Compliance of smokeless tobacco supply chain actors and products with tobacco control laws in Bangladesh, India and Pakistan: Protocol for a multicentre sequential mixed-methods study

Introduction: South Asia is home to more than 300 million smokeless tobacco (ST) users. Bangladesh, India and Pakistan as signatories to the Framework Convention for Tobacco Control (FCTC) have developed policies aimed at curbing the use of tobacco. The objective of this study is to assess the compliance of ST point-of-sale (POS) vendors and the supply chain with the articles of the FCTC and specifically with national tobacco control laws. We also aim to assess disparities in compliance with tobacco control laws between ST and smoked tobacco products.Methods and analysis: The study will be carried out at two sites each in Bangladesh, India and Pakistan. We will conduct a sequential mixed-methods study with five components: (1) mapping of ST POS, (2) analyses of ST samples packaging, (3) observation, (4) survey interviews of POS and (5) in-depth interviews with wholesale dealers/suppliers/manufacturers of ST. We aim to conduct at least 300 POS survey interviews and observations, and 6-10 in-depth interviews in each of the three countries. Data collection will be done by trained data collectors. The main statistical analysis will report the frequencies and proportions of shops that comply with the FCTC and local tobacco control policies, and provide a 95% CI of these estimates. The qualitative in-depth interview data will be analysed using the framework approach. The findings will be connected, each component informing the focus and/or design of the next component.Ethics and dissemination: Ethical approvals for the study have been received from the Health Sciences Research Governance Committee at the University of York, UK. In-country approvals were taken from the National Bioethics Committee in Pakistan, the Bangladesh Medical Research Council and the Indian Medical Research Council. Our results will be disseminated via scientific conferences, peer-reviewed research publications and press releases

Conducting tobacco control surveys among schoolchildren in Bangladesh, India and Pakistan:A feasibility study

Most of the world's 300 million smokeless tobacco (ST) users live in South Asia but ST policies for that region are poorly researched, developed and implemented. Longitudinal studies to understand the uptake and use of ST and smoking, and influences on these, such as health promotion strategies, are lacking. We planned to conduct longitudinal surveys among secondary school students in three countries with the highest ST burden: Bangladesh, India and Pakistan to explore ST and smoking uptake, use and health promoting strategies. Before running that longitudinal study, we assessed the feasibility of conducting such a multi country survey using a mixed-methods design. The survey (and feasibility study) was conducted in 24 secondary schools (eight per country, three classes per school). Three data sources, researcher records/fieldnotes, survey data of 1179 students, and interview/focus group discussion data from 24 headteachers, 64 teachers and 76 students, were used to understand the feasibility of three study tasks: 1) selecting, recruiting, and retaining schools and student participants; 2) survey administration; and 3) robustness of the data collection instruments. The datasets were analysed separately and triangulated. Overall, we could select and recruit schools and students using consistent methods across countries although recruitment was challenged by securing higher authority permissions and parental consent. Recommended improvements were for permission/consent processes. Survey administration was generally feasible and acceptable with recommendations for scheduling and researcher-student ratios. Questionnaire completion was 83%-100% across countries, with suggestions to improve readability and understanding, addressing students' queries and questionnaire simplification. Due to COVID-19, we could not conduct follow-up surveys, so were unable to assess school or student retention. In conclusion, incorporating the lessons learnt from this study would improve the feasibility of conducting such a multi-country survey in the future. Reported benefits included increasing tobacco health risks' knowledge with potential for increased tobacco control support.</p

Global impact of tobacco control policies on smokeless tobacco use : A systematic review protocol

Introduction Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated. Methods and analysis A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used. Ethics and dissemination Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC-IEC-06-2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences. PROSPERO registration number CRD42020191946

Health worker and patient views on implementation of smoking cessation in routine tuberculosis care

Böckmann M, Warsi S, Noor M, et al. Health worker and patient views on implementation of smoking cessation in routine tuberculosis care. NPJ primary care respiratory medicine. 2019;29(1): 34.Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up

The molecular basis of functional diversity in the Aux/IAA gene family in Arabidopsis thaliana

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Policy perspective on the global use of Smokeless Tobacco (ST): a literature review

Background Globally, Smokeless Tobacco (ST) is consumed by over 300 million people. ST is addictive and most products cause cancers of the oral cavity, pharynx and oesophagus. The aim of this review was to identify knowledge gaps in the implementation of key demand-reduction measures with regard to ST. Methods A series of focused literature reviews was conducted and findings were synthesized by relevant Articles (6 - 14) of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Results We found sufficient evidence to support implementation of key demand-reduction measures for ST. For example, raising taxes can reduce ST consumption, with price elasticity on a par with, or sometimes higher than, cigarettes. Similarly, graphic pictorial warnings on ST packaging are far more effective than text-only warning labels. But despite supportive evidence, countries have either not implemented measures or have kept the bar much lower than that for cigarettes. For example, very few countries regulate the contents of ST products. Some have raised ST taxes but not to the extent of cigarette taxes, risking product substitution. Similarly, health-warning requirements for ST are less strict than those for cigarettes. Even where strong policies exist, compliance has been poor. For example, despite bans on ST advertising, most suppliers continue to promote products, especially at points of sale and via print and digital media. Consequently, ST demand-reduction measures have had limited impact. Conclusions The full implementation of FCTC Articles 6-14 is likely to reduce the global demand for ST, but their current state of implementation lags behind that for cigarettes. The existing policy gaps can be addressed through better knowledge of ST products, setting unambiguous standards, innovative systems for tax administration, building capacity in testing ST products and undertaking targeted research

Artificial selection reveals complex genetic architecture of shoot branching and its response to nitrate supply in Arabidopsis.

Funder: FP7 Ideas: European Research Council; funder-id: http://dx.doi.org/10.13039/100011199; Grant(s): 294514Quantitative traits may be controlled by many loci, many alleles at each locus, and subject to genotype-by-environment interactions, making them difficult to map. One example of such a complex trait is shoot branching in the model plant Arabidopsis, and its plasticity in response to nitrate. Here, we use artificial selection under contrasting nitrate supplies to dissect the genetic architecture of this complex trait, where loci identified by association mapping failed to explain heritability estimates. We found a consistent response to selection for high branching, with correlated responses in other traits such as plasticity and flowering time. Genome-wide scans for selection and simulations suggest that at least tens of loci control this trait, with a distinct genetic architecture between low and high nitrate treatments. While signals of selection could be detected in the populations selected for high branching on low nitrate, there was very little overlap in the regions selected in three independent populations. Thus the regulatory network controlling shoot branching can be tuned in different ways to give similar phenotypes

Artificial selection reveals complex genetic architecture of shoot branching and its response to nitrate supply in Arabidopsis.

Quantitative traits may be controlled by many loci, many alleles at each locus, and subject to genotype-by-environment interactions, making them difficult to map. One example of such a complex trait is shoot branching in the model plant Arabidopsis, and its plasticity in response to nitrate. Here, we use artificial selection under contrasting nitrate supplies to dissect the genetic architecture of this complex trait, where loci identified by association mapping failed to explain heritability estimates. We found a consistent response to selection for high branching, with correlated responses in other traits such as plasticity and flowering time. Genome-wide scans for selection and simulations suggest that at least tens of loci control this trait, with a distinct genetic architecture between low and high nitrate treatments. While signals of selection could be detected in the populations selected for high branching on low nitrate, there was very little overlap in the regions selected in three independent populations. Thus the regulatory network controlling shoot branching can be tuned in different ways to give similar phenotypes