Current Smokeless Tobacco Users Research Articles

Impact of Smokeless Tobacco on Cardiovascular Disease Risk in a Nigerian Metropolitan City.

The use of smokeless tobacco products (STP) as a substitute for tobacco smoking is driving increasing consumption of these products especially in developing countries. The study sought to make comparison of cardiovascular risk profile between chronic STP users and suitably matched tobacco-naïve controls. This is a preliminary report from the cross sectional part of a two-arm prospective study of Smokeless Tobacco Products Composition and Exposure Outcome in Enugu metropolis, Nigeria. Consecutively recruited current Smokeless tobacco users, who had no history of cigarette smoking, aged 18years and above, residing in selected communities in Enugu metropolis, Nigeria were recruited for the study from October 2022 to July 2023. Age and sex matched non-tobacco users from same localities as the study subjects served as controls. Written informed consent to participate in the study was obtained from all study participants. All participants were screened by the investigators, using the study case report forms, to obtain data on medical history, demographic, clinical, laboratory, and electrocardiographic evaluation. Data from 54 STP-users and 54 non-STP-users (mean age 56.58 ± 8.15years) were analyzed. Anthropometric parameters were similar in both groups. Smokeless tobacco users had higher erect and supine blood pressure indices as well asgreater postural drop in systolic blood pressure. The occurrence of diabetes mellitus (20.37% versus 5.56%) and hypertension (25.93%; 11.11%) was significantly higher in the STP-users than in the non-user population, (p = 0.02192 and 0.04751 respectively). Electrocardiographic evaluation showed significantly increased QTc and dispersions of P-wave, QRS and QT intervals as well as reduced PR interval in STP users. Electrocardiographic abnormalities observed in STP users include left ventricular hypertrophy, left atrial enlargement, ST-segment elevation, short PR interval and long QTc. Use of smokeless tobacco products is associated with increased risk burden of diabetes mellitus and hypertensive heart disease. Electrocardiographic findings linked to STP-use in this study are features consistent with arrhythmia, ventricular repolarization abnormality, myocardial hypertrophy and ischaemia, suggesting that smokeless tobacco products are not safe substitutes for tobacco smoking.

Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis.

The purpose of this study was to (1) evaluate the rates of postoperative complications following ankle or hindfoot arthrodesis among current smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in current smokeless tobacco users vs people who smoke tobacco cigarettes. A retrospective cohort study was conducted using a large national database. For patients who underwent ankle or hindfoot arthrodesis, smokeless tobacco users (n = 131) and people who smoke (n = 1948) were matched 1:4 with controls, and smokeless tobacco users (n = 131) were matched 1:4 with people who smoke tobacco cigarettes (n = 524). Orthopaedic complications within 90 days, 1 year, and 2 years were compared using multivariable logistic regressions. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly higher rates of hardware removal (odds ratio [OR] 5.01, 95% CI 1.65-15.20), wound disruption or dehiscence (OR 3.00, 95% CI 1.21-7.44), and pooled complications (16.0% vs 5.9%, OR 2.84, 95% CI 1.50-5.38) compared with tobacco-naïve controls. The rates of hardware removal, wound disruption and dehiscence, and pooled complications remained significant in the smokeless tobacco cohort at 1 and 2 years. At 2 years following ankle or hindfoot arthrodesis, smokeless tobacco users additionally demonstrated significantly higher rates of infection (OR 6.08, 95% CI 1.15-32.05) and nonunion (OR 2.35, 95% CI 1.31-4.20) compared with tobacco-naïve controls. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly lower rates of malunion or nonunion than patients who smoke tobacco cigarettes (OR 0.34, 95% CI 0.12-0.97), whereas all other complications were not significantly different. Smokeless tobacco use is associated with higher rates of complications following ankle or hindfoot arthrodesis compared with tobacco-naïve controls, and physicians should screen for smokeless tobacco use specifically and encourage cessation before operating electively. Level III, retrospective cohort study.

Tobacco use and dependence among adults residing in an urbanized village, Delhi, India.

Tobacco use is one of the most significant public health concerns globally as it is a risk factor for chronic illnesses. GATS-2 concluded that 28.6% of all adults currently use Tobacco in India and 17.8% in Delhi. It is important to conduct such surveys in local areas to make specific and effective action plans. Community-based cross-sectional study conducted between January 2020-June 2021 in Aliganj, an urbanized village in South Delhi. Four hundred ninety participants were enrolled using simple random sampling. The first author conducted the interview using GATS and Fagerstrom nicotine dependence test. Data was analyzed using SPSS-21. Median age-35 (26.75-75.00), range-15-84 years. Of the 490 participants, 20.0% were current tobacco users (10.6% smokeless, 7.3% smoked, and 2.2% both). Among current smokers, 78.3% had low, 17.4% moderate, and 4.3% had high dependence on nicotine dependence. Among current smokeless tobacco users, 52.4% had, low, 36.5% moderate, and 11.1% had high dependence. Males had significantly higher odds [6.6 (2.9-15.1)] of tobacco use than females. Higher education [0.3 (0.2-0.8)] compared to no formal education had significantly lower odds of using tobacco. Students [0.1 (0.04-0.4)] and homemakers [0.1 (0.01-0.5)] had significantly lower odds of using tobacco as compared to those employed. One in every five adults is a tobacco user in Aliganj. Manufactured cigarettes, bidi, and water pipes were the most common products among smokers. Among smokeless tobacco users, the most common products were chewing tobacco gutka, and khaini. A larger proportion of smokeless tobacco users had high nicotine dependence than smoked tobacco users.

Determinants of Undetected Hypertension among Women Aged 15–49 Years in India with Special Reference to Use of Smokeless Tobacco

Abstract Background: Hypertension significantly contributes to avoidable morbidity and mortality. The literature indicates an increased risk of hypertension among tobacco users. This study examines the determinants of undetected hypertension among women in India and infers its relationship with smokeless tobacco (SLT) use. Materials and Methods: A nationally representative sample of 699,686 women (aged 15–49 years) in the National Family Health Survey-4 (2015–2016) was utilized. Women participants who did not self-report hypertension but their mean blood pressure measured during the interview were above 140/90 mmHg were considered as having undetected hypertension. Multivariate logistic regression was used to examine the association between hypertension and predictor variables including the use of SLT. Results: The prevalence of undetected hypertension was found to be 9.1% among women in India, and in comparison to non-SLT users, a higher prevalence of hypertension was observed among current SLT users. Age, illiteracy, obesity, use of SLT, alcohol consumption, and residing in Northeast India were found to be significant determinants of hypertension. Conclusion: Preventing the use of SLT through socioculturally tailored tobacco control interventions, raising awareness for behavior and lifestyle changes, and regular screening for hypertension in communities may have the potential to reduce the increasing burden of hypertension among women in India.

Factors Influencing Tobacco Cessation in India: Findings from the Global Adult Tobacco Survey-2.

The study aimed to assess the socio-demographic and other correlates of cessation behavior across tobacco products among the adult population in India. We used data of adults (aged ≥15 years) who were current or former tobacco users (smoking and/or smokeless tobacco) from the Global Adult Tobacco Survey (GATS) India, conducted during 2016-17. The detailed analysis was done for current daily smokers (N=7,647), former daily smokers (N=1,353), and current daily smokeless tobacco users (N=1,2721). Multivariate logistic regression was separately performed to find the associated factors with attempts to quit, successful quitting, different cessation methods of smoking, and smokeless tobacco use. The findings of the study indicated that daily smokers, higher educated, urban residents and employed were more likely to quit smoking compared to their counterparts. Successful quitting of smoking was higher for employed, higher educated, current users of smokeless tobacco and older adults. For smokeless tobacco users, non-daily users, highly educated, urban residents, and employed were more likely to attempt to quit compared to their counterparts. Successful quitting of smokeless tobacco was higher for unemployed, highly educated, urban residents and current non-smokers, and higher age group adults. The findings of this study suggest a need for professionally channelized cessation interventions to reduce the prevalence and relapse of tobacco use and increase the quit rate. Well-designed, large-scale research into specific tobacco cessation methods is needed to establish the association between different tobacco cessation methods and increased quit rates.

Perceived Truthfulness of Reduced Lung Cancer Risk Advertising Claims Influences Consumers' Intention to try and to Purchase Snus.

The objective of the current study was to evaluate the impact of a reduced risk claim about lung cancer, presented in various formats, on smokers' and non-smokers' interest in trying Camel Snus and intention to purchase Camel Snus. We varied claim formats by varying advertising messages for Camel Snus in 4 ways (1) text only; (2) bar chart; (3) text/testimonial; and (4) bar chart/testimonial. 3001 participants were recruited from a web-based consumer specialty panel via an email invitation. In 2015, a second study was conducted, using similar methods, where 3001 additional participants were recruited. Overall, controlling for other factors, the presence of an MRTP claim was not significantly related to interest in trying snus [X2 (4) = 8.567, P = .073], or purchase intentions [X2 (4) = 1.148, P = .887]. Relative to a control ad where no explicit health risk claim was made, the Graphic + testimonial [OR = 1.29] or Text only [OR = 1.41] claims did significantly increase interest in trying Camel Snus. However, the adverting format did not impact interest in purchasing Camel Snus. While current smokeless tobacco users (95%) and smokers (59%) expressed interest in trying Camel Snus, non-tobacco users (7%) showed low interest in trying or purchasing Camel Snus (P < .001). Interest in trying Camel Snus was stronger in younger smokers compared to older smokers. Among current smokers, worry about lung cancer (the key focus of the reduced risk claim) was not associated with interest in trying Camel Snus or with purchase intention [OR = .91, 95% CI: .72, 1.14] or intention to purchase snus [OR = 1.07, 95% CI: .86, 1.32]. Future research should evaluate how claim and messaging formats influence perceived truthfulness and whether this effect differs among sub-groups of consumers, such as adolescents, those with tobacco-related disease, and former smokers. It will also be helpful to understand whether perceptions of ad truthfulness result in changes in product use patterns over time. In sum, giving people truthful, credible information about relative product risks, such as through authorized MRTP claims, is important, but such information is likely insufficient to get smokers to switch.

How Does Tobacco Use Affect the Cognition of Older Adults? A Propensity Score Matching Analysis Based on a Large-Scale Survey.

Tobacco is a well-established risk factor for cancer, but its association with other morbidities needs consideration. The low-income and middle-income countries (LMICs) with unprecedented demographic transformation lack evidence on tobacco use and its impact on cognitive health. Using a propensity score matching approach, we utilized data from the Longitudinal Ageing Study of India. Study employed 1:1 nearest neighbor matching with the replacement methodology. We estimated the odds of the poor cognitive score and tobacco use among older adults based on five different models for ever tobacco user, former tobacco user, current tobacco user, current smokers, and current smokeless tobacco users with reference to never tobacco users. The estimated average treatment effect for the treated and the untreated group has shown a higher likelihood of cognitive decline among ever (OR -0.26; 95%CI -0.43 to -0.09), current (OR -0.28; 95%CI -0.45 to -0.10), and former (OR -0.53; 95%CI -0.87 to -0.19) tobacco users compared to never tobacco users. The finding further suggests the odds of lower cognitive scores among older adults who were smokers (OR -0.53; 95%CI -0.87 to -0.19) and smokeless tobacco users (OR -0.22; 95%CI -0.43 to -0.01) as compared to never tobacco users. Interventions designed to prevent the incidence of cognitive impairment should focus on limiting the use of tobacco. Strategies under the tobacco-free generation initiative should be amplified in order to prevent future generations from productivity loss, premature ageing and to promote healthy aging. Evidence of a definitive association between tobacco consumption and cognition among older adults is sporadic in LMICs. Though tobacco is a risk factor for various diseases including cancer, the extent of its impact on cognitive health among the older population is limited. This study contributes to the existing literature by highlighting poor cognitive outcomes among older adults who smoke tobacco and/or consume smokeless tobacco as compared to never-tobacco users. Our findings emphasize the need to accelerate programmes related to tobacco-free generation in LMICs to reach a higher quality of life and healthy aging in pursuit of achieving the sustainable development goal of "good health and well-being."

Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021.

This manuscript examines prevalence of awareness and use of nicotine pouches among U.S. middle and high school students by sociodemographic characteristics and other tobacco product use and characterizes nicotine pouch and other tobacco product use behaviors among current nicotine pouch users. Data are from the 2021 National Tobacco Youth Survey, a cross-sectional, school-based survey of middle and high school students (N = 20 413; overall response rate: 44.6%), which included questions on nicotine pouches in 2021 for the first time. Prevalence estimates, 95% confidence intervals, and estimated population counts were assessed for nicotine pouch awareness, ever use, and current (past 30 days) use, and for use behaviors related to nicotine pouches (frequency of use, flavor(s) used) and other tobacco products (ever, current, frequency of use) among current nicotine pouch users. Over one-third of students (35.5%) had ever heard of nicotine pouches. An estimated 1.9% (490 000) reported ever using them, while 0.8% (200 000) reported current use. Among current nicotine pouch users, 61.6% reported flavored nicotine pouch use, 64.2% reported current e-cigarette use, and 52.6% used multiple (≥2) tobacco products. Current use of nicotine pouches was common among current smokeless tobacco users (41.3%). Overall, in 2021, while relatively few students had ever tried nicotine pouches or currently used them, more than one-third had heard of them. Current nicotine pouch users tended to use other tobacco products, particularly e-cigarettes and smokeless tobacco. Given previous rapid increases in youth uptake of e-cigarettes, it is important to continue monitoring nicotine pouch use among young people. This study's findings provide an important baseline for future monitoring of nicotine pouch awareness and use among middle and high school students. Emerging tobacco products, particularly those that are flavored, widely available, discreet, and inexpensive have the potential to attract youth. Given the potential of these products to appeal to young people, ongoing monitoring of nicotine pouch use behaviors is important to inform public health and regulatory efforts.

Prevalence of smokeless tobacco use in India and its association with various occupations: A LASI study.

More than two-thirds of deaths in developing countries are due to non-communicable diseases, and tobacco is a leading risk factor. There are numerous different socio-demographic factors that impact on the use of smokeless tobacco, of which occupation is one. The objectives of this study are to find out the overall prevalence of smokeless tobacco use (ever and current use), the pattern of association with various occupations and related variables (current and past workers), and the role of childhood adversity on initiation and use. This study used data from the Longitudinal Aging Study in India (LASI) wave 1, a nationally representative cross-sectional study collected in 2017-18. Current and previous users of smokeless tobacco are taken into consideration as the target population. For the data analysis, survey-weighted tools have been applied for descriptive statistics and multivariable logistic regression model. The weighted data analysis has been done using R studio with R version 4. From the sample size of 65,561, 38% have used either smoking or smokeless tobacco. Among them, 40% use tobacco in smoke form, 51% use smokeless tobacco, and 9% take both. At the population level, 22.8 and 20.4% are previous and current users of smokeless tobacco, respectively. Type of occupation, type of employer, place of work, kind of business, and workload were found to be significantly associated with smokeless tobacco use. A deaddiction and tobacco quitting policy targeting rural male informal workers should be the focus of the Government.

Hardcore use of smoked and smokeless tobacco products among men and women in Bangladesh: data from two rounds of the global adult tobacco survey

This study examines the prevalence of and factors associated with “hardcore” use of smoked and smokeless tobacco (SLT) products in Bangladesh and the variation in the ages people started using them daily. Data from the 2009 and 2017 rounds of the Global Adult Tobacco Survey for Bangladesh were analyzed using multilevel logistic regression. The prevalence of “hardcore” use of smoked tobacco among current smokers decreased from 15.5% in 2009 to 13.1% in 2017. Almost all hardcore smokers were male in both rounds. Among the current users of SLT, 7.0% were “hardcore” users in 2009, with a higher proportion of females (8.9%) than males (4.8%) and these percentages remained similar in 2017. The current smokers in the age-group 25-64 and the current SLT users in the age-group 45-65+ were more likely than their counterparts to be “hardcore” users. The earlier the participants started using daily, the more likely they were to become “hardcore” users. There was regional variation in the prevalence of “hardcore” use. Coordinated preventive interventions and comprehensive treatment programmes and their equitable geographical distribution are needed.

Prevalence of Periodontal Disease Among Coal Mine Workers in Tamilnadu

Coal miners are predisposed to poor oral hygiene and the resulting dental diseases. we planned to investigate the factors that contribute to the prevalence and severity of periodontal disease among Tamil Nadu coal mine workers. 1500 coal mine workers over the age of 18 were enrolled. A proforma was used to record information about socioeconomic status and habits, followed by a clinical examination that included periodontal parameters such as probing pocket depth (PPD), clinical attachment level (CAL), number of missing teeth, and periodontal screening and recording index (PSR). The study population was divided into three age groups. On analyzing the influence of age on the periodontal health, of the participants, PPD, PSR, and the number of missing teeth were found to be higher in the age group of 51-60 years and CAL was found to be higher in the age group of 41-50 years. Also, the periodontal health of the subjects was influenced by their tobacco usage. The PPD and PSR was found to be higher among past smokers than current users of smokeless tobacco. The number of missing teeth was found to be higher among current users of the smokeless form and clinical attachment level was found to be higher among current users of both forms of tobacco. Our findings indicate that periodontal disease was more prevalent among coal mine workers in Tamil Nadu than in the general population. This highlights the importance of including oral health education and tobacco cessation programs to educate workers on the importance of periodontal health and treatment.

Smokeless tobacco use and oral potentially malignant disorders among people living with HIV (PLHIV) in Pune, India: Implications for oral cancer screening in PLHIV.

In India, smokeless tobacco (SLT) is a predominant form of tobacco used among people living with HIV (PLHIV). Despite SLT being a risk factor for oral potentially malignant disorders (OPMDs), no prior studies have quantified the association of OPMDs with SLT use among PLHIV. This limits the planning of preventive and control strategies for oral cancer among PLHIV, who are at higher risk for the disease. We enrolled 601 PLHIV and 633 HIV-uninfected individuals in an oral cancer screening study at BJ Government Medical College, Pune, India. Oral cavity images were collected using an m-Health application and reviewed by three clinicians. Participants with two clinician positive diagnoses were deemed to have suspected OPMDs. Prevalence ratios (PRs) were used to quantify the association between suspected OPMDs and SLT use among PLHIV. PRs for current SLT users, across HIV status and use duration were also estimated. Corrected PRs were obtained by modifying the maximum likelihood estimation. Models were adjusted for age, smoking, alcohol use and CD4 counts. Of those enrolled, 61% were men, median age was 36 years (IQR: 28-44), and 33% currently use SLT. Proportion of current SLT users was similar across PLHIV and HIV-uninfected groups but use duration for current SLT use was higher among PLHIV(p<0.05). Among PLHIV, current SLT users had a 5-times (95% CI:3.1-7.0) higher prevalence of suspected OPMDs, compared to non-users. Relative to HIV uninfected individuals with the same SLT use duration, significant associations with suspected OPMDs were seen for PLHIV with<10 use years (PR: 3.5, 95% CI: 1.5-8.1) but not for PLHIV with≥10 use years (PR: 1.3, 95% CI: 0.9-1.8). PLHIV that are current SLT users are at high risk of OPMDs and potentially oral cancer. The development of strategies for screening, early detection, and management of OPMDs must be considered for this group.

Abstract LB160: Oral cancer incidence among smokers and smokeless tobacco users compared to nonusers of tobacco products - contemporary analysis of cancer registry data

Abstract Tobacco use has been identified as a risk factor for oral cancer (oral cavity and pharynx). However, the differential oral cancer risk among users of cigarettes and smokeless tobacco (ST) products has not been well studied. In this study, we estimate oral cancer incidence among adult males who were current smokers that had never used ST products (SM), ST users who had never smoked (STU), and nonusers of cigarettes or ST products (NON) using data from state-wide cancer registries and national surveys. Oral cancer incidence rates were estimated using Colorado, Florida, North Carolina, and Texas cancer registries from the years 2014 through 2017 (the most recent 4 years of available data). State-specific population counts by tobacco use status were estimated from the Tobacco Use Supplement to the Current Population Survey. Missing values in tobacco use status in cancer registry data were imputed either by assuming missing at random (MR) or using multiple imputation (MI). Poisson regression was used to estimate incidence rate ratios (IRR) by state and age group. A random-effect meta-analysis approach was used to summarize estimates by state and age groups while considering potential heterogeneity using the Mantel-Haenszel model. Cases of oral cancer among adult males 35 years and older with tobacco use data numbered 19,536 in the geographies studied over the covered period. Assuming MR, the pooled oral cancer IRR relative to NON were 1.0 (95% CI = 0.7 to 1.3) for STU and 3.4 (95% CI = 3.0 to 3.9) for SM, resulting in an IRR of 3.5 (95% CI = 2.5 to 4.9) for SM relative to STU. The corresponding MI-based estimates relative to NON were 1.4 (95% CI = 1.1 to 1.9) for STU and 3.6 (95% CI = 3.2 to 4.1) for SM, resulting in an IRR of 2.6 (95% CI = 2.0 to 3.3) comparing SM relative to STU. These estimates should be considered in the context of certain limitations, such as the estimates were not adjusted for other potential confounding variables (e.g., alcohol intake and other lifestyle factors, duration of tobacco use, and other tobacco product use) due to the lack of such information in data sources. Our population estimates based on state cancer registry data demonstrate that current ST users had a substantially lower oral cancer risk than current smokers. While causal relationships cannot be concluded, the large sample size in this contemporary analysis suggests that oral cancer risks among smokers may be reduced by switching to ST products; however, quitting all tobacco use is the optimal path for reducing oral cancer risks. Citation Format: Brendan Noggle, Hui Cheng, Mohamadi Sarkar. Oral cancer incidence among smokers and smokeless tobacco users compared to nonusers of tobacco products - contemporary analysis of cancer registry data [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB160.

Oral Nicotine Product Awareness and Use Among People Who Smoke and Vape in the U.S.

Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use. This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February-June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts. Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18-24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping. Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).

Predictors of hypertension among current smokeless tobacco users in India; analysis from the fourth round of National Family Health Survey (2015-2016).

Hypertension is a major modifiable risk factor for cardiovascular and cerebrovascular diseases. The association between different risk factors including smoking and hypertension is studied extensively; however, there is a paucity of literature with respect to association between smokeless tobacco use and hypertension in India. In the current study, the relationship between smokeless forms of tobacco use and hypertension is being investigated. This study analyzed the data from fourth round of National Family Health Survey conducted during 2015-2016. Socio-demographic variables such as age, sex, education, wealth index, body mass index, smoked forms of tobacco use, and smokeless forms of tobacco like paan, gutkha, Khaini, etc., presence of co-morbidities were the independent variables. Hypertension was the dependent variable. It was observed from the present analysis that, smokeless tobacco use is a risk factor for hypertension both in the case of females OR-1.1**(1.08-1.13) as well as males OR-1.07**(1.03-1.1). The other predictors observed were overweight, consumption of alcohol, and diabetes. It was concluded from the present study, that consumption of smokeless tobacco use acts as an independent risk factor for hypertension.

Modeling mortality risk effects of cigarettes and smokeless tobacco: results from the National Health Interview Survey Linked Mortality File Data

BackgroundCigarettes and smokeless tobacco (SLT) products are among a wide range of tobacco products that are addictive and pose a significant health risk. In this study, we estimated smoking- and SLT use-related mortality hazard ratios (HRs) among U.S. adults by sex, age group, and cause of death, for nine mutually exclusive categories of smoking and/or SLT use.MethodsWe used data from the public-use National Health Interview Survey Linked Mortality with mortality follow-up through 2015. We used Cox proportional hazard models to estimate mortality HRs, adjusted by race/ethnicity, education, poverty level, body mass index, and tobacco-use status.ResultsWith never users as reference group, HRs for smoking-related diseases for male exclusive current smokers aged 35–64 and 65+ were 2.18 (95% confidence interval [CI]: 1.79–2.65), and 2.45 (95% CI: 2.14–2.79), respectively. Similar significant HR estimates were found for females and for all-cause mortality (ACM) and other-cause mortality (OCM) outcomes. HRs for exclusive current SLT users were only significant for males aged 35–64 for ACM (HR: 2.04, 95% CI: 1.27–3.27) and OCM (HR: 2.80, 95% CI: 1.50–5.25). HRs for users who switched from cigarettes to SLT products were significant for males aged 65+ for smoking-related diseases (HR: 2.06, 95% CI: 1.47–2.88), SLT-related diseases (HR: 1.99, 95% CI: 1.36–2.89), and ACM (HR: 1.63, 95% CI: 1.21–2.19).ConclusionsMale exclusive current SLT users aged 35–64 had a significant HR for ACM and OCM outcomes, suggesting that deaths not attributed to SLT use could be contributing to the ACM elevated HR for exclusive current SLT users.

Resilience and its associated factors in head and neck cancer patients in Pakistan: an analytical cross-sectional study

IntroductionThe study aimed to assess resilience and its associated factors in head and neck cancer patients, post-treatment in a low middle income country (LMIC) such as Pakistan.MethodsAn analytical cross-sectional study was conducted from November 2019 to May 2020 among head and neck cancer patients aged at least 18 years at the largest private tertiary care hospital, in Karachi, Pakistan. Information regarding their resilience scores was collected through Wagnild and Young’s Resilience scale that comprises of 14 items (RS-14). Moreover, depression and anxiety were also assessed via Hospital Anxiety and Depression Scale (HADS) and social support was assessed by Enriched Social Support Instrument (ESSI).ResultsThe data was analyzed by linear regression modeling. Unadjusted and adjusted beta coefficients with 95% CI were reported. A total of 250 head and neck cancer patients were recruited, 79% of them were males. Mean age of the patients was 51.59 years with 93% having high social support and only 8% having severe depression and 3% having severe anxiety. After adjusting for the covariates in multivariable analysis resilience was associated with severe depression (− 17[− 20.98,-12.93]) or borderline depression (− 4[− 8.41,-0.39]), severe anxiety (− 11 [− 17.88,-4.18]), low social support (− 6[− 9.62,-1.71]), having family members of > 6 in the household (− 2[− 4.31,-0.29), smokeless tobacco users post- treatment (10[5.79, 14.45]), and those who underwent tracheotomy (− 4[− 7.67,-0.21]). There was a significant interaction between education and role in the family (decision maker).ConclusionIn Pakistan, a South Asian LMIC, collectivist culture prevails, family ties are greatly promoted thus resilience and social support is highly prevalent in head and neck cancer patients resulting in lower prevalence of depression and anxiety. Our study highlights that higher resilience is prevalent among small families less than six members, as the welfare of the individual is prioritized over multiple needs of the family. Formal Education and role in household/decision making power are effect modifiers in our study, demonstrating its protective effect on the mental health of head and neck cancer patients. High resilience scores were reported among current smokeless tobacco users as compared to quitters post treatment. Resilience-building interventions should be formulated to aid head and neck cancer patients to cope with the disease and its sequel.

Exploring barriers of quitting smokeless tobacco among coronary artery disease patients of India: A qualitative study.

Cessation of all forms of tobacco is necessary for controlling mortality associated with coronary artery diseases (CADs). In India, smokeless tobacco (SLT) is the most used form of tobacco. With around 60% of the world's smokeless tobacco users living in India, the task of tobacco cessation has become daunting and complicated for Indian researchers and policy makers. We conducted the present study to understand CAD patients' perspectives towards their SLT use and to identify barriers of SLT cessation. Using a semi-structured interview method, we obtained data from 12 CAD patients who were currently using some form of SLT. Thematic analysis suggests that CAD patients were unable to quit SLT addiction due to (a) certain socio-environmental factors that support SLT, (b) prevalence of misconceptions about the link between SLT use and their cardiac condition, (c) perceived lower self-efficacy to quit, (d) fatalistic attitude towards health outcomes and (e) substituting addiction with perceived lesser harmful products. The findings reveal that factors responsible for the continuation of SLT usage are multipronged. Current SLT users' perspectives can facilitate the development of effective intervention and rehabilitation programs aimed at de-addiction of cardiac patients.

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.

Smokeless Tobacco Use and Oral Potentially Malignant Disorders Among People Living with HIV (PLHIV) in Pune, India: Implications for Oral Cancer Screening in PLHIV

Background: In India, smokeless tobacco (SLT) is a predominant form of tobacco used among people living with HIV (PLHIV). Despite SLT being a risk factor for oral potentially malignant disorders (OPMDs), no prior studies have quantified the association of OPMDs with SLT use among PLHIV. This limits the planning of preventive and control strategies for oral cancer among PLHIV, who are at higher risk for the disease. Methods: We enrolled 601 PLHIV and 633 HIV-uninfected individuals in an oral cancer screening study at BJ Government Medical College, Pune, India. Oral cavity images were collected using an m-Health application and reviewed by three clinicians. Participants with two clinician positive diagnoses were deemed to have suspected OPMDs. Prevalence ratios (PRs) were used to quantify the association between suspected OPMDs and SLT use among PLHIV. PRs for current SLT users, across HIV status and use duration were also estimated. Corrected PRs were obtained by modifying the maximum likelihood estimation. Models were adjusted for age, smoking, alcohol use and CD4 counts. Findings: Of those enrolled, 61% were men, median age was 36 years (IQR: 28-44), and 33% currently use SLT. Proportion of current SLT users was similar across PLHIV and HIV-uninfected groups but use duration for current SLT use was higher among PLHIV(p<0.05). Among PLHIV, current users had a 5-times (95% CI:3·1-7·0) higher prevalence of suspected OPMDs, compared to non-users. Relative to HIV uninfected individuals with the same SLT use duration, significant associations with suspected OPMDs were seen for PLHIV with<10 use years (PR: 3·5, 95% CI: 1·5 – 8·1) but not for PLHIV with≥10 use years (PR: 1·3, 95% CI: 0·9 – 1·8). Interpretation: PLHIV that are current SLT users are at high risk of OPMDs and potentially oral cancer. The development of strategies for screening, early detection, and management of OPMDs must be considered for this group. Funding: This work was supported by amfAR, The Foundation for AIDS Research, with support from the U.S. National Institutes of Health’s National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Diabetes and Digestive and Kidney Diseases, and the Fogarty International Center, as part of the International Epidemiology Databases to Evaluate AIDS (IeDEA; U01AI069907) and the NIH-funded Johns Hopkins Baltimore-Washington-India Clinical Trials Unit for NIAID Networks [UM1AI069465]. Declaration of Interest: The authors have no competing interests to declare. Ethical Approval: The Institutional Review Board of Johns Hopkins University (JHU) and Ethics Committee of BJGMC-JHU Clinical Research Site approved the project.