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More than 360 million people worldwide consume smokeless tobacco (SLT) products, with more than 90% of them living in lower HDI countries (LMICs), largely in South Asia. Most SLT users live in India, with more than 199 million (21% prevalence), and Bangladesh, with 22 million (27.5% prevalence) adult SLT users in 2018. The use of SLT has a strong relationship with cultural practices and is culturally and socially acceptable in much of South Asia. Adult females in these countries are more likely to initiate with and then to use SLT than other forms of tobacco. Recently, male tobacco users in India reported a greater preference for SLT, and there is evidence of adult female smokers shifting to using SLT in several countries. The documented use of SLT products by youth in more than 140 countries is also concerning and poses a global public health challenge.

There is a wide variety of SLT products (e.g., khaini, gutka, pan masala, snuff, snus, etc.) that come in many different forms, sizes, and shapes and at different prices. It is estimated that more than 90% of SLT products worldwide are sold in traditional markets, where they are held to no or very loose standards, with wide variations in ingredients and health risks. Most of these SLT products are known to contain high levels of nicotine, which causes chronic dependence. Use of these SLT products is known to cause several forms of cancer and is associated with cardiovascular deaths and poor birth outcomes. The use of SLT is responsible for 2.5 million lost disability-adjusted life years (DALYs) and 90,791 deaths globally due to oral cancer, esophageal cancer, and pharyngeal cancer and more than 6 million lost DALYs and 258,006 deaths from ischemic heart disease. Most of the burden of SLT use falls on lower-HDI countries, with the South and Southeast Asian regions accounting for more than 80% of the SLT-related burden.

Despite the huge burden they impose on lower-HDI countries, SLT products are poorly regulated in these countries. Regulatory mechanisms that oversee the composition and sales of SLT products, such as product standards and licensing, either do not exist or, if they do, are poorly enforced. Taxes on SLT products are usually lower than those on cigarettes and are easily avoided or evaded. In Bangladesh, only 20 SLT manufacturers pay excise taxes. Typically, in many lower-HDI countries, SLT manufacturers are not registered, sell their SLT products illegally, and thus do not pay any taxes at all. As a result, SLT products have become increasingly affordable. Moreover, many SLT product packages are very small (1 gram or less) and the unit prices are very low, which makes them affordable even for very poor and/or young people. Some countries are starting to address these issues. For example, India has sought to raise SLT taxes, ban the sale of gutkha and other flavored SLT products, and impose pictorial health warnings on packages. However, due to problematic policy design and/or a lack of enforcement, violations of these policies occur regularly.

Bringing SLT products into tobacco control regulatory frameworks is essential but challenging. Most SLT products are sold in informal markets outside of regulations. Formalizing the SLT sector is a complicated and long-term process that requires comprehensive and enduring efforts from the government. Due to the varied nature of SLT products, enforcement of existing SLT control policies, including tax and price policies—which have been shown to reduce SLT use—is difficult. The low capacity of tax authorities and the interference of the SLT industry in the development and implementation of effective SLT control policies are other barriers to taxing and regulating SLT products adequately. With the rise of SLT use and its high burden in some lower-HDI countries, governments in these countries should put more effort into strengthening their SLT policies to tax and regulate SLT products more effectively.

In 2017, consumption of SLT products caused the loss of more than 8.6 million disability-adjusted life years (DALYs) and more than 340,000 deaths, with 85% of those affected living in south and Southeast Asia.


SLT use in India and Bangladesh:

Sinha DN, Gupta PC, Kumar A, Bhartiya D, Agarwal N, Sharma S, Singh H, Parascandola M, Mehrotra R. The poorest of poor suffer the greatest burden from smokeless tobacco use: A study from 140 countries. Nicotine Tob Res. 2018 Nov 15;20(12):1529-1532. doi: 10.1093/ntr/ntx276. PMID: 29309692; PMCID: PMC6454457.

The use of SLT in South Asia:

Khan Z, Tonnies J, Muller S. Smokeless tobacco and oral cancer in South Asia: a systematic review with meta-analysis. J Cancer Epidemiol. 2014;2014:394696. doi: 10.1155/2014/394696.

Shifting to using SLT among adult female smokers:

Suliankatchi RA, Sinha DN, Rath R, Aryal KK, Zaman MM, Gupta PC, Karki KB, Venugopal D. Smokeless tobacco use is “replacing” the smoking epidemic in the South-East Asia region. Nicotine Tob Res. 2019 Jan 1;21(1):95-100. doi: 10.1093/ntr/ntx272. PMID: 29281083.

Wide variations in ingredients and health risks of SLT products:

Smokeless Tobacco and Public Health: A global perspective. Bethesda, USA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Institutes of Health, National Cancer Institute, 2014.

Smokeless tobacco health burden:

Siddiqi K, Husain S, Vidyasagaran A, Readshaw A, Mishu MP, Sheikh A. Global burden of disease due to smokeless tobacco consumption in adults: An updated analysis of data from 127 countries. BMC Med. 2020 Aug 12;18(1):222. doi: 10.1186/s12916-020-01677-9. PMID: 32782007; PMCID: PMC7422596.

Difficulty in enforcement of existing SLT control policies:

John RM, Yadav A, Sinha DN. Smokeless tobacco taxation: Lessons from Southeast Asia. Indian J Med Res. 2018;148(1):46-55. doi:10.4103/ijmr.IJMR_1822_17.

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