Knowledge, attitudes, practices, and prevalence of nicotine pouches in Pakistan: where do we stand?

INTRODUCTION

Nicotine pouches (NPs) are a relatively new type of oral smokeless tobacco-free nicotine product. NPs are small receptacles that contain white nicotine powder which a user places in between upper lip and gum, leaving nicotine to release.¹ These products are sold as pre-portioned pouches similar to snus, but instead of containing tobacco leaf, these are filled with white nicotine-containing powder extracted from tobacco leaves.² NPs are sold in a variety of fruit (e.g., black cherry, citrus) and other (e.g., peppermint, coffee) flavors, and vary in nicotine content per pouch (e.g., Dryft: 2 mg and 7 mg; Velo: 2 mg and 4 mg; Lyft: 4 mg and 6 mg).³ Companies use product descriptors such as “tobacco-free” or “tobacco leaf-free” in product marketing which has surely contributed towards an increasing trend in consumption as they are new, and large companies are branding them as safe to use but without any evidence.

Studies conducted at a global level to assess the prevalence of smokeless tobacco and nicotine products show a rising trend in consumption. A survey conducted among 121 countries in 2015 reported that there were 352 million users (351.9 million) in 121 countries and nearly 95% (333.1 million) of these lived in developing countries especially in south-east Asia region.^4,5 Similarly, the studies in Europe have been showing similar rising trends in smokeless tobacco and nicotine consumption. Sweden reported an increase of 10-fold in consumption which was significantly higher than the rest of Europe with more prevalence observed in males than in females.⁶ The use of nicotine and smokeless tobacco products in Asian countries such as India, Bangladesh, Sri Lanka, and China have also shown an upward trend in the recent years.^7-9 Over 22 million people in Pakistan also smoke tobacco.¹⁰ NPs are being marketed as an alternative nicotine delivery system to assist in quitting smoking. A study using a cross sectional survey with 351 undergraduate students from rural India showed that reasons for using smokeless tobacco and nicotine products included a desire to stop using tobacco cigarettes (29.51%).¹¹ Furthermore, studies conducted in Pakistan also show that nicotine products are becoming a mainstream trend as alternates for the conventional cigarette smoking.^12,13 However, the studies conducted in Pakistan are very few, and limited to small population sizes with paucity of nationwide studies. Many factors have been seen to influence the use of smokeless tobacco and nicotine products and result in the increased global, regional, and local prevalence rates.

The widespread marketing and increasing consumption of NPs such as VELO due to availability in wide range of flavours and be able to use discreetly, has perhaps appealed to the youth and the young adults. In addition to their adverse effects and the potential to cause dependence, there lies paucity of evidence of KAP of NPs from developing nations like Pakistan. Our study aimed to assess knowledge, attitude, practices, and prevalence of use of NPs among Pakistani population. Having data from various cities will lead us to determine the cities with highest prevalence of use of NPs and hence allow for targeted interventions to reduce the use of NPs in those specific cities. Moreover, being the first study done across Pakistan and targeting the general population without any other restrictions, it will give a numerical prevalence of NPs in the country which is still unknown and will provide a benchmark for future research on the topic.

METHODS

Study design and setting

This study was conducted in the general population of Pakistan during March to May 2022, as a cross-sectional study using an anonymous web-based survey after obtaining permission from Ethical Review Committee of the Aga Khan University, Karachi, Pakistan (reference ID: 2021-6362-18200). A non-probability purposive sampling technique was used to collect the data. The questionnaire was produced by using google forms and was spread on various internet forums in both English and Urdu language to address the language barrier during data collection. The study included people residing in various provinces, cities, states, and districts of Pakistan, irrespective of age, having internet access and access to the link of the Google form, and were willing to give consent were included in this study.

Study instrument and data collection

A pre-validated KAP questionnaire was modified slightly according to the topic and was administered as an online form.¹⁴ All data collected via the Google forms was stored in the Google drive protected by password, which was only accessible by the principal investigator and co-investigators. Each participant was given an auto generated code number in order to maintain privacy. A pilot study in 50 participants was conducted to ensure clarity and compliance, following which necessary changes were made accordingly and these responses were discarded.

The questionnaire was administered in both English and Urdu language. Consent from adults and parental consent and assent from minors was taken before filling out the questionnaire. The questionnaire had five sections. The first section consisted of sociodemographic variables; age, gender, marital status, province, occupation, income, and education. The second section was past medical history and the third, fourth and fifth sections collected data on knowledge, attitude, and practices respectively. The knowledge and attitude responses were converted to scores and were accumulated to measure the final scores. In the knowledge sections, 6 questions were scored. The respondents were given score of 1 for agreeing with the statement and 0 for not agreeing or choosing I don’t know. The total maximum score for the knowledge section was 6 and the cut off for adequate knowledge was kept at a score of ≥4. Similarly in the attitude part, 8 questions were scored, the total maximum score for attitude section was 8 and the cut off for negative attitude was kept at a score of ≥5. Negative attitude is considered as people disliking and considering NPs to be as harmful.

Data analysis and sample size

A minimum sample of 1051 individuals were required to carry out the study successfully. Sample size was calculated via Openepi software with a 95% significance level, 2% absolute precision and an anticipated prevalence of NP users ranging from 9.4% to 11.2%.^5,15 Data from the Google forms was converted to an Excel Spreadsheet from where statistical analysis was conducted using SPSS version 26. Continuous data was represented as means and standard deviation, whereas categorical data was represented as frequencies and proportions. Descriptive analysis was performed to assess the prevalence and sociodemographic factors of the study population. Univariate analysis was performed to establish any relationship between the exposure variables (sociodemographic factors) and the outcome variables (KAP scores). Independent T-test/Mann-Whitney test was performed to find any association between all exposure and outcome variables. Pearson correlation test was used to assess any correlation between age, total knowledge, and attitude scores. A p value of less than 0.05 was treated as significant.

RESULTS

Socio-demographic characteristics

A total of 1749 responses were collected in the study. Among these, 1078 (61.6%) were female and 671 (38.4%) were male. The age of the respondents ranged between 13-56 years with a mean (SD) age of 20.6 (3.6) years. The majority of the respondents belonged to Punjab (58.7%) province followed by Sindh (27.6%). The household income was greater than 60,000 Pakistani rupees (PKR) for 41.9% of the participants. Table 1 shows detailed distribution of socio demographic variables.

Medical and smoking background

Among the 1749 participants, 7.1% respondents reported a diagnosis of hypertension while 6.6% reported having asthma. Almost 40% of the participants reported a previously diagnosed psychiatric illness while 53.2% believed themselves to be currently under stress (Table 1).

Knowledge, attitude and practices related to NPs

The knowledge section had a total of 6 marks and 686 (39.22%) people were considered to have adequate knowledge (scored ≥4) regarding NPs. Around 10.0% of people scored zero while 97 (5.54%) people scored the maximum score of 6. The mean score for knowledge of the respondents was 3.001. Most of the respondents knew what NPs through the internet or friends as their sources of information. Most of them knew that this causes addiction and potentially have long term health consequences. However, majority (68.0%) was not aware of the ingredients of NPs, as shown in Table 2.

The attitude section had a total of 8 marks and 879 (50.26%) people had a score of ≥5 and were categorized into people having a negative towards NPs i.e. disliking and considering NPs to be as harmful. The mean score for the attitude of the participants was 4.75. Majority of the participants thought that either psychological factors (37.5%) or the urge to quit smoking (38.4) makes people start using NPs and 57.2% people believe NPs might be slightly effective in assisting cessation of smoking. In contrast to this, 34% of the respondents believe they are equally addictive and 26.5% think they are equally harmful to health when compared to cigarettes. Around 63.0% people admitted they will never try NPs even if a friend offers them and 1475 (84.3%) people say they will never promote or recommend it to anyone, as shown in Table 2.

For practices regarding NPs, 300 (17.2%) participants reported using nicotine products at least once in their life and the mean age at which they tried it was 20.3 (4.3) years. The rest of the respondents who never tried NPs, 80.4% of them were not interested and 1.7% preferred cigarettes. Among the users, 164 (54.7) were current users of NPs and 41.4% of these users were daily users. Most of these users started using NPs either to quit conventional cigarette smoking (n=53, 32.3%) or out of curiosity (n=28, 17.1%) for the new product. Cigarette smoking alongside NPs was also recorded (n=70) and more than half of these individuals described a reduction in smoking habits but statistically no difference observed in median (IQR) cigarettes used before and after the start of NPs use (median=3, IQR=2-6), as shown in Table 2.

Univariate and multivariate analysis

A univariate analysis was conducted for knowledge and attitude scores with the demographic and medical history variables, as shown in Table 3. Most demographic variables were significant for knowledge scores except marital status and medical history. The people in the age group 23-25 and 20-22 years had 2.22 times and 1.12 times, respectively, more adequate knowledge when compared to people under the age of 20 years. People currently not under any kind of stress had 1.27 times more adequate knowledge regarding NPs when compared to people under stress. For attitude scores only monthly income and province of the respondent were significant variables. Lower income and belonging to Balochistan and KPK was associated with a negative attitude towards NPs.

A multivariate analysis for significant variables in univariate was conducted, as shown in Table 4. Gender (p<0.001), province (p=0.01), education (p<0.001), and monthly income (p=0.001) had a significant association with Knowledge scores. Male participants had 1.76 times more adequate knowledge than the females. For province, when compared to Punjab the people living in Sindh had 0.29 times less knowledge regarding NPs. People with a master’s degree or above had 2.18 times more adequate knowledge when compared to school going children. All the categories of monthly income, as shown in Table 3, had significant association with adequate knowledge when compared to people earning more than 60,000 PKR, except for people earning between 22,500-30,000 PKR. For multivariate analysis of attitude scores (Table 5), only province (p=0.17) and monthly income were significant (p=0.18). People residing in Sindh had 1.34 times more negative attitude towards NPs when compared to people residing in Punjab. People earning between 9000-15,000 PKR had 1.60 times more negative attitude when compared to people earning more than 60,000 PKR.

DISCUSSION

NPs have recently been launched in the Pakistani market with the introduction of ‘Velo’ in 2019 and until now there have been very few studies conducted on this product to investigate its harmful effects and the public’s opinion and their practices.¹⁶ There is a sudden upsurge in the advertisements and free of cost distribution of NPs in various cities across Pakistan. This trend is similar to the one that was once observed in the early 1900s when cigarettes were being advertised extensively in an attempt to make them socially acceptable. There is little information available about the safety and contents of NPs, and yet they are being endorsed by various influential institutions and social media platforms. The lack of anti-narcotic campaigns has led to a delusional perception among the general population that NPs are safe to use and help in smoking cessation, however, there is no scientific evidence to support this. The current study reported 17.2% prevalence of NPs among the Pakistani population and 54.7% of these users were actively using NPs regularly. This prevalence is higher than the prevalence noted in a previous study from year 2021 on NPs from Pakistan.¹⁷ This shows a rising trend in NP use across the country. This can potentially be explained by the unethical marketing practices; companies are promoting them as safe; their campaign is unregulated by the government and the national celebrities are promoting this product on social media without checking its safety. Free samples are being provided to youngsters without checking any proof of age to promote the product.^18,19 Due to such unregulated campaigns, the public is getting the perception that these are safe alternatives when in reality the harmful effects can include gum diseases, cavities, cancers of the oral cavity, and a higher risk of heart disease and stroke.

The mean score of knowledge and attitude towards NPs was 3.001 and 4.75, respectively. Both the scores were lower than the cut offs decided (at least 50% score) for adequate knowledge and negative attitude. This is consistent with previous studies on alternate nicotine delivery systems in Pakistan.²⁰ Low knowledge regarding NPs and the unsolicited notion that these can serve as an alternative to smoking cessation, as is evident by the growing percentage of concurrent smoking and NP use, indicates a high probability for NPs to become a threat to our youth in terms of widespread use of a harmful product. Higher monthly income was found to be associated with a negative attitude towards NPs. The use of NPs has been linked to being ‘cool’ and has widely been endorsed by celebrities. The main source of awareness regarding NPs are television and social media. Therefore, it is not surprising that the upper class are endorsing the product more given the price range of a nicotine pouch pack ranging from Rs. 600/- to Rs. 1100/-.

NPs brands such as ‘Velo’ are increasingly available for sale across Pakistan. A study conducted by the Institute for Global Tobacco Control showed that 22% of tobacco vendors across 8 cities of Pakistan had ‘Velo’ products displayed at their stores and 13% of tobacco vendors had advertisements for ‘Velo’ posted at their point-of-sale.¹⁷ The Pakistan National Heart Association (PANAH) strongly appealed the government to curb the increasing addiction of NPs in the youth stating that it contained harmful chemicals that can cause heart ailments, cancer, kidney diseases, or stunted growth.^21,22 Therefore, it is imperative to take measures to address the rising issue of NPs addiction amongst our youth.

Our study recruited a large sample size and was the first study to assess the use and KAP of NPs at a national level. However, it had some limitations. The sample size is acceptably large but might not be enough to be representative of the entire Pakistani population, including unequal responses from all provinces of the country, the findings require cautious interpretation and generalization. Also, information bias and selection bias cannot be eliminated in a web-based study. Moreover, due to the cross-sectional design of the study, the temporal relationship cannot be studied. However, future research in this area can make use of perspective and longitudinal designs to establish temporal associations. The participants were approached through convenience sampling through online forms and as a result most of the participants were from the younger age group. As per a survey by Pakistan Telecommunication Authority, around 63% of the 76 million internet users in Pakistan, belong to the ages between 20 and 25 years.²³ The survey also included the educated class with most of the respondents currently in inter/A levels (57.2%); this can potentially overestimate knowledge and attitudes of Pakistan’s population.

CONCLUSION

Data from our study shows a 10.0% prevalence of current NP consumption among our youth with below adequate knowledge regarding their ingredients. Furthermore, our study shows contradicts the perception that NPs help in smoking cessation. There is little data available regarding the safety of NPs, and considering the increasing trends of its use, our study highlights the need for country-wide interventions to prevent this trend from becoming an addiction through education and regulated distribution.

ACKNOWLEDGEMENTS

Special thanks to Abdullah Khattak for his participation in the broadcasting of the google link during the data collection process. He is no more with us but we would like to honor his memory by acknowledging his contribution to the project. His hard work in collecting the data made a significant impact on the project. His efforts will always be remembered and appreciated.

We would also like to thank Ms Safia Awan in helping us analyzing and organizing the data and formulating the final results tables.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of the Aga Khan University, Karachi, Pakistan (Reference ID: 2021-6362-18200)

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