Smokeless Tobacco Users Research Articles

Retrospective Analysis of the Anti Spitting Laws in Various Geographical Locations and Implementing Sectors in India

Objective: Public spitting attributable to Smokeless Tobacco (SLT) use not only causes a threat to public cleanliness but also to the people exposed around them. An electronic search on various anti-spitting laws and ban in India was done using Google search engine for duration of three months (November 2018 to January 2019). Material and Methods: The original state gazettes were reviewed to extract the data on spit ban and penalty. Renewals of Acts were also thoroughly checked for recent updates of penalty or severity of the act. The law implementing bodies were broadly classified as National, State, Municipal, Village councils (Gram Panchayat), Airports, Metro Railway, and Company Law Tribunal. Results: A total of 42 Anti-spitting laws were identified in this search and 16 states had anti spitting law under different sectors. Discussion: Under these laws, sign boards and warnings are placed commonly at Airports, Railway stations, and metro stations. States with high rates of SLT users like Tripura, Arunachal Pradesh and Mizoram did not have any policy on spitting. Conclusion: Strong enforcement of anti-spitting laws in India will not only reduce spread of communicable diseases but also indirectly will reduce the act of using SLT also.

Tobacco consumption influencing the prevalence of hypertension among Indian women aged above 15 years: An in-depth analysis using National Family Health Survey (NFHS - 5), 2019–2021

Objectives: Globally, hypertension associated with tobacco consumption is one of the leading causes of death. The aim of this study is to explore the possible association between tobacco consumption and hypertension among women aged 15 years and above in India. Methods: Data available from the National Family Health Survey (NFHS 5) survey was used for the study. The study examined the relationship between tobacco consumption and hypertension by analysing blood pressure indices among women aged above 15 years in India. The weighted proportion was computed with 95% CI for the cross-tabulations. Multivariable logistic regression was used to determine the risk factors for hypertension, high mean arterial pressure, and wide pulse pressure. Results: Among 625116 women aged 15 years and above, 41181 (6.6%) of them were tobacco consumers; among them, 3.4% had wide pulse pressure, 6% had hypertension, and 20.2% had high mean arterial pressure. Tobacco consumers were 1.11 times (1.03-1.20) and 1.09 (1.05-1.14) times more likely to have hypertension and high mean arterial pressure respectively, compared to those who didn't consume tobacco. Smokeless tobacco consumers were 1.12 (1.04-1.21) times more likely to develop hypertension. Conclusion: From this study, we found that factors like older age, mixed diet, alcohol use, and obesity have contributed to the risk of hypertension. Smokeless tobacco users were at risk of developing hypertension compared to users of other forms of tobacco.

Evaluation of the Smokeless Tobacco Awareness, Attitude, and Response Knowledge (STAARK) Scale With Integrated Risk Assessment for Tailored Intervention.

Background Smokeless tobacco (SLT) use, particularly gutkha, is prevalent in India, with cultural acceptance contributing to widespread use, especially among tribal populations. Despite awareness programs, there is limited assessment of their effectiveness, leading to continued vulnerability, even among educated groups. This study aims to evaluate public health strategies by developing and validating the SLT Awareness, Attitude, and Response Knowledge (STAARK) scale, which assesses knowledge and attitudes post-awareness programs on SLT usage through questionnaires, identifying vulnerable individuals, and enabling targeted interventions to reduce SLT use and associated health risks, particularly through integrated risk assessment (IRA). Methods This study was performed during an SLT awareness program in Nagaland, utilizing a comprehensive survey to assess participants' demographics, knowledge, and attitudes. The STAARK score was calculated by combining normalized attitude and knowledge scores, ranging from 0 to 10, categorizing participants' comprehension and attitudes toward SLT usage awareness. The obtained scores were assessed twice for consistency evaluation of the scale, and vulnerable individuals were subjected to IRA for targeted intervention recommendations. Reliability and correlation analyses were performed, with Cronbach's alpha validating the scale's internal consistency. Results About 182 participants took up the assessment, with only 180 completing the survey among the population attending the awareness program. Demographic data revealed a diverse participant group, with ages ranging from 13 to 42 years. The survey assessed participants' knowledge and attitudes toward SLT, scoring them on a 0-10 scale for knowledge and a 10-60 scale for attitude. The STAARK scale was developed to combine these scores, providing a comprehensive measure of participants' understanding and attitudes toward SLT. The mean STAARK score was 5.27 with an observed lower limit of 2.40 and an upper limit of 6.50 in the responded population. Reliability testing using Cronbach's alpha showed acceptable internal consistency, though attitude had a weaker correlation with the overall STAARK score compared to knowledge. In a follow-up assessment with 88 participants, the STAARK score averaged 5.10, reinforcing the initial findings. The risk assessment of 17 participants with STAARK scores above six identified varying levels of risk, with most falling into the low- or moderate-risk categories. The study highlights the importance of targeted interventions to address SLT usage, particularly in populations with lenient attitudes toward its consumption. Conclusions The STAARK scale can serve as a key tool for evaluating SLT awareness programs by assessing participants' knowledge and attitudes and identifying high-risk individuals requiring personalized interventions for SLT usage cessation. It standardizes the assessment, enabling comparison across groups and times, and helps identify individuals with lenient attitudes toward SLT for targeted interventions. Its reliability ensures consistency, and by tracking changes in scores before and after programs, it assesses impact and guides future improvements. The STAARK scale is crucial for personalized, evidence-based public health efforts to reduce SLT use. However, eradicating SLT requires ongoing commitment, adaptability, and a focus on long-term outcomes to translate knowledge into lasting change.

Treatment of Gingival Recession in Smokeless Tobacco User

Treatment of Gingival Recession in Smokeless Tobacco User

Understanding addictive behaviour of a group of slum dwelling female SLT users on the basis of PRIME theory: A case study in Odisha, India

ABSTRACT Context: Tobacco addiction is an important public health problem. Among several theories of addiction proposed, PRIME theory of motivation is found to be a comprehensive one to synthesise prevention strategies. Aims: This case study was conducted on the basis of PRIME theory to explain smokeless tobacco (SLT) addiction patterns among slum dwelling female residents of Cuttack district, Odisha. Settings and Design: Cuttack district of Odisha state and Qualitative synthesis. Methods and Material: Qualitative semistructured face-to-face interviews and framework analysis techniques were employed. The study was conducted over a period of 2 months between February 2020 and March 2020. Face-to-face interviews of 26 participants of Dasha Sahi slum using a semistructured questionnaire assessing responses based on five main themes including P, Plans; R, Responses; I, Impulses And Inhibitory Forces; M, Motives; and E, Evaluations of the said theory. Statistical Analysis Used: Verbatim transcripts were analysed using thematic framework analysis. Results: A majority of the participants were multiple SLT product users, and they did not have an immediate plan to quit. Most of the participants showed strong emotional attachment with these products and considered them the only source of pleasure (want) in a life full of miseries. The words “Tobacco” and “Nicotine” were medical jargons for them. Though they were aware of the harmful effects, they had a positive evaluative belief about its use because of cognitive dissonance. Most of them were habitual users living in an environment full of physical and social cues. Conclusions: This case study is well in line with the PRIME theory in explaining the addictive behaviour; a comprehensive multi-strategic approach was formulated for inculcating quitting behaviour among this disadvantaged section of the population as suggested by the proposer of this theory.

Abstract A092: Tobacco use and prevalence of oral premalignant lesions, among Malayali tribes, Yelagiri Hills, Tamil nadu, India

Abstract BACKGROUND: India has the second largest tribal population of the world next to the African countries. About half of the world’s autochthonous people live in India, thus making India home to many tribes which have an interesting and varied history of origins, customs and social practices. The present study was conducted to assess the tobacco use and prevalence of precancerous lesions and oral cancer among Malayali tribes, Yelagiri Hills, Tamil nadu, India. METHODOLOGY The inhabitants of the 14 villages of the Yelagiri hills, who have completed 18years and residing for more than 15years present on the day of examination and who were willing to participate in the study were included. Data was collected from a cross-sectional survey, using a Survey Proforma, clinical examination and a pre-tested questionnaire. An intra-oral examination was carried out by a single examiner using WHO Oral Health Surveys – Basic Methods Proforma (1997). ResultsThe overall prevalence of smokeless and smoking tobacco was 78.8% and 65.2% respectively among 1550 study population. Of those who had the habit of smoking, 26% smoked beedi, 10.9% smoked cigarette, 65% chewed raw tobacco, 18% chewed Hans and 28% had a combination of smoking and smokeless tobacco usage. Around 49.8% of samples were stained positive for precancerous and cancerous lesions of the oral cavity. The highest number of positive samples were from buccal mucosa with 46.2% subjects and 12% for labial mucosa. The reason for practicing these habits were as a measure to combat the cold, relieving stress and body pain after work, and the lack of awareness of the hazards of the materials used. Prevalence of oral mucosal lesions in the study population was due to tobacco usage and alcohol consumption and lack of awareness regarding the deleterious effects of the products used. CONCLUSION Oral cancer is highly prevalent in this Malayali tribes owing to high tobacco consumption rates and habits warranting the cessation center a priority. Also, early detection and screening are vital to attaining better outcomes. Citation Format: Delfin Lovelina Francis. Tobacco use and prevalence of oral premalignant lesions, among Malayali tribes, Yelagiri Hills, Tamil nadu, India [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A092.

Noticing health warning labels and intentions to quit smokeless tobacco products: results from two Global Adult Tobacco Survey rounds, India

Introduction: Health warning labels (HWLs) are one of the key strategies for tobacco control. The current study assessed the individual characteristics affecting the noticeability of HWLs and the thought of quitting smokeless tobacco (SLT) on noticing HWLs. We further estimated the temporal changes in noticeability and thought of quitting after noticing HWLs over time in India. Methods: Data from two rounds (2009–2010 and 2016–2017) of GATS (Global Adult Tobacco Survey) from India were analysed to understand the pattern of SLT usage and estimate the relative changes in the noticeability of HWLs and the thought of quitting SLT among those who noticed HWLs. Sampling weights were used during the analysis. Multivariate binary logistic regression was used to explore the determinants for the noticeability of HWLs and encourage the intention to quit SLT after noticing the HWLs. Results: About 25.9% and 20.6% of participants consumed SLT daily or non-daily in two rounds of GATS. Overall, there was a 14% relative increase in noticing the HWLs and a 20% increase in the thought of quitting in GATS-2 compared with GATS-1. The adjusted odds ratio of observing HWLs among SLT users was 1.51 times (95% confidence interval (CI), 1.44–1.58) in round 2 compared with round 1, while the odds ratio concerning the thought of quitting SLT after noticing HWLs was 1.95 times (95% CI, 1.84–2.06) in round 2 compared with round 1. Conclusions: We observe a consistent increase in the noticeability of HWLs and intentions to quit in SLT users, with significant variations across socio-demographic characteristics calling for concerted efforts. SLT being the major form of tobacco usage in India and Asian countries, HWLs alone cannot bring down the consumption rates, and it needs to be supported by strict implementation of SLT legislation for long-lasting impact.

Variability in addictive and carcinogenic potential of smokeless tobacco products marketed in Mumbai, India: a surveillance study

India has the highest incidence worldwide of smokeless tobacco (SLT)-associated oral cancer, accounting for nearly 70% of all SLT users globally. Nicotine and tobacco-specific N-nitrosamines (TSNA) play critical roles in the addictive and carcinogenic potential, respectively, of SLT products. Our group has previously reported substantial variability in nicotine and TSNA levels across a small SLT product sample in India, calling for systematic surveillance. However, there is no information available on the current levels of these constituents in Indian SLT. We analysed 321 samples representing 57 brands of eight popular types of manufactured SLT products purchased from five local markets in Mumbai, India between August, and September 2019. The sampling locations were Mumbai Central, Kurla, Thane, Vashi, and Airoli. Product pH, moisture content, total and unprotonated (biologically available) nicotine, and TSNA levels were measured at the Advanced Centre for Treatment, Research, and Education in Cancer (ACTREC) in Mumbai. Total nicotine content ranged from 0.45 to 35.1mg/g across products. The unprotonated nicotine fraction contributed 0.1-100% of the total nicotine content. The carcinogenic TSNA levels ranged 0.06-76 ug/g for N'-nitrosonornicotine (NNN), 0.02-19.2 ug/g for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), and 0.01-6.51 ug/g for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL). Consistent with our previous study, we observed substantial variations across different brands of the same product type. This is the most extensive and the first within-country study to report brand-specific nicotine and TSNA levels in SLT products marketed in Mumbai, India. Our results show that levels of these constituents remain extremely variable across Indian SLT and are strikingly high in many products. Enhanced public education and continued efforts to reduce SLT use prevalence in India are critical for reducing the global burden of SLT-associated morbidity and mortality. Regulation of nicotine and TSNA levels in SLT products should be considered. This work was supported by the National Institutes of Health (USA) grant R01-TW010651 and, in part, by grants R01-CA180880 and R50-CA211256. The LC-MS/MS analysis was supported in part by XII Plan project funding from the Department of Atomic Energy, Government of India.

Comparative Evaluation of Salivary Cathelicidin and 8-Isoprostane Levels Among Smokeless Tobacco Users and Non-users and Their Correlation With Periodontal Health and Disease: A Cross-Sectional Study.

Introduction Periodontal diseases arise from host-microbial interactions influenced by tobacco products. Salivary antimicrobial peptides such as salivary cathelicidin and prostaglandins such as 8-isoprostane are part of the inflammatory cascade affecting periodontal disease pathogenesis. Methodology A total of 93 patients, 31 in each group that is healthy, periodontitis, and periodontitis with smokeless tobacco habit patients, were enrolled. The case history was recorded, and clinical examination was performed using periodontal parameter analysis of oral hygiene index simplified (OHIS), Russell's index, periodontal pocket depth (PPD), and clinical attachment level (CAL). The saliva samples were collected and subjected to an enzyme-linked immunosorbent assay (ELISA) to evaluate cathelicidin and 8-isoprostane. The results were analysed and compared statistically. Results The OHIS, Russell's index, pocket probing depth, and CAL were high in patients with periodontitis and tobacco habit (p<0.001). The cathelicidin levels were the highest in patients with periodontitis and the tobacco habit (1.6 g/mL). The level of 8-isoprostane was the highest in patients with periodontitis with tobacco habit (1.8 pg/mL). Smokeless tobacco users showed higher levels of cathelicidin and 8-isoprostane in periodontitis with tobacco than in the healthy group. Conclusion Increased cathelicidin and 8-isoprostane levels in smokeless tobacco users with periodontitis suggest risk biomarkers for tobacco-influenced periodontitis.

Comparative proteomic analysis of saliva from chewing tobacco users and oral cancer patients reveals shared biomarkers: A case control observational study

ObjectiveThe aim of this study was to compare the salivary proteomic profile of smokeless tobacco users with that of non-users and oral cancer patients using Liquid Chromatography-Mass Spectrometry/ Mass Spectrometry (LC-MS/MS). MethodsSaliva samples from 65 participants were collected in three groups: control (25 participants), smokeless tobacco users (25 participants), and oral cancer (15 participants). ResultsThe analysis revealed 343 protein groups with significantly altered abundance in the saliva samples (P < 0.05). Among these, 43 out of 51 dysregulated proteins in the smokeless tobacco group were also dysregulated in the oral cancer group. Notably, Apolipoprotein A1 (ApoA1) and Pon1 were found to be significantly increased in both smokeless tobacco users and oral cancer patients (p < 0.05). Furthermore, six out of the 20 most significantly altered proteins were mitochondrial proteins, and all of these were decreased relative to controls in both smokeless tobacco users and cancer samples. ConclusionThe proteomic profile of users of chewing (smokeless) tobacco (SLT) shows substantial overlap in the altered pathways and dysregulated proteins with those altered in oral cancer samples, suggesting that SLT use induces a shift toward an oncogenic state. Specifically indicated pathways included blood microparticles, platelet α-granules and protease inhibitors as well as indicators of oxidative stress and exogenous compound processing. What differentiates oral cancer samples from SLT users is enrichment of alterations related to cytoskeletal organisation and tissue remodelling. Clinical SignificanceThe findings emphasize the importance of salivary proteomic profiles because changes in certain proteins may be indicators for early oral cancer identification and risk assessment in smokeless tobacco users.

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

IntroductionIndia 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. MethodSemi-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. ResultsWe 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. DiscussionNuanced 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 PracticeOur study provides useful insights to tailor cessation interventions to the type of tobacco consumed in order to enhance their acceptability and effectiveness.

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.

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

ObjectivesTo describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO...

Intention to Quit Tobacco due to Media Advertisements in India: Findings from Global Adult Tobacco Survey 2016-17.

Tobacco has been among the most important causes of morbidity and mortality worldwide. In reducing tobacco consumption, media campaigns are crucial in raising awareness and encouraging individuals to quit. The present study aimed to profile participants of GATS-2, including tobacco usage patterns and media exposure, and explore the factors associated with quitting in the presence of media exposure. Secondary data analysis of Global Adult Tobacco Survey-India (2016-17) data was done among current daily cigarette smokers and smokeless tobacco users. The primary independent variable was an intention to quit, while media exposure was the primary independent variable. Respondents were profiled as per various socio-demographic variables, and exposure to media advertisements and intention to quit were assessed using weighted bivariate analysis and multivariate log regression analysis. Males, and respondents aged 15 to 45, had more exposure to media and advertisements than female respondents. Cigarette smokers with moderate consumption, better awareness, those who had made any quit attempts in the last 12 months, and moderate to high media exposure depicted better intention to quit. In SLT users, intention to quit depicted significant odds per education level quit attempts and exposure to media and advertisements. We report a high intention to quit among those exposed to advertisements. Media campaigns play an important role in promoting tobacco control. There is a need to assess the impact of such advertisements on behavioral aspects. At the same time, comprehensive tobacco control policies should go hand in hand in reducing smoking rates.

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

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

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

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. 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. 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). 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.

Process evaluation of a pragmatic feasibility trial on smokeless tobacco cessation intervention delivered in dental hospitals

BackgroundArticle 14 of the WHO ‘Framework Convention on Tobacco Control’ recommends, that all oral healthcare providers provide support for tobacco cessation, to all patients. Despite evidence on the effectiveness of tobacco cessation interventions in dental settings, implementation remains low in most high-burden countries like Pakistan. A pragmatic pilot trial of a dentist-delivered behavioural support intervention for smokeless tobacco (ST) cessation, was conducted in dental hospitals in Pakistan. This paper presents the findings of the process evaluation of the trial.MethodsA mixed-method process evaluation of a multi-centre randomised control pilot trial of dentist-delivered behavioural support intervention ST cessation was conducted. The intervention included three sessions namely: pre-quit, quit and post-quit sessions. The process evaluation involved: semi-structured interviews with trial participants (n = 26, of which dental patients were n = 13 and participating dentists were n = 13 conducted from June-August 2022); and fidelity assessment of audio recordings of the intervention sessions (n = 29). The framework approach was used to thematically analyse the interview data.ResultsOverall the trial procedures were well accepted, however, young patients expressed uneasiness over revealing their ST use status. The intervention was received positively by dentists and patients. Dentists identified some challenges in delivering behavioural support to their patients. Of these, some were related to the contents of the intervention whereas, others were related to the logistics of delivering the intervention in a clinical setting (such as workload and space). Acceptability of the intervention resources was overall low amongst young patients as they did not take the intervention resources home due to fear of their family members finding out about their ST use. The intervention was successful in achieving the intended impact (in those who engaged with the intervention), i.e., change in the patients’ ST use behaviour. Giving up ST with the aid of behavioural support also had an unintended negative effect i.e., the use of harmful substances (cannabis, cigarettes) to give up ST use. Patients’ satisfaction with their dental treatment seemed to influence the intervention outcome.ConclusionWhile there are many variables to consider, but for the participants of this study, behavioural support for abstinence delivered through dentists during routine dental care, appears to be an acceptable and practical approach in helping patients give up ST use, in a country like Pakistan, where negligible support is offered to ST users.

Effects of Smokeless Tobacco on Oral Health: A Cross-Sectional Study.

Smokeless tobacco (SLT) consumption poses a significant global public health challenge because of its adverse effects on oral health. Although the detrimental impact of SLT on oral tissues is well-documented, understanding its multifaceted effects is essential for effective prevention and intervention strategies. This study aimed to comprehensively assess the impact of SLT on oral health, focusing on various clinical parameters and their differences between placement and non-placement sites of SLT. A cross-sectional study involving 528 habitual users of SLT was conducted. Clinical parameters included the plaque index (PI), gingival index (GI), gingival bleeding index (GBI), gingival recession (GR), and probing depth (PD). Oral mucosal changes at SLT placement sites have also been reported. Statistical analysis was performed to compare parameters between the placement and non-placement sites. The study involved 528 subjects, mostly male (82%) and aged 21-40 years (mean±SD=31.14±9.10), habitual users of SLT. Prevalent SLT types included tobacco with betel nuts/masala/gutkha (59.9%) and tobacco with lime (54.5%). Significant differences were observed between SLT placement and non-placement sites: higher gingival inflammation (GI) at placement sites (1.54±0.61 vs. 1.45±0.54, p=0.01), lower GBI at placement sites (40.0% vs. 84.3%, p=0.001), and more prevalent GR (65.7% vs. 34.3%, p=0.03) at placement sites. Probing depths ≥ 3 mm were also less frequent at placement sites (2.67±0.72) than non-placement sites (3.37±1.03, p=0.001). These results highlight the detrimental impact of SLT on periodontal health, emphasizing the need for targeted interventions among SLT users. SLT use is associated with adverse effects on oral health, including GI, plaque accumulation, gingival bleeding, GR, and changes in the oral mucosa. Targeted interventions and public health policies are needed to address these issues effectively.

A Study On Insight Into Cessation Attempts Among Current Smokeless Tobacco Users In An Urban Slum Of Ahmedabad

Introduction:According to GATS-2 report, one out of every five persons in Gujarat uses smokelesstobacco (SLT).Tobacco causes addiction &amp; dependence over a period of time.Tobacco cessation is anintegral part of the National Tobacco Control Programme.Objective:To estimate the proportion ofprevious quit attempts and its determinants among current SLT users of an urban slum inAhmedabad.Methods:A community-based, cross-sectional study using consecutive sampling wasconducted between June 2023 - August 2023 among 250 current SLT users in an urban slum ofAhmedabad( Ward number 15). A pre-tested, semi-structured questionnaire adapted from GATS-2(Global Adult Tobacco Survey-2) Tobacco Questions for Surveys was administered among theparticipants for eliciting sociodemographic characteristics, SLT consumption pattern and quittingattempts. Results:In this study, 68.8% of the participants had at least one past quit attempt out ofwhich 94.7% tried self- control methods. The most common reason for not being able to quit wasperceived as addiction (70.9%). A larger part of SLT users (89%) had noticed warning labels intobacco packets and 18.3% of them reported that they thought of quitting seeing that warning. Threefourth of the participants were advised by at least one person to not consume tobacco products &amp; in60% of the cases, it was the spouse.Conclusions and recommendations:The results suggest that there is an obvious lacuna in the community's utilization of services, despite the fact that National Tobacco Control Programme (NTCP) provides nationwide cessation services. This demonstrates theneed for extensive community-based tobacco cessation activities. Keywords:Smokelesstobacco(SLT), Addiction,Quit Attempt, National Tobacco Control Programme(NTCP)

The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD.

Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live. We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh, and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year-old male adoloscent would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs, and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST. This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.