The Human Papillomavirus Enigma: A Narrative Review of Global Variations in Oropharyngeal Cancer Epidemiology and Prognosis.

Oropharyngeal cancers (OPCs) in Asia account for 42% of the global burden and over 50% of related deaths. Human papillomavirus (HPV) is involved in over 70% of OPC cases in the Western hemisphere, but its role in the Eastern hemisphere is unclear. This study reviews OPC epidemiology, including prevalence, etiological factors (such as smokeless tobacco and HPV), and their interaction. Among the SEAR countries, India had the highest incidence of HPV-related OPCs at 38.4%, while data were unavailable for most African countries, with only a 14% incidence reported. Conversely, the American region exhibited one of the highest HPV positivity rates, reaching up to 65% in different states of the USA, while Brazil reported an incidence of up to 38%. In the European Union, the UK had the highest incidence of HPV-associated OPC, reaching up to 52%. In the Western Pacific region, New Zealand demonstrated the highest incidence at up to 78%. Smokeless tobacco consumption was higher in SEAR countries, which had a relatively lower incidence of HPV infection, suggesting a negative correlation between the two. Based on our literature search, the most common detection methods used globally are immunohistochemistry for p16 and polymerized chain reaction. OPCs are a global health concern, and proper identification and classification are vital. HPV-driven cancers have better survival rates, emphasizing the need for focused research on specific problem areas based on the burden of HPV-positive or HPV-negative cancers.

Microbial community and functions involved in smokeless tobacco product: a metagenomic approach.

Smokeless tobacco products (STPs) are attributed to oral cancer and oral pathologies in their users. STP-associated cancer induction is driven by carcinogenic compounds including tobacco-specific nitrosamines (TSNAs). The TSNAs synthesis could enhanced due to the metabolic activity (nitrate metabolism) of the microbial populations residing in STPs, but identifying microbial functions linked to the TSNAs synthesis remains unexplored. Here, we rendered the first report of shotgun metagenomic sequencing to comprehensively determine the genes of all microorganisms residing in the Indian STPs belonging to two commercial (Moist-snuff and Qiwam) and three loose (Mainpuri Kapoori, Dohra, and Gudakhu) STPs, specifically consumed in India. Further, the level of nicotine, TSNAs, mycotoxins, and toxic metals were determined to relate their presence with microbial activity. The microbial population majorly belongs to bacteria with three dominant phyla including Actinobacteria, Proteobacteria, and Firmicutes. Furthermore, the STP-linked microbiome displayed several functional genes associated with nitrogen metabolism and antibiotic resistance. The chemical analysis revealed that the Mainpuri Kapoori product contained a high concentration of ochratoxins-A whereas TSNAs and Zink (Zn) quantities were high in the Moist-snuff, Mainpuri Kapoori, and Gudakhu products. Hence, our observations will help in attributing the functional potential of STP-associated microbiome and in the implementation of cessation strategies against STPs. KEY POINTS: •Smokeless tobacco contains microbes that can assist TSNA synthesis. •Antibiotic resistance genes present in smokeless tobacco-associated bacteria. •Pathogens in STPs can cause infections in smokeless tobacco users.

The association between smoking and smokeless tobacco use with dental caries among Pakistani patients.

BACKGROUND: Tobacco use is widely recognised as a significant risk factor for oral cancer and periodontal diseases. However, the relationship between various types of tobacco use and dental caries has been inconsistent. This study aimed to determine the association between smoking and smokeless tobacco and dental caries among patients in a tertiary care hospital in Quetta, Pakistan. METHODS: This cross-sectional study was conducted from November 2020 to March 2021 among patients in a tertiary care hospital in Quetta, Pakistan. Oral examinations and interviews were performed according to the WHO Oral Health Survey basic methods (5th edition) to determine dental caries status, tobacco use, and oral health behaviours. The odds ratio and binary logistic regression were analysed to assess the association between the types (smoking tobacco, smokeless tobacco, and use of both types), duration, and frequency of tobacco use and high caries level (DMFT ≥ 5). RESULTS: Four hundred participants aged 18-65 were included, and 67.8% were tobacco users. Use of both smoking and smokeless tobacco (aOR = 14.7, 95%CI = 1.87-115.96, p = 0.011), smokeless tobacco only (aOR = 5.90, 95%CI = 1.89-18.37, p = 0.002), and smoking only (aOR = 2.18, 95%CI = 1.23-3.88, p = 0.008) were associated with significantly increased risk of high caries. Using tobacco for longer periods and more frequently daily also significantly increases the risk of high caries. CONCLUSION: Smoking and smokeless tobacco are significantly associated with high dental caries after adjusting for other factors. Due to the high severity of dental caries and the high prevalence of tobacco use among Pakistani patients in this study, it is highly recommended to strengthen policies aimed at reducing tobacco usage, including smokeless forms.

Smokeless Tobacco Use and Quit Behaviour Assessment in a Middle Aged to Elderly Population in a Rural Setting - An Evaluative Study.

INTRODUCTION: Expanding knowledge on tobacco use and quitting outcomes in Chhattisgarh, India, is crucial. Limited data hinder the assessment of tobacco use prevalence and quitting outcomes in the region. This household-based cross-sectional study aimed to assess smokeless tobacco (SLT) use and quit behaviour among village dwellers aged 35-44 and 65-74 years in Jamul, Chhattisgarh. MATERIALS AND METHODS: A survey was conducted among 450 participants, utilising a pretested questionnaire and data analysis using IBM Statistical Package for the Social Sciences (SPSS) v23. RESULTS: The study revealed that among the survey participants, 61.1% were males and 38.9% were females. The prevalence of SLT use was found to be 67.8%, with 59.1% of current SLT users reporting daily use. Middle-aged individuals predominantly chose gutkha, while khaini was more common among the elderly. Tobacco and paan with tobacco were also commonly used forms. Gudakhu, a popular SLT product for oral hygiene and easy defecation, was reported by 71.34% of participants. Television warnings and SLT packages proved to be successful methods for disseminating information about the dangers of SLT use. However, SLT users who attempted to quit independently reported encountering one or more withdrawal symptoms, which posed significant obstacles to quitting SLT. CONCLUSION: Community-based awareness programmes are implemented via regional television (TV) channels, coupled with cessation initiatives, including professional counselling, pharmaceutical interventions and support of peer. Changing attitudes against SLT use and promoting tobacco-free environments are prioritized. These strategies will effectively address SLT use and improve quitting outcomes in Jamul, Chhattisgarh, fostering a healthier community.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation in Bangladesh, India and Pakistan: A pilot randomized controlled trial.

BACKGROUND AND AIMS: Smokeless tobacco (ST) use in South Asia is high, yet interventions to support its cessation are lacking. We tested the feasibility of delivering interventions for ST cessation in South Asia. DESIGN: We used a 2 × 2 factorial design, pilot randomized controlled trial with a duration of 26 weeks, including baseline and follow-up (6, 12 and 26 weeks) assessments. SETTING: Two primary health-care facilities each in Dhaka (Bangladesh) and Karachi (Pakistan) and a walk-in cancer screening clinic in Noida (India) took part. PARTICIPANTS: Adult daily ST users willing to make a quit attempt within 30 days. Of 392 screened, 264 participants [mean age: 35 years, standard deviation = 12.5, 140 (53%) male] were recruited between December 2020 and December 2021; 132 from Bangladesh, 44 from India and 88 from Pakistan. INTERVENTIONS: Participants were randomized to one of three treatment options [8-week support through nicotine replacement therapy (NRT, n = 66), a behavioural intervention for smokeless tobacco cessation in adults (BISCA, n = 66) or their combination (n = 66)] or the control condition of very brief advice (VBA) to quit (n = 66). MEASUREMENTS: Recruitment and retention, data completeness and feasibility of intervention delivery were evaluated. Biochemically verified abstinence from tobacco, using salivary cotinine, was measured at 26 weeks. FINDINGS: Retention rates were 94.7% at 6 weeks, dropping to 89.4% at 26 weeks. Attendance in BISCA pre-quit (100%) and quit sessions (86.3%) was high, but lower in post-quit sessions (65.9%), with variability among countries. Adherence to NRT also varied (45.5% Bangladesh, 90% India). Data completion for key variables exceeded 93% among time-points, except at 26 weeks for questions on nicotine dependence (90%), urges (89%) and saliva samples (62.7%). Among follow-up time-points, self-reported abstinence was generally higher among participants receiving BISCA and/or NRT. At 26 weeks, biochemically verified abstinence was observed among 16 (12.1%) participants receiving BISCA and 13 (9.8%) participants receiving NRT. CONCLUSIONS: This multi-country pilot randomized controlled trial of tobacco cessation among adult smokeless tobacco users in South Asia demonstrated the ability to recruit and retain participants and report abstinence, suggesting that a future definitive smokeless tobacco cessation trial is viable.

Process evaluation of a pragmatic feasibility trial on smokeless tobacco cessation intervention delivered in dental hospitals.

BACKGROUND: Article 14 of the WHO 'Framework Convention on Tobacco Control' recommends, that all oral healthcare providers provide support for tobacco cessation, to all patients. Despite evidence on the effectiveness of tobacco cessation interventions in dental settings, implementation remains low in most high-burden countries like Pakistan. A pragmatic pilot trial of a dentist-delivered behavioural support intervention for smokeless tobacco (ST) cessation, was conducted in dental hospitals in Pakistan. This paper presents the findings of the process evaluation of the trial. METHODS: A mixed-method process evaluation of a multi-centre randomised control pilot trial of dentist-delivered behavioural support intervention ST cessation was conducted. The intervention included three sessions namely: pre-quit, quit and post-quit sessions. The process evaluation involved: semi-structured interviews with trial participants (n = 26, of which dental patients were n = 13 and participating dentists were n = 13 conducted from June-August 2022); and fidelity assessment of audio recordings of the intervention sessions (n = 29). The framework approach was used to thematically analyse the interview data. RESULTS: Overall the trial procedures were well accepted, however, young patients expressed uneasiness over revealing their ST use status. The intervention was received positively by dentists and patients. Dentists identified some challenges in delivering behavioural support to their patients. Of these, some were related to the contents of the intervention whereas, others were related to the logistics of delivering the intervention in a clinical setting (such as workload and space). Acceptability of the intervention resources was overall low amongst young patients as they did not take the intervention resources home due to fear of their family members finding out about their ST use. The intervention was successful in achieving the intended impact (in those who engaged with the intervention), i.e., change in the patients' ST use behaviour. Giving up ST with the aid of behavioural support also had an unintended negative effect i.e., the use of harmful substances (cannabis, cigarettes) to give up ST use. Patients' satisfaction with their dental treatment seemed to influence the intervention outcome. CONCLUSION: While there are many variables to consider, but for the participants of this study, behavioural support for abstinence delivered through dentists during routine dental care, appears to be an acceptable and practical approach in helping patients give up ST use, in a country like Pakistan, where negligible support is offered to ST users.

Oral microbiome dysbiosis among cigarette smokers and smokeless tobacco users compared to non-users.

Tobacco use significantly influences the oral microbiome. However, less is known about how different tobacco products specifically impact the oral microbiome over time. To address this knowledge gap, we characterized the oral microbiome of cigarette users, smokeless tobacco users, and non-users over 4 months (four time points). Buccal swab and saliva samples (n = 611) were collected from 85 participants. DNA was extracted from all samples and sequencing was carried out on an Illumina MiSeq, targeting the V3-V4 region of the 16S rRNA gene. Cigarette and smokeless tobacco users had more diverse oral bacterial communities, including a higher relative abundance of Firmicutes and a lower relative abundance of Proteobacteria, when compared to non-users. Non-users had a higher relative abundance of Actinomyces, Granulicatella, Haemophilus, Neisseria, Oribacterium, Prevotella, Pseudomonas, Rothia, and Veillonella in buccal swab samples, compared to tobacco users. While the most abundant bacterial genera were relatively constant over time, some species demonstrated significant shifts in relative abundance between the first and last time points. In addition, some opportunistic pathogens were detected among tobacco users including Neisseria subflava, Bulleidia moorei and Porphyromonas endodontalis. Overall, our results provide a more holistic understanding of the structure of oral bacterial communities in tobacco users compared to non-users.

Smokeless tobacco consumption among women of reproductive age: a systematic review and meta-analysis.

Smokeless tobacco (SLT) poses many negative health impacts. Despite its longstanding presence in societies across the world, the health implications of SLT have only been rigorously studied in recent decades. This systematic review and meta-analysis aimed to consolidate existing research to provide a comprehensive understanding of the global prevalence of SLT use among women of reproductive age. Relevant articles were extracted from databases such as PubMed, EMBASE, Web of Science, and Scopus from their inception until November 11, 2023. Observational studies reporting the number of SLT users among women of reproductive age were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) tool. The meta-analysis used a random-effects model to determine SLT prevalence, supported by statistical tools like forest plots, I2 statistics, and sensitivity analyses to ensure the accuracy and comprehensiveness of the results. All statistical analyses were performed in R version 4.3. From 10 studies involving 2,053,667 participants, a pooled prevalence for SLT use among women of reproductive age was found to be 9.3% (95% CI: 0.038 to 0.21), with significant heterogeneity among studies (I2 = 100%). Publication bias was suspected among the studies. Sensitivity analysis and subgroup analysis couldn't resolve the heterogeneity. Our analysis shows a significant prevalence of SLT use in women of reproductive age, especially in low socioeconomic and developing countries like India, Pakistan, and Nepal. For women of reproductive age, the use of smokeless tobacco (SLT) can lead to infertility, pregnancy complications, and adverse fetal outcomes, including low birth weight and preterm birth. The results highlight the necessity for specific public health measures and policy changes to decrease SLT consumption among reproductive-age women. Further studies are needed to investigate the reasons behind SLT usage in this group and to assess the impact of intervention strategies, to guide more effective public health initiatives and policies.

Multi-endpoint in vitro toxicological assessment of snus and tobacco-free nicotine pouch extracts.

'Modern' oral tobacco-free nicotine pouches (NPs) are a nicotine containing product similar in appearance and concept to Swedish snus. A three-step approach was taken to analyse the biological effects of NPs and snus extracts in vitro. ToxTracker was used to screen for biomarkers for oxidative stress, cell stress, protein damage and DNA damage. Cytotoxicity, mutagenicity, and genotoxicity were assessed in the following respective assays: Neutral Red Uptake (NRU), Ames and Mouse Lymphoma Assay (MLA). Targeted analysis of phosphorylation signalling and inflammatory markers under non-toxic conditions was used to investigate any potential signalling pathways or inflammatory response. A reference snus (CRP1.1) and four NPs with various flavours and nicotine strengths were assessed. Test article extracts was generated by incubating one pouch in 20 mL of media (specific to each assay) with the inclusion of the pouch material. NP extracts did not induce any cytotoxicity or mutagenic response, genotoxic response was minimal and limited signalling or inflammatory markers were induced. In contrast, CRP1.1 induced a positive response in four toxicological endpoints in the absence of S9: Srxn1 (oxidative stress), Btg2 (cell stress), Ddit3 (protein damage) and Rtkn (DNA damage), and three endpoints in presence of S9: Srxn1, Ddit3 and Rtkn. CRP1.1 was genotoxic when assessed in MLA and activated signalling pathways involved in proliferation and cellular stress and specifically induced phosphorylation of c-JUN, CREB1, p53, p38 MAPK and to a lesser extent AKT1S1, GSK3α/ß, ERK1/2 and RSK1 in a dose-dependent manner. CRP 1.1 extracts resulted in the release of several inflammatory mediators including cytokines IL-1α, IL5, IL6, IL8, IL-1RA, MIF and TNF-ß, receptor IL-2RA, and growth factors FGF-basic, VEGF and M-CSF. In conclusion these assays contribute to the weight of evidence assessment of the potential comparative health risks of NPs and snus.

Prevalence, Reach of Anti-smokeless Tobacco Messages and Quit Attempts by Product Type: A Secondary Data Analysis from the Global Adult Tobacco Survey (GATS - 2016-17).

OBJECTIVE: India has the highest number of smokeless tobacco (SLT) products available in different forms, consumed in various ways. The current study aimed to understand the pattern of daily SLT use according to different product categories and whether Quit intention and Quit attempts vary by SLT type and exposure to media messages. METHODS: Data from Global Adult Tobacco Surveys (GATS), 2016-17, was used to find access to media messages and warning labels by SLT type. Quit attempt and Quit intention were calculated for each of the SLT types. Logistic regression analyses were employed to identify whether access to media messages, warning labels influenced, quit intention and attempts vary by SLT type. RESULTS: Khaini or tobacco lime mixture was the most common SLT type consumed by 37% of SLT users, whereas SLT users consuming more than one product accounted for 23% of SLT users. Exposure to media messages and warning labels was high among Gutkha/ paan masala tobacco users (74.7% and 81.2%) and low among oral tobacco (Mishri, Gul, Gudakhu) users (56.1% and 60.0%). Quit attempts and quit intention were high among Gutkha/ paan masala tobacco users (38.3% and 22.3%) and low among oral tobacco (Mishri, Gul, Gudakhu) users (25.3% and 13.6%). Users of Oral tobacco and khaini or tobacco-lime mixture were significantly less likely to attempt quitting (AOR 0.806(95%CI: 0.676-0.962), 0.839(95%CI: 0.736-0.956), and have quit intention (AOR 0.681(95%CI: 0.702-0.976), 0.733(95%CI: 0.627-0.857) compared to Gutkha/ paan masala with tobacco users. CONCLUSION: The reach of media messages and warning labels varies by SLT type. Quit intention and attempts vary by SLT type and access to media messages and warning labels. There is a need to re-strategise the tobacco control Information, Education and Communication (IEC) to reach out with effective messaging to the most unreached.

Smokeless tobacco keratosis in oral mucosa with epithelial dysplasia: A case report.

RATIONALE: Smokeless tobacco use is a risk factor for the development of various oral lesions, among which is smokeless tobacco keratosis (STK). This condition is caused by constant frictional irritation of smokeless tobacco products against the oral mucosa and appears as a White-to-gray plaque with wrinkling. PATIENT CONCERNS: A 50-year-old man who had been using smokeless tobacco for 24 years visited our clinic complaining of changes in the lower right sulcus of the oral cavity for 10 days. Clinical examination revealed a unilateral, nonhomogeneous White lesion in the area of the complaint. Histopathological examination showed hyperkeratosis, areas of keratin plugging, and mild dysplastic epithelial changes. DIAGNOSIS: The clinico-histopathological correlation suggested a diagnosis of STK with focal mild epithelial dysplasia. INTERVENTION AND OUTCOME: A comprehensive management plan included maintaining oral hygiene, education on the detrimental effects of smokeless tobacco, advice to cease smoking, and regular follow-up to monitor the potential for malignant transformation. The patient was referred to a tobacco cessation society for tailored advice and counseling. On follow-up visits, there was an improvement in the lesion after habitual cessation. LESSONS: The diagnosis of tobacco-related oral lesions is often delayed, which may result in malignant transformation. This illustrates the need to train healthcare professionals to identify tobacco-related conditions at an early stage and to educate patients regarding the harmful effects of tobacco use.

Tobacco and nicotine use among active component U.S. military service members: a comparison of 2018 estimates from the Health Related Behaviors Survey and the Periodic Health Assessment.

This study compared estimates of the prevalence of and risk factors for tobacco and nicotine use obtained from the 2018 Health Related Behaviors Survey (HRBS) and Periodic Health Assessment (PHA) survey. The HRBS and the PHA are important Department of Defense sources of data on health behavior collected from U.S. military service members. While their collection methods differ, some survey questions are similar, which provides an opportunity to compare survey estimates. Active duty service members consistently reported a much lower prevalence of all types of tobacco and nicotine use on the PHA compared to the HRBS: cigarettes (11.1% vs. 18.4%), e-cigarettes (7.3% vs. 16.2%), chewing tobacco (9.7% vs. 13.4%), any tobacco or nicotine use (25.3% vs. 37.8%), and use of 2 or more tobacco or nicotine products (5.8% vs. 17.4%). Associations between tobacco and nicotine use as well as demographic and other behavioral variables were fairly similar, including age, sex, education, race and ethnicity, rank, and alcohol use. The associations with service branch, body mass index, and sleep were inconsistent. This results of this study suggest that the PHA can provide timely information on trends in military tobacco and nicotine use over time, but much higher estimates from the confidential, voluntary HRBS reported in this study suggest that the command-directed PHA may substantially underestimate the prevalence of all types of tobacco and nicotine use.

Determinants of Quit Attempts and Short-Term Abstinence among Smokeless Tobacco Users in India: Global Adult Tobacco Survey, 2016-17.

OBJECTIVE: Smokeless tobacco is the preponderant form of tobacco in India. The cessation indicators are weaker for smokeless tobacco users than smokers. There is a dearth of literature on the effectiveness of the interventions that motivate and assist smokeless tobacco users in quitting in program settings. METHODS: Data from Global Adult Tobacco Surveys (GATS), 2016-17, was analysed. Quit attempts in the previous 12 months among SLT users and duration of abstinence were the two outcome variables. The chief exposure variables were the receipts of various interventions that warned about the dangers of smokeless tobacco or encouraged quitting. Logistic regression analyses were employed to identify determinants of quit attempts. For the hazard of relapse to tobacco use, survival analysis was used. RESULTS: The odds of quit attempts among SLT users in the previous 12 months were more among those who received advice from healthcare providers (OR 2.09; 1.87-2.34), noticed messages from media that made them think about quitting (OR 1.67; 1.50-1.86) and noticed a warning label that made them think about quitting (OR 1.39; 1.25-1.55). Those who used counselling (HR 0.81; 0.70-0.93) or medication (HR 0.79; 0.66-0.95) sustained abstinence from smokeless tobacco for a longer duration compared to those who did not use any cessation method. CONCLUSION: Quit advice by healthcare providers is an influential determinant of a quit attempt, and this intervention needs to be scaled up. The media messages and warning labels were effective among those who considered quitting after noticing them. Cessation methods can help prolong the abstinence from smokeless tobacco, but the reach of cessation methods is limited.

Using Exogenous Social Media Exposure Measures to Assess the Effects of Smokeless Tobacco-Related Social Media Content on Smokeless Tobacco Sales in the United States.

INTRODUCTION: Prior research on the effects of social media promotion of tobacco products has predominantly relied on survey-based self-report measures of marketing exposure, which potentially introduce endogeneity, recall, and selection biases. New approaches can enhance measurement and help better understand the effects of exposure to tobacco-related messages in a dynamic social media marketing environment. We used geolocation-specific tweet rate as an exogenous indicator of exposure to smokeless tobacco (ST)-related content and employed this measure to examine the influence of social media marketing on ST sales. AIMS AND METHODS: Autoregressive error models were used to analyze the association between the ST-relevant tweet rate (aggregated by 4-week period from February 12, 2017 to June 26, 2021 and scaled by population density) and logarithmic ST unit sales across time by product type (newer, snus, conventional) in the United States, accounting for autocorrelated errors. Interrupted time series approach was used to control for policy change effects. RESULTS: ST product category-related tweet rates were associated with ST unit sales of newer and conventional products, controlling for price, relevant policy events, and the coronavirus disease 2019 (COVID-19) pandemic. On average, 100-unit increase in the number of newer ST-related tweets was associated with 14% increase in unit sales (RR = 1.14; p = .01); 100-unit increase in conventional ST tweets was associated with ~1% increase in unit sales (p = .04). Average price was negatively associated with the unit sales. CONCLUSIONS: Study findings reveal that ST social media tweet rate was related to increased ST consumption and illustrate the utility of exogenous measures in conceptualizing and assessing effects in the complex media environment. IMPLICATIONS: Tobacco control initiatives should include efforts to monitor the role of social media in promoting tobacco use. Surveillance of social media platforms is critical to monitor emerging tobacco product-related marketing strategies and promotional content reach. Exogenous measures of potential exposure to social media messages can supplement survey data to study media effects on tobacco consumption.

Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches.

BACKGROUND: Nicotine pouches without tobacco are new products that deliver nicotine into the body via the oral mucosa. There is a lack of independent research on the chemical composition and product characteristics of these products, contributing to uncertainties regarding product regulation. This study sought to address knowledge gaps by assessing levels of nicotine and screening for tobacco-specific nitrosamines (TSNAs) in a sample of these products. METHODS: Nicotine pouches (n=44) and nicotine-free pouches (n=2) from 20 different manufacturers were analysed regarding their contents of nicotine and TSNAs by gas chromatography with flame ionisation and liquid chromatography-tandem mass spectrometry, respectively. Product labelling and pH values of aqueous extracts were determined. RESULTS: Nicotine contents of products ranged from 1.79 to 47.5 mg/pouch; median product weight, pH, and proportion of free-base nicotine were 0.643 g, 8.8, and 86%, respectively. A clear labelling of the nicotine content was missing on 29 products and nicotine strength descriptions were ambiguous. TSNAs were detected in 26 products, with a maximum of 13 ng N-nitrosonornicotine/pouch. CONCLUSION: Although nicotine pouches may potentially be a reduced risk alternative for cigarette smokers or users of some other oral tobacco products, nicotine contents of some pouches were alarmingly high. Presence of carcinogenic TSNAs in the nicotine pouches is of serious concern. Better manufacturing processes and quality control standards should be implemented. Labels of nicotine strength on most products are misleading. A strict regulation regarding nicotine contents and its labelling would be advisable.

Factors associated with transitions in tobacco product use states among young adults aged 18-29 years.

BACKGROUND AND OBJECTIVES: This study examined young adults' tobacco use transitions based on their past 30-day use states, and identified factors associated with their transitions. METHODS: Participants (N = 12377) were young adults aged 18-29 years at Wave 1 of the Population Assessment of Tobacco and Health (PATH) study. Self-reported tobacco use states were categorized by the number of past-month use days (0, 1-4, 5-8, 9-12, 13-30 days) for cigarettes, electronic cigarettes [e-cigarettes], traditional cigars, filtered cigars, cigarillos, smokeless tobacco (SLT), and hookah. Multistate Markov models examined transitions between use states across Waves 1-5 of unweighted PATH data and multinomial logistic regressions examined predictors of transitions. RESULTS: Most young adults remained nonusers across adjacent waves for all products (88%-99%). Collapsed across waves, transitioning from use at any level to nonuse (average 46%-67%) was more common than transitioning from nonuse to use at any level (average 4%-10%). Several factors that predicted riskier patterns of use (i.e., transitioning to use and/or remaining a user across adjacent waves) were similar across most products: male, Black, Hispanic, lower education levels, and lower harm perceptions. In contrast, other factors predicted riskier patterns for only select products (e.g., e-cigarette and SLT use among Whites). DISCUSSION AND CONCLUSIONS: Few sampled young adults escalated their tobacco use over time, and escalations for many products were predicted by similar factors. SCIENTIFIC SIGNIFICANCE: Prevention and regulatory efforts targeted towards adolescents should continue, but also be expanded into young adulthood. These same efforts should consider both shared and unique factors that influence use transitions.

The Diversity in Tobacco Use Among Women of Reproductive Age (15-49 Years) in Pakistan: A Secondary Analysis of a Multiple Indicator Cluster Survey 2016-2018.

INTRODUCTION: Tobacco use in women of reproductive age group (15-9 years) may contribute to poor maternal and child health outcomes. We estimated the prevalence of smokeless tobacco (ST), cigarette, and waterpipe use among these women in Pakistan and explored associations with socio-economic differences and birth weights after recent childbirths (past 2 years). AIMS AND METHODS: We used the Multiple Indicator Cluster Surveys datasets from three provinces in Pakistan. Prevalence was generated for current use of tobacco among women with recent childbirth (WWRC) and without recent childbirth (WWoRC). We further compared socio-economic status and birth weights between tobacco users and non-users. RESULTS: The prevalence of current ST use was 1.4% and 2.5%, and waterpipe smoking was 1.2% and 1.8%, in WWRC and WWoRC, respectively. ST use varied across Pakistan's provinces by 13 percentage points in WWRC and WWoRC while waterpipe smoking by 10 and 15 percentage points, respectively. The odds of using any form of tobacco were significantly lower with higher levels of education or wealth index. Compared to children born to mothers who did not use tobacco, the birth weight of children born to mothers who smoked waterpipe was on average 0.83 kg (95% CI -1.6 to -0.1) lower whereas it was 0.33 kg (95% CI -0.9 to 0.3) higher for ST users. CONCLUSIONS: Tobacco use among women of reproductive age in Pakistan varied significantly based on province and tobacco type. Waterpipe smoking was associated with a reduction in birth weight. Raising awareness of the harms of tobacco use among women of reproductive age and targeting interventions in high-burden regions of Pakistan should be prioritized. IMPLICATIONS: The prevalence of current smokeless tobacco use and waterpipe smoking varied significantly in Pakistan (~13 and ~15 percentage points, respectively) among women of reproductive age, and there seems to be little change in tobacco use behavior around pregnancy and early motherhood. The study highlights a need to better understand the prevalence of tobacco use in Pakistan, and further contextual research is warranted to understand the reasons for such high tobacco use in certain areas. This information highlights the need for improving current tobacco control interventions and policies, including measures that could help reduce its use and prevent its uptake. Furthermore, compared to children born to mothers who did not use any form of tobacco, we found a statistically significant difference (830 g) in birth weight for babies born to mothers who at the time of the interview smoked waterpipe and a non-statistically significant difference of about 330 g for children born to mothers who at the time of the interview used smokeless tobacco. In addition to our findings, some literature suggests the association of waterpipe smoking with low birth weight. A possible explanation could be the exposure to smoke that contains toxicants from the tobacco product itself in addition to the burning of charcoal, which is required when using waterpipe. Waterpipe smoking also results in high exposures to carbon monoxide and polycyclic aromatic hydrocarbons, which are known to be carcinogenic and teratogenic. In terms of smokeless tobacco use, further research is warranted to understand its impact on birth outcomes through longitudinal studies accounting for diverse products, its constituents and the amount of consumption.

Health effects associated with chewing tobacco: a Burden of Proof study.

Chewing tobacco use poses serious health risks; yet it has not received as much attention as other tobacco-related products. This study synthesizes existing evidence regarding the health impacts of chewing tobacco while accounting for various sources of uncertainty. We conducted a systematic review and meta-analysis of chewing tobacco and seven health outcomes, drawing on 103 studies published from 1970 to 2023. We use a Burden of Proof meta-analysis to generate conservative risk estimates and find weak-to-moderate evidence that tobacco chewers have an increased risk of stroke, lip and oral cavity cancer, esophageal cancer, nasopharynx cancer, other pharynx cancer, and laryngeal cancer. We additionally find insufficient evidence of an association between chewing tobacco and ischemic heart disease. Our findings highlight a need for policy makers, researchers, and communities at risk to devote greater attention to chewing tobacco by both advancing tobacco control efforts and investing in strengthening the existing evidence base.