Reducing harm from smokeless tobacco use in South Asia - Global Health Research feature

The NIHR Global Health Research Group on Addressing Smokeless Tobacco and Building Research Capacity in South Asia (ASTRA) was launched in 2018 with a £2 million grant from NIHR’s Global Health Research programme funded by UK Official Development Assistance (ODA). It aims to develop the research base and support interventions to reduce harm from smokeless tobacco and carrying out policy research to inform public health policies in the region. 

ASTRA, a partnership with Aga Khan University and Khyber Medical University in Pakistan, Maulana Azad Medical College, Public Health Foundation and National Institute of Cancer Prevention and Research in India and the University of Dhaka and ARK Foundation, a non-profit research-based organisation in Bangladesh, and the University of York, completed its research in April 2020 and continues to publish and disseminate its findings.   

Kamran Siddiqi, Professor in Public Health at the University of York and Director of ASTRA, said: “ASTRA has put smokeless tobacco firmly on the global health agenda and for the first time allowed researchers in Bangladesh, India and Pakistan to work together to address it.”

Often considered a less harmful alternative to cigarettes, smokeless chewing tobacco products are widely used across South Asia. The products are highly addictive and many contain high levels of heavy metals and carcinogens that are responsible for cancers of the mouth, pharynx and oesophagus. Every year smokeless tobacco results in more than 90,000 cancer-related deaths and accounts for more than 250,000 deaths from heart disease. 

As outlined in the Tobacco Atlas, at least 80% of the world’s 360 million users of smokeless tobacco live in South Asia, where the poorest populations experience the greatest burden of related disease. Easily available and cheaper than most smoking products, its consumption is well integrated into mainstream culture and considered socially acceptable in situations where cigarettes are not. 

Poorer men are the highest users of smokeless tobacco although consumption is high among women in Bangladesh and some Indian states. Use during pregnancy is linked to poor birth outcomes including pre-term delivery, low birth weight and stillbirth. 

Despite the serious health risks, regulation has proved difficult. Smokeless tobacco products are often produced in small cottage industries and sold in unregulated markets as alternatives to cigarettes. Unlike the public movement against smoking, the health risks of smokeless tobacco use have received little attention from the public, researchers or policymakers in a region where its use is more common than smoking. 

India, Pakistan and Bangladesh are among 181 countries that signed up to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Through the WHO FCTC’s Global Knowledge Hub at the Indian Council of Medical Research’s National Institute of Cancer Prevention and Research, it aims to reduce tobacco demand and supply. It also encourages regulation of the contents, packaging and labelling of tobacco products.

ASTRA investigated several interlinked areas relating to smokeless tobacco’s use, including young people, marketing and selling, cessation, economics and related policies.   

Working alongside partners in South Asia, the Group’s research programme has provided new evidence to support and drive forward policy change to improve public health. As 90% of smokeless tobacco users begin their habit as teenagers, the ASTRA-Youth study carried out school-based surveys of adolescents (aged 13 to 17 years) across eight schools in each partner country to assess whether WHO FCTC policies had reduced their uptake of smokeless tobacco. 

Their separate analysis of data collected by the Global Youth Tobacco Survey, a survey of over 23,000 teenagers, showed that three times as many teenagers used smokeless tobacco than smoked cigarettes. Published in the journal Nicotine & Tobacco Research, they found that exposure to electronic advertising for tobacco and being offered free tobacco products increased its use by this age group, while refusal by shopkeepers to sell products and classroom education about the harmful effects of tobacco both made its use less likely. These findings have helped the national tobacco control cell in Pakistan to focus their efforts on specific policies in order to reduce tobacco uptake in youth.    

So what would help users quit? To understand the reasons behind people’s continued use of smokeless tobacco, the ASTRA-Cessation team interviewed 33 adults in all three countries about their habit. Also published in Nicotine & Tobacco Research, their interviews revealed that three-quarters of participants had made short-lived attempts to quit but none had sought cessation support, reflecting the gap between the need and awareness of or access to the service. 

As one participant explained: "I didn’t even last one day, I had to have [smokeless tobacco]. I tried to quit many times, but I never succeeded. I would last for a maximum of one day.”

Dr Shalini Singh, Director of the National Institute of Cancer Prevention and Research in India and Principal Investigator for the ASTRA-Cessation study in India said: “South Asian smokeless tobacco users are highly motivated to quit smoking. They have been unsuccessful because environmental and social factors encourage smokeless tobacco use and they have lacked formal support to quit.” 

The team tested the new intervention among 260 people in Bangladesh, Pakistan and India who wanted to quit smokeless tobacco. Successful engagement with community members showed the intervention could be used to help people quit. ASTRA followed this study by training more smokeless tobacco cessation practitioners and organised an online cessation course attended by participants from 10 countries.

During the Covid-19 pandemic ASTRA also assessed its impact on Indian adults’ efforts to quit smokeless tobacco. Published in Clinical Epidemiology and Global Health, the study of more than 200 participants showed that around 30% of the participants quit between January and October 2020 due to lack of availability, increased cost of products and isolation from social circles. This gave an insight into effective policy strategies to reduce smokeless tobacco use that could be combined with cessation support.

The ASTRA-Sellers study evaluated how well retailers of smokeless tobacco brands complied with local regulations and WHO FCTC directives. For example, the team analysed products from general retailers and exclusive sellers of smokeless tobacco in three different regions of Pakistan. Published in Nicotine & Tobacco Research, the study found that retailers frequently broke the local laws, with exclusive sellers less likely to comply with advertisement and promotion regulations. More than half of all retailers advertised the products inside their shops and none displayed any written or pictorial health warnings. Through this work ASTRA has drawn attention to the lack of proper regulation and implementation of control policies. The team continues to work with policy makers to devise better ways to regulate smokeless tobacco vendors.

In addition to its impact on health, smokeless tobacco use exerts a huge economic burden in South Asia. The ASTRA-Economics study adapted and validated an existing economic model to estimate the actual economic burden and examined how potential new strategies may reduce these costs. The results have been communicated to the policy makers in each country through a webinar series on the economics of smokeless tobacco in South Asia.

The ASTRA-Policy study investigated how well WHO FCTC policies had improved smokeless tobacco control. It identified gaps enabling the inappropriate sale, marketing and subsequent continued use of smokeless tobacco products. 

In one of their studies focusing on policy gaps in Pakistan and published in Nicotine & Tobacco Research, ASTRA’s analysis found that no laws were applied to smokeless tobacco other than restricted advertising and sale near places of education. This showed a significant lag in implementing policies compared with cigarettes and an area to target. 

Overall, the ASTRA-Policy study identified and promoted key priority areas to improve smokeless tobacco policies. These included banning its sale to and by minors, advocacy campaigns, taxes and standardising packaging. In line with ASTRA’s aims, the analysis helped guide ASTRA’s research direction and generated demand for further research. 

The team has contributed to many health promotion and policy discussions across the partner countries. For example, the team provided evidence for tobacco tax reform to academics, policy makers and a member of the Bangladesh parliament, who supported the proposal and is working on its implementation. The Group’s advocacy work through networks in Pakistan also contributed to a tax on smokeless tobacco being introduced in one province. It also supported the introduction of a new law in 2020 banning tobacco advertising at points-of-sale. 

ASTRA’s website shares information and resources with interested parties, where factsheets illustrating the problems caused by smokeless tobacco in Pakistan are used for public health promotion. Following the success of ASTRA’s awareness-raising video campaigning against smokeless tobacco in Pakistan, several more videos have been made and widely shared on social media in India, for example “Health hazards of tobacco” on YouTube. 

ASTRA is a founder member of the Global Health Respiratory Network, which brings together respiratory health experts from ten NIHR Global Health Research Groups and Units. Its collective aim is to increase research around respiratory disorders, deliver interventions and build upon skills to improve health in LMICs. ASTRA shares training resources, expertise and connections with other network members including NIHR Global Health Research Unit on Respiratory Health (RESPIRE) and the NIHR Global Health Research Group: Improving Outcomes in Mental and Physical Multimorbidity and Developing Research Capacity (IMPACT) in South Asia.

The Group’s commitment to its training programme is building essential research skills in its partner countries. These skills will ultimately help LMIC institutions develop and lead projects related to ASTRA in the future. Professor Siddiqi is a member of the steering group for NIHR’s Global Health Training Programme, which supports early career researchers and PhD students working with ASTRA and other Global Health Research programmes. He said: "Training research teams at our partner institutions to conduct high quality applied health research has also increased our capacity to support wider tobacco control efforts in the South Asia region."

Central to the aim and success of ASTRA’s work has been their community engagement activities, which have ensured that some particularly vulnerable population groups have been identified, including children who do not attend school and pregnant women using smokeless tobacco during their pregnancies. Feedback from communities has given insight into why some people are reluctant to participate in research and has helped shape ASTRA’s research tools, making them locally acceptable and relevant, and ultimately improving the health of some of the world’s poorest and most vulnerable people. 

Professor Ravi Mehrotra, Adjunct Professor of Epidemiology at the Rollins Institute of Public Health, Emory University, US and Co-Director of ASTRA, said: “Smokeless tobacco use requires a comprehensive approach to reducing consumption and implementing appropriate policies. ASTRA has advanced knowledge and evidence in this area of public health, especially at the policy level. Its efforts towards smokeless tobacco control will be maintained and expanded by the research capacity that has been developed.”

Find out more information about the ASTRA project.