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Abstract Introduction The Global Adult Tobacco Survey (GATS) is the global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. Methods Using a multistage stratified cluster design, 9856 households were sampled, and one individual was randomly selected from each household. Standard GATS questionnaire was used to collect information on tobacco use, cessation, second-hand smoke, knowledge, attitudes, and perceptions. Data were analyzed per standard GATS protocol. Results Of 9856 individuals, 7831 individuals completed the interview. The response rate was 81%. Overall, 19.1% adults were currently using tobacco products and among them, 12.4% smoked tobacco, and 7.7% smokeless tobacco. Exposure to second-hand smoke was seen in 86% in a restaurant while it was 76% on public transportation. A total of 24.7% smokers made a quit attempt in the past 12 months. Anticigarette smoking information was observed by 37.7% adults, while 29.7% current smokers thought about quitting after reading health warning labels on cigarette packages. Most (85%) adults favored no smoking in public places, and 74.8% favored increasing taxes on tobacco products. Current cigarette smokers spent Pakistani Rupees 767.3 per month (7.78 USD) on manufactured cigarettes and consumed 4500 cigarette sticks (225 packs) annually. Conclusions Besides 19.1% tobacco users, the majority (86%) were exposed to second-hand smoke at public places indicating that ban on tobacco use in public places is not being followed. A quarter of current smokers wants to quit smoking who may be provided assistance to reduce tobacco burden. Implications This study provides national-level data about tobacco use and its burden and also indicates weak implantation of tobacco control laws. There is need to devise a strategy for proper implementation of these laws to reduce the tobacco burden in the country.

Nicotine replacement medications are moderately effective in increasing quit rates. However, some smokers reject such aids, suggesting the value of considering alternative options. Snus, a smokeless tobacco product with low nitrosamine content, could offer an alternative. This study compared smoking cessation rates for snus, with and without information about reduced risk relative to smoking, with a nicotine lozenge (without relative risk information). A randomized, open-label, multicenter clinical trial was performed with 649 smokers, aged 21 to 65, who smoked at least 10 cigarettes per day for the past year and who were motivated to quit smoking. Participants were followed for up to 12 months and were provided no counseling or support. Smoking cessation was analyzed as continuous smoking abstinence (no smoking following quit date) and repeated point prevalence abstinence (no smoking within past 7 days). Abstinence rates did not differ significantly between snus and the nicotine lozenge-continuous abstinence did not differ at any time point, and point prevalence rates differed only at month 3, when the lozenge group showed higher abstinence rates (17.4%) than either of the two snus groups (snus alone: 8.7%; snus plus information: 10.1%). Large percentages of participants used the products during the treatment period. Providing relative risk information to snus users did not affect snus use. The amount of use did not predict subsequent outcome. Adverse events were reported at similar rates across the three groups. Smoking cessation rates were comparable between snus and a nicotine lozenge, but success rates in this trial were low. This randomized trial of the nicotine lozenge, snus, or snus plus information on the relative risks of smokeless tobacco versus smoking found comparable but low smoking cessation rates for all three groups at weeks 12, 26, and 52. The one-time provision of relative risk information did not lead to greater snus use among those provided the information, suggesting no effect for this brief intervention.

The single-dose pharmacokinetics (PK) of a novel, non-tobacco-based nicotine pouch, ZYN, 3 and 6 mg, were compared with 8 mg General snus (part 1) and ZYN 8 mg was compared with 18 mg Longhorn moist snuff (part 2). The present study demonstrates the characteristics of three strengths of a novel tobacco-free oral snus, ZYN, viz. the extraction of nicotine from the oral cavity and its uptake into the systemic blood circulation. Comparison is made to Swedish General snus and American Longhorn moist snuff and from literature 4 mg Nicorette gum and mean of 13 brands of e-cigarettes. A single-dose randomized crossover design was used. In vivo extraction and PK parameters were determined. Part 1. The AUCinf of ZYN 3 mg was 27% smaller than that of 8 mg General and the AUCinf of ZYN 6 mg was 34% larger than that of 8 mg General. Less nicotine was extracted from ZYN 3 mg (1.5 mg) and more from ZYN 6 mg (3.5 mg) than from 8 mg General (2.4 mg). The extracted fractions of nicotine for both ZYN products (56% and 59%) were significantly larger than for 8 mg General (32%). Part 2. Close to identical plasma nicotine curves, AUCinf and Cmax were found for ZYN 8 mg and Longhorn Natural 18 mg moist snuff. The extracted amount of nicotine from ZYN 8 mg (3.8 mg) was larger than the amount extracted from Longhorn Natural 18 mg (3.0 mg), but smaller than the extracted amount of nicotine from General 2 × 8 mg snus pouches (5.0 mg). The extracted fraction of nicotine for ZYN 8 mg (50%) was larger than for Longhorn Natural (19%) and General 2 × 8 mg snus pouches (33%). The two higher doses of ZYN (6 and 8 mg) deliver nicotine as quickly and to a similar extent as existing smokeless products, with no significant adverse effects.

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Background Smokeless tobacco (ST) is consumed by more than 300 million people worldwide. The distribution, determinants and health risks of ST differ from that of smoking; hence, there is a need to highlight its distinct health impact. We present the latest estimates of the global burden of disease due to ST use. Methods The ST-related disease burden was estimated for all countries reporting its use among adults. Using systematic searches, we first identified country-specific prevalence of ST use in men and women. We then revised our previously published disease risk estimates for oral, pharyngeal and oesophageal cancers and cardiovascular diseases by updating our systematic reviews and meta-analyses of observational studies. The updated country-specific prevalence of ST and disease risk estimates, including data up to 2019, allowed us to revise the population attributable fraction (PAF) for ST for each country. Finally, we estimated the disease burden attributable to ST for each country as a proportion of the DALYs lost and deaths reported in the 2017 Global Burden of Disease study. Results ST use in adults was reported in 127 countries; the highest rates of consumption were in South and Southeast Asia. The risk estimates for cancers were also highest in this region. In 2017, at least 2.5 million DALYs and 90,791 lives were lost across the globe due to oral, pharyngeal and oesophageal cancers that can be attributed to ST. Based on risk estimates obtained from the INTERHEART study, over 6 million DALYs and 258,006 lives were lost from ischaemic heart disease that can be attributed to ST. Three-quarters of the ST-related disease burden was among men. Geographically, > 85% of the ST-related burden was in South and Southeast Asia, India accounting for 70%, Pakistan for 7% and Bangladesh for 5% DALYs lost. Conclusions ST is used across the globe and poses a major public health threat predominantly in South and Southeast Asia. While our disease risk estimates are based on a limited evidence of modest quality, the likely ST-related disease burden is substantial. In high-burden countries, ST use needs to be regulated through comprehensive implementation of the World Health Organization Framework Convention for Tobacco Control.

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.

Smokeless tobacco is consumed by 356 million people globally and is a leading cause of head and neck cancers. However, global efforts to control smokeless tobacco use trail behind the progress made in curbing cigarette consumption. In this Policy Review, we describe the extent of the policy implementation gap in smokeless tobacco control, discuss key reasons on why it exists, and make recommendations on how to bridge this gap. Although 180 countries have agreed that the WHO Framework Convention on Tobacco Control is the best approach to control the demand and supply of smokeless tobacco, only 138 (77%) Parties define smokeless tobacco in their statutes. Only 34 (19%) Parties tax or report taxing smokeless tobacco products, six (3%) measure content and emissions of smokeless tobacco products, and 41 (23%) mandate pictorial health warnings on these products. Although awareness of the harms related to smokeless tobacco is growing in many parts of the world, few Parties collect or present data on smokeless tobacco use under global or national surveillance mechanisms (eg, Global Tobacco Surveillance System and WHO STEPwise). Only 16 (9%) Parties have implemented a comprehensive ban on smokeless tobacco advertisement, promotion, and sponsorships. Globally, a smaller proportion of smokeless tobacco users are advised to quit the use of smokeless tobacco products compared to tobacco users. Use of smokeless tobacco is becoming a global cause of concern, requiring a greater commitment on the full implementation of the WHO Framework Convention on Tobacco Control measures.

Background Smokeless tobacco use is popular in some regions worldwide, but it receives less attention compared to cigarette smoking. We aimed to estimate the recent prevalence of, and trends in, smokeless tobacco use and to examine its associated factors among adolescents aged 12–16 years in 138 countries/territories (hereafter “countries”) from 1999 to 2019. Methods Data from the Global Youth Tobacco Survey conducted in 138 countries in 2010–2019 and the National Youth Tobacco Survey conducted in the United States in 2019 were used to calculate the prevalence of current smokeless tobacco use and investigate its associated factors among adolescents aged 12–16 years. We also assessed the trend in the prevalence of smokeless tobacco use in 100 countries that had conducted more than one survey from 1999 to 2019. Results The overall prevalence of current smokeless tobacco use was 4.4% (95% confidence interval [CI] 4.0–4.9), with 5.7% (5.1–6.3) for boys, 3.1% (2.6–3.5) for girls, 3.9% (3.5–4.4) for adolescents aged 12–14 years and 5.4% (4.8–5.9) for those aged 15–16 years. The prevalence was highest in the South-East Asian region (6.1%, 4.4–7.7) and lowest in the Western Pacific region (2.0%, 1.7–2.4). The prevalence of smokeless tobacco use decreased in 57 of 100 countries, increased in 32 countries, and remained unchanged in 11 countries. Current cigarette smoking (odds ratio [OR]=2.00, 95% CI=1.68–2.39), other tobacco product use (OR=6.03, 95% CI=4.92–7.40), tobacco advertisement exposure (OR=1.44, 95% CI=1.19–1.74), being offered free tobacco products (OR=2.01, 95% CI=1.66–2.42), and not being taught about dangers of smoking (OR=1.28, 95% CI=1.09–1.50) were all positively associated with current smokeless tobacco use. Conclusions Smokeless tobacco use among adolescents remains a public health concern worldwide. Although the prevalence among adolescents decreased in most countries, it remains high especially in the South-East Asian region. More strict and effective strategies and measures are needed to further curb the smokeless tobacco use among adolescents.

Smokeless tobacco products (STP) contain diverse microbial communities that contribute to the formation of harmful chemical byproducts. This is concerning since 300 million individuals around the globe are users of smokeless tobacco. Significant evidence has shown that microbial metabolic activities mediate the formation of carcinogens during manufacturing. In recent years, studies have revealed a series of additional health impacts that include lesions and inflammation of the oral mucosa and the gastrointestinal tract, as well as alterations of the endogenous microbiota. These findings are due to recent developments in molecular technologies that allowed researchers to better examine the microbial component of these products. This new information illustrates the scale of the STP microbiota and its diversity in the finished product that is sold for consumption. Additionally, the application of metagenomics and metatranscriptomics has provided the tools to look at phylogenies across bacterial, viral, and eukaryotic groups, their functional capacities, and viability. Here we present key examples of tobacco microbiology research that utilizes newer approaches and strategies to define the microbial component of smokeless tobacco products. We also highlight challenges in these approaches, the knowledge gaps being filled, and those gaps that warrant further study. A better understanding of the microbiology of STP brings vast public health benefits. It will provide important information for the product consumer, impact manufacturing practices, and provide support for the development of attainable and more meaningful regulatory goals.Key pointsNewer technologies allowed quicker and more comprehensive identification of microbes in tobacco samples, encapsulating microorganisms difficult or impossible to culture.Current research in smokeless tobacco microbiology is filling knowledge gaps previously unfilled due to the lack of suitable approaches.The microbial ecology of smokeless tobacco presents a clearer picture of diversity and variability not considered before.

People living with HIV (PLWH) who use tobacco face significant public health risks compared to non-users, including an average loss of 12.3 years of life expectancy. Tobacco use increases the likelihood of non-communicable diseases (NCDs), such as cardiovascular diseases, hypertension, diabetes mellitus, and non-AIDS-related cancers. This study investigated factors associated with tobacco smoking and smokeless tobacco (SLT) use among PLWH in Zambia. Data were obtained from a national cross-sectional survey involving 5,204 PLWH from 193 clinics across Zambia's 10 provinces. Tobacco smoking, SLT use, behavioral patterns, and clinical characteristics were assessed. Logistic regression was used to determine unadjusted (UOR) and adjusted odds ratios (AOR) at a 95% confidence interval (CI). Among the 5,204 PLWH surveyed, 9.7% were current tobacco smokers (21.9% men, 3.7% women), while 1.4% used smokeless tobacco (1.81% men, 1.26% women). In the multivariable analysis, several factors were identified as predictors of tobacco smoking. Male individuals had significantly higher odds of smoking (AOR: 4.81, 95% CI: 3.36-6.90). In contrast, higher educational attainment was associated with lower odds of smoking (AOR: 0.29, 95% CI: 0.16-0.52). Alcohol consumption was associated with an increased likelihood of smoking (AOR: 4.97, 95% CI: 2.93-8.44). Additionally, overweight or obese individuals were less likely to smoke, with adjusted odds ratios of 0.55 (95% CI: 0.35-0.85) and 0.36 (95% CI: 0.17-0.79), respectively. Non-adherence to antiretroviral therapy (ART) was also associated with higher smoking rates (AOR: 1.75, 95% CI: 1.14-2.67). Similarly, several factors were identified as predictors of smokeless tobacco (SLT) use. Individuals with an annual income exceeding 4,000 ZMW had lower odds of using SLT (AOR: 0.31, 95% CI: 0.14-0.73). In contrast, alcohol users exhibited significantly higher odds of SLT use (AOR: 14.74, 95% CI: 1.99-109.02). Furthermore, non-adherence to ART was associated with an increased likelihood of SLT use (AOR: 3.32, 95% CI: 1.54-7.17). Our findings highlight the urgent need for targeted interventions to reduce tobacco use among PLWH in Zambia. Integrating these measures within the existing healthcare framework can maximize impact. Gender-specific programs addressing unique risk factors, alongside economic empowerment initiatives for low-income females, could help curb SLT use. Additionally, reinforcing ART adherence through tobacco cessation counseling within HIV care settings may lower smoking rates. Given the strong association between alcohol consumption and tobacco use, structured behavioral interventions and support programs should also be prioritized. Strengthening collaborations between health authorities and community organizations can further enhance accessibility and outreach. By embedding these strategies within primary care and ART clinics, Zambia can effectively reduce tobacco use among PLWH, ultimately improving overall health outcomes and strengthening HIV management efforts.