Sarwat Shah

Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries

BackgroundSmokeless tobacco is consumed in most countries in the world. In view of its widespread use and increasing awareness of the associated risks, there is a need for a detailed assessment of its impact on health. We present the first global estimates of the burden of disease due to consumption of smokeless tobacco by adults.MethodsThe burden attributable to smokeless tobacco use in adults was estimated as a proportion of the disability-adjusted life-years (DALYs) lost and deaths reported in the 2010 Global Burden of Disease study. We used the comparative risk assessment method, which evaluates changes in population health that result from modifying a population’s exposure to a risk factor. Population exposure was extrapolated from country-specific prevalence of smokeless tobacco consumption, and changes in population health were estimated using disease-specific risk estimates (relative risks/odds ratios) associated with it. Country-specific prevalence estimates were obtained through systematically searching for all relevant studies. Disease-specific risks were estimated by conducting systematic reviews and meta-analyses based on epidemiological studies.ResultsWe found adult smokeless tobacco consumption figures for 115 countries and estimated burden of disease figures for 113 of these countries. Our estimates indicate that in 2010, smokeless tobacco use led to 1.7 million DALYs lost and 62,283 deaths due to cancers of mouth, pharynx and oesophagus and, based on data from the benchmark 52 country INTERHEART study, 4.7 million DALYs lost and 204,309 deaths from ischaemic heart disease. Over 85 % of this burden was in South-East Asia.ConclusionsSmokeless tobacco results in considerable, potentially preventable, global morbidity and mortality from cancer; estimates in relation to ischaemic heart disease need to be interpreted with more caution, but nonetheless suggest that the likely burden of disease is also substantial. The World Health Organization needs to consider incorporating regulation of smokeless tobacco into its Framework Convention for Tobacco Control.

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations.

INTRODUCTION Almost a fifth of the worlds tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these. METHODS We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations. RESULTS We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit. CONCLUSIONS Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

Gender disparity in tuberculosis cases in eastern and western provinces of Pakistan

BackgroundAlthough globally, the number of notified TB cases is higher for males, a few countries in the Eastern Mediterranean Region (Afghanistan; Lebanon; Iran and Pakistan) of the World Health Organization have a relatively higher number of female cases. Pakistan ranks fifth amongst the highest TB burden countries and poses a rich ground for exploratory research to address the gender differences in TB cases. It is uniquely neighboured by India on the East, having higher number of cases in males than in females, and by Afghanistan and Iran on the West, having higher number of cases in females than in males. The objective is to see whether these gender differences are evenly distributed across the country or vary by geographies, to enable effective targeting of TB control strategies.MethodsCross-sectional analysis was carried out on secondary data, obtained from National Tuberculosis Program. Disaggregated at the provincial level, the sex-specific case notification rates (CNR) were calculated and trends over a 10-year span (2001–2010) were examined. Sex-specific differences for the four Pakistani provinces were analyzed using chi-square test and odds ratios with corresponding confidence intervals. Cumulative countrywide sex-specific notification rates were used as the reference group.ResultsThe trends for 2001–2010 in the western provinces of Pakistan show higher female CNR as compared to those seen in the eastern provinces having slightly higher male CNR. The proportions of female notified TB cases are approximately twice as high in the western provinces when compared to the eastern provinces and Pakistan over all.ConclusionsThese findings suggest that females are particularly affected by TB disease burden in the west parts of Pakistan. This gender disparity requires a coordinated regional and international effort to further explore triggers and moderators of increased acquisition and progression of TB disease among females in the region to guarantee effective TB control.

Effect of Cessation Interventions on Hookah Smoking: Post-Hoc Analysis of a Cluster-Randomized Controlled Trial

INTRODUCTION We explored the differential effect of cessation interventions (behavioral support sessions with [BSS+] and without [BSS] bupropion) between hookah and cigarette smokers. METHODS We reanalyzed the data from a major cluster-randomized controlled trial, ASSIST (Action to Stop Smoking In Suspected Tuberculosis), which consisted of 3 conditions: (a) behavioral support sessions (BSS), (b) behavioral support sessions plus 7 weeks of bupropion therapy (BSS+), and (c) controls receiving usual care. The trial originally recruited 1,955 adult smokers with suspected tuberculosis from 33 health centers in the Jhang and Sargodha districts of Pakistan between 2010 and 2011. The primary endpoint was continuous 6-month smoking abstinence, which was determined by carbon monoxide levels. Subgroup-specific relative risks (RRs) of smoking abstinence were computed and tested for differential intervention effect using log binomial regression (generalized linear model) between 3 subgroups (cigarette-only: 1,255; mixed: 485; and hookah-only: 215). RESULTS The test result for homogeneity of intervention effects between the smoking forms was statistically significant (p-value for BSS+: .04 and for BSS: .02). Compared to the control, both interventions appeared to be effective among hookah smokers (RR = 2.5; 95% CI = 1.3-4.7 and RR = 2.2; 95% CI = 1.3-3.8, respectively) but less effective among cigarette smokers (RR = 6.6; 95% CI = 4.6-9.6 and RR = 5.8; 95% CI = 4.0-8.5), respectively. CONCLUSIONS The differential intervention effects on hookah and cigarette smokers were seen (a) because the behavioral support intervention was designed primarily for cigarette smokers; (b) because of differences in demographic characteristics, behavioral, and sociocultural determinants; or (c) because of differences in nicotine dependency levels between the 2 groups.

Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low-income and middle-income countries

Summary Background Tobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). We assessed the prevalence of tobacco use among people living with HIV in LMICs. Methods We used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. We estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15–59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15–49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. We estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. We computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. We computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals. Findings The overall prevalence among HIV-positive men was 24·4% (95% CI 21·1–27·8) for tobacco smoking, 3·4% (1·8–5·6) for smokeless tobacco use, and 27·1% (22·8–31·7) for any tobacco use. We found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 [95% CI 1·26–1·57]) and tobacco smoking (1·46 [1·30–1·65]) than in HIV-negative men (both p<0·0001). The difference in smokeless tobacco use prevalence between HIV-positive and HIV-negative men was not significant (1·26 [1·00–1·58]; p=0·050). The overall prevalence among HIV-positive women was 1·3% (95% CI 0·8–1·9) for tobacco smoking, 2·1% (1·1–3·4) for smokeless tobacco use, and 3·6% (95% CI 2·3–5·2) for any tobacco use. We found a higher prevalence in HIV-positive women of any tobacco use (RR 1·36 [95% CI 1·10–1·69]; p=0·0050), tobacco smoking (1·90 [1·38–2·62]; p<0·0001), and smokeless tobacco use (1·32 [1·03–1·69]; p=0·030) than in HIV-negative women. Interpretation The high prevalence of tobacco use in people living with HIV in LMICs mandates targeted policy, practice, and research action to promote tobacco cessation and to improve the health outcomes in this population. Funding South African Medical Research Council and the UK Medical Research Council.

Muslim communities learning about second-hand smoke (MCLASS): study protocol for a pilot cluster randomised controlled trial

BackgroundIn the UK, 40% of Bangladeshi and 29% of Pakistani men smoke cigarettes regularly compared to the national average of 24%. As a consequence, second-hand smoking is also widespread in their households which is a serious health hazard to non-smokers, especially children. Smoking restrictions in households can help reduce exposure to second-hand smoking. This is a pilot trial of ‘Smoke Free Homes’, an educational programme which has been adapted for use by Muslim faith leaders, in an attempt to find an innovative solution to encourage Pakistani- and Bangladeshi-origin communities to implement smoking restrictions in their homes. The primary objectives for this pilot trial are to establish the feasibility of conducting such an evaluation and provide information to inform the design of a future definitive study.Methods/DesignThis is a pilot cluster randomised controlled trial of ‘Smoke Free Homes’, with an embedded preliminary health economic evaluation and a qualitative analysis. The trial will be carried out in around 14 Islamic religious settings. Equal randomisation will be employed to allocate each cluster to a trial arm. The intervention group will be offered the Smoke Free Homes package (Smoke Free Homes: a resource for Muslim religious teachers), trained in its use, and will subsequently implement the package in their religious settings. The remaining clusters will not be offered the package until the completion of the study and will form the control group. At each cluster, we aim to recruit around 50 households with at least one adult resident who smokes tobacco and at least one child or a non-smoking adult. Households will complete a household survey and a non-smoking individual will provide a saliva sample which will be tested for cotinine. All participant outcomes will be measured before and after the intervention period in both arms of the trial. In addition, a purposive sample of participants and religious leaders/teachers will take part in interviews and focus groups.DiscussionThe results of this pilot study will inform the protocol for a definitive trial.Trial registrationCurrent Controlled Trials ISRCTN03035510

Determinants of Salivary Cotinine among Smokeless Tobacco Users: A Cross-Sectional Survey in Bangladesh.

Introduction More than 80% of all smokeless tobacco (ST) products in the world are consumed in South Asia; yet little is known about their consumption behaviour, addictiveness, and toxic properties. This paper, for the first time, describes associations between salivary cotinine concentrations among ST users in Bangladesh and their socio-demographic characteristics and tobacco use behaviours. Methods In a survey of ST users in Dhaka, Bangladesh, we purposively recruited 200 adults who were non-smokers but consumed ST on a regular basis. In-person interviews were conducted to obtain information about socio-demographic and ST use behaviours, and saliva samples were collected to measure cotinine concentration. Simple and multiple linear regression analyses were conducted to test associations between the log transformed salivary cotinine concentration and other study variables. Results The geometric mean of cotinine concentration among ST users was 380ng/ml (GSD:2). Total duration of daily ST use in months had a statistically significant association with cotinine concentration. Other ST use characteristics including type and quantity of ST use, swallowing of tobacco juice, urges and strength of urges and attempts to cut down on tobacco use were not found to be associated with cotinine concentration in a multivariable model. Conclusion This is the first report from Bangladesh studying cotinine concentration among ST users and it points towards high levels of addiction. This warrants effective tobacco control policies to help ST cessation and prevention.

Tuberculosis in women from Pashtun region: an ecological study in Pakistan.

SUMMARY In general, tuberculosis (TB) is more common in men than women. However, for reasons currently not understood, women are 1.5-2 times more likely to report TB compared to men in Pashtun region (Afghanistan, adjacent provinces Pakistan and Iran). We explored whether or not gender disparity in TB notifications in the Pashtun region of Pakistan can be explained by Pashtun ethnicity. Using an ecological linear regression design, we estimated the effect of Pashtun ethnicity on female-to-male ratio (FMR) in TB notifications after adjusting for other determinants of womens health, in Pakistan. Districts with a high proportion of women of Pashtun ethnicity had a 44% (95% confidence interval 27-61) increase in FMR of notified TB cases compared to those with low proportions, after controlling for confounders. Genetic predisposition and distinct socio-cultural determinants could be possible causative factors. However, these hypotheses need further evaluation through rigorous longitudinal studies.

Xpert® MTB/RIF under routine conditions in diagnosing pulmonary tuberculosis: a study in two hospitals in Pakistan.

Xpert(®) MTB/RIF testing was offered to consecutive patients with presumptive tuberculosis (TB) attending two hospitals in Pakistan during April-May 2012, in addition to routine diagnostic protocol (smear microscopy, chest radiography and clinical judgement). We assessed the relative contribution of each tool in detecting pulmonary TB under routine conditions. Of 606 participants, 121 (20%) were detected as pulmonary TB: 46 (38%) by microscopy, 38 (31%) by Xpert alone and 37 (31%) on clinical and radiological grounds; 41 (65%) were detected by both Xpert and microscopy. One patient had rifampicin resistance. Although Xpert detected approximately twice as many TB cases as microscopy (n = 79, 65%), clinical judgement remained favoured by clinicians even when smear and Xpert were negative.

Muslim communities learning about second-hand smoke: a pilot cluster randomised controlled trial and cost-effectiveness analysis

Background:In the United Kingdom, men of Bangladeshi and Pakistani origin have higher smoking rates than the general population. This makes non-smokers in their households more vulnerable to second-hand smoke (SHS) exposure than the general population.Aims:The aim of this study was to investigate the feasibility of implementing and pilot testing the effectiveness and cost-effectiveness of a ‘Smoke-free Homes’ (SFH) intervention in Islamic religious settings to encourage families of Bangladeshi and Pakistani origin to apply smoking restrictions in their homes.Methods:We allocated Islamic religious settings (clusters) to either receive SFH—an educational intervention—or to a control arm. Within each cluster, we recruited households with at least one smoker and one non-smoker. SHS exposure among non-smokers was measured using salivary cotinine.Results:Seven (50%) clusters were randomised to each trial arm. A total of 468 households were assessed for eligibility and 62% (n=289) were eligible, of which 74% (n=213) agreed to participate in the trial. Six of the seven intervention clusters delivered the intervention, and all clusters were retained throughout the trial. In all, 81% (n=172) of households provided data at follow-up. No evidence of a difference in log cotinine level was observed (adjusted mean difference −0.02, 95% confidence interval (CI) −1.28–1.23, P=0.97) between the two trial arms. The direct mean cost of delivering the intervention was £18.18 per household (range £3.55–42.20).Conclusions:It was possible to recruit, randomise and retain Islamic religious settings and participant households. However, some of the original assumptions, in particular our ability to collect primary outcome data, need to be revisited before a definitive trial.