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

Background: The sustained anti-tobacco campaign initiated in response to the mounting evidence against tobacco smoking has driven tobacco companies and smokers to look for alternative choices, such as smokeless tobacco (SLT) products. If this strategy advances, it could undermine several gains made by the campaign over the years. Our objective was to examine the trends in the prevalence of different tobacco types in three countries (Bangladesh, India, and Nepal) of South-East Asia. Methods: Data from national surveys were used to estimate the trends of weighted and age-standardized prevalence (along with 95% CI) of different tobacco products. The share of each tobacco type was then calculated as a percentage of total tobacco use for each time point and country. Results: In all the three countries, smoking prevalence declined (by 6% in Bangladesh, 3% in India, and 7% in Nepal) but SLT use increased (by 3% in Bangladesh, 6% in India, and 4% in Nepal) over the study period. SLT use increased irrespective of whether the total tobacco use increased or decreased. The share of SLT as a percentage of total tobacco use increased from 15% to 19% among Bangladeshi men, from 46% to 61% in India, and from 29% to 41% in Nepal. Conclusions: In South-East Asia, a clear shift in the product preference from smoking to SLT was noted. Misleading advertising by tobacco companies may be responsible for the increase in the SLT prevalence, which is as harmful as smoking. Countries should strengthen policies to restrict SLT usage and prevent the rise of its use. Implications: It has been documented that the smoking prevalence has been declining in most countries of the South-East Asia region where effective anti-tobacco laws have been implemented. But, due to a number of factors, the prevalence of smokeless tobacco has been increasing steadily, making the entire anti-tobacco movement less effective in terms of reducing the tobacco-attributable disease burden. In this context, this study has provided a detailed comparative analysis of the prevalence of smokeless tobacco use and smoking in three countries of the SEAR where such data were available. It can be clearly seen that the preference for smoking has shifted towards the smokeless tobacco in all the three study countries. This study recommends that tobacco control interventions should be aligned with the changing dynamics of the tobacco epidemic, and the need of the hour is placing restrictions of smokeless tobacco use so as to drive forward the gains of the anti-tobacco movement.

The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice.

Objectives: Clinical empathy is an important predictor of patient outcomes. Several factors affect physician's empathy and client perceptions. We aimed to assess the association between physician and client perception of clinical empathy, accounting for client, physician, and health system factors. Methods: We conducted a hospital-based cross-sectional study in 3 departments (family medicine, internal medicine, and surgery) of King Saud Medical City in Riyadh, Saudi Arabia. We interviewed 30 physicians and 390 clients from 3 departments. Physicians completed the Jefferson Scale of Empathy (JSE) and the clients responded to the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). We used a hierarchical multilevel generalized structural equation approach to model factors associated with JSE and JSPPPE and their inter-relationship. Results: Mean (SD) score of client-rated physician empathy was 26.6 (6) and that of physician self-rated was 111 (12.8). We found no association between the 2 (b = 0.06; 95% confidence intervals CI: -0.1, 0.21), even after adjusting for client, physician, and health system factors. Physician's nationality (0.49; 0.12, 0.85), adequate consultation time (1.05; 0.72, 1.38), and trust (1.33; 0.9, 1.75) were positively associated whereas chronic disease (-0.32; -0.56, -0.07) and higher waiting times (-0.26; -0.47, -0.05) were negatively associated. Conclusion: A physician's self-assessed empathy does not correlate with clients' perception. We recommend training and monitoring to enhance clinical empathy.

Trends in tobacco consumption in India 1987-2016: impact of the World Health Organization Framework Convention on Tobacco Control.

OBJECTIVES: We describe national and subnational trends in tobacco use over three decades in India, assess the impact of the World Health Organization's Framework Convention on Tobacco Control (FCTC) on them and draw inferences for regional tobacco control policy. METHODS: Data from nine cross-sectional surveys conducted between 1987 and 2016 were analysed. Time trends in gender- and state-wise prevalence were derived for different forms of tobacco. To assess Framework Convention's impact, relative changes in tobacco prevalence before and after its implementation were estimated. Progress towards global noncommunicable diseases target was also measured. RESULTS: Post-implementation of the FCTC, smoking and smokeless tobacco use declined by 52.9% and 17.6%, respectively. The tobacco product mix (exclusive smokeless/exclusive smoked/dual) underwent a reversal from 37:52:11 in 1987 to 65:22:13 in 2016. Having achieved 20.5% relative reduction since 2009, India is en route to achieving the global noncommunicable diseases target. CONCLUSIONS: Steep declines in tobacco use have followed the implementation of FCTC in India. However, the impact has been unequal on smokeless and smoked forms. Tobacco-control policies in high smokeless burden countries should take cognizance of this pattern and design comprehensive and flexible policies.