The global impact of tobacco control policies on smokeless tobacco use: a systematic review

Monika Arora*, Aastha Chugh, Neha Jain, Aishwarya Vidyasagaran, Anne Elizabeth Readshaw, Aziz Sheikh, Jappe Eckhardt, Kamran Siddiqi, Mansi Chopra, Masuma Pervin Mishu, Mona Kanaan, Muhammad Aziz Rahman, Ravi Mehrotra, Rumana Huque, Sarah Forberger, Liyanaarachchilage Dahanayake, Zohaib Khan, Melanie Boeckmann, Omara Fatima Dogar

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review


Smokeless tobacco (ST), used by more than 300 million people globally, results in substantial morbidity and mortality. For ST control, many countries have adopted policies beyond the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC), which has been instrumental in reducing smoking prevalence. The impact of these ST related policies (FCTC and non-FCTC) on ST remains unclear.
We systematically searched 11 electronic databases and grey literature from 2005 to September 2021 in English and key south Asian languages, to summarise ST policies and their impact. Two reviewers independently screened articles; data were extracted after standardisation . Quality of studies was appraised using the Effective Public Health Practice Project Quality Assessment Tool. Outcomes for impact assessment included ST prevalence, uptake, cessation, and health. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised.
We identified 252 eligible studies describing ST policies. Fifty-seven countries had policies targeting ST of which 17 had non-FCTC policies for ST (e.g., spitting bans). Eighteen studies evaluated the impact. These were of variable quality (6 strong, 7 moderate and 5 weak) and reported mainly on prevalence of ST use. The body of work evaluating FCTC-based policy initiatives found that these were associated with reductions in ST prevalence: between -4.4% to -30.3% for taxation and -22.2% to -70.9% for multi-faceted policies. Two studies evaluating the non-FCTC policy of sales bans reported significant reductions in ST sale (-6.4%) and use (-17.6%); one however reported an increased trend in ST use in the youth after total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found 13.3% increase in quit attempts in those exposed (47.5%) to FCTC policy: Education, communication, training, and public awareness, compared to non-exposed (34.2%).
Many countries have implemented ST control policies, including those that extend beyond FCTC. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in ST use.
Original languageEnglish
Pages (from-to)E953-E968
Number of pages16
JournalThe Lancet Global Health
Issue number6
Publication statusPublished - 1 Jun 2023

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