"The ban is there, but it is not there": perceptions of cigarette users and tobacco vendors regarding ban on the sale of loose cigarettes in India.

Introduction: Banning the sales of loose cigarettes is recommended by Article 16 of the World Health Organization - Framework Convention on Tobacco Control. This study aims to understand the perceptions of cigarette users and tobacco vendors regarding such a ban. Methods: Using a systematic recruitment and interview protocol, we interviewed cigarette users (n = 28) and tobacco vendors (n = 28) from two Indian cities where sales of loose cigarettes were banned (Mumbai) or not banned (Delhi). Separate semi-structured interview guides were used for users and vendors. Interview questions focused on reasons for purchasing loose cigarettes, preference for buying and selling loose vs. packs, thoughts on the necessity of banning loose cigarettes, and the perceived impact of the policy ban for vendors and cigarette users. We performed thematic analysis and used NVivo for organizing transcript coding. Results: The main reasons users cited for purchasing loose cigarettes were financial constraints, social restrictions (fear of getting caught), and limiting cigarette consumption. In Mumbai, awareness of the existing ban was poor among both users and vendors. Those who were aware did not think the policy had been implemented. Users thought that loose cigarettes promoted smoking initiation and prevented them from quitting. Both users and vendors reported that a ban on loose cigarettes would reduce cigarette consumption and promote quit attempts as it would not be possible for everyone to purchase packs because of financial and social reasons. Conclusion: Users in both cities reported easy access to and widespread availability of loose cigarettes. Low awareness of the ban in Mumbai suggested inadequate enforcement. A country-wide ban on the sale of loose cigarettes could be highly effective in preventing smoking initiation and promoting quitting.

Diabetes and gastric cancer incidence and mortality in the Asia Cohort Consortium: A pooled analysis of more than a half million participants.

BACKGROUND: Evidence suggests a possible link between diabetes and gastric cancer risk, but the findings remain inconclusive, with limited studies in the Asian population. We aimed to assess the impact of diabetes and diabetes duration on the development of gastric cancer overall, by anatomical and histological subtypes. METHODS: A pooled analysis was conducted using 12 prospective studies included in the Asia Cohort Consortium. Among 558 981 participants (median age 52), after a median follow-up of 14.9 years and 10.5 years, 8556 incident primary gastric cancers and 8058 gastric cancer deaths occurred, respectively. Cox proportional hazard regression models were used to estimate study-specific hazard ratios (HRs) and 95% confidence intervals (CIs) and pooled using random-effects meta-analyses. RESULTS: Diabetes was associated with an increased incidence of overall gastric cancer (HR 1.15, 95% CI 1.06-1.25). The risk association did not differ significantly by sex (women vs men: HR 1.31, 95% CI 1.07-1.60 vs 1.12, 1.01-1.23), anatomical subsites (noncardia vs cardia: 1.14, 1.02-1.28 vs 1.17, 0.77-1.78) and histological subtypes (intestinal vs diffuse: 1.22, 1.02-1.46 vs 1.00, 0.62-1.61). Gastric cancer risk increased significantly during the first decade following diabetes diagnosis (HR 4.70, 95% CI 3.77-5.86), and decreased with time (nonlinear p < .01). Positive associations between diabetes and gastric cancer mortality were observed (HR 1.15, 95% CI 1.03-1.28) but attenuated after a 2-year time lag. CONCLUSION: Diabetes was associated with an increased gastric cancer incidence regardless of sex, anatomical subsite, or subtypes of gastric cancer. The risk of gastric cancer was particularly high during the first decade following diabetes diagnosis.

Diabetes is associated with increased liver cancer incidence and mortality in adults: A report from Asia Cohort Consortium.

There has been growing evidence suggesting that diabetes may be associated with increased liver cancer risk. However, studies conducted in Asian countries are limited. This project considered data of 968,738 adults pooled from 20 cohort studies of Asia Cohort Consortium to examine the association between baseline diabetes and liver cancer incidence and mortality. Cox proportional hazard model and competing risk approach was used for pooled data. Two-stage meta-analysis across studies was also done. There were 839,194 subjects with valid data regarding liver cancer incidence (5654 liver cancer cases [48.29/100,000 person-years]), follow-up time and baseline diabetes (44,781 with diabetes [5.3%]). There were 747,198 subjects with valid data regarding liver cancer mortality (5020 liver cancer deaths [44.03/100,000 person-years]), follow-up time and baseline diabetes (43,243 with diabetes [5.8%]). Hazard ratio (HR) (95% confidence interval [95%CI]) of liver cancer diagnosis in those with vs. without baseline diabetes was 1.97 (1.79, 2.16) (p < .0001) after adjusting for baseline age, gender, body mass index, tobacco smoking, alcohol use, and heterogeneity across studies (n = 586,072; events = 4620). Baseline diabetes was associated with increased cumulative incidence of death due to liver cancer (adjusted HR (95%CI) = 1.97 (1.79, 2.18); p < .0001) (n = 595,193; events = 4110). A two-stage meta-analytic approach showed similar results. This paper adds important population-based evidence to current literature regarding the increased incidence and mortality of liver cancer in adults with diabetes. The analysis of data pooled from 20 studies of different Asian countries and the meta-analysis across studies with large number of subjects makes the results robust.

Evaluation of the effectiveness of the Indian government's policies to strengthen health warning labels on smokeless tobacco products: findings from the 2010-2019 Tobacco Control Project India Surveys.

BACKGROUND: Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs. METHODS: Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010-2011, n=5911), Wave 2 (2012-2013, n=5613) and Wave 3 (2018-2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively. RESULTS: The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT. DISCUSSION: There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

Obesity is associated with biliary tract cancer mortality and incidence: A pooled analysis of 21 cohort studies in the Asia Cohort Consortium.

Body fatness is considered a probable risk factor for biliary tract cancer (BTC), whereas cholelithiasis is an established factor. Nevertheless, although obesity is an established risk factor for cholelithiasis, previous studies of the association of body mass index (BMI) and BTC did not take the effect of cholelithiasis fully into account. To better understand the effect of BMI on BTC, we conducted a pooled analysis using population-based cohort studies in Asians. In total, 905 530 subjects from 21 cohort studies participating in the Asia Cohort Consortium were included. BMI was categorized into four groups: underweight (<18.5 kg/m2 ); normal (18.5-22.9 kg/m2 ); overweight (23-24.9 kg/m2 ); and obese (25+ kg/m2 ). The association between BMI and BTC incidence and mortality was assessed using hazard ratios (HR) and 95% confidence intervals (CIs) by Cox regression models with shared frailty. Mediation analysis was used to decompose the association into a direct and an indirect (mediated) effect. Compared to normal BMI, high BMI was associated with BTC mortality (HR 1.19 [CI 1.02-1.38] for males, HR 1.30 [1.14-1.49] for females). Cholelithiasis had significant interaction with BMI on BTC risk. BMI was associated with BTC risk directly and through cholelithiasis in females, whereas the association was unclear in males. When cholelithiasis was present, BMI was not associated with BTC death in either males or females. BMI was associated with BTC death among females without cholelithiasis. This study suggests BMI is associated with BTC mortality in Asians. Cholelithiasis appears to contribute to the association; and moreover, obesity appears to increase BTC risk without cholelithiasis.

Lung Cancer Risk Prediction Models for Asian Ever-Smokers.

INTRODUCTION: Although lung cancer prediction models are widely used to support risk-based screening, their performance outside Western populations remains uncertain. This study aims to evaluate the performance of 11 existing risk prediction models in multiple Asian populations and to refit prediction models for Asians. METHODS: In a pooled analysis of 186,458 Asian ever-smokers from 19 prospective cohorts, we assessed calibration (expected-to-observed ratio) and discrimination (area under the receiver operating characteristic curve [AUC]) for each model. In addition, we developed the "Shanghai models" to better refine risk models for Asians on the basis of two well-characterized population-based prospective cohorts and externally validated them in other Asian cohorts. RESULTS: Among the 11 models, the Lung Cancer Death Risk Assessment Tool yielded the highest AUC (AUC [95% confidence interval (CI)] = 0.71 [0.67-0.74] for lung cancer death and 0.69 [0.67-0.72] for lung cancer incidence) and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model had good calibration overall (expected-to-observed ratio [95% CI] = 1.06 [0.90-1.25]). Nevertheless, these models substantially underestimated lung cancer risk among Asians who reported less than 10 smoking pack-years or stopped smoking more than or equal to 20 years ago. The Shanghai models were found to have marginal improvement overall in discrimination (AUC [95% CI] = 0.72 [0.69-0.74] for lung cancer death and 0.70 [0.67-0.72] for lung cancer incidence) but consistently outperformed the selected Western models among low-intensity smokers and long-term quitters. CONCLUSIONS: The Shanghai models had comparable performance overall to the best existing models, but they improved much in predicting the lung cancer risk of low-intensity smokers and long-term quitters in Asia.

Upscaling a behavioural intervention program for tobacco use cessation - A randomised controlled study.

A randomised control trial was conducted among school teachers in Bihar, India for upscaling a tested, evidence-based tobacco intervention using train-the-trainer model. Six blocks in three districts were selected and randomised into intervention and control blocks. Cluster coordinators in intervention blocks were given training in the details of intervention. Cluster coordinators routinely train headmasters and they were asked to include intervention training in their routine. Except for the training material, no additional resources were provided to cluster coordinators and headmasters. Headmasters implemented the intervention along with the teachers in the school. Post-intervention random sample of 70 schools out of 219 schools from intervention blocks and 70 schools out of 224 schools in control blocks were surveyed. The survey was self-administered among 429 school teachers in intervention schools and 331 among control schools. For all 140 headmasters, the survey was interviewer administered. Almost all headmasters in intervention schools had attended the training and had involved teachers in the intervention program. Odds ratios for carrying out the recommended activities in intervention schools compared to control schools were very high and significant. In addition, intervention schools also conducted activities such as including intervention messages in classroom teaching and conveying them to parents, activities that were not directly recommended in intervention program. Thus, this train-the-trainer model demonstrated that it is possible to upscale the intervention programs successfully with the resources within the system.

MPOWER Measures and Its Effect on Tobacco Control: A Cross-sectional Comparison of Global Adult Tobacco Surveys, India.

OBJECTIVES: To study the MPOWER measures over time (GATS-1 vs GATS-2) and their effects on tobacco control indicators in India. STUDY DESIGN AND METHODS: The study used a cross-sectional design to compare the common questions identified from GATS-1 and GATS-2. Odds ratios for various MPOWER measures were estimated using a multivariate logistic regression model. RESULTS: Compared with GATS-1, the current any tobacco use was reduced by 32% in females and 17% in males in GATS-2 (M-measures). The P-measures have reduced across the survey periods. Under O-measures, compared with mixed users, only the male smokeless tobacco (SLT) users reported receiving more advice from a doctor to quit and reported trying more to stop SLT use. Compared with never users (W-measures), the health warnings were noticed on SLT products more by past users, smokers (males), and SLT users, while it was noticed on cigarette packages more by male past users and smokers. Promotion (E-measures) of cigarette and bidi was reported more by smokers (including mixed users), and promotion of SLT product was reported more by smokers (including mixed users) and male SLT users than by never users. CONCLUSION: Overall, MPOWER measures have shown improvement, with most changes highly reported by the never users and past users than by the current tobacco users. Stringent methods for the enforcement of MPOWER measures to reach all forms of tobacco users and integration of the National Tobacco Control Programme with other national health programs are imperative for highest achievements. Also, specific targeted strategies for the effective control of SLT use are highly recommended to be included in the MPOWER package.

Awareness and Use of e-cigarettes among Adolescents and Their Adult Caregivers in Two Cities of India.

INTRODUCTION/OBJECTIVE: E-cigarette use poses an additional risk for individuals who are not cigarette smokers, especially adolescents. The marketing tactics of the industry have substantially increased the prevalence of e-cigarettes, use among adolescents. India banned e-cigarette in September 2019 that has been criticized by interested groups.  We investigated that among adults and adolescents, who are more aware and using e-cigarette more? METHODS: The data were taken from a population-based representative household survey conducted in Mumbai and Kolkata in the year 2019-2020.  A household was enrolled if it had a 12-14 year old adolescent living in it and both adolescent and adult caregivers agreed to participate in the survey. The data from 944 adolescents out of 15,436 enumerated in Mumbai and 1038 out of 24,284 enumerated in Kolkata and their caregivers were analyzed for awareness and ever use of e-cigarettes.  Result: The awareness of e-cigarettes among 12-14 year olds in Mumbai was 15.5%, almost identical among boys and girls whereas is in Kolkata it was 11.2%. In contrast, among the adolescents' adult caregivers in Mumbai, the awareness was low, 3.9% and in Kolkata, 4.6%. Overall awareness was significantly higher among adolescents than among caregivers, especially among adolescent girls than among female caregivers in both cities. CONCLUSION: The awareness and the use of e-cigarette were very little and the messages from the e-cigarette industry seem to be targeted more towards adolescents than adults.  The ban on an e-cigarette in India has helped in prevented the marketing of ENDS to adolescents.

Family functioning within the context of families with adolescent children in urban India.

Research on family functioning within given cultural contexts is needed. This study aims to describe salient dimensions of family functioning in two urban contexts in India and to examine differences in family functioning by sociodemographic groups. We measured differences in family functioning using cross-sectional survey questionnaire data collected from 13 to 15-year-old adolescents and one of their parents/primary caregivers in Mumbai (n = 843) and Kolkata (n = 913) during 2019-2020. We drew a multi-stage sample representative of neighborhoods and households in both cities. We assessed a multi-dimensional family functioning latent factor that included parent-reported measures (parent-adolescent communication, family cohesion, and parent monitoring of peers) and adolescent-reported measures (parent support, family cohesion, and parent supervision). Our results support an overall measure of family functioning manifested by multiple dimensions for parent- and adolescent-reported data. Families with male adolescents had worse adolescent-reported family functioning in Mumbai and parent-reported family functioning in Kolkata. Higher socioeconomic status was associated with better parent-reported family functioning in both cities and better adolescent-reported family functioning in Kolkata. Muslim religious identification in Kolkata and the Hindi native language in both cities were associated with better adolescent-reported family functioning. Our findings indicate heterogeneity in family functioning across demographic and social-cultural groups within the two urban contexts of India. This study may inform the development of culturally congruent prevention interventions for families with adolescents in India.

Smoking-related psychosocial beliefs and justifications among smokers in India: Findings from Tobacco Control Policy (TCP) India Surveys.

BACKGROUND: Previous research in high-income countries (HICs) has shown that smokers reduce their cognitive dissonance through two types of justifications over time: risk minimizing and functional beliefs. To date, however, the relationship between these justifications and smoking behaviors over time has limited evidence from low- and middle-income countries. This study examines these of justifications and their relation to quitting behavior and intentions among smoking tobacco users in India. METHODS: The data are from the Tobacco Control Policy (TCP) India Survey, a prospective cohort of nationally representative sample of tobacco users. The respondents include smoked tobacco (cigarettes and bidi) users (n = 1112) who participated in both Wave 1 (W1; 2010-2011) and Wave 2 (W2; 2012-2013) surveys. Key measures include questions about psychosocial beliefs such as functional beliefs (e.g., smoking calms you down when you are stressed or upset) and risk-minimizing beliefs (e.g., the medical evidence that smoking is harmful is exaggerated) and quitting behavior and intentions at Wave 2. FINDINGS: Of the 1112 smokers at W1, 78 (7.0%) had quit and 86 (7.8%) had intentions to quit at W2. Compared to W1, there was a significant increase in functional beliefs at W2 among smokers who transitioned to mixed use (using both smoking and smokeless tobacco) and a significant decrease among those who quit. At W2, smokers who quit held significantly lower levels of functional beliefs, than continuing smokers, and mixed users ((M = 2.96, 3.30, and 3.93, respectively, p < .05). In contrast, risk-minimizing beliefs did not change significantly between the two waves. Additionally, higher income and lower functional beliefs were significant predictors of quitting behavior at W2. CONCLUSION: These results suggest that smokers in India exhibit similar patterns of dissonance reduction as reported in studies from HICs: smokers who quit reduced their smoking justifications in the form of functional beliefs, not risk-minimizing beliefs. Smokers' beliefs change in concordance with their smoking behavior and functional beliefs tend to play a significant role as compared to risk-minimizing beliefs. Tobacco control messaging and interventions can be framed to target these functional beliefs to facilitate quitting.

Association between body mass index and oesophageal cancer mortality: a pooled analysis of prospective cohort studies with >800 000 individuals in the Asia Cohort Consortium.

BACKGROUND: The association between body mass index (BMI) and oesophageal cancer (OC) has been consistently negative among Asians, whereas different associations based on histological OC subtypes have been observed in Europeans and North Americans. We examined the association between BMI and OC mortality in the Asia Cohort Consortium. METHODS: We performed a pooled analysis to evaluate the association between BMI and OC mortality among 842 630 Asians from 18 cohort studies. Cox regression models were used to estimate hazard ratios (HRs) and 95% CIs. RESULTS: A wide J-shaped association between BMI and overall OC mortality was observed. The OC mortality risk was increased for underweight (BMI <18.5 kg/m2: HR = 2.20, 95% CI 1.80-2.70) and extreme obesity (BMI ≥35 kg/m2: HR = 4.38, 95% CI 2.25-8.52) relative to the reference BMI (23-25 kg/m2). This association pattern was confirmed by several alternative analyses based on OC incidence and meta-analysis. A similar wide J-shaped association was observed in oesophageal squamous cell carcinoma (OSCC). Smoking and alcohol synergistically increased the OC mortality risk in underweight participants (HR = 6.96, 95% CI 4.54-10.67) relative to that in reference BMI participants not exposed to smoking and alcohol. CONCLUSION: Extreme obesity and being underweight were associated with an OC mortality risk among Asians. OC mortality and BMI formed a wide J-shaped association mirrored by OSCC mortality. Although the effect of BMI on OSCC and oesophageal adenocarcinoma mortality can be different in Asians, further research based on a large case-control study is recommended.

Neighbourhood tobacco retail access and tobacco use susceptibility in young adolescents in urban India.

BACKGROUND: Neighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence. METHODS: In 2019-2020, a population-based sample (n=1759) of adolescents aged 13-15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco). RESULTS: There was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access. CONCLUSIONS: Efforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

Tobacco cessation in India-Current status, challenges, barriers and solutions.

The attention to tobacco cessation (TCs) has increased globally by WHO through the Framework Convention on Tobacco Control (FCTC) and MPOWER. In India, NTCP (National Tobacco Control Program), the National and three Regional Quitlines and mCessation, some apex national institutes, and professional dental bodies and others have eased an access to quit, the proportion of the former users has been dismally low-below 2% at population level. The challenges of not having: (1) TCCs at secondary and tertiary care as well as in the larger private healthcare setups; (2) participatory health system and healthcare professionals; (3) motivated tobacco users to quit even in short-term; (4) focused NTCP due to convergent NHM (National Health Mission); and, (5) optimal coverage to the health-insured "need a priority attention". Also, there is need to eliminate the barriers existing: (a) at all levels in the governance, health system and other stake-holding sectors; and, (b) due to the interference of the tobacco industry. Overall, (i) setting the norm of quitting since all tobacco users are actually patients; (ii) increasingthe awareness of benefits of quitting and incentivizing it; (iii) establishing a systems approach in all health facilities of screening, treatment and follow-up of the treated tobacco users besides coding them; plus (iv) amending COTPA (the Cigarettes and Other Tobacco Products Act of 2003) can increase the quit rates in India and LMICs.

Blood Pressure and Cardio-Metabolic Risk Profile in Young Saudi Males in a University Setting.

Background and Objectives: The prevalence of cardiovascular diseases (CVDs) poses significant clinical and public health challenges across the world. This study aimed to study the metabolic risk factors and the association with blood pressure alteration. Materials and Methods: This was a cross-sectional study conducted between 2017 and 2018 among 284 male university students in Eastern province, Saudi Arabia. The obesity and cardiovascular measurements were taken using standardized instruments, including blood pressure (BP), mean arterial pressure, body mass index (BMI), body adiposity index (BAI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body fat percentage (BFP), and basal metabolic rate (BMR). Statistical Analysis: Blood pressure was classified according to the United States of America, Sixth Joint National committee (JNC-VI) guidelines. The mean and standard error were calculated for each hypertension group variable. Logistic regression was applied to predict associations. Results: The prevalence of hypertension in the present study was 61.6%., and that of overweight and obesity was 16.5% and 34.9%, respectively. The cut-off values of BMI and WC were 22.23 and 75.24, respectively. Conclusions: The results demonstrated that BMI, WC, WHR, and WHtR significantly predict hypertension and that WC has a greater discrimination capacity than other measures. The findings also emphasize the importance of cardiovascular risk screening for young adults to detect any alterations in blood pressure and thus identify the population that is vulnerable to CVDs at an early stage. The findings highlight the need for health and university policymakers to adopt measures to monitor and control hypertension and obesity at the university level.

Observed Circumvention of the Gutka Smokeless Tobacco Ban in Mumbai, India.

OBJECTIVES: Gutka is industrially manufactured in India and some Indian states have instituted bans on the sale of manufactured gutka as a public health initiative. We explored whether gutka was still available for purchase after the ban and also sought to observe methods of ban circumvention. METHODS: We visited 5 different markets at different locations separated by at least 15-20 km around the Mumbai Metropolitan Region (MMR) area, consisting of Mumbai and its satellite towns in Maharashtra, India during August- September, 2019. In each location, purveyors were queried as to the availability of gutka. RESULTS: Tobacco purchases were made in 5 locations/sections of MMR. At all markets, banned gutka was not displayed , and could only be purchased after requesting from the shopkeeper. Three methods of ban circumvention were observed: (1) packages marked 'export only'; (2) use of twin packaging in which pan masala and tobacco are sold together for immediate mixing to create gutka; and, (3) non-descript packaging without mention of 'gutka'. CONCLUSIONS: Although not readily displayed in shops, gutka is readily available in MMR, despite a statewide ban in Maharashtra. Marketers have used multiple methods to circumvent the statewide gutka ban.

Association between educational level and total and cause-specific mortality: a pooled analysis of over 694 000 individuals in the Asia Cohort Consortium.

OBJECTIVE: To study the association of educational level and risk of death from all causes, cardiovascular disease (CVD) and cancer among Asian populations. DESIGN: A pooled analysis of 15 population-based cohort studies. SETTING AND PARTICIPANTS: 694 434 Asian individuals from 15 prospective cohorts within the Asia Cohort Consortium. INTERVENTIONS: None. MAIN OUTCOME MEASURES: HRs and 95% CIs for all-cause mortality, as well as for CVD-specific mortality and cancer-specific mortality. RESULTS: A total of 694 434 participants (mean age at baseline=53.2 years) were included in the analysis. During a mean follow-up period of 12.5 years, 103 023 deaths were observed, among which 33 939 were due to cancer and 34 645 were due to CVD. Higher educational levels were significantly associated with lower risk of death from all causes compared with a low educational level (≤primary education); HRs and 95% CIs for secondary education, trade/technical education and ≥university education were 0.88 (0.85 to 0.92), 0.81 (0.73 to 0.90) and 0.71 (0.63 to 0.80), respectively (ptrend=0.002). Similarly, HRs (95% CIs) were 0.93 (0.89 to 0.97), 0.86 (0.78 to 0.94) and 0.81 (0.73 to 0.89) for cancer death, and 0.88 (0.83 to 0.93), 0.77 (0.66 to 0.91) and 0.67 (0.58 to 0.77) for CVD death with increasing levels of education (both ptrend <0.01). The pattern of the association among East Asians and South Asians was similar compared with ≤primary education; HR (95% CI) for all-cause mortality associated with ≥university education was 0.72 (0.63 to 0.81) among 539 724 East Asians (Chinese, Japanese and Korean) and 0.61 (0.54 to 0.69) among 154 710 South Asians (Indians and Bangladeshis). CONCLUSION: Higher educational level was associated with substantially lower risk of death among Asian populations.

Association of BMI, Smoking, and Alcohol with Multiple Myeloma Mortality in Asians: A Pooled Analysis of More than 800,000 Participants in the Asia Cohort Consortium.

BACKGROUND: To date, few epidemiologic studies have been conducted to elucidate lifestyle-related risk factors for multiple myeloma in Asia. We investigated the association of body mass index (BMI), smoking, and alcohol intake with the risk of multiple myeloma mortality through a pooled analysis of more than 800,000 participants in the Asia Cohort Consortium. METHODS: The analysis included 805,309 participants contributing 10,221,623 person-years of accumulated follow-up across Asia Cohort Consortium cohorts. HRs and 95% confidence intervals (95% CI) for the association between BMI, smoking, and alcohol at baseline and the risk of multiple myeloma mortality were assessed using a Cox proportional hazards model with shared frailty. RESULTS: We observed a statistically significant dose-dependent association between BMI categories and the risk of multiple myeloma mortality (<18.5 kg/m2: HR = 0.80, 95% CI: 0.52-1.24; 18.5-24.9 kg/m2: reference; 25.0-29.9 kg/m2: HR = 1.17, 95% CI: 0.94-1.47; ≥30 kg/m2: HR = 1.61, 95% CI: 0.99-2.64, P trend = 0.014). By sex, this association was more apparent in women than in men (P for heterogeneity between sexes = 0.150). We observed no significant associations between smoking or alcohol consumption and risk of multiple myeloma mortality. CONCLUSIONS: This study showed that excess body mass is associated with an increased risk of multiple myeloma mortality among Asian populations. In contrast, our results do not support an association between smoking or alcohol consumption and the risk of multiple myeloma mortality in Asian populations. IMPACT: This study provides important evidence on the association of BMI, smoking, and alcohol with the risk of multiple myeloma mortality in Asian populations.

The impact of heat waves on mortality in Northwest India.

Heat waves are anticipated to worsen with climate change. India, an understudied area with >15% of the world's population, commonly experiences temperature extremes and already resembles potential future climates of more temperate regions. Registry data from local municipal corporations and government offices were collected and translated, yielding daily all-cause mortality for 4 communities in Northwest India for all or part of the period 2000-2012. Heat waves were defined as ≥2 days with local temperature ≥97th percentile for that community. An alternate definition matching that used by the Indian Meteorological Department was also developed, to enhance policy relevance. Community-specific average daily maximum temperature over the entire record ranged from 32.5 to 34.2 °C (90.5-93.6 °F). Across communities, total mortality increased 18.1% during heat wave days compared with non-heat-wave days [95% confidence interval (CI): -5.3%, 47.3%], with the highest risk in Jaipur (29.9% [95% CI: 24.6%, 34.9%]). Evidence of effect modification by heat wave characteristics (intensity, duration, and timing in season) was limited. Findings indicate health risks associated with heat waves in communities with high baseline temperatures. Results can inform heat wave-health assessments in temperate regions in future, and improve our understanding of temperature-health associations under climate change. Further investigation of potential effect modification by heat wave characteristics is needed.

Advancing our Understanding of Heat Wave Criteria and Associated Health Impacts to Improve Heat Wave Alerts in Developing Country Settings.

Health effects of heat waves with high baseline temperatures in areas such as India remain a critical research gap. In these regions, extreme temperatures may affect the underlying population's adaptive capacity; heat wave alerts should be optimized to avoid continuous high alert status and enhance constrained resources, especially under a changing climate. Data from registrars and meteorological departments were collected for four communities in Northwestern India. Propensity Score Matching (PSM) was used to obtain the relative risk of mortality and number of attributable deaths (i.e., absolute risk which incorporates the number of heat wave days) under a variety of heat wave definitions (n = 13) incorporating duration and intensity. Heat waves' timing in season was also assessed for potential effect modification. Relative risk of heat waves (risk of mortality comparing heat wave days to matched non-heat wave days) varied by heat wave definition and ranged from 1.28 [95% Confidence Interval: 1.11-1.46] in Churu (utilizing the 95th percentile of temperature for at least two consecutive days) to 1.03 [95% CI: 0.87-1.23] in Idar and Himmatnagar (utilizing the 95th percentile of temperature for at least four consecutive days). The data trended towards a higher risk for heat waves later in the season. Some heat wave definitions displayed similar attributable mortalities despite differences in the number of identified heat wave days. These findings provide opportunities to assess the "efficiency" (or number of days versus potential attributable health impacts) associated with alternative heat wave definitions. Findings on both effect modification and trade-offs between number of days identified as "heat wave" versus health effects provide tools for policy makers to determine the most important criteria for defining thresholds to trigger heat wave alerts.