Update on numbers of tobacco-attributable deaths by country in the South-East Asia region: implications for policy.

BACKGROUND: The WHO South-East Asia Region is home to around 33% of adult tobacco users. To inform tobacco control policy and practice, we conducted a study using the latest available data to update mortality attributable to overall tobacco use, including smoked tobacco, smokeless tobacco (SLT) and secondhand smoke (SHS) exposure, in the 11 countries of the Region. METHODS: We estimated smoking, SLT use and SHS exposure using the latest available surveys for each country during 2016-2021, and then estimated all-cause and lung cancer-attributable annual deaths for each using the population-attributable fraction method. Finally, we estimated the annual total tobacco-attributable deaths including all three exposures using the multiplicative aggregation method. RESULTS: We estimated the occurrence of 4 087 920 all-cause deaths and 105 279 lung cancer deaths annually attributable to tobacco use among the 11 countries investigated. India accounted for 63.9% of all-cause tobacco-attributable deaths. CONCLUSIONS: The high annual number of tobacco-attributable deaths in the Region highlights the need for accelerating progress in reducing tobacco use. Implementation of the WHO Framework Convention on Tobacco Control (FCTC) and MPOWER policy package needs prioritisation at the country level. Tobacco cessation services, supply-side measures and policies to counter tobacco industry interference should be strengthened. Further work is needed to monitor progress towards FCTC implementation and analyse the impacts of policies on tobacco-related outcomes, including attributable mortality and disease burden, to inform advocacy efforts.

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

OBJECTIVES: To describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO South-East Asia Region (SEAR), to inform policies for SLT control in the Region. METHODS: For each SEAR country, we obtained data from Global Adult Tobacco Surveys, WHO STEPwise Approach to NCD Risk Factor Surveillance surveys and Demographic and Health Surveys conducted since 2010 to estimate prevalence of SLT use by country, sex and year. Using data from the World Population Prospects database we estimated the number of users by country. Next, using the results of previous meta-analyses and prevalence results, we estimated the population attributable fractions and attributable mortality and morbidity in terms of annual deaths and disability-adjusted life years lost. We then characterised trends in attributable deaths and disease burden for countries with comparable data. RESULTS: There were wide differences in SLT use prevalence by country. We estimated that, during 2015-2019, there were 165 803 900 SLT users across SEAR, with 479 466 attributable deaths annually of which India accounted for 79.9% with 383 248. Attributable annual deaths increased in some countries during 2015-2019. CONCLUSIONS: Annual deaths and disease burden attributable to SLT remain high across SEAR and have only declined modestly in recent years. Effective implementation of all WHO Framework Convention on Tobacco Control measures, addressing both supply-side and demand-side issues, in relation to SLT and areca nut products must be prioritised to ensure reductions in mortality and disease burden are sustained and accelerated.

Taxation and prices of smokeless tobacco products in India: A success story.

India is the second-largest consumer of tobacco in the world, second only to China. The World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) is an evidence-based treaty which consists of demand reduction and supply reduction measures. Article 6 of the WHO FCTC requires the Parties to implement tax policies and where appropriate, price policies, on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption. The article aimed to analyze the association between taxation structures of smokeless tobacco (SLT) and the prevalence of SLT use at the country level. The article concluded that just as cigarettes, SLT taxes, and prices are also key factors in controlling the demand for SLT products. It calls for uniform taxation across all types of tobacco products for effective and sustained impact and also to prevent product substitution.

Regulating smokeless tobacco and processed areca nut in South-East Asia region: The journey so far and the road ahead.

South-East Asia Region (SEAR) has more smokeless tobacco users as compared to smokers. The growing prevalence and cultural acceptance of consumption of flavored areca nut and related products, for example, supari and pan masala in many countries are confounding the scenario. The prevalence of a variety of tobacco products makes regulation a challenge which gets more complicated in view of weak enforcement of regulatory policies aggressive marketing of such products by the tobacco industry. Some countries have attempted to regulate smokeless tobacco and related products by enforcing bans. However, limited evidence base along with lack of technical and regulatory capacities have restricted the SEAR countries to effectively implement product regulation in respect of smokeless tobacco and related products. This paper lays out specific priorities for research and need to enhance regulatory capacity for smokeless tobacco and processed areca nut in the SEAR countries. A systematic and comprehensive search was conducted to identify all original published literature related to regulating smokeless tobacco and processed areca nut. Studies reporting on the same were obtained through searches in relevant academic databases. Relevant World Health Organization (WHO) documents and reports on tobacco products regulation were consulted. Generating the right evidence along with the need to build the capacity of the countries to test the smokeless tobacco and processed areca nut products by establishing testing facilities and providing practical guidelines is of paramount importance. The countries of the SEAR need to prioritize the implementation of Articles 9 and 10 of the WHO Framework Convention on Tobacco Control to strengthen the regulation of smokeless tobacco and processed areca nut products.

Getting real with the upcoming challenge of electronic nicotine delivery systems: The way forward for the South-East Asia region.

Electronic nicotine delivery systems (ENDS) are being marketed to tobacco smokers for use in places where smoking is not allowed or as aids similar to pharmaceutical nicotine products to help cigarette smokers quit tobacco use. These are often flavored to make them more attractive for youth - ENDS use may lead young nonsmokers to take up tobacco products. Neither safety nor efficacy as a cessation aid of ENDS has been scientifically demonstrated. The adverse health effects of secondhand aerosol cannot be ruled out. Weak regulation of these products might contribute to the expansion of the ENDS market - in which tobacco companies have a substantial stake - potentially renormalizing smoking habits and negating years of intense tobacco control campaigning. The current situation calls for galvanizing policy makers to gear up to this challenge in the Southeast Asia Region (SEAR) where the high burden of tobacco use is compounded by large proportion of young vulnerable population and limited established tobacco cessation facilities. Banning ENDS in the SEAR seems to be the most plausible approach at present. In the SEAR, Timor-Leste, Democratic People's Republic of Korea, and Thailand have taken the lead in banning these products. The other countries of the SEAR should follow suit. The SEAR countries may, however, choose to revise their strategy if unbiased scientific evidence emerges about efficacy of ENDS as a tobacco cessation aid. ENDS industry must show true motivation and willingness to develop and test ENDS as effective pharmaceutical tools in the regional context before asking for market authorization.

Using public interest litigation for tobacco control: Insights from India.

The Indian notion of "Public Interest Litigation (PIL)" represents a moral and humane process for providing justice to an individual or a group in matters relating to infringement of fundamental rights or denial of civil privileges. The goal of PIL in India is to counter governmental lawlessness, administrative deviance, and exploitation of disadvantaged groups by denying them their rights and entitlements. Although this paper selectively describes the use of the PIL mechanism for ensuring implementation of large graphic health warnings on packages of tobacco products in India, there is a sufficient published literature to corroborate the successful use of this mechanism in India in different tobacco control settings. In fact, over the years, this legal tool has allowed the tobacco control community in India, to extensively promote human rights approach to tobacco control. In the wake of growing interference of tobacco industry worldwide, this paper explores PIL as a potent and effective tool for claiming public health rights related to tobacco control. The PIL has considerable potential to be used for enforcement of tobacco control measures and for stopping tobacco industry from engaging in activities which are detrimental to the health of the people at large. It is important to continuously identify potential avenues through which lessons and recommendations pertaining to PIL could be incorporated into the WHO Framework Convention on Tobacco Control implementation plans and guidelines, with special focus on different intercessional mechanisms that are available from time to time. To set the ball rolling, the authors suggest two such avenues.

Assessment of urinary cotinine levels in women with gynecological complaints at a tertiary care hospital: A pilot study.

Gynecological effects due to smokeless tobacco exposure are not well studied. This cross-sectional study was undertaken with the objective to evaluate the urinary cotinine levels in women of reproductive age with gynecological complaints. The study was conducted in 2015 at the outpatient clinic of the Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. A total of 192 consecutive women presenting with gynecological complaints (pelvic inflammatory disease (PID), infertility, and menstrual abnormality) were recruited. Their demographic details and tobacco exposure were recorded. All of them denied exposure to any form of tobacco. Urinary cotinine level of each participant was measured. The mean urinary cotinine level was 23.60 ± 12.00 ng/ml. PID was the most common gynecological complaint. Women with PID had significantly higher urinary cotinine levels compared to those with menstrual complaints and infertility: 24.9548 (±12.259) ng/ml versus 20.2042 (±10.9248) ng/ml. This study highlights the importance of addressing the issue of secondhand smoke exposure and reproductive morbidities in women.

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations.

INTRODUCTION: Almost a fifth of the world's tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these. METHODS: We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations. RESULTS: We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit. CONCLUSIONS: Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

Safety, efficacy and health impact of electronic nicotine delivery systems (ENDS): an umbrella review protocol.

BACKGROUND: Electronic nicotine delivery systems (ENDS), commonly known as e-cigarettes or vapes, have witnessed a rise in popularity, particularly among the youth. Although they were initially introduced as an alternative to traditional smoking, the design and function of ENDS vary. The potential health effects of ENDS, especially in comparison to traditional cigarettes, are a matter of ongoing debate. Given the increasing number of clinical studies and systematic reviews on this topic, there exists a demand for an umbrella review that offers a comprehensive assessment. The goal of this study is to perform an umbrella review of systematic reviews and meta-analyses to assess the safety, efficacy, health implications and potential gateway effect associated with ENDS. METHODS AND ANALYSIS: This umbrella review will adhere to the Joanna Briggs Institute (JBI) framework and the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A planned literature search will be executed across databases such as OVID, PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science. The inclusion criteria are systematic reviews that discuss ENDS and e-liquids in the context of safety, efficacy and health outcomes. The exclusion criteria include narrative reviews, non-systematic reviews and studies not in English. Quality of the selected studies will be evaluated using the AMSTAR V.2 Scale. An overlap assessment will be done using the Corrected Covered Area, and data synthesis will be presented both narratively and in tabulated forms ETHICS AND DISSEMINATION: Ethics approval is not required for this study, as it does not involve the collection of original data. The results will be disseminated through peer-reviewed publication. The findings will offer crucial insights for stakeholders, policy-makers and the general public, underlining the health implications and the role of ENDS in tobacco cessation.

Physical and chemical characterization of smokeless tobacco products in India.

The rapid proliferation of smokeless tobacco (SLT) in India has occurred without adequate information on the possible dangers and toxicity of these products. Tobacco flavors as well as nicotine (both protonated and un-protonated) are responsible for health dangers and addiction. The study aimed to offer information on the physical characteristics of commonly used smokeless tobacco products (including microscopic analysis), along with nicotine content (both total and un-protonated), pH, moisture, and flavors. The Standard Operating Procedures (SOPs) validated by the World Health Organization (WHO) recognized Tobacco Testing Laboratory TobLabNet) were applied for the analysis of various constituents of the SLTs. The microscopic analysis indicated that some of the SLT products like khaini were finely processed and available in filter pouches for users' convenience and prolonged use leading to prolonged retention and addiction potential. Nicotine absorption and availability (both protonated and un-protonated) are affected by moisture and pH. Essences provide a pleasant aroma and flavor, with an increased risk of misuse and other health problems. Few chewing tobacco and Zarda had the lowest levels of un-protonated nicotine (0.10-0.52% and 0.15-0.21%, respectively), whereas Gul, Gudhaku, and Khaini had the highest levels, ranging from 95.33 to 99.12%. Moisture and pH ranged from 4.54 to 50.19% and 5.25-10.07 respectively. Menthol (630.74-9681.42 µg/g) was the most popular flavour, followed by Eucalyptol (118.16-247.77 µg/g) and camphor (148.67 and 219.317 µg/g). SLT's health concerns and addiction dangers are exacerbated by the high proportion of bioavailable nicotine coupled with flavors. The findings of this study have important implications for the regulation and use of SLT in countries where use of SLT is prevalent.

Using a smokeless tobacco control mass media campaign and other synergistic elements to address social inequalities in India.

The burden of tobacco-related morbidity and mortality in India is substantial, with smokeless tobacco being the predominant form of tobacco use. Use of smokeless tobacco (for example gutkha, paan, khaini, and pan masala) is linked to a host of socioeconomic and cultural factors including gender, regional differences, educational level, and income disparities. Given the scale of the problem, a national social marketing campaign was developed and implemented. The creative approach used testimonials from a surgeon and patients at Tata Memorial Hospital in Mumbai. The communication message approach was designed to reflect the realities of disfiguring, disabling, and fatal cancers caused by smokeless tobacco. Evaluation of the campaign identified significant differences across a range of campaign behavioral predictors by audience segments aware of the campaign versus those who were "campaign unaware". Significant findings were also identified regarding vulnerable groups by gender (female/male) and rural/urban disparities. Findings are discussed in relation to the powerful impact of using graphic, emotive, and testimonial imagery for tobacco control with socially disadvantaged groups.

Results of a national mass media campaign in India to warn against the dangers of smokeless tobacco consumption.

OBJECTIVE: Smokeless tobacco consumption in India is a significant source of morbidity and mortality. In order to educate smokeless tobacco users about the health harms of smokeless tobacco and to denormalise tobacco usage and encourage quitting, a national television and radio mass media campaign targeted at smokeless tobacco users was aired for 6 weeks during November and December 2009. METHODS: The campaign was evaluated with a nationally representative household survey of smokeless tobacco users (n = 2898). The effect of campaign awareness was assessed with logistic regression analysis. RESULTS: The campaign affected smokeless tobacco users as intended: 63% of smokeless-only users and 72% of dual users (ie, those who consumed both smoking and smokeless forms) recalled the campaign advertisement, primarily through television delivery. The vast majority (over 70%) of those aware of the campaign said that it made them stop and think, was relevant to their lives and provided new information. 75% of smokeless-only users and 77% of dual users said that it made them feel concerned about their habit. Campaign awareness was associated with better knowledge, more negative attitudes towards smokeless tobacco and greater cessation-oriented intentions and behaviours among smokeless tobacco users. CONCLUSIONS: Social marketing campaigns that utilise mass media are feasible and efficacious interventions for tobacco control in India. Implications for future mass media tobacco control programming in India are discussed.

Advancing Tobacco Cessation in LMICs.

Tobacco kills more than 8 million people worldwide every year. Over 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries (LMICs), where the future burden is projected to grow. At the same time, progress in tobacco control has not advanced as far as in many LMICs. In particular, the implementation of tobacco-cessation programs and interventions remains limited. The bulk of the evidence for tobacco-cessation interventions comes from high-income countries and may not reflect the context in LMICs, particularly as resources and training for tobacco cessation are limited. This paper summarizes the current evidence for tobacco-cessation interventions in LMICs and highlights some key challenges and research gaps. Overall, there is a need to build capacity for locally relevant research and implementation science to support tailored cessation interventions and strategies for LMICs.

Cross-national epidemiology of DSM-IV major depressive episode.

BACKGROUND: Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative. METHODS: Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults. RESULTS: The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed. CONCLUSIONS: MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.

Increasing evidence for the efficacy of tobacco control mass media communication programming in low- and middle-income countries.

Antitobacco mass media campaigns have had good success at changing knowledge, attitudes, and behaviors with respect to smoking in high-income countries provided they are sustained. Mass media campaigns should be a critical component of tobacco control programs in low- and lower-middle-income countries. Mounting evidence shows that graphic campaigns and those that evoke negative emotions run over long periods of time have achieved the most influence. These types of campaigns are now being implemented in low- and middle-income countries. The authors provide 3 case studies of first-ever graphic warning mass media campaigns in China, India, and Russia, 3 priority high-burden countries in the global Bloomberg Initiative to Reduce Tobacco Use. In each of these countries, message testing of core messages provided confidence in messages, and evaluations demonstrated message uptake. The authors argue that given the initial success of these campaigns, governments in low- and middle-income countries should consider resourcing and sustaining these interventions as key components of their tobacco control strategies and programs.

Tobacco control policies in India: implementation and challenges.

Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.

Tobacco Advertising, Promotion and Sponsorship in India and Indonesia: Present Regime and the Way Forward.

One of the important factors contributing to tobacco epidemic is tobacco advertising, promotion, and sponsorship (TAPS). TAPS is employed by tobacco industry to increase demand for its products, often through targeting specific groups or market segments. The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) recommends implementation of comprehensive bans on TAPS as part of an effective set of tobacco control policies. Article 13 of the WHO FCTC and its guidelines mandate a comprehensive ban on all TAPS. Besides, TAPS ban is one of the MPOWER strategy and is included in the 'Best Buys' for effective tobacco control. However, many countries, especially low-income and middle-income countries, primarily implement only partial TAPS bans, allowing the tobacco industry to directly or indirectly advertise and promote its products via multiple media. This review article analyzes the current state of affairs in respect of TAPS in India and Indonesia, the two of the largest countries in the WHO South-East Asia Region of the world, and discusses the way forward to address the identified gaps in TAPS ban policy formulation and implementation focusing on strengthening its compliance and enforcement at the country level.

Implementation of MPOWER Package in the South-East Asia Region: Evidence from the WHO Report on the Global Tobacco Epidemic (2009-2021).

The WHO MPOWER package is a set of six evidence-based and cost-effective measures which was introduced on 7 February 2008 to facilitate the implementation of the provisions of the WHO Framework Convention on Tobacco Control at the ground level. These measures are: Monitoring tobacco use and prevention policies (M); Protecting people from tobacco smoke (P); Offering help to quit tobacco use (O); Warning about the dangers of tobacco (W); Enforcing bans on tobacco advertising, promotion and sponsorship (E); and Raising taxes on tobacco (R). Since its launch, the MPOWER package has become the guiding principle for all the countries of the South-East Asia Region in their crusade against the tobacco epidemic. This review article tracks the implementation of the MPOWER measures in the 11 member countries of the Region based on the last seven WHO Report on the Global Tobacco Epidemic (GTCR), i.e., GTCR2/2009-GTCR8/2021. This is with an aim to enable the countries to review their progress in implementing the MPOWER measures and to take steps to improve their advancement towards reducing the demand for tobacco products at the country level.

The Economic Cost of Tobacco Farming in Bangladesh.

The extent of tobacco cultivation remains substantially high in Bangladesh, which is the 12th largest tobacco producer in the world. Using data from a household survey of current, former, and never tobacco farmers, based on a multi-stage stratified sampling design with a mix of purposive and random sampling of households, this study estimated the financial and economic profitability per acre of land used for tobacco cultivation. The environmental effects of tobacco cultivation on land and water resources were estimated using laboratory tests of sample water and soil collected from tobacco-cultivating and non-tobacco cultivating areas. The study finds that tobacco cultivation turns into a losing concern when the opportunity costs of unpaid family labour and other owned resources, and the health effects of tobacco cultivation are included. Tobacco cultivation poses a significantly high environmental cost that causes a net loss to society. Nevertheless, the availability of unpaid family labour and the options of advanced credit as well as a buy back guarantee from the tobacco companies attract farmers to engage in and continue tobacco cultivation. Therefore, supply side interventions to curb the tobacco epidemic in Bangladesh need to address major drivers of tobacco cultivation to correct the wrong incentives and motivate tobacco farmers to switch to alternative livelihood options.