sectional study in an industrial township

BACKGROUND

Anti-tobacco policies are focused on curbing smoking. Less attention is given to the use of smokeless tobacco use. This raises the concern whether these policies lead to increased use of smokeless tobacco use. The present study addresses this issue.

MATERIALS AND METHODS

A stratified random sample of 399 participants over 18 years and both genders were part of this cross-sectional study. They included an interview of urban and rural residents by house-to-house survey including outpatients, inpatients, and college students. Information was collected by face-to-face interview on a standard instrument for recording tobacco use. Additional questions were added to elicit switch from smoking to smokeless forms of tobacco. In-depth interviews were also held with some tobacco vendors.

STATISTICAL ANALYSIS

Data were summarized in percentages and with mean and standard deviation. Chi-square and two sample t-tests were used to explore associations.

RESULTS

Prevalence of smokeless tobacco use was 36.59% (95% confidence interval: 31.97%-41.41%). Smokeless tobacco use was highest in rural community at 60.20% compared to urban community in which it was 40%. Unskilled workers had the highest prevalence of smokeless tobacco use at 48.57% compared to lowest prevalence among professionals (12.50%). Years of schooling was inversely related to both smoking and smokeless tobacco use. Prevalence of smoking at 20.55% was much less than use of smokeless tobacco use. Awareness of adverse health effects and ban in public places were the main reasons for quitting smoking. About 10% of those who quitted smoking took smokeless tobacco.

CONCLUSION

There was a tendency among tobacco users to switch over to smokeless tobacco use due to awareness of health effects and ban on smoking in public places. A much higher prevalence of smokeless tobacco use compared to smoking suggests that the problem of smokeless tobacco use is receiving less attention from policymakers vis-à -vis smoking control policies.

Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: systematic review and meta-analysis

OBJECTIVES

To systematically review and meta-analyse the studies investigating the association between smokeless tobacco (SLT) use and all-cause mortality and cause-specific mortality outcomes among adult users of SLT and estimate the number of attributable deaths worldwide.

METHODS

Random-effects meta-analysis was used to estimate the pooled risk of death due to SLT use. Population attributable fractions were derived and used to calculate the number of attributable deaths. Observational studies published upto 2015 were identified through MEDLINE, IndMED, Google Scholar and other databases. Data on the prevalence of SLT use was obtained from latest reports or national surveys. Data on the disease burden were obtained from the Global Burden of Disease Study. Hospital-based or community-based case-control and cohort studies that adjusted for the smoking status were included.

RESULTS

16 studies that provided estimates for mortality due to all cause, all cancer, upper aerodigestive tract (UADT) cancer, stomach cancer, cervical cancer, ischaemic heart disease (IHD) and stroke were included. A significant association was found for mortality due to all cause (1.22; 1.11-1.34), all cancer (1.31; 1.16-1.47), UADT cancer (2.17; 1.47-3.22), stomach cancer (1.33; 1.12-1.59), cervical cancer (2.07; 1.64-2.61), IHD (1.10; 1.04-1.17) and stroke (1.37; 1.24-1.51). Subgroup analysis showed major regional differences. Globally, the number of attributable deaths from all-cause mortality was 652 494 (234 008-1 081 437), of which 88% was borne by the South-East Asian region.

CONCLUSIONS

SLT is responsible for a large number of deaths worldwide with the South-East Asian region bearing a substantial share of the burden.

Alcohol and economic development: Observations on the kingdom of Bhutan

Bhutan is a small country undergoing rapid social change arising from income growth, urbanisation and Western cultural influence. Markers of poverty, namely infectious disease and infant mortality, have improved dramatically. The attention of health authorities is now focused on the non-communicable disease and injury burdens, to which alcohol consumption is a major contributor. The paper draws on official data to characterise the consumption of alcohol and related harm, and the nature of the alcohol market, with commentary on crucial aspects of availability policies and drink-driving regulation that need reform. Kypri K, Dorji G, Dalton C. Alcohol and economic development: Observations on the kingdom of Bhutan. Drug Alcohol Rev 2017;36:333ȃ336.].

Smokeless tobacco-associated cancers: A systematic review and meta-analysis of Indian studies

The International Agency for Research on Cancer (IARC) has concluded that there is sufficient evidence in humans for the carcinogenicity of smokeless tobacco (SLT) for mouth, oesophagus and pancreas, based largely on Western studies. We wanted to confirm this by conducting a systematic review using Indian studies because India faces the biggest brunt of SLT-attributable health effects. A systematic search was conducted for published and unpublished studies. Two authors independently reviewed the studies and extracted data. Summary odds ratio (OR) for each cancer type was calculated using fixed and random effects model. The population attributable fraction (PAF) method was used to calculate the attributable burden of incident cases. A significant association was found for oral-5.55 (5.07, 6.07), pharyngeal-2.69 (2.28, 3.17), laryngeal-2.84 (2.18, 3.70), oesophageal-3.17 (2.76, 3.63) and stomach-1.26 (1.00, 1.60) cancers. But in random effects model, laryngeal-1.79 (0.70, 4.54) and stomach-1.31 (0.92, 1.87) cancers became non-significantly associated. Gender-wise analysis revealed that women had a higher risk (OR = 12.0 vs. 5.16) of oral but a lower risk (1.9 vs. 4.5) of oesophageal cancer compared with men. For oral cancer, studies that adjusted for smoking, alcohol and other factors reported a significantly lower OR compared with studies that adjusted for smoking only or smoking and alcohol only (3.9 vs. 8.4). The annual number of attributable cases was calculated as 49,192 (PAF = 60%) for mouth, 14,747 (51%) for pharynx, 11,825 (40%) for larynx, 14,780 (35%) for oesophagus and 3,101 (8%) for stomach.