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Global Burden of Disease Due to Smokeless Tobacco Consumption In Siddiqi et al. BMC Medicine (2020) 18:222 https://doi.org/10.1186/s12916-020-01677-9 RESEARCH ARTICLE Open Access Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries Kamran Siddiqi1,2*, Scheherazade Husain1, Aishwarya Vidyasagaran1, Anne Readshaw1, Masuma Pervin Mishu1 and Aziz Sheikh3 Abstract 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. Keywords: Cancer, Chewing, Ischaemic heart disease, Mouth, Oral, Oesophagus, Pharynx, Smokeless tobacco * Correspondence: [email protected] 1Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, UK 2Hull York Medical School, University of York, Heslington, York YO10 5DD, UK Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Siddiqi et al. BMC Medicine (2020) 18:222 Page 2 of 22 Background Nordic countries, where the manufacturing process Smokeless tobacco (ST) refers to various tobacco- removes many of the toxins from the finished product containing products that are consumed by chewing, keep- [6, 17]. Using this approach, we estimated the worldwide ing in the mouth or sniffing, rather than smoking [1]. ST burden of disease attributable to ST consumption, mea- products of many different sorts are used by people in sured in terms of disability adjusted life years (DALYs) every inhabited continent of the world (Table 1)[1]. For lost and the numbers of deaths in 2010 [16]. Here, we example, in Africa, toombak and snuff are commonly update this estimate to include data up to 2019, provid- used, while in South America, chimó is the product of ing an indication of how the global ST arena has chan- choice. In Australia, indigenous people use pituri or min- ged in the intervening years. gkulpa [2], and in Central Asia, nasvay consumption is very common. In North America, plug or snuff are Methods favoured, and even in Western Europe, where ST products Our methods for updating the estimates of ST disease are largely banned, there are exemptions allowing people burden were broadly the same as those used in our earl- in Nordic countries to use snus [3]. All the above products ier publication; these are well described elsewhere [16]. vary in their preparation methods, composition and asso- Here, we will summarise these methods and explain any ciated health risks (Table 1), but it is in South and South- modification made, particularly in relation to the revised east Asia where the greatest diversity of ST products timelines. We assessed disease burden for individual exists, accompanied by the highest prevalence of use [4]. countries by varying their populations’ exposure to ST, Here, the level of cultural acceptability is such that ST using the comparative risk assessment method [15]. products are often served like confectionery at weddings These individual estimates were then summarised for 14 and other social occasions. World Health Organization (WHO) sub-regions (Add- ST products contain nicotine and are highly addictive. itional file 1: Appendix 1) as well as for the world. Often, they also contain carcinogens, such as tobacco- We first searched the literature to identify the latest specific nitrosamines (TSNA), arsenic, beryllium, cad- point prevalence of ST use among adults ≥ 15 years in mium, nickel, chromium, nitrite and nitrate, in varying men and women for each country (see Additional file 1: levels depending on the product [5, 6]. The pH of the Appendix 2 for detailed methods). We searched for the products also varies widely, with some (e.g. khaini, latest estimates for x countries included in our previous zarda) listing slaked lime among their ingredients [7]. study as well as those additional y countries where esti- Raising the pH in this way increases the absorption of mates have been made available since 2014 for the first nicotine and enhances the experience of using the ST time. We derived single estimates for each country pre- product, increasing the likelihood of dependence. The ferring nationally representative surveys using inter- elevated pH also increases the absorption of carcinogens, nationally comparable methods over non-standardised leading to higher toxicity and greater risk of harm [7]. national or sub-national surveys. The harmful nature of many ST products, and the fact We also updated risk estimates for individual diseases that 300 million people around the world use ST [8], make caused by ST; however, we kept to the original list of ST consumption a global public health issue. Many ST conditions, i.e. cancers of the oral cavity, pharynx and products lead to different types of head and neck cancers oesophagus, ischemic heart disease and stroke. We only [9, 10]. An increased risk of cardiovascular deaths has searched for papers published since our last literature been reported [11], and its use in pregnancy is associated search; our updated search strategies can be found in with stillbirths and low birth weight [12, 13]. Additional file 1: Appendix 3. As before, all searches and Because of the diversity described above, ST should data extraction were independently scrutinised by a sec- not be considered as a single product, but rather as ond researcher and any discrepancies were arbitrated by groups of products with differences in their toxicity and a third researcher. All case definitions for diseases and addictiveness, depending on their composition. As a exposure (ST use) used in the retrieved articles were consequence, it is difficult to estimate the global risks of checked for accuracy and consistency and all analyses ST to human health and to agree on international pol- undertaken in these studies were assessed to see if they icies for ST prevention and control. Several country- controlled for key confounders (mainly smoking and al- specific studies [14, 15] have been carried out, and in cohol). We assessed study quality using the Newcastle- 2015, we published an estimate of the global burden of Ottawa Scale for assessing non-randomised studies in disease associated with ST use [16]. We used a novel ap- meta-analysis [24]. For all new studies, we log trans- proach, whereby we classified ST products according to formed their risk estimates and 95% confidence intervals their availability in different geographical regions of the to effect sizes and standard errors and added these to world. For example, ST products in South Asia pose a the rerun of our random-effects meta-analyses to esti- much greater risk to health than those available in mate pooled risk estimates for individual conditions. Table 1 Smokeless tobacco products consumed most commonly across the world Siddiqi Smokeless Regions (WHO) Countries (highest Other ingredients Preparation and use pHa Nicotinea Total TSNAa tobacco consumption) (mg/g) (ng/g) et al.
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