The prevalence of current SLT use was high among rural women in Burkina Faso, and given the current state of epidemiologic transition, the relationship of SLT use with noncommunicable diseases should make SLT use a public health concern.
Prevalence of SLT use
The prevalence of current SLT use among rural women in Burkina Faso was 13.8% (95% CI: 12.2-15.5), while only one woman used ST. Such statistics suggest a socially permissive attitude towards SLT use by females. A lower standardized prevalence estimate of 3.86% (95% CI: 3.22-4.48) was noted two years earlier (in 2011 and only in the sample of women aged 15-49 years) [1]. A current prevalence of SLT use of 17.4% (95% CI: 14.5-20.5) was found in rural women in three Ethiopian pastoral communities in which SLT chewing was a longstanding tradition [6], and the current prevalence of SLT use was 10.1% (95% CI: 8.8-11.4) in Mozambique [20]. Studies focusing on female SLT consumption with details for subgroups of rural and urban women are scarce in SSA, especially in West Africa. However, 3.3% of women and 4.7% of rural residents in Kenya were reported to be SLT users [21], as were 2.8% of women in Uganda [3]. Produced using a traditional technique, SLT is equivalent to a local psychoactive product and is widely available in rural Burkina Faso. There is no inventory concerning local psychoactive substances in Burkina Faso, and SLT seemed to be among the favourites of rural Burkinabé women, along with the roots of Sarcocephalus latifolius (a plant that provides synthetic tramadol), or non-medical tramadol, in Cameroon [22, 23] and khat/miraa in rural Kenya [24, 25].
Co-use of alcohol
Current SLT users were also frequently current alcohol users (aOR = 2.80; 95% CI: 2.06-3.80), as has been reported for women in Cambodia (aOR = 1.49; 95% CI: 1.12-1.98) [26] and in Kenya (aOR = 2.58; p = 0.001 for those with alcohol experience; aOR = 4.84; p = 0.007 for episodic binge drinkers) [21]. SLT and alcohol are both psychoactive substances containing nicotine and ethanol molecules, respectively [27], and their synergistic interactive effects potentiate physical and psychological pleasure [28]. Therefore, polyconsumption of both tobacco and alcohol was not surprising [29]. Unfortunately, the use of tobacco and alcohol are considered major cardiovascular risk factors. Drinking alcohol is known to increase both HDL-C and total cholesterol concentrations [30], and the concurrent use of tobacco and alcohol enhances these increases [31]. Although the mean HDL cholesterol and total cholesterol values were not higher in SLT users than in nonusers, the mean total cholesterol value was significantly higher in concurrent current SLT and alcohol users than in nonusers (Table 2).
Blood pressure and SLT use
SLT use was associated with increases in SBP (aOR = 1.01; p<0.05) and differential blood pressure (aOR = 1.01; p<0.05) (Table 3). Substantial nicotine is absorbed from SLT products [14]. The predominant cardiovascular effects of nicotine result from the activation of the sympathetic nervous system, which causes a hypertensive effect [32]; the increase in SBP in our sample (aOR = 1.01; p<0.05) was consistent with this effect and was consistent with the findings of Onwuchekwa in rural Niger (aOR = 2.32; p<0.05 among rural residents) [33]. Furthermore, age-related increases in SBP have been reported to be greater in women than men [34, 35]; thus, the increase in SBP was more perceptible in our sample of women than it might have been in a sample of both men and women. However, we observed a decrease in DBP with age (0.97; p<0.01) (Table 3) in SLT users. We should note that there was an increase in DBP level with age from an average of 78.4 (±9.5) mmHg at approximately 36 years of age to 83.1 (±11.8) mmHg at 53 years and then a decrease to 73.4 (±10.1) mmHg at 69 years of age [36]. An inverse association of DBP and age has been well established [36], and it may partly explain our finding. Nicotine interacts with central oestrogenic pathways [37], which may help explain the non-homogenous effects of nicotine on SBP and DBP. SLT is usually locally produced using a non-standardized processed, and tobacco is grown in different types of soils in which mineralogic contents (such as sodium) may affect blood pressure in users [38]. In addition, the use of pesticides in rural Burkina Faso may cause soil contamination by staining tobacco leaves [39], which has been implicated in BP increases [40]. The effects of chronic consumption of kola nuts on the cardiovascular system should be considered [41, 42]. Research showed that one in two adults used kola nuts in Burkina Faso [43], usually under similar conditions (i.e., dental health impairment conditions [44]). Unspecified effects of interactions between SLT and kola nut products on BP may be possible. In short, cardiovascular disturbance in SLT users was evident in the substantial increase in differential blood pressure (aOR = 1.01; p = 0.041; Table 3).
Dental symptoms
SLT use was associated with the presence of some dental symptoms (aOR = 2.59; 95% CI: 1.91-3.51). Cheema et al. reported an association with poor oral status (aOR = 3.90; 95% CI: 1.75-8.69) in Qatar [4]. Users of this psychoactive substance (SLT) develop various expectancies for using it according to the different effects generated by its consumption depending on the context. Oro-dental pain and burning mouth syndrome are common in SSA countries, and poor oral health service utilization has been reported in these countries [45, 46]. The nicotine delivered by SLT products increases sensory irritation [47], and because dental care is not available in rural Burkina Faso [44], rural women are likely to use SLT for the pain or discomfort associated with dental symptoms. Because chewing food might exacerbate dental pain, in the absence of treatment, those with dental symptoms use SLT to locally anaesthetize teeth or the oral cavity to be able to eat without pain. Such behaviour was noted in a supplemental qualitative study (interview) in three Ethiopian pastoral communities with a long tradition of SLT chewing [6]. Furthermore, psychoactive substance consumption resulting from addictive behaviours includes gestural rituals [48] that have been established over time. Tooth and periodontal damage was found to be common in SLT users [49], mainly female chewers [50], and the intention to use SLT for dental pain suppression could establish a vicious circle between dental symptoms and the repeated and inefficient application of SLT as treatment.
Undernourishment
The prevalence we found (16.0%) was similar to the results reported in previous studies in Burkina Faso (14.8% in rural and urban women in 2010 [51] and 19.9% in 2016 [52]). The weighted prevalence of 14.8% was considered to be the greatest among the 33 SSA countries investigated, following the prevalences in Senegal (20.8% in 2011) and Gambia (15.7% in 2013) [51]. Moreover, the high prevalence of 31.0% found by Ramsey et al. in rural Burkina Faso was the highest among the three rural African areas involved in their study [53]. SLT use was associated with undernourishment (aOR = 1.78; p<0.01), as it was in rural Ghanaian women (aOR = 2.78; p = 0.002) [54]. Tobacco delivers nicotine, which is an anti-appetite component [55]. There is low food availability in rural Burkina Faso [56], and hunger and an empty stomach generate discomfort. The belief that minimum food intake combined with SLT consumption helps allay hunger further exposes individuals to insufficient food intake. Similar habits were reported for addictions to tea and SLT among Malian Tuaregs living in Sahelian areas and suffering from hunger in a harsh climate [57].
No significant impairment in the lipid profile or blood sugar among SLT users
Lower HDL cholesterol and higher total cholesterol among smokers and tobacco chewers than among nonusers have been reported [58, 59]. However, the SLT users and nonusers in our current sample had identical mean values of HDL cholesterol and total cholesterol, and there was no significant risk of lipid profile impairment in SLT users (Tables 2 & 3). These results were not surprising in our context because SLT users were more frequently affected by undernourishment (28.6% vs. 13.9% in nonusers; p<0.001) and not by overweight/obesity (only 5.5% vs. 14.4% in nonusers; p<0.001; Table 2). The women in our study would frequently have moderate or insufficient amounts of fat in their bodies, including in blood vessels. Similarly, there was no association with increased blood sugar in users; their mean blood sugar was in fact significantly lower than that of nonusers (3.8 ± 1.5 mmol/l vs. 4.1 ± 1.5 in nonusers; p<0.05; Table 2). However, further investigations should consider the hypothesis of a positive association.
Sociodemographic factor influences
SLT use increased with age in our study (Table 3). It has previously been reported that elderly individuals have an increased number of cardiovascular risk factors [60] and that SSA countries under demographic and epidemiologic transitions have severely affected cardiovascular risk [61]. An additional modifiable factor, such as SLT use, should be avoided. Uneducated people were frequently exposed to SLT use (Table 3), which indicated that formal instruction, as well as public health education, focused on cardiovascular risk factors and SLT-related health consequences would be effective in reducing prevalence and risk [62].
Limitations
We used national data from the STEPS survey, which studied the prevalence of and knowledge of common risk factors for noncommunicable diseases. However, the sample size calculation was based on the prevalence of HBP. Data collection methods for dental symptoms were based only on self-reporting and did not include examinations by health professionals. Thus, self-reporting may have included incorrect statements and dental assessments.