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   2018| July  | Volume 148 | Issue 1  
    Online since September 25, 2018

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Relationship between type of smokeless tobacco & risk of cancer: A systematic review
Sanjay Gupta, Ruchika Gupta, Dhirendra N Sinha, Ravi Mehrotra
July 2018, 148(1):56-76
DOI:10.4103/ijmr.IJMR_2023_17  PMID:30264755
Background & objectives: Causative linkages of smokeless tobacco (SLT) use with oral potentially malignant disorders and cancers of oral cavity, oesophagus and pancreas have been reported. Published meta-analyses have provided pooled risk estimates for major cancers caused by SLT, both on global and regional levels. This systematic review was aimed at summarizing the available studies on occurrence and mortality risk of common cancers due to various SLT products. Methods: PubMed and Google Scholar databases were systematically searched from 1985 till January 2018 for observational studies on SLT and cancer. The included studies were evaluated and data were extracted and reviewed. Results: The review included 80 studies providing 121 risk estimates for various cancers. Majority of the studies from South-East Asian Region (SEAR) and Eastern Mediterranean Region (EMR) showed a significant positive association of SLT use with oral [odds ratio (OR) ranging from 1.48 to 27.4] and oesophageal cancers (OR between 2.06 and 12.8), while studies from European Region (EUR) reported a positive association with pancreatic cancer (OR between 1.6 and 2.1). Cancer-related mortality was evaluated in a few reports with higher risk of mortality for lung (OR between 2.0 and 9.1), cervical (OR 2.0) and prostate (OR 2.1) cancers. A wide variation was noted in the association of various cancers and specific SLT products based on their nature, methods of use and inherent toxicity. The majority of chewing tobacco products displayed higher risk for oral and oesophageal cancers while the same was not observed for snus. Interpretation & conclusions: This review emphasizes on the significantly positive association of SLT use with oral and oesophageal cancers in SEAR and EMR and pancreatic cancer in EUR. Mortality estimates for SLT-associated cancers need further analysis. Risk analysis for cancers of other sites in SLT users also requires multicentric well-designed studies.
  7 2,313 523
Global challenges in smokeless tobacco control
Ravi Mehrotra, Dhirendra N Sinha
July 2018, 148(1):1-3
DOI:10.4103/ijmr.IJMR_32_18  PMID:30264747
  5 1,038 509
Oral health consequences of smokeless tobacco use
Arvind Muthukrishnan, Saman Warnakulasuriya
July 2018, 148(1):35-40
DOI:10.4103/ijmr.IJMR_1793_17  PMID:30264752
Smokeless tobacco (SLT) use has many oral effects including oral cancer, leukoplakia and erythroplakia, oral submucous fibrosis (if mixed with areca nut), loss of periodontal support (recession) and staining of teeth and composite restorations. This review was aimed to provide information to identify oral lesions that occur due to the use of smokeless tobacco so that effective interventions can be undertaken to reduce morbidity and mortality from the use of SLT.
  3 3,046 625
Smokeless tobacco taxation: Lessons from Southeast Asia
Rijo M John, Amit Yadav, Dhirendra N Sinha
July 2018, 148(1):46-55
DOI:10.4103/ijmr.IJMR_1822_17  PMID:30264754
Southeast Asia accounts for nearly 86 per cent of the smokeless tobacco (SLT) consumers in the world. The heterogeneous nature of SLT is a major impediment to using taxation as a tool to regulate SLT. This study was aimed to review issues around fiscal policies on SLT with the objective of providing clarity on the use of taxation as an effective policy instrument to regulate SLT use. Descriptive statistics and graphical representations were used to analyze published data from different sources. An analysis of prices and tax between smoke and SLT products was done to understand the impact of tax policies on SLT consumption. India, Bangladesh and Myanmar together account for 71 per cent of the world SLT users. The retail prices (PPP$) and tax were lower for SLT in low- and lower-middle-income countries and higher in high-income countries, on an average, suggesting a direct relationship between the two. Evidence from India and Bangladesh suggested that taxation had significantly reduced SLT use among adults. The compounded levy scheme used in India to tax SLT was found effective after incorporating speed of packing machines into the assessment of deemed production and tax on SLT products. The current analysis shows that taxation can be an effective instrument to regulate SLT consumption if tax rates are harmonized across SLT products and in a manner not to encourage substitution with other tobacco products. It is also imperative to set a minimum floor price on all tobacco products including SLT.
  3 1,155 231
Setting research priorities in smokeless tobacco control: A retrospective review
Harleen Kaur Gulati, Amit Kumar, Ajay Singh Dhama, Ruchika Gupta, Amitesh Kumar Sharma, Harpreet Singh, Dhirendra Narain Sinha, Ravi Mehrotra
July 2018, 148(1):103-109
DOI:10.4103/ijmr.IJMR_80_18  PMID:30264759
Background & objectives: Smokeless tobacco (SLT) has become a global menace; India being one of the high-burden countries contributes about 67 per cent of its users. Although research is ongoing on various aspects of SLT use and its effects, there is a need to identify the still under-researched areas in this field. This study was aimed at delineating the quantum of research on various topics of SLT, with intent to delineate research gaps for guiding future research priorities. Methods: Data about research in SLT were collected from PubMed database using ‘smokeless tobacco’ as a keyword and applying Medical Subject Headings (MeSH) terms filter. Data were extracted in XML (Extensible Markup Language) format and parsed into database to extract necessary fields such as PubMed IDs, authors' names, affiliations and MeSH terms. Quantum of research in various aspects of SLT was identified for individual MeSH terms and compared for global and Indian data. Results: Data analysis of 2857 records revealed that maximum number of articles was devoted to adverse effects (35.6%) followed by epidemiology (32.4%). In comparison, India contributed only 11.7 per cent of records with maximum number of articles on the topics of epidemiology (26%) and adverse effects (45.8%). Higher proportion of research was published on epidemiology, aetiology and prevention and control at global level, while adverse effects of SLT were researched more in Indian studies as compared to global data. Interpretation & conclusions: The present analysis highlighted the paucity of research studies on important topics such as economics and alternative strategies of SLT control, both on the global and regional levels.
  2 586 224
Role of World Health Organization Framework Convention on Tobacco Control Global Knowledge Hub on Smokeless Tobacco
Ravi Mehrotra, Shekhar Grover, Anshika Chandra
July 2018, 148(1):7-13
DOI:10.4103/ijmr.IJMR_2036_17  PMID:30264749
Smokeless tobacco (SLT) is a recognized public health challenge, having over 350 million users globally, concentrated particularly in South-East Asia. A need for research on curbing major challenges in regulating SLT use has been long felt and subsequently highlighted in several sessions of the Conference of Parties (COP) of the Framework Convention on Tobacco Control (FCTC). The sixth session of COP established a knowledge hub on SLT at the Indian Council of Medical Research- National Institute of Cancer Prevention and Research India, with a mandate to (i) generate and share expertise, information and knowledge; (ii) promote and facilitate communication among Parties, organizations and stakeholders; and (iii) support the Convention Secretariat in contributing to technical aspects of SLT control. The hub disseminates scientific evidence through an interactive website and publications and supports national and international partners in SLT research. The hub is a contributor to many events/conferences and has conducted several workshops on SLT control, including an inter-country meeting on SLT policy implementation status, which brought together representatives from across the globe, and framed recommendations for policy reform. The hub is dedicated to interaction and collaboration with relevant tobacco control organizations to generate evidence, support and policy orientation in line with its mandates and recommendations under the World Health Organization FCTC.
  2 878 361
Implementation of Article 20 of the World Health Organization Framework Convention on Tobacco Control
Dhirendra Narain Sinha, Amit Kumar, Ruchika Gupta, Harleen Kaur Gulati, Sanjay Gupta, Ravi Mehrotra
July 2018, 148(1):110-115
DOI:10.4103/ijmr.IJMR_288_18  PMID:30264760
Background & objectives: Article 20 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) deals with surveillance and research on all tobacco products including smokeless tobacco (SLT). Here we describe the availability of indicators related to SLT among 180 Parties to the convention (countries ratifying the WHO FCTC are referred as Parties to the Convention). Methods: Data on SLT use among adults and adolescents and SLT-related economic and health indicators among Parties were obtained through rigorous literature search. Data analysis for high-burden parties was done using SPSS. Results: Nearly 92 per cent (166) of the Parties reported SLT use prevalence among adults or adolescents at national or subnational level, of these nearly one-fifth of the Parties (20.5%) were high-burden Parties. Comparable SLT tax incidence rate was available for 19.4 per cent (n=35) Parties, and SLT attributable morbidity and mortality risks of major diseases were available for only five per cent (n=10) of Parties. Interpretation & conclusions: SLT use is a global epidemic widespread among Parties to the Convention. There are a data gap and dearth of research on SLT-related issues. Parties need to monitor SLT use and related health and economic indicators regularly at periodic intervals.
  1 580 205
Regulation of toxic contents of smokeless tobacco products
Amit Kumar, Deeksha Bhartiya, Jasmine Kaur, Suchitra Kumari, Harpreet Singh, Deepika Saraf, Dhirendra Narain Sinha, Ravi Mehrotra
July 2018, 148(1):14-24
DOI:10.4103/ijmr.IJMR_2025_17  PMID:30264750
Effective regulation of contents of tobacco products is one of the primary milestones to reduce negative health effects associated with the use of smokeless tobacco (SLT) products. As per the available sources, testing of some SLT products has been done on ad hoc basis, but there is a lack of comprehensive and periodic analysis of these products. In addition, the available results indicate huge variations among the levels of pH, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, N-nitrosonornicotine, benzo[a]pyrene, heavy metals and nicotine within different products as well as within different brands of the same product. This review was aimed to throw light on the variations and gaps in testing of SLT products and emphasize the need for strong policy regulation for monitoring the chemical constituents of these products.
  1 1,851 432
A systematic review on association between smokeless tobacco & cardiovascular diseases
Ruchika Gupta, Sanjay Gupta, Shashi Sharma, Dhirendra N Sinha, Ravi Mehrotra
July 2018, 148(1):77-89
DOI:10.4103/ijmr.IJMR_2020_17  PMID:30264756
Background & objectives: The association of smokeless tobacco (SLT) with cardiovascular diseases has remained controversial due to conflicting reports from various countries. Earlier meta-analyses have shown significantly higher risk of fatal myocardial infarction and stroke in SLT users. However, the risk of hypertension (HTN) with SLT products has not been reviewed earlier. This systematic review was undertaken to summarize the evidence available from global literature on the association of SLT with cardiovascular outcomes – heart disease, stroke and HTN. Methods: A systematic literature search was performed in PubMed and Google Scholar since their inception till October 2017 using pre-decided search terms and inclusion/exclusion criteria. Data were extracted from studies included independently by two authors and reviewed. Results: The review included 50 studies - 23 on heart disease, 14 on stroke and 14 on HTN. Majority of the studies evaluating heart disease or stroke were conducted in the European Region and most of these did not find a significant association between SLT use and either of these outcomes. On the other hand, 70 per cent of the studies on HTN were reported from South-East Asian Region and about half of the studies found a higher risk of HTN in SLT users. Interpretation & conclusions: Current available evidence is insufficient to conclusively support the association of cardiovascular diseases with SLT use due to variability in results and methodological constraints in most of the studies. Region and product-specific well-designed studies are required to provide this evidence to the policymakers. However, advice on cessation of SLT products should be offered to patients presenting with cardiovascular diseases.
  1 1,169 314
A review of trade practices of smokeless tobacco products in terms of prohibition on sale, manufacturing & importation in Framework Convention on Tobacco Control ratified Parties
Deepika Singh Saraf, Ravi Mehrotra, Kumar Chandan, Dhirendra N Sinha, Amit Yadav
July 2018, 148(1):90-97
DOI:10.4103/ijmr.IJMR_2027_17  PMID:30264757
Background & objectives: Over the past decade, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has served as a powerful tool to initiate and advance global tobacco control efforts. However, the control strategies have mainly targeted demand-side measures. The goal of a tobacco-free world by 2040 cannot be achieved if the supply-side measures are not addressed. This analysis was undertaken to examine the tobacco control legislations of various Parties ratifying WHO FCTC with an objective to ascertain the status of prohibition of importation, sale and manufacturing of smokeless tobacco products. Methods: All 180 Parties to WHO FCTC were included for the study. A comprehensive database of all the parties to FCTC was created and tobacco control legislations and regulations of all parties were studied in detail. Results: Overall, the sale of smokeless tobacco (SLT) products was prohibited in 45 Parties. Eleven Parties prohibited manufacturing of SLT products and six Parties imposed a ban on importation of SLT products. Australia, Bhutan, Singapore and Sri Lanka banned all three. Interpretation & conclusions: Comprehensive tobacco control strategy with effective tobacco cessation programme should complement strong legal actions such as prohibition on trade in SLT products to meet the public health objective of such laws and regulations. In addition, multisectoral efforts are needed for effective implementation of such restrictions imposed by the governments.
  1 653 195
Well-being therapy: Treatment manual and clinical applications
Uma Hirisave
July 2018, 148(1):120-122
  - 357 162
Iodine deficiency disorders and their elimination
Umesh Kapil
July 2018, 148(1):120-120
  - 267 160
Dohra- a mixture of potent carcinogens
Vishwas Sharma, Amrita Nandan, Ajay Kumar Shukla, Anshika Chandra, Ravi Kaushik, Dhirendra Narain Sinha, Ravi Mehrotra
July 2018, 148(1):116-119
DOI:10.4103/ijmr.IJMR_39_18  PMID:30264761
Background & objectives: Dohra is a areca nut preparation used with or without tobacco in a few of the areas of Uttar Pradesh (UP), India. There is evidence that it causes potentially malignant disorders and oral cancer. This study was undertaken to provide information on dohra by searching through literature and also through a survey in three areas of Uttar Pradesh (UP), India. Methods: The information on dohra was collected through literature search, study tour to different areas of UP, where group discussions with dohra vendors and with community members of different age group were done to obtain information. Results: Dohra was prepared by the users for their personal use or prepared by small-scale industry for sale. It was available mostly in betel shops or any other store/kiosks and was also available in special dohra shops. Dohra was available in both dry and wet form. Its common constituents were areca nut, catechu (Acacia catechu), edible lime, peppermint (Mentha piperita), cardamom (Elettaria cardamomum) and some flavoring agents. Dohra was consumed as such or with tobacco. Interpretation & conclusions: Different varieties of Dohra were available such as sukha dohra, sukha mulethi dohra and geela dohra. Different processing methods for producing dohra existed. As dohra increases the risk of cancer, it needs to be banned or it should be sold in packets with the details of its constituents and also statutory warning about its adverse health effects.
  - 1,279 232
Feedback from vendors on gutka ban in two States of India
Gaurav Kumar, MS Pednekar, Sameer Narake, Gauri Dhumal, PC Gupta
July 2018, 148(1):98-102
DOI:10.4103/ijmr.IJMR_121_18  PMID:30264758
Background & objectives: Beginning in 2012, all States in India eventually banned the sale of gutka. This study was conducted to investigate gutka vendors' knowledge on gutka ban, products covered under ban, penalties for non-compliance and action for enforcement by government agencies. Methods: Twenty vendors were interviewed, 10 each in Mumbai (Maharashtra) and Indore (Madhya Pradesh) during May - June, 2013, one year after ban was imposed. Interviewers used a standardized questionnaire to assess vendors' knowledge of gutka ban, their attitude towards it and compliance to it in practice. Results: All 20 vendors were aware that gutka sale was banned. However, despite ban, eight of the 10 vendors in Mumbai perceived sale of pan masala as legal. In Indore, all 10 vendors perceived sale of Indori Tambakoo, a local gutka variant, as legal. No vendor was sure about the quantum of fine applicable on being caught selling the banned product. Two vendors in Mumbai and nine in Indore admitted selling gutka. Five vendors in Mumbai and four in Indore supported an existing ban on gutka. Interpretation & conclusions: All vendors were aware of the ban on gutka and reason for it. Many vendors supported the ban. However, awareness of other products covered under ban and on fines in case of non-compliance was low. Law enforcement system needs to be intensified to implement ban. Notification of ban needs to be further strengthened and made unambiguous to explicitly include all smokeless tobacco products.
  - 906 199
Determinants of smokeless tobacco use in India
JS Thakur, Ronika Paika
July 2018, 148(1):41-45
DOI:10.4103/ijmr.IJMR_27_18  PMID:30264753
Non-communicable diseases (NCDs) contributes to more than 50 per cent disability adjusted life years (DALYs) in India; and tobacco contributes to 7·4 per cent of DALYs which is next to diet and high blood pressure. According to Global Burden of Disease (GBD) 2015, tobacco use contributed to 5.9 per cent out of total DALYs in India. Smokeless tobacco (SLT) consumption is a multifactorial process influenced by varied range of contextual factors i.e., social, environmental, psychological and the genetic factors which are linked to the tobacco use. The determinants associated with the SLT use are gender, educational level, wealth index (inverse association), urban-rural residence, socio-economic status and low tax. Taking the view from tobacco control programmes, there is a need to address determinants of SLT use with State level monitoring and socio-economic inequalities, progress and review of the taxation of the SLT use in India.
  - 1,273 338
Smokeless tobacco control: Litigation & judicial measures from Southeast Asia
Amit Yadav, Arpita Singh, Badri Bahadur Khadka, Hemantha Amarasinghe, Nisha Yadav, Ranjit Singh
July 2018, 148(1):25-34
DOI:10.4103/ijmr.IJMR_2063_17  PMID:30264751
Recourse to litigation and positive judicial interventions is one of the most effective tools to meet public health objectives. The present review envisions compiling litigation and judicial measures in Southeast Asia Region (SEAR) while assessing their role in advancing smokeless tobacco (SLT) control, and equally highlighting, how tobacco industry has used litigation to undermine tobacco control efforts in the Region. The litigation, especially from the SEAR, up to 2017, that have facilitated SLT control or have been used by the tobacco industry to challenge an SLT control policy decision were reviewed. Most of the litigation related to SLT control from the Region are on pictorial health warnings. Bhutan has imposed a complete prohibition on sale, manufacture and import of all kinds of tobacco products and the litigation there relates to the prosecution of offenders for violating the ban. Judiciary in the Region is well informed about the ill-effects of tobacco use and remains positive to tobacco control initiatives in the interest of public health. In India, several SLT-specific litigation helped in better regulation of SLT products in the country. Litigation has compelled governments for effective enforcement of the domestic tobacco control laws and the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). Parties to the WHO FCTC must now use Treaty Article 19 to strengthen their legal procedures and make the tobacco industry liable, for both criminal and civil wrongs.
  - 1,788 299
Development of comprehensive data repository on chemicals present in smokeless tobacco products: Opportunities & challenges
Jasmine Kaur, Arun Sharma, Ruchika Gupta, Harpreet Singh
July 2018, 148(1):4-6
DOI:10.4103/ijmr.IJMR_108_18  PMID:30264748
  - 881 354