Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment

Abstract Introduction Smokeless tobacco (ST) is a significant South Asian public health problem. This paper reports a qualitative study of a sample of South Asian ST users. Methods Interviews, using a piloted topic guide, with 33 consenting, urban dwelling adult ST users explored their ST initiation, continued use, and cessation attempts. Framework data analysis was used to analyze country specific data before a thematic cross-country synthesis was completed. Results Participants reported long-term ST use and high dependency. All reported strong cessation motivation and multiple failed attempts because of ease of purchasing ST, tobacco dependency, and lack of institutional support. Conclusions Interventions to support cessation attempts among consumers of South Asian ST products should address the multiple challenges of developing an integrated ST policy, including cessation services. Implications This study provides detailed understanding of the barriers and drivers to ST initiation, use, and cessation for users in Bangladesh, India, and Pakistan. It is the first study to directly compare these three countries. The insight was then used to adapt an existing behavioral support intervention for ST cessation for testing in these countries.


INTRODUCTION
Smokeless tobacco (ST) are non-combustible tobacco products that are chewed, snorted through the nose or placed in the oral cavity [1]. Consumed by more than 300 million people in at least 127 countries, ST in 2017 is estimated to have caused over 90,000 deaths due to oral, pharynx and oesophageal cancers and a loss of 2.5 million disability adjusted life years [2]. ST use also correlates with increased cardiovascular mortality risk and poor pregnancy outcomes [2,3]. More than 85% of this disease burden concentrates in South and South East Asia [2].
The WHO Framework Convention on Tobacco Control (FCTC) [4] proposes a range of measures to reduce the consumption of tobacco products, including tobacco dependence treatment.
Implementation of FCTC measures for ST products in general is limited [5], particularly with regard to cessation. Barriers exist [6], with many countries lacking policy and appropriate quit services [7].
Data informing the process of developing appropriate interventions to support cessation attempts among people consuming South Asian ST products is lacking. This paper reports the results of a qualitative study of a sample of South Asian ST users used to inform the adaptation of a behavioural support intervention for ST cessation [13]. Urban settings in Bangladesh, India and Pakistan were used and 10-12 per country, exclusive (nonsmoking), daily (for the past six months or at least 25 days in the past month) adult ST users were interviewed. Purposive sampling incorporated both sexes, varied education levels and users of various ST products. Participants were recruited from a primary care clinic, through local social workers, and community networks. Identified potential participants received study information and gave permission to share contact details before being contacted to arrange an interview.
Face-to-face interviews were conducted in local languages by trained and mentored country research teams in locations ensuring privacy. Online methods and analysis training was delivered by an experienced UK based qualitative researcher (CJ). Before interview start, the researcher discussed the study information sheet and secured participant consent. Participants marked or initialled the item(s) to which they consented. To ensure consistency a topic guide was developed and piloted in all settings. Changes created better contextualisation of questions, a streamlined order and improved clarity.
The audio-recorded interviews were transcribed verbatim, checked for accuracy by the interviewers and translated into English. Framework data analysis [14] was conducted and findings collated for

RESULTS
Thirty-three ST users were interviewed between January-August 2019 (Table 1). Interviews lasted between 24 and 83 minutes.

Smokeless tobacco initiation and use routines
Length of ST use varied by gender and country, from 1.5-6 years for Indian women up to 45 years in Bangladeshi men. Pakistani participants had all used ST for at least 10 years. Types of ST used varied by country. In Bangladesh paan with zarda was commonly reported whilst guthka and khaini were preferred by Indian respondents. Regional variation was observed in Pakistan, with naswar used in Peshawar and guthka in Karachi. Initiation triggers included curiosity, observation of others' use or replacing behaviours such as smoking (Quotes 1,2, Supplementary Material 1).
In Bangladesh and India women reported lower consumption frequencies than men (4-8 times/day compared to 15-40 in Bangladesh; 2-3 times/day compared to 7-8 in India). In Pakistan frequency ranged from 5-6 to 25-30 times/day. First daily intake was integrated into early morning routines  A minority of participants also described the perceived negative health impacts of not using ST.
These could be a reduced ability to work, feelings of malaise or imbalance, physical symptoms such as stomach problems, dizziness and seizures or mental health problems such as agitation and aggression (Quote 13, Supplementary Material 1). Participants did not believe they had sufficient willpower to succeed (Quote 14, Supplementary Material 1).

DISCUSSION
The disease burdens of ST use are concentrated in in South and South East Asia [2]. This is the first qualitative needs assessment synthesising the views of ST users across South Asia about their ST behaviours. The results would inform the adaptation of a ST cessation behavioural intervention [13].
The participant accounts confirm previously reported quantitative findings of long-term personal use and high dependency typical of South Asian ST users [9,[15][16][17][18]. This gives confidence that data saturation was achieved and that the findings are generalisable [14].
New data has emerged with respect to ST cessation. All reported strong cessation motivation but many failed attempts because of ease of purchasing ST, tobacco dependency and lack of institutional support. ST use among South Asians has been reported as culturally acceptable with strong social foundations [9]. Our participants reported a more nuanced role of significant others in their ST use.
Whilst having ST using friends, family and colleagues encouraged continued personal use, A c c e p t e d M a n u s c r i p t participants also described discouragement from younger family members and work supervisors which created a pressure to quit, stigmatising public ST use and encouraging lying about behaviour.
Strengths and limitations of this study should be noted. We recruited men and women in three countries, across education levels, who used a variety of ST products and offered a diversity of views about their ST use. A key limitation was the failure to recruit women in one Pakistani location (Peshawar), reported to be because female ST use was considered culturally unacceptable. Secondly, we recruited from urban locations alone and acknowledge that ST use in rural areas may be more prevalent [15][16][17]. Further research should address this study's limitations.
Discouraging ongoing South Asian ST use requires population-level interventions to tackle opportunity factors, such as legislation, price increases and advertising bans [10], in addition to individual cessation support. This study suggests that implementation of policy measures and services for ST cessation is limited [5]. Most South Asian countries lack policy, including the provision of services in which appropriately adapted behavioural resources are embedded, to help in ST cessation.
In conclusion, these South Asian ST users were highly motivated to attempt cessation yet were persistently unsuccessful because of socio-environmental factors encouraging ST initiation, persistent drivers to continue ST consumption and lack of formal cessation resources and support.
Initiatives should address these challenges in developing an integrated ST control policy which includes cessation support for individual ST users.