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EDITORIAL
Year : 2018  |  Volume : 148  |  Issue : 1  |  Page : 1-3

Global challenges in smokeless tobacco control


1 WHO FCTC Global Knowledge Hub on Smokeless Tobacco, ICMR-National Institute of Cancer Prevention and Research, Noida 201 301, Uttar Pradesh, India
2 School of Preventive Oncology, Patna 801 505, Bihar, India

Date of Submission04-Jan-2018
Date of Web Publication25-Sep-2018

Correspondence Address:
Ravi Mehrotra
WHO FCTC Global Knowledge Hub on Smokeless Tobacco, ICMR-National Institute of Cancer Prevention and Research, Noida 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_32_18

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How to cite this article:
Mehrotra R, Sinha DN. Global challenges in smokeless tobacco control. Indian J Med Res 2018;148:1-3

How to cite this URL:
Mehrotra R, Sinha DN. Global challenges in smokeless tobacco control. Indian J Med Res [serial online] 2018 [cited 2018 Dec 11];148:1-3. Available from: http://www.ijmr.org.in/text.asp?2018/148/1/1/242228

Smokeless tobacco (SLT) products are consumed without combustion or pyrolysis at the time of use[1]. SLT use has now become a significant part of the global tobacco problem and over 90 per cent of users live in low- and low-middle-income countries[2]. SLT use has been reported in over 140 countries[3],[4]. It has been estimated that there are around 357 million adult SLT users globally, with 83 per cent of them living in South-East Asia[3]. SLT use amongst adolescents in over 100 countries is a matter of concern and poses a global challenge[4].

Health effects of SLT use have been documented by several groups[2],[5],[6],[7],[8],[9]. The International Agency for Research on Cancer (IARC) confirmed the association of SLT use with oral, oesophageal and pancreatic cancers in humans[5],[6],[7]. In addition, it has a significant association with all-cause mortality and cancers of the upper aerodigestive tract, stomach and cervix, along with ischaemic heart disease and stroke[8],[9].

The SLT products are largely unregulated and underreported[2]. Limited data are available on the properties, production, ingredients and health hazards of these preparations. Many of these products are consumed with areca nut (a Group I human carcinogen) and are culturally acceptable[2].

Tobacco manufacturers regularly try to introduce newer SLT products, increasing consumer appeal by adding attractive flavouring, newer delivery methods and brand mimicking[2]. This is complemented by targeted marketing (towards vulnerable population groups such as youth as well as existing consumers with ‘intention to quit’, etc.), producing an impact on tobacco use behaviour. Awareness of the hazards of smoke tobacco use is also exploited by the tobacco industry, proposing SLT use as a harm reduction measure. The industry advertises SLT products as a safer alternative to cigarettes and advocates switching[10].

The prevention and control of SLT use is a complex public health challenge and has so far received limited attention from researchers and policymakers worldwide. In 2014, at the sixth session of Conference of the Parties, the Parties agreed to accelerate research activities on various tobacco products including SLT and agreed for strict regulation of new and existing products[11]. This was a landmark step towards global SLT control. Another important development was the release of the National Cancer Institute (NCI) monograph in the same year[2]. In subsequent years, there has been a considerable push by the WHO Secretariat to give adequate coverage of SLT in all guidelines and reporting instruments[12].

There have been continuous efforts by several organizations and stakeholders to generate information on SLT, but still, there is a dearth of adequate research in this area. Three-quarters of the Parties (72% of the countries ratifying WHO Framework Convention on Tobacco Control) have data on SLT use among adults at the national level, nearly 60 per cent of the Parties have adolescent SLT use data, and among them, only a few have recent data. Periodic data to report trends are meagre. Some information is also available on health (10 parties) and economic (32 parties) consequences of SLT use[13].

Policy analysis by the WHO Framework Convention on Tobacco Control (FCTC) Global Knowledge Hub on SLT (GKH-SLT) has shown that there is a wide gap between cigarettes and SLT policies. Only a few Parties have adopted policies related to different articles of FCTC[14]. Of the 179 Parties, only 112 have categorically defined SLT under ‘Tobacco Products’. A total of 120 (67%) Parties have implemented the provisions of Article 16 for SLT products[13]. Pictorial health warnings (PHWs) are one of the most effective tobacco control measures. High SLT burden parties such as India (85%) and Nepal (90%) have implemented large and multiple PHWs. However, many high-burden countries such as Bangladesh are in different stages of its full implementation[15]. In 2016, 36 per cent of Parties had conducted at least one national mass media campaign[16]; however, inclusion of an SLT component in these campaigns was not known. Four Parties from Asia used different media strategies including print and social media for raising awareness on harmful effects of SLT use. India is the only Party to have implemented a comprehensive mass media campaign against SLT use[14]. Nearly one-third (31%) of the parties have a national quit line[13]. However, only a few parties (2%) have experience in SLT cessation. India has started a national quit line with varying success rates. SLT cessation practices by healthcare providers have only been studied in three Parties, namely India, Bangladesh and Kenya. With regard to Article 6, a key demand reduction measure requires data on price and taxation of SLT. This information is only available for 32 parties[13].

Based on the decision of the sixth session of Conference of Parties of WHO FCTC, the Secretariat proposed a dedicated knowledge hub on SLT to serve as a repository of information, product-specific SLT burden and research needs, as well as to help member countries in SLT control including sharing of best practices with member countries through inter-country meetings and implementation challenges concerning SLT[13]. In 2016, the ICMR-National Institute of Cancer Prevention and Research, Noida, India, was designated as the WHO FCTC GKH on SLT[14].

The primary responsibility of the hub is to analyze, synthesize and disseminate knowledge relating to SLT control in collaboration with various national and international stakeholders, non-governmental organizations, as well as partners of the Convention Secretariat. The Hub also has a dedicated platform http://untobaccocontrol.org/kh/smokeless-tobacco, for dissemination of gathered information.

Several best practices have been implemented by countries, for example, India, Maldives and Thailand have raised taxes on SLT products; Nepal and India have the largest PHWs on SLT packages, and Nepal has also prohibited the use of SLT products in public places[15]. The decreasing trend of SLT in India as shown by the second round of Global Adult Tobacco Survey (GATS)[17] is a proof of success of those interventions.

This special issue of IJMR is timely, pertinent, informative and an example of Hub's commitment. Hopefully, it will lead to increased awareness and give a boost to research in this neglected area to battle this dreadful scourge.

Conflicts of Interest: None.



 
   References Top

1.
World Health Organization. Scientific Advisory Committee on Tobacco Products Regulation: Recommendation on Smokeless Tobacco Products. Geneva: WHO. Available from: http://www.who.int/tobacco/publications/prod_regulation/smokeless/en/, accessed on December 20, 2017.  Back to cited text no. 1
    
2.
National Cancer Institute and Centers for Disease Control and Prevention. Smokeless tobacco and public health: A global perspective. Bethesda, MD: US Department of Health and Human Services, Center for Disease Control and Prevention, and National Institute of Health, National Cancer Institute; 2014.  Back to cited text no. 2
    
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Sinha DN, Gupta PC, Kumar A, Bhartiya D, Agarwal N, Sharma S, et al. The poorest of poor suffer the greatest burden from smokeless tobacco use: A study from 140 countries. Nicotine Tob Res 2017; December 22. doi 10.1093/ntr/nt3c276.  Back to cited text no. 3
    
4.
Sinha DN, Kumar A, Bhartiya D, Sharma S, Gupta PC, Singh H, et al. Smokeless tobacco use among adolescents in global perspective. Nicotine Tob Res 2017; 19 : 1395-6.  Back to cited text no. 4
    
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IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. IARC Monogr Eval Carcinog Risks Hum 2004; 85 : 1-334.  Back to cited text no. 5
    
6.
International Agency for Research on Cancer, World Health Organization. Smokeless tobacco and some tobacco-specific N-nitrosamines/IARC working group on the evaluation of carcinogenic risks to humans, Vol. 89. Lyon, France: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans; 2004. Available from: https://monographs.iarc.fr/wp-content/uploads/2018/06/mono89.pdf, accessed on January 1, 2018.  Back to cited text no. 6
    
7.
International Agency for Research on Cancer, World Health Organization. A review of human carcinogens. Part E: Personal habits and indoor combustions, Vol. 100E. Lyon, France: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans; 2009. Available from: https://monographs.iarc.fr/wp-content/uploads/2018/06/mono100E.pdf, accessed on January 1, 2018.  Back to cited text no. 7
    
8.
Sinha DN, Suliankatchi RA, Gupta PC, Thamarangsi T, Agarwal N, Parascandola M, et al. Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: Systematic review and meta-analysis. Tob Control 2018; 27 : 35-42.  Back to cited text no. 8
    
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Vidyasagaran AL, Siddiqi K, Kanaan M. Use of smokeless tobacco and risk of cardiovascular disease: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23 : 1970-81.  Back to cited text no. 9
    
10.
Peeters S, Gilmore AB. Understanding the emergence of the tobacco industry's use of the term tobacco harm reduction in order to inform public health policy. Tob Control 2015; 24 : 182-9.  Back to cited text no. 10
    
11.
World Health Organization, Framework Convention on Tobacco Control. Conference of the Parties. Report of the sixth session of the Conference of the Parties to the WHO FCTC. Moscow: Russian Federation; October 13-18, 2014. Available from: http://www.who.int/fctc/cop/sessions/COP6_report_FINAL_04122014.pdf?ua=1, accessed on December 21, 2017.  Back to cited text no. 11
    
12.
World Health Organization Framework Convention on Tobacco Control. Available from: http://www.who.int/fctc/en/, accessed on December 1, 2017.  Back to cited text no. 12
    
13.
Mehrotra R, Sinha DN, Szilagyi T, Global smokeless tobacco control policies and their implementation, WHO FCTC Global Knowledge Hub on Smokeless Tobacco, ICMR-National Institute of Cancer Prevention and Research, Noida, India; 2017. Available from: http://www.nicpr.res.in/images/Global-smokeless-NICPR-imp19418-1.pdf, accessed on June 30, 2018.  Back to cited text no. 13
    
14.
World Health Organization, Framework Convention on Tobacco Control. Global Knowledge Hub on Smokeless Tobacco. Factsheets; 2017. Available from: http://www.untobaccocontrol.org/kh/smokeless-tobacco/background-documents/#factsheets, accessed on December 21, 2017.  Back to cited text no. 14
    
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Singh PK, Thamarangsi T. Accelerating tobacco control in South-East Asia in the sustainable development goal era. Indian J Public Health 2017; 61 : S1-2.  Back to cited text no. 15
    
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World Health Organization. Tobacco Free Initiative. WHO report on the global tobacco epidemic. 2017. Available from: http://www.who.int/tobacco/global_report/2017/en/, accessed on January 1, 2018.  Back to cited text no. 16
    
17.
Ministry of Health and Family Welfare, Government of India. Second round of global adult tobacco survey. 2016-17. Available from: https://www.mohfw.gov.in/sites/default/files/GATS-2%20FactSheet.pdf, accessed on January 1, 2018.  Back to cited text no. 17
    




 

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