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 countryspecific 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 STrelated 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.

Introduction We investigated the influence of COVID-19 on smoking patterns in Pakistan. Methods In a longitudinal survey, we asked cigarette smokers in Pakistan about their smoking behaviours before and since COVID-19. Smokers were recruited before COVID-19 using two-stage random probability sampling. Since COVID-19, three subsequent waves were conducted over the telephone, asking additional questions on social determinants, mental health and wellbeing. Based on the first two waves, we estimated the proportion of smokers who stopped, decreased, maintained, or increased smoking. We also explored any factors associated with the change in smoking patterns. In those who stopped smoking soon after COVID-19, we estimated the proportion relapsed in subsequent waves. We estimated all proportions based on complete-case analysis. Results We recruited 6,014 smokers between September 2019 and February 2020; of these, 2,087 (2,062 reported smoking outcomes) were followed up in May 2020 after COVID-19. Since COVID-19, 14% (290/2,062) smokers reported quitting. Among those who continued smoking: 68% (1210/1772) reduced, 14% (239/1772) maintained, and 18% (323/1772) increased cigarette consumption; 37% (351/938) reported at least one quit attempt; 41% (669/1619) were more motivated while 21% (333/1619) were less motivated to quit. Changes in smoking patterns varied with nicotine dependence, motivation to quit, and financial stability since COVID-19. Among those reporting quitting soon after COVID-19, 39% (81/206) relapsed in the subsequent months (June-July 2020). Conclusions There have been significant bidirectional changes in smoking patterns since COVID-19 in Pakistan. While many people stopped, reduced, or tried quitting smoking, some increased smoking, and some relapsed after quitting. Implications We observed significant and complex changes in people’s smoking patterns, which are likely to be attributable to the COVID-19 pandemic and replicated in similar events in the future. Assessing these changes are essential for most low- and middle-income countries like Pakistan, where the vast majority of tobacco users live, but cessation support is still rudimentary. If provided routinely, smoking cessation interventions can potentially support millions of highly motivated individuals in quitting successfully both in general as well as in global events like COVID-19, in particular.

Background. Children in low-income developing countries are likely to suffer from undergrowth. Dental caries is another common problem in these countries. Aim. To examine the association between untreated dental caries in primary and permanent teeth with age-adjusted height and weight among 6–12-year-old children in Bangladesh. Design. Social, behavioural, and clinical data were collected from 1699 children in nine different randomly selected primary schools in socially deprived areas of Bangladesh. The associations of age-adjusted weight and height and being underweight with dental caries were examined adjusting for sex, area of residence, socioeconomic position, skipping meals, tooth cleaning, and doctor visits. Results. 26% of the children were underweight and 55% had untreated dental caries. Children with at least one decayed tooth were significantly underweight with odds ratios 1.6 (95% CI 1.1, 2.3) and 1.5 (95% CI 1.1, 2.0) for 6–8-years and 9–12-year-old children, respectively, in the adjusted model. The number of decayed teeth was inversely and significantly associated with the standardized age-adjusted weight. Conclusions. The findings highlight the association between untreated dental caries and being underweight in primary school children in socially deprived areas in low-income developing countries and emphasize the need to integrate oral and general health policies with social policies.

Background Tobacco uptake in adolescents is associated with a range of predictors. We examined the predictors of cigarette smoking, smokeless tobacco (ST) consumption and use of both ST and cigarettes among adolescents in four South Asian countries. Methods We analysed the Global Youth Tobacco Surveys (GYTS) data for Bangladesh (2013), India (2009), Pakistan (2013), and Sri-Lanka (2015), using multinomial regression to examine associations between several predictors and tobacco use. Results Data from 23,681 adolescents were analyzed. Overall, 82.8% of the study population were between 13 and 15 years and 52.7% were girls, 2% were cigarette smokers, 6.5% were ST users and 1.1% used both ST and cigarettes, in the past 30-days. Exposure to smoking in public places was associated with past 30-days smoking (RRR 5.59, 95%CI 4.28-7.28), ST use (RRR 2.07, 95%CI 1.84-2.32) and use of both ST and cigarettes (RRR 11.42, 95%CI 7.44-17.54). Exposure to tobacco use in electronic media and being offered free tobacco products were associated with all forms of tobacco use. Shopkeepers’ refusal to sell cigarettes protected adolescents from smoking (RRR 0.47, 95%CI 0.36-0.63) and ST use (RRR 0.65, 95%CI 0.45-0.95). However, exposure to anti-tobacco mass media messages was not protective for any form of tobacco use. Adolescents taught at school about harmful effects of tobacco were less likely to use ST; no evidence of this association was observed for smoking. Conclusion The associations between tobacco use and pro-tobacco factors were strong but the associations with anti-tobacco factors lacked strength and consistency in this study population.

Purpose People with severe mental ill health (SMI) are less physically active and more sedentary than the general population. There is limited research investigating the correlates of physical activity (PA) in people with SMI impeding the development of successful interventions. This study aimed to assess the factors associated with regular participation of PA among a large sample of people with SMI. Methods The data for this study were collected from the 'Closing the Gap: Lifestyle Health and Wellbeing' (HWB) cohort that collected data through self-administered questionnaire from participants with SMI. Self-reported participation in regular PA was the main outcome variable. Potential predictors of PA were grouped as demographic, biological, psychological and behavioural variables. Multivariable logistic regressions were conducted considering PA participation as the dependent variable adjusted for possible correlated predictors. Results In total, 3287 people with SMI [mean (SD) age 47.7 (14.58) years, 59% male] were included; 38% reported undertaking regular PA and 61% wanted to undertake more physical activity. Multivariable logistic regressions showed that the following factors were associated with undertaking more regular PA: being male, aged 18-65 years, having a body mass index between 18.5 and 30 kg/m 2 , having better self-perceived general health condition, not having a health problem that limits activity, giving higher importance to maintain a healthy lifestyle, and eating more fruit and vegetables. Conclusions Having a better self-perceived general health and placing importance on maintaining a healthy lifestyle were important predictors of regular PA. Lifestyle interventions targeting increased PA among people with SMI should be shaped by their health perception and informed by their needs.