More than 300 million adults in 70 countries across all WHO regions use smokeless tobacco. The largest share, 89 percent, is in South-East Asia. More than 250 million adult ST users are in low- and middle-income countries.

In a few countries, notably India and Bangladesh, ST use is very high and surpasses smoking.

Smokeless tobacco use prevalence varies significantly across individual countries and regions, between youth and adults, and between males and females.

Among youth and adults, males generally show higher prevalence of use than females. However, among adults, use by women is similar to or greater than use by men in some countries, including Bangladesh, Thailand, Cambodia, Malaysia, Vietnam, and some African countries, such as South Africa, Mauritania, and Sierra Leone.

Current ST prevalence is especially high (>15 percent) among adults in Myanmar, Bangladesh, India, Bhutan, Nepal, Sweden, Sri Lanka, and among youth in Congo and Namibia. All six WHO regions reported prevalence of greater than 10 percent among boys, men, or overall in at least one country.

Although data were available to measure overall prevalence for many countries, longitudinal data and data on patterns of use are lacking in most regions.

A global view
Globally, ST products vary greatly in chemical composition, with some products containing extremely high levels of nicotine, free nicotine, and carcinogens. Hence, the wide spectrum of ST products appears to represent differing levels of addictiveness, toxicity, carcinogenicity and harmful health effects.

Smokeless tobacco products may be premade (sold ready to use) or custom-made (assembled by the user or a vendor according to user preferences). Premade products range from manufactured products made in factories or large production facilities to cottage industry products made in market stalls or shops.

Levels of toxicity, carcinogens, and free nicotine in ST products are influenced by the tobacco species type used, growing conditions, curing methods, tobacco processing, production methods, including the addition of certain ingredients and product storage conditions.

The presence of microorganisms (e.g., bacteria, fungi) in tobacco or their formation during production can potentially increase the levels of some carcinogens or toxicants in tobacco products.

Reduction or elimination of fire-cured tobacco, microbial contamination, fermentation, and certain ingredients (areca nut, tonka bean) and improvements in storage conditions are potential means of reducing carcinogens or toxicants in ST products.

Elimination of nicotine-enriched tobacco species and greatly reduced use of alkaline agents are means of reducing users’ exposure to high nicotine levels and the addictive potential of some ST products.

Health consequences
Compared with the vast amount of information, linking adverse health effects to cigarette smoking, studies on ST use are not comprehensive. Epidemiologic studies of ST use have less information about what levels of use are associated with particular outcomes and, in some countries, fewer numbers of ST users on which to base conclusions. Also, because ST products contain varying levels of many known carcinogens as well as other plant materials, such as areca nut or tonka bean, comprehensive risk assessments must address complex mixtures of ingredients.

There is sufficient evidence that ST products cause addiction; precancerous oral lesions, cancer of the oral cavity, esophagus, and pancreas, and adverse reproductive and developmental effects including stillbirth, preterm birth, and low birth weight. Some, but not all, ST products are associated with increased risk of fatal ischemic heart disease, type 2 diabetes, and fatal stroke.

The extent of ST-related risks appears to vary by region, most likely due in part to differing levels of harmful constituents and ways in which these products are used.
The proportion of cases of cancers of the oral cavity, esophagus, and pancreas that can be attributed to ST use (the attributable fraction) is greater in countries where ST use is highly prevalent. A high burden of ST-related cancers is estimated to occur in India because of the large population, high prevalence of ST use, and high incidence of cancers known to be associated with ST use.

The public health impact of ST use can be estimated from the disease risk associated with the particular product, the prevalence and manner of use, and the population burden of disease known to be associated with ST use. The impact of ST use may be difficult to quantify where data specific to a product or region are lacking

The economy
Very limited data exist on ST prices, tax rates, and tax structures, which makes research into the impact of ST taxes and prices on ST use very difficult, if not impossible. Very little is known about the extent to which higher ST taxes translate into higher ST prices and how these prices affect the affordability of ST products. Little is known about the comparability of tax levels between smoked and smokeless products.

The best available estimates indicate that, by volume, 91 percent of ST products sold worldwide are sold through ‘traditional’ markets (cottage industry and custom-made).
The tax system that best suits public health goals is likely to be country-specific. The excise tax system that should be favored is that which most effectively raises the prices of ST products and makes ST products less affordable over time, because this will discourage ST consumption. The current best practice for cigarette taxation favors the use of a specific excise tax that is regularly adjusted for inflation.

The effectiveness of tax collection systems and the impact of higher taxes on ST use will also depend on the standardization of ST products. Lack of standardization complicates not only tax collection, but also scientific research, as it hinders the use of econometric methods.

Data on ST prices, taxes, ST tax revenue, and ST trade (both licit and illicit) are needed. Currently, the WHO FCTC reporting standards do not require collection of data on all types of tobacco products. Attention should be dedicated to monitoring and regulating the ST supply chain (manufacturing, trade, distribution) in order to develop an effective ST tax regime.

Practices by industry
In some high-income countries, tobacco manufacturers have introduced novel ST products, using product innovations such as portion pouches, dissolvable tobacco, unique flavorings, and varying nicotine levels which may make novel products more attractive to consumers, including those who have not previously used ST products. Tobacco manufacturers, including cigarette manufacturers, have marketed new ST products to smokers for use in situations where they cannot smoke or do not want to smoke, such as at work, in airplanes, in smoke-free bars, or around family members. These marketing strategies may have an adverse public health impact if they encourage dual use or use of multiple tobacco products, discourage cessation, or encourage new tobacco use initiation.
In low- and middle-income countries, product innovations may also make sale and use of products more convenient. For example, in India the gutka industry has promoted a packaged ready-to-use product based on a traditional custom-made mixture.

Marketing encompasses more than advertising. Marketing practices of the ST industry should be thought of in terms of the 4 Ps: Product, price, placement and promotion. Products are designed to appeal targeted consumers, they are offered at a desirable price, and they are promoted effectively using multiple communication and placement channels.
Understanding consumer perceptions of and responses to novel products is essential to assessing the public health impact of changing product and marketing strategies. Research is needed into the perceptions of consumers and their attitudes toward marketing messages, product packaging, and product characterization in order to support evidence-based control and regulation of ST products.

Greater monitoring and research is needed regarding marketing practices in low- and middle-income countries.

Prevention and cessation
School-based and community-based prevention programs lead to short-term reductions in prevalence. Involvement of youth in the planning and implementation of programs is an important contributor to their success.

School programs that are supplemented by effective family-based and mass media programs improve success over school programs alone.

For adult ST users, dental office interventions and clinic interventions involving multiple sessions and counselor support have been shown to be effective treatments, although most studies have been conducted in high-income countries. Phone counseling and oral exam feedback appear to be key elements of an effective intervention. Training oral health professionals to intervene with ST users may also be an effective avenue for intervention.
For resource-constrained countries, mailed self-help materials with follow-up contact by telephone or using mobile technology may be a cost-effective intervention method.
Pharmacotherapies, with the possible exception of varenicline, have not been found effective in improving ST cessation rates. However, these medications may reduce withdrawal symptoms in individuals who stop using ST products.

Public awareness and understanding of the detrimental health effects of ST use is incomplete and in some countries, extremely limited. Educational efforts on these harmful effects through media or health care systems are essential to support implementation of large-scale interventions.

More research is necessary in order to develop country-specific ST intervention programs and to explore the best ways to make these interventions accessible to ST users; especially in countries were resources are limited.
To be continued…

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