This study has addressed the gender perception related to SLT which was not studied before from our country. Around 8.6% of Pakistan’s population uses SLT in the 2014 survey (19). Our study revealed that marital status, age of initiation, source of SLT, concurrent smoking, first exposure, and reasons for starting SLT use were positively correlated among men and women. While previous studies (14, 20) on SLT use in South Asia have directly linked low educational status to the prevalence of SLT in the region, our research did not find a significant correlation between educational status with SLT. Our respondents comprised of varying educational statuses (uneducated, primary, secondary, and higher secondary levels) and SLT appeared to be prevalent in all of them. This necessitates the need for anti-tobacco campaigns to target not only the uneducated sector but also reinforce the harmful repercussions of using SLT products in the educated sector of the country.
The age at which participants started using SLT was an alarming concern. While most of the participants were in the 21 to 30-year age group, a significant number of people, mostly men had also started using SLT products in the 10–20 years age group and even in the less than 10 years age group. These findings are also supported by a 2013 Global Youth Tobacco Survey which revealed that 7.3% of Pakistani youth from ages 13 to 15 years of age indulge in SLT (21).
SLT is a part of Pakistani Culture. It is widely used in public occasions and celebrations in a form of a dish called ‘Paan’.(22). Paandan are passed on to women as part of their dowry (23). Both men and women have identified using SLT to relieve emotional stress. The turbulent relationship of Nicotine in tobacco and the human stress response has been extensively studied in the literature. Nicotine cessation is known to aggravate anxiety and stress, resulting in nicotine dependence (24, 25). A majority of women revealed using SLT because it was the norm among family and friends. Therefore, this greater social acceptability allows women to casually indulge in SLT use in their households. More men have identified using SLT as an alternative to cigarette smoking. The perception that SLT is less harmful than cigarette smoke attributes to their decision to start using SLT. There is an existing ethical debate regarding the use of SLT as an alternative to cigarette smoking as a harm reduction strategy despite its known side effects (26, 27).
Our study also revealed that a majority of both men and women are not aware of the carcinogenic properties of SLT. The world health organization (WHO) has identified SLT as the leading cause of oral cancer (28). A systemic review of Indian studies on SLT found a significant association between SLT and oral, pharyngeal, laryngeal, esophageal and stomach cancers. Further analysis on the bases of gender revealed that women using SLT had a higher risk of oral but lower risk of esophageal cancer compared to men (29). Both male and female participants were generally unaware of the effects of SLT and pregnancy too like low birth weight, preterm birth, still birth and long for gestational age (30).
Pakistan is part of the WHO’s Framework Convention for Tobacco Control (FCTC)- (31). One of the aims of the FCTC is to use effective government policy to ban the sale of tobacco products to minors. However there seems to be a mismatch between Pakistan’s stance on SLT and implementation of policy on a local level. While the government has made strides in combatting tobacco use, the focus of its efforts has primarily been on cigarette smoke rather than tobacco as a whole (32, 33). SLT is widely sold and relatively accessible to adults and adolescents in the country. There is no check on SLT products, which are being sold without any health warnings (34). Therefore, effective measures need to be taken to address the burden of SLT use in the nation. There is a dire need for anti-Smokeless tobacco campaigns to target not only adults but also adolescents of various socioeconomic backgrounds.
To our best knowledge this was the first study that have seen difference in gender perception but it has few limitations, (1) We relied on self-reported estimates of SLT misreporting of tobacco through self-report cannot be ruled out. (2)We did not use biochemical verification techniques due to financial limitations. Further studies should incorporate a broader study population and use biochemical validation measures.