Smokeless tobacco use: A meta-analysis of risk and attributable mortality estimates for India.

BACKGROUND: Use of smokeless tobacco (SLT) is widely prevalent in India and Indian subcontinent. Cohort and case–control studies in India and elsewhere report excess mortality due to its use. OBJECTIVE: The aim was to estimate the SLT use‑attributable deaths in males and females, aged 35 years and older, in India. MATERIALS AND METHODS: Prevalence of SLT use in persons aged 35 years and older was obtained from the Global Adult Tobacco Survey in India and population size and deaths in the relevant age‑sex groups were obtained from UN estimates (2010 revision) for 2008. A meta‑relative risk (RR) based population attributable fraction was used to estimate attributable deaths in persons aged 35 years and older. A random effects model was used in the meta‑analysis on all‑cause mortality from SLT use in India including four cohort and one case–control study. The studies included in the meta‑analysis were adjusted for smoking, age and education. RESULTS: The prevalence of SLT use in India was 25.2% for men and 24.5% for women aged 35 years and older. RRs for females and males were 1.34 (1.27–1.42) and 1.17 (1.05–1.42), respectively. The number of deaths attributable to SLT use in India is estimated to be 368127 (217,076 women and 151,051 men), with nearly three‑fifth (60%) of these deaths occurring among women. CON CLUSION: SLT use caused over 350,000 deaths in India in 2010, and nearly three‑fifth of SLT use‑attributable deaths were among women in India. This calls for targeted public health intervention focusing on SLT products especially among women.

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region.

BACKGROUND: At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South‑East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time. METHODS: This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor‑Leste during 2006–2013. GYTS is a nationally representative survey of 13–15‑year‑old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software. RESULTS: According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011. CONCLUSION: The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Influence of tobacco industry advertisements and promotions on tobacco use in India: Findings from the Global Adult Tobacco Survey 2009-2010.

INTRODUCTION: The developing world, including countries like India, has become a major target for the tobacco industry to market its products. This study examines the influence of the marketing (advertising and promotion) of tobacco products on the use of tobacco by adults (ages 15 and over) in India. METHOD: Data from Global Adult Tobacco Survey 2009–2010 was analyzed using methods for complex (clustered) sample designs. Multivariate logistic regression was employed to predict the use of different tobacco products by level of exposure to tobacco marketing using adults who have never used tobacco as the reference category. Odds ratios (ORs) were adjusted for education, gender, age, state of residence, wealth index, and place of residence (urban/rural). RESULTS: Adults in India were almost twice as likely to be current smokers (versus never users) when they were exposed to a moderate level of bidi or cigarette marketing. For bidis, among adults with high exposure, the OR for current use was 4.57 (95% confidence interval [CI]: 1.6, 13.0). Adults were more likely to be current users of smokeless tobacco (SLT) with even a low level of exposure to SLT marketing (OR = 1.24 [95% CI: 1.1, 1.4]). For SLT, the ORs showed an increasing trend (P for trend < 0.001) with greater level of exposure (moderate, OR = 1.55 [95% CI: 1.1, 2.2]; high, OR = 2.05 [95% CI: 0.8, 5.1]). The risk of any current tobacco use rose with increasing level of exposure to any marketing (minimum, OR = 1.25 [1.1–1.4]; moderate, OR = 1.38 [1.1–1.8]; and high, OR = 2.73 [1.8–4.2]), with the trend highly significant (P < 0.001). CONCLUSION: Exposure to the marketing of tobacco products, which may take the form of advertising at the point of sale, sales or a discounted price, free coupons, free samples, surrogate advertisements, or any of several other modalities, increased prevalence of tobacco use among adults. An increasing level of exposure to direct and indirect advertisement and promotion is associated with an increased likelihood of tobacco use.

Profile of dual tobacco users in India: An analysis from Global Adult Tobacco Survey, 2009-10.

Introduction: Individuals who use both smoked and smokeless tobacco products (dual tobacco users) form a special group about which little is known. This group is especially relevant to India, where smokeless tobacco use is very common. The aim of this study was to characterise the profile of dual users, study their pattern of initiation to the second product, their attitudes toward quittingas well as their cessation profile. Methods and Materials: The GATS dataset for India was analyzed using SPSS; . Results: In India, dual tobacco users (42.3 million; 5.3% of all adults; 15.4% of all tobacco users) have a profile similar to that of smokers. Some 52.6% of dual users started both practices within 2 years. The most prevalent product combination was bidi-khaini (1.79%) followed by bidi-gutka (1.50%), cigarette-khaini (1.28%), and cigarette-gutka (1.22%). Among daily users, the correlation between the daily frequencies of the use of each product was very high for most product combinations. While 36.7% of dual users were interested in quitting, only 5.0% of dual users could do so. The prevalence of ex-dual users was 0.4%. Conclusion: Dual users constitute a large, high-risk group that requires special attention.

Predictors of tobacco smoking and smokeless tobacco use among adults in Bangladesh.

Introduction: To examine predictors of current tobacco smoking and smokeless tobacco use among the adult population in Bangladesh. Materials and Methods: We used data from the 2009 Global Adult Tobacco Survey (GATS) in Bangladesh consisting of 9,629 adults aged ΃15 years. Differences in and predictors of prevalence for both smoking and smokeless tobacco use were analyzed using selected socioeconomic and demographic characteristics that included gender, age, place of residence, education, occupation, and an index of wealth. Results: The prevalence of smoking is high among males (44.7%, 95% confidence interval [CI]: 42.5-47.0) as compared to females (1.5%, 95% CI: 1.1-2.1), whereas the prevalence of smokeless tobacco is almost similar among both males (26.4%, 95% CI: 24.2-28.6) and females (27.9%, 95% CI: 25.9-30.0). Correlates of current smoking are male gender (odds ratio [OR] = 41.46, CI = 23.8-73.4), and adults in older age (ORs range from 1.99 in 24-35 years age to 5.49 in 55-64 years age), less education (ORs range from 1.47 in less than secondary to 3.25 in no formal education), and lower socioeconomic status (ORs range from 1.56 in high wealth index to 2.48 in lowest wealth index. Predictors of smokeless tobacco use are older age (ORs range from 2.54in 24-35 years age to 12.31 in 55-64 years age), less education (ORs range from 1.44 in less than secondary to 2.70 in no formal education), and the low (OR = 1.34, CI = 1.0-1.7) or lowest (OR = 1.43, CI = 1.1-1.9) socioeconomic status. Conclusion: Implementation of tobacco control strategies needs to bring special attention on disadvantaged group and cover all types of tobacco product as outlined in the WHO Framework Convention on Tobacco Control (FCTC) and WHO MPOWER to protect people's health and prevent premature death.

Tobacco use, exposure to second-hand smoke, and cessation training among the third-year medical and dental students in selected Member States of South-East Asia region: A trend analysis on data from the Global Health Professions Student Survey, 2005-2011.

Background: The Medical and Dental Global Health Professions Student Surveys (GHPSS) are surveys based in schools that collect self-administered data from students on the prevalence of tobacco use, exposure to second-hand smoke, and tobacco cessation training, among the third-year medical and dental students. Materials and Methods: Two rounds of medical and dental GHPSS have been conducted in Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand, among the third-year medical and dental students, between 2005 and 2006 and 2009 and 2011. Results: The prevalence of any tobacco use among third-year male and female medical students did not change in Bangladesh, India, and Nepal between 2005 and 2006 and 2009 and 2011; however, it reduced significantly among females in Myanmar (3.3% in 2006 to 1.8% in 2009) and in Sri Lanka (2.5% in 2006 to 0.6% in 2011). The prevalence of any tobacco use among third-year male dental students did not change in Bangladesh, India, Nepal, and Thailand between 2005 and 2006 and 2009 and 2011; however, in Myanmar, the prevalence increased significantly (35.6% in 2006 to 49.5% in 2009). Among the third-year female students, a significant increase in prevalence was noticed in Bangladesh (4.0% in 2005 to 22.2% in 2009) and Thailand (0.7% in 2006 to 2.1% in 2011). It remained unchanged in the other three countries. Prevalence of exposure to second-hand smoke (SHS) both at home and in public places, among medical students, decreased significantly in Myanmar and Sri Lanka between 2006 and 2009 and in 2011. Among dental students, the prevalence of SHS exposure at home reduced significantly in Bangladesh, India, and Myanmar, and in public places in India. However, there was an increase of SHS exposure among dental students in Nepal, both at home and in public places, between 2005 and 2011. Medical students in Myanmar, Nepal, and Sri Lanka reported a declining trend in schools, with a smoking ban policy in place, between 2005 and 2006 and 2009 and 2011, while proportions of dental students reported that schools with a smoking ban policy have increased significantly in Bangladesh and Myanmar. Ever receiving cessation training increased significantly among medical students in Sri Lanka only, whereas, among dental students, it increased in India, Nepal, and Thailand. Conclusion: Trends of tobacco use and exposure to SHS among medical and dental students in most countries of the South-East Asia Region had changed only relatively between the two rounds of GHPSS (2005-2006 and 2009-2011). No significant improvement was observed in the trend in schools with a policy banning smoking in school buildings and clinics. Almost all countries in the SEA Region that participated in GHPSS showed no significant change in ever having received formal training on tobacco cessation among medical and dental students.