ObjectiveOral tobacco products contain nicotine and carcinogenic tobacco-specificN-nitrosamines (TSNAs) that can be absorbed through the oral mucosa. The aim of this study was to determine typical pH ranges and concentrations of total nicotine, unionised nicotine (the most readily absorbed form) and five TSNAs in selected oral tobacco products distributed globally.MethodsA total of 53 oral tobacco products from 5 World Health Organisation (WHO) regions were analysed for total nicotine and TSNAs, including 4-(methyl-nitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), using gas chromatography or liquid chromatography with mass spectrometric detection. Unionised nicotine concentrations were calculated using product pH and total nicotine concentrations. Fourier transform infrared spectroscopy was used to help categorise or characterise some products.ResultsTotal nicotine content varied from 0.16 to 34.1 mg/g product, whereas, the calculated unionised nicotine ranged from 0.05 to 31.0 mg/g product; a 620-fold range of variation. Products ranged from pH 5.2 to 10.1, which translates to 0.2% to 99.1% of nicotine being in the unionised form. Some products have very high pH and correspondingly high unionised nicotine (eg, gul powder, chimó, toombak) and/or high TSNA (eg, toombak, zarda, khaini) concentrations. The concentrations of TSNAs spanned five orders of magnitude with concentrations of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) ranging from 4.5 to 516 000 ng/g product.ConclusionsThese data have important implications for risk assessment because they show that very different exposure risks may be posed through the use of these chemically diverse oral tobacco products. Because of the wide chemical variation, oral tobacco products should not be categorised together when considering the public health implications of their use.

ABSTRACT

SummaryBackgroundTobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). We assessed the prevalence of tobacco use among people living with HIV in LMICs.MethodsWe used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. We estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15–59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15–49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. We estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. We computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. We computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals.FindingsThe overall prevalence among HIV-positive men was 24·4% (95% CI 21·1–27·8) for tobacco smoking, 3·4% (1·8–5·6) for smokeless tobacco use, and 27·1% (22·8–31·7) for any tobacco use. We found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 [95% CI 1·26–1·57]) and tobacco smoking (1·46 [1·30–1·65]) than in HIV-negative men (both p<0·0001). The difference in smokeless tobacco use prevalence between HIV-positive and HIV-negative men was not significant (1·26 [1·00–1·58]; p=0·050). The overall prevalence among HIV-positive women was 1·3% (95% CI 0·8–1·9) for tobacco smoking, 2·1% (1·1–3·4) for smokeless tobacco use, and 3·6% (95% CI 2·3–5·2) for any tobacco use. We found a higher prevalence in HIV-positive women of any tobacco use (RR 1·36 [95% CI 1·10–1·69]; p=0·0050), tobacco smoking (1·90 [1·38–2·62]; p<0·0001), and smokeless tobacco use (1·32 [1·03–1·69]; p=0·030) than in HIV-negative women.InterpretationThe high prevalence of tobacco use in people living with HIV in LMICs mandates targeted policy, practice, and research action to promote tobacco cessation and to improve the health outcomes in this population.FundingSouth African Medical Research Council and the UK Medical Research Council.

This study underscores the need for enhanced measures to secure patients' PHI to avoid undermining their trust.