Prevalence, regional patterns and socio-demographic factors associated with poly-tobacco use in India: A secondary data analysis.

BACKGROUND: Tobacco use is associated with early, intermediate and long-term complications throughout the life course. With an influx of newer products containing nicotine, poly-tobacco use is slowly emerging as a public health concern, that is defined as existing tobacco users currently using two or more tobacco or nicotine products. While many studies have investigated single use tobacco, there is a paucity of research on regional patterns and socio-demographic factors associated with poly-tobacco use in India. OBJECTIVES: To assess prevalence of poly-tobacco use and determine the socio-demographic factors associated with poly-tobacco use in India. METHODS: Data from the Global Adult Tobacco Survey 2 (GATS, 2016-17) was analysed, which included information on tobacco use among people aged >15 years. The pattern of current tobacco status was described using descriptive statistics. Multiple logistic regression models were estimated to determine factors associated with poly-tobacco use. RESULTS: The prevalence of poly-tobacco use in India was found to be 9.8%. Among the current tobacco users, the prevalence was 33%. Significant socio-demographic factors associated with poly-tobacco use included younger age, male gender, religion and backward caste. North-eastern region reported highest prevalence of poly-tobacco use in the country, followed by the central region. CONCLUSION: The number of poly-tobacco users in India is considerably high and a matter of concern, more so in north east and central regions of the country. There is a need to create awareness about dangerous effects of all types of tobacco products and strengthen implementation of tobacco control policies with special focus on regions with high burden.

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study.

OBJECTIVE: This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation. DESIGN: Qualitative semi-structured interviews. SETTING: Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically. PARTICIPANTS: Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated. RESULTS: The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation. CONCLUSION: Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Perceptions of novel warnings compared with current warning on tobacco packs, and warnings on cigarette sticks: A cross-sectional survey of college students in Southern India.

INTRODUCTION: In India there is insufficient knowledge of the risks associated with tobacco use. Increasing awareness of these risks is critical, with pictorial warnings on tobacco packs a cost-effective way to communicate this information. We explored perceptions of the current warning, 'Tobacco causes cancer', displayed on packs in India and four novel warnings about other potential impacts of tobacco use including social, financial, and environmental, but also complications with diabetes. As loose cigarette sales are common in India, we also explored perceptions of warnings on cigarette sticks. METHODS: A cross-sectional survey of college students aged ≥18 years in Karnataka, India, was conducted between January 2019 and February 2020. Participants were asked about salience, believability, and cognitive processing of warnings currently on packs. They were then shown an image of one current and four novel warnings and asked about their perceived effectiveness in preventing uptake and reducing and stopping tobacco use. They were then asked about warnings on cigarette sticks. RESULTS: Most participants (70.2%) recalled warnings on packs and considered them believable (55.7%), but only 12.0% read and 12.4% thought about them often. Warnings about the health impacts of tobacco use were viewed as most effective in preventing uptake, and reducing and stopping tobacco use. Nevertheless, at least a third of participants rated warnings pertaining to financial, social, and environmental impacts effective in preventing uptake, and reducing and stopping tobacco use. Approximately one-fifth (22.0%) thought that warnings on cigarette sticks would deter initiation. CONCLUSIONS: Our results suggest that health warnings are perceived as most effective in discouraging tobacco use among college students in Karnataka. While viewed as less effective than health warnings, novel non-health related messages were viewed as effective in preventing uptake, and reducing and stopping tobacco use by at least one in three participants. Warnings on cigarette sticks may help complement warnings on cigarette packs.

Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol.

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

The association between the retail price of manufactured cigarettes and bidis on current smoking status in India.

INTRODUCTION: In India, the retail prices of bidis and cigarettes varied between the two Global Adult Tobacco Surveys (GATS) conducted in 2009-2010 and 2016-2017. The relationship between the retail price of smoked tobacco products and their use is unclear for India. Our study thus aimed to use available datasets to investigate the association between the retail price and current smoking status of bidis and cigarettes in India. METHODS: Current smoking status data for bidis and cigarettes were obtained from the two GATS rounds. The average state-level retail prices of bidis and cigarettes were obtained from India's Consumer Price Index- Industrial Workers database. Descriptive statistics were used to describe current smoking status patterns. Generalized Linear Mixed Models were used to investigate the association between the retail prices and current smoking status of bidis and cigarettes. RESULTS: For cigarettes, an increase in the average retail price by one Indian Rupee was associated with a reduction in the odds of being a current smoker of 7% (OR=0.925; 95% CI: 0.918-0.932, p<0.001). For bidis, the association between the retail price and current smoking status was not statistically significant (OR=1.01; 95% CI: 1.00-1.02, p=0.082). CONCLUSIONS: Current increases in the retail prices of tobacco products in India seem to have an impact on the use of cigarettes but not bidis. This highlights the need for tobacco product tax increases that result in sufficient retail prices increase to make all tobacco products less affordable and reduce their use.

Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India.

INTRODUCTION: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression. RESULTS: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]). CONCLUSIONS: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising. IMPLICATIONS: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

Prospective cohort study of exposure to tobacco imagery in popular films and smoking uptake among children in southern India.

BACKGROUND: Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. METHODS: We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. RESULTS: We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. CONCLUSION: Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries.

Beedi Rollers' Perception toward Alternative Means of Livelihood amid Economic Benefits.

BACKGROUND: Beedi rolling is one of the principal occupations of women residing in coastal Karnataka. The beedi worker's welfare fund consists of a combination of schemes to improve the living conditions of beedi workers and their families. On the other hand, the government is introducing several anti-tobacco policies, which could lead to insecurity among beedi rollers about their future. As a result, majority of the trade unions believe that alternate livelihood must be provided to the workers. In the midst of economic benefits and stringent tobacco control policies, this study explores the perception of beedi rollers to quit tobacco rolling and engage with an alternative livelihood. OBJECTIVES: The objectives of this study were as follows: (1) to explore the opinion of beedi workers toward alternate means of livelihood and (2) to identify the benefits availed by the beedi workers. METHODOLOGY: The study was conducted with a semi-structured questionnaire by interview method in all the seven blocks of the Udupi district of Karnataka with a total of 381 respondents through convenience sampling. The interviewer administered the survey with the help of a predesigned user application which was developed through Kobo Toolbox, and the analysis was carried out using IBM SPSS version 26. RESULTS: Although 69% of the respondents believed that beedi rolling is not a secured job, three-fourth of the respondents were not ready to quit the beedi rolling job due to low education, higher age, and lack of financial support to invest in other occupations. CONCLUSION: Our study showed that most of the participants were full-time beedi rollers and most of them were not ready to shift to other jobs due to old age, lack of experience with other vocations, and benefits availed. There is a need to focus on strengthening skill development programs and introduce sustainable economic alternatives to the beedi rollers.

Cervical cytology and associated factors among tribal women of Karnataka, India.

BACKGROUND: Reproductive well-being is a crucial element of women's health. Due to the asymptomatic nature of gynaecological morbidities, women rarely seek medical advice in the initial period leading to delayed diagnosis and poor prognosis of subsequent disease. The present study aimed to explore the cervical cytology and its associated risk factors among women from tribal communities of the southern part of coastal Karnataka, India. METHODS: Papanicolaou (Pap) smear test was performed among 1140 women from three tribal populations, to detect cervical lesions, infections and reactive changes. A semi-structured questionnaire was administered to collect data on socio-demographic and reproductive characteristics of the study population. RESULTS: The most predominant gynaecological complaint among the participants was severe lower back ache (77.6%), followed by white discharge per vagina (29.0%) and menstrual irregularities (25.9%). Of the 1140 women screened, 12.4% showed cervical microbial infections, 23.6% were reported to have reactive changes, and 0.2% had epithelial cell abnormalities in the cervix. Cervical microbial infections were found to be associated with younger age group, low socio-economic status and younger age at sexual debut. CONCLUSION: Most of the symptoms suggestive of gynaecological morbidities reported in this study are preventable or treatable. Strengthening ongoing cervical cancer screening programme and implementation of health education programmes among tribal population would be the right policy approach to prevent, detect and treat these symptoms at an early stage and to achieve acceptable health outcomes among tribal women.

Knowledge, Attitude and Practices Towards Cervical Cancer and its Screening Among Women from Tribal Population: a Community-Based Study from Southern India.

BACKGROUND: Cervical cancer continues to be a leading cancer among women in India. Despite availability of various screening techniques, majority of Indian women remain unscreened for cancer cervix. The increasing incidence could be attributed to the lack of awareness regarding cervical cancer screening and paucity of organized screening facilities in the country. This study assessed the knowledge, attitude and practices (KAP) towards cervical cancer screening among tribal women of coastal Karnataka, southern India. METHODS: A community-based cross-sectional study was conducted among 1140 women aged 20-65 years from three tribes. Information on their KAP towards cervical cancer screening was collected using a semi-structured questionnaire. RESULTS: Mean age of the participants was 39.8 ± 10.1 years. Although 82.9% of the participants reported to have heard of cervical cancer, 51% were aware that the disease could be prevented, and only 2.3% knew that it can be detected at an early stage. Over 75% of the participants did not have adequate knowledge regarding cervical cancer. However, majority of them (99.9%) had a favourable attitude towards cervical cancer screening. None of them had undergone cervical cancer screening prior to the study. The knowledge scores were significantly associated with age group, marital status, education level, socioeconomic status and tribal community of the participants (p < 0.05). CONCLUSION: Overall knowledge regarding cervical cancer among the surveyed women was poor, though they exhibited a positive attitude. This calls for a sustained health education and screening program to create awareness and improve the uptake of cervical cancer screening among these women.

Regulatory Compliance of Health Warnings on Tobacco Packs in Karnataka, India.

INTRODUCTION: In September 2014, the Government of India introduced legislation requiring all tobacco packaging to display a health warning covering 85% (60% pictorial, 25% text) of the principal display area of the pack, of at least 4 cm in height and 3.5 cm width, with legible text in a white font on a black background and in English and/or the same Indian language as the language used on the pack. We evaluated compliance with this legislation in the Udupi district of Karnataka, India. METHODS: We procured one example of every tobacco pack of cigarettes, beedis, chewing tobacco, and snuff sold by a convenience sample of retailers in one urban and two rural areas in each of the five administrative blocks of the Udupi district between June and August 2018. For each pack we measured the size of the health warning, calculated the proportion of the pack covered, and assessed the legibility. RESULTS: A total of 365 packs were collected from retailers, with 357 of these branded and eight, all packs of snuff, unbranded. Warnings on 320 (87.3%) packs did not reach the legally required proportional magnitude, warnings on 140 (38.4%) packs were not legible, and warnings on 117 packs (32.1%) did not meet the language requirement. Only 45 packs (12.3%) were fully compliant. CONCLUSIONS: Compliance with warning legislation in this district of India is low, highlighting the need for more effective enforcement. IMPLICATIONS: Warnings on tobacco packaging are an important and inexpensive means of communicating the harms associated with tobacco use. However, relatively few studies have explored regulatory compliance with warnings. We collected all unique tobacco packs from 66 retailers in a district in Karnataka in India and assessed whether each met the legislative requirements in terms of warning size and proportion of the pack covered, legibility, and the language used. Of the 365 packs collected, only one in eight was compliant with the legislative requirements. This study highlights the importance of assessing warning compliance and the need for enforcement in India.

A pilot study to assess compliance and impact of health warnings on tobacco products in the Udupi district of Karnataka State, India.

INTRODUCTION: The Government of India has taken several steps to reduce tobacco use, including legislation in the Cigarettes and Other Tobacco Products Act (COTPA) requiring health warnings on tobacco products. This study assessed compliance with the legislation on warnings, and awareness of these warnings and their perceived impact in preventing tobacco uptake among college students in a district of Karnataka, India. METHODS: This study consisted of two components, pack collection and a survey. For the first, tobacco packs were obtained from all tobacco selling shops in an urban and a rural locality in the Karkala block of Udupi district. Empty cigarette packs were collected from shops, and full packs were purchased if empty packs were not available . The packs were collected to measure their dimensions, as per the Tobacco Pack Surveillance System guidelines, and assessed for compliance, as per COTPA. For the second component of the study, a questionnaire was distributed to each college student to fill in; this was done to assess awareness of the new warnings at the time of the pilot survey, knowledge of harms, and perceptions of the warnings in reducing tobacco uptake. RESULTS: We collected 26 tobacco packs. Two (8%) packs had warnings that were the correct size (85% of the main display areas), 15 (58%) packs had clear and legible warnings, and 18 (69%) packs had warning messages in the appropriate language. In the student survey, 60% of males and 52% of females indicated that they would not start using any tobacco products on seeing the new warnings. CONCLUSIONS: Only a few studies other than our pilot study have assessed compliance with legislation on health warnings in low- or middle-income countries. Although health warnings were perceived as a deterrent to tobacco use among students, compliance with national legislation in this pilot study was found to be low.

Human papilloma and other DNA virus infections of the cervix: A population based comparative study among tribal and general population in India.

BACKGROUND: Despite being preventable, cervical cancer remains a major health concern among women. Persistent Human Papillomavirus (HPV) and other viral co-infections may influence cervical dysplasia. We determined and compared the prevalence and risk factors of cervical viral infections among the tribal and general population of southern coastal Karnataka, India. METHODS: A population-based cross-sectional survey was conducted among 1140 and 1100 women from tribal and general population, respectively. Cervical infections with HPV, Epstein-Barr Virus (EBV), Cytomegalovirus (CMV) and Herpes-Simplex Virus (HSV) were examined using polymerase chain reactions (PCR) and DNA sequencing. RESULTS: HPV prevalence was higher among tribal women (40.6%) than general population (14.3%) while the prevalence of EBV (55.1%) and CMV (49.4%) were lower among tribal women than general population (74.3% and 77.5%, respectively). HSV infection was observed in tribal women only (1.8%). Among HR-HPV strains, HPV-18 was predominant among tribal population (28.3%) while, HPV-16 was predominant among the general population (9.1%). Infections were associated with age, educational status, unemployment and personal hygiene of tribal women. Phylogenetic analysis revealed that HPV-16 variants of tribal participants were closely related to non-European sublineages indicating greater risk of HPV persistence and carcinogenesis. CONCLUSION: The study provides a comparative estimate for DNA virus infections of the cervix among women from general as well as tribal population in this region and also reveals a different type-specific pattern of viral infection. Further research is required to delineate the role of specific interactions between multiple virus infections and their role in carcinogenesis.

Pre-Hypertension among Young Adults (20-30 Years) in Coastal Villages of Udupi District in Southern India: An Alarming Scenario.

INTRODUCTION: According to Joint National Committee-7 (JNC-7) guidelines, a systolic blood pressure (SBP) of 120 to 139 mm Hg and/or diastolic blood pressure (DBP) of 80 to 89 mm Hg is considered as pre-hypertension. Existing evidence suggest that the cardiovascular morbidities are increasing among pre-hypertensive individuals compared to normal. OBJECTIVE: To assess the magnitude and factors associated with pre-hypertension among young adults (20-30 years) in coastal villages of Udupi Taluk (an area of land with a city or town that serves as its administrative centre and usually a number of villages), Udupi District, Karnataka state, India. DESIGN: Community based cross sectional study. SETTING: 6 (out of total 14) coastal villages of Udupi Taluk, Karnataka state, India. SAMPLE: 1,152 young adults (age group: 20-30 years) selected by stratified random sampling in 6 coastal villages of Udupi Taluk, Karnataka state, India. METHOD: A semi structured pre-tested questionnaire was used to elicit the details on socio-demographic variables, dietary habits, tobacco use, alcohol consumption, physical activity, family history of hypertension and stress levels. Anthropometric measurements and blood pressure were recorded according to standard protocols. Serum cholesterol was measured in a sub sample of the study population. Multivariate logistic regression was applied to identify the independent correlates of pre-hypertension among young adults (20-30 years). MAIN OUTCOME MEASURES: Prevalence, Odds ratio (OR) and adjusted (adj) OR for pre-hypertension among young adults (20-30 years). RESULTS: The prevalence of pre-hypertension in the study population was 45.2% (95%CI: 42.4-48). Multivariate logistic regression analysis revealed that age group of 25-30 years (adj OR: 4.25, 95% CI: 2.99-6.05), white collared (adj OR: 2.29, 95% CI: 1.08-4.85) and skilled occupation (adj OR: 3.24, 95% CI: 1.64-6.42), students (adj OR: 2.46, 95% CI: 1.22-4.95), using refined cooking oil (adj OR: 0.53, 95% CI: 0.29-0.95), extra salt in meals (adj OR: 2.46, 95% CI: 1.52-3.99), salty food items (adj OR: 6.99, 95% CI: 3.63-13.48), pre-obese (adj OR: 1.66, 95% CI: 1.03-2.67) and obese (adj OR: 9.16, 95% CI: 2.54, 36.4) were the significant correlates of pre-hypertension. CONCLUSION: In the study population, prevalence of pre-hypertension among young adults (20-30 years) was high (45.2%). Biological (age 25-30 years, pre-obesity and obesity) and behavioral (sedentary occupation, intake of extra salt in meals/salty food and not using refined cooking oil) factors were associated with pre-hypertension. Study emphasizes the need of community based screening of pre-hypertension under National Rural Health Mission. It also provides apt information for the evidence based designing of interventions for lifestyle modifications among high risk young adults in the study area.