Abstract
Background
Pakistan has over 30 million active adult smokers, making it one of the most vulnerable low-and middle-income nations. The problem deepens with the popularity of non-cigarette smoked tobacco products (NCSTPs) such as cigars, pipes, and shisha. While studies have been conducted evaluating regular cigarette usage, there is a gap in literature exploring other means of smoked tobacco in these regions. Our study aims to analyze the public’s knowledge, attitudes, and patterns of usage regarding NCSTP.
Methods
Using an online questionnaire, we conducted a nationwide web-based cross-sectional survey in Pakistan. Convenience sampling was used to disseminate and validate the questionnaire. The participants' knowledge, attitudes, and use of NCSTP were evaluated using this questionnaire. The responses of the participants were described using descriptive statistics, and SPSS Version 26 was used to perform logistic regression at a p-value of less than 0.05.
Results
In our sample of 1195 respondents with a mean age of 33 years, 93.3% of respondents had heard of NCSTP before with 57.1% believing they contained both tobacco and nicotine. 45.1% disagreed when asked if NCSTP are exclusively for adults. Removal of stress (29.8%) was the most cited motivator for use while negative health effects (61.4%) was the most selected deterrent. The vast majority of respondents (86.6%) who had used NCSTPs were also users of conventional cigarettes. On accounting for demographic and other variables, our regression analysis revealed that appetizing flavors (OR: 1.788, p = 0.006) and usage as cigarette alternatives (OR: 2.623, p = 0.000) were the two factors significantly associated with usage. On the other hand, social stigma (OR: 0.576, p = 0.004), bad taste (OR: 0.663, p = 0.018), and environmental pollution (OR: 0.493, p = 0.000) were the deterrents significantly associated with decreased usage.
Conclusion
Our findings demonstrate the varied knowledge, attitudes, and usage patterns regarding non-cigarette smoked tobacco products (NCSTP) among participants in an LMIC. Despite a high level of awareness, misconceptions persist regarding their contents and associated risks. While a substantial proportion of the participants have experimented with NCSTPs, the majority have not, citing deterrents such as health concerns and social unacceptability playing significant roles. Notably, the appeal of flavors and the potential for stress relief emerged as the most prevalent motivating factors among users. These insights emphasize the importance of comprehensive strategies aimed at both discouraging use and promoting accurate knowledge about NCSTP.