Beyond Cigarettes- Insights into Public Knowledge, Attitudes and Patterns of Use of Non-Cigarette Smoked Tobacco Products (NCSTPs): A National Cross-Sectional Study from Pakistan

Beyond Cigarettes- Insights into Public Knowledge, Attitudes and Patterns of Use of Non-Cigarette Smoked Tobacco Products (NCSTPs): A National Cross-Sectional Study from Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Cigarettes- Insights into Public Knowledge, Attitudes and Patterns of Use of Non-Cigarette Smoked Tobacco Products (NCSTPs): A National Cross-Sectional Study from Pakistan Hammad Atif Irshad, Umair Saleem, Hamzah Jehanzeb, Wamiq Ali Shaikh, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4625171/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pakistan has over 30 million active adult smokers, making it one of the most vulnerable low-and middle-income nations. The problem deepens with the popularity of non-cigarette smoked tobacco products (NCSTPs) such as cigars, pipes, and shisha. While studies have been conducted evaluating regular cigarette usage, there is a gap in literature exploring other means of smoked tobacco in these regions. Our study aims to analyze the public’s knowledge, attitudes, and patterns of usage regarding NCSTP. Methods Using an online questionnaire, we conducted a nationwide web-based cross-sectional survey in Pakistan. Convenience sampling was used to disseminate and validate the questionnaire. The participants' knowledge, attitudes, and use of NCSTP were evaluated using this questionnaire. The responses of the participants were described using descriptive statistics, and SPSS Version 26 was used to perform logistic regression at a p-value of less than 0.05. Results In our sample of 1195 respondents with a mean age of 33 years, 93.3% of respondents had heard of NCSTP before with 57.1% believing they contained both tobacco and nicotine. 45.1% disagreed when asked if NCSTP are exclusively for adults. Removal of stress (29.8%) was the most cited motivator for use while negative health effects (61.4%) was the most selected deterrent. The vast majority of respondents (86.6%) who had used NCSTPs were also users of conventional cigarettes. On accounting for demographic and other variables, our regression analysis revealed that appetizing flavors (OR: 1.788, p = 0.006) and usage as cigarette alternatives (OR: 2.623, p = 0.000) were the two factors significantly associated with usage. On the other hand, social stigma (OR: 0.576, p = 0.004), bad taste (OR: 0.663, p = 0.018), and environmental pollution (OR: 0.493, p = 0.000) were the deterrents significantly associated with decreased usage. Conclusion Our findings demonstrate the varied knowledge, attitudes, and usage patterns regarding non-cigarette smoked tobacco products (NCSTP) among participants in an LMIC. Despite a high level of awareness, misconceptions persist regarding their contents and associated risks. While a substantial proportion of the participants have experimented with NCSTPs, the majority have not, citing deterrents such as health concerns and social unacceptability playing significant roles. Notably, the appeal of flavors and the potential for stress relief emerged as the most prevalent motivating factors among users. These insights emphasize the importance of comprehensive strategies aimed at both discouraging use and promoting accurate knowledge about NCSTP. cigar smoked tobacco developing country public health Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Despite increasing public health awareness, consumption of tobacco products is still one of the leading causes of otherwise preventable, and premature deaths worldwide( 1 – 3 ). While cigarette smoking accounts for the predominant form of smoked tobacco consumption, the development and emergence of non-cigarette smoked tobacco products (NCSTP) in the form of bidis, chillum, cigars, water-pipes (hookah), kreteks have been one of the major reasons for the evolving patterns of usage among the regular smokers ( 4 ). While there is proven evidence of the deleterious health effects of various carcinogens found in smoked tobacco, the use of smoked tobacco has only grown exponentially, contributing to significant morbidity and mortality with an estimated 8 million deaths annually by the year 2030 ( 5 – 7 ) The consumption of various types of smoked tobacco products can be categorized geographically; cigarettes and cannabis are used globally while bidis, chillum, and kreteks are predominantly a part of Southeast Asian culture( 8 ). Particularly, in countries like Pakistan, prevalence is fueled not only by addiction but also by cultural norms and societal acceptance of tobacco use in its various forms ( 9 ). Moreover, increasing use of smoked tobacco products can also be attributed to factors like widespread availability, peer pressure, and certain common misconceptions such as hookah being relatively less hazardous than cigarettes ( 10 ). The growing consumption of smoked tobacco products causes health and social dilemmas and imposes a dramatic economic burden. One of the studies estimated a total of $ 3.85 billion smoking-attributable economic cost of all health complications in Pakistan( 11 ). While there is substantial data available highlighting existing behaviors of cigarette smokers as well as the execution of tobacco control measures targeting cigarettes, there is very limited information available from developing countries like Pakistan where the landscape of smoked tobacco consumption is evolving, with newer forms of NCSTP gaining popularity among different demographics ( 12 , 13 ). It is therefore critical to understand people’s perception towards the NCSTP forms to alleviate its consumption at the grassroot level. In addition, although there have been localized studies on NCSTPs( 14 ), a national study is needed to inform public policy. Our comprehensive study aims to fill the existing gap, and understand the public’s perceptions, knowledge, attitudes, and patterns of usage of NCSTP. We believe that findings of this study hold long-term implications to develop targeted interventions aimed at reducing the overall tobacco-related morbidity and mortality through clinical practice, tobacco control initiatives, and public health policies in Pakistan. Methods Study Setting and Population This cross-sectional study was approved by the Aga Khan University Hospital's (AKUH) Ethical Review Committee (ERC) and was conducted throughout Pakistan using an online questionnaire. This questionnaire was intended for adults living in Pakistan who were at least eighteen years old. Data Collection Tool A comprehensive questionnaire was created combining components from the Global Adult Tobacco Surveys (GATs) and other instruments that have previously been used in Pakistan because there was no previous questionnaire appropriate for our designated population ( 15 – 18 ). An independent translator with experience translating questionnaires and fluency in both English and Urdu, the native language of Pakistan, translated the English version of the questionnaire. The questionnaires in Urdu and English were pilot tested with 50 respondents in order to guarantee face validity. Pilot testing involved the use of questionnaires with seven knowledge, twenty-seven attitude, and five usage questions. The internal consistency of each of these domains was assessed by calculating the Cronbach's alpha value, which came out to be 0.8597, 0.9503, and 0.86 for the knowledge, attitudes, and usage domains, respectively. These results showed, in order, good, exceptional, and good consistency. The finalized questionnaire underwent a thorough examination in close collaboration with AKUH faculty members who specialize in tobacco research in the Section of Pulmonary and Critical Care Medicine. Based on the evaluations of two subject matter experts, a content validity index (CVI) for this survey's relevance, essentiality, and clarity was calculated. Davis (1992)( 19 ) determined that a CVI of 0.942, 0.942, and 0.8986 was computed for each of these three values, respectively. The final survey started with a consent form explaining the study and then contained the following four sections: Sociodemographic, Knowledge, Attitudes (with Motivators and Deterrents) and Patterns of Use. Sample Size Calculation The sample size was calculated using OpenEpi( 20 ). According to the Pakistan Demographic and Health Survey 2017-18, the current smoking prevalence among men ages 15–49 is 31.8%( 21 ). Using that statistic, at least 334 participants aged 18 years and above were determined to be recruited. An additional 10% margin of error was taken for a minimum required sample size of 367. Sampling Technique and Data Collection Procedure For this study, both convenience sampling and snowball sampling were used to reach adults across the country, with convenience sampling being our primary technique. Multistage cluster sampling technique was also used. The online questionnaire was shared on social media platforms and circulated from person to person. A questionnaire that was available in Pakistan's official language of Urdu as well as English was used to gather responses. Adults (≥ 18) were asked to complete our questionnaire, which was distributed as a Google Form on private social media networks including Facebook groups and WhatsApp groups. As the data was collected, it was compiled into a Google Sheet. This Google Sheet was password protected and accessible only to members of the research team. Upon completion of data collection, the Google Sheet was downloaded as an Excel sheet, which was password protected. The Google Sheet and individual questionnaire responses were available to the research team for 3 months after data collection was complete, after which they were erased. The data, in the form of the password protected Excel sheet, will be stored for 7 years to meet the requirements of Ethical Review Committee (ERC) audits. Ethical Considerations The Aga Khan University Ethical Review Committee (ERC) granted ethical clearance for our work (ID: 2023-8608-24823). The original form used to acquire informed consent included information about the study's objectives, the participant's right to withdraw from the study at any time, and how the participants' confidentiality would be maintained. The other portions of the questionnaire could be completed by the subject if they consented to participate in the study. In order to protect the participants' privacy, identifiers like names weren't requested. Furthermore, the poll did not capture respondents' emails to preserve anonymity. It was explained to the participants that there are no incentives, dangers, or quick rewards for taking the survey. Statistical Analysis Statistical analyses were run using Statistical Package for Social Sciences (SPSS) version 26. Continuous data such as age was reported using mean and standard deviation. Categorical data consisting of the results of the Likert scales and multiple-choice questions have been reported as frequencies (gross numbers) and percentages (n; %). Logistic regression was used to determine significant motivators and deterrents for use of NCSTPs. A p value < 0.05 was considered statistically significant for all analyses. Results In our research study, we collected data from a total of 1,195 participants ( Supplementary Table 1 ). The mean age of the sample was 33.2 ± 3.7 years, consisting of 41.8% male and 58.2% female participants. Most participants hailed from either of the two most populous provinces, Sindh (42.1%) and Punjab (32.3%). In terms of ethnicity, the largest group was Urdu-speaking (29.3%), followed by Punjabi (22.5%), and Pashtun (17.5%). Participants in our study came from a wide range of socioeconomic backgrounds, with the most common reported monthly income being 100,000–500,000 Rupees (360–1,800 US Dollars) (43.4%), and an additional 42.4% of respondents having a monthly family income of less than 100,000 Rupees (360 US Dollars). Additionally, most participants reported visiting a doctor or healthcare provider 1–2 times in the past 12 months (50.6%). Most participants (93.3%) had heard about smoked products other than cigarettes ( Table 1 ). When asked about the contents of these products, 57.1% believed they contained both nicotine and tobacco, while 25.0% thought they contained only nicotine. Concerning harm perception, 50.7% believed that smoked tobacco is equally harmful as traditional cigarettes, while 24.1% considered it less harmful, and 23.3% considered it more harmful. Notably, 43.3% thought these products were not prohibited by law and 31.2% were unsure if these products were prohibited by law. Perceptions of health-related knowledge of NCSTPs are outlined in Fig. 1 . Regarding health risks, 52.7% strongly agreed that these products can cause serious illnesses like cancer and stroke. Additionally, 41.2% believed these products had added chemicals. Interestingly, the majority either disagreed (36.3%) or strongly disagreed (19.3%) with the statement that occasional use of these products is not addictive or harmful. Lastly, a major proportion, 72.2%, strongly disagreed that these products are safe to use during pregnancy, and 72.1% strongly disagreed that they are safe for individuals with underlying medical conditions such as heart disease, blood pressure, and diabetes. The greatest proportion, 57.0%, responded "Don't know" when asked about the satisfaction level of using smoked tobacco compared to traditional cigarettes. When exploring the attitudes of our participants towards NCSTPs, a major proportion disagreed or strongly disagreed that they make one feel happy (33.6%), young (50.7%), or evoke a sense of shame or guilt (34.3%). Additionally, many also disagreed or strongly disagreed with the notion that these products are exclusively for adults (45.1%) and that health effects are genetic and don't happen to everyone (73.4%). On the other hand, a significant number of participants, 64.0%, believed that more research is needed on these products, while 54.3% agreed or strongly agreed that NCSTPs make one feel unwell. The general attitudes of the public towards NCSTPs are depicted in Fig. 2 . We examined the impact of various motivators on encouraging individuals to consider or pursue smoked tobacco products ( Fig. 3 ) . Among these motivators, the most substantial impact in encouraging their use was their potential to alleviate stress, with 29.8% of participants reporting a significant impact. Additionally, the enjoyable experience offered by NCSTPs had a notable impact on 26.8% of respondents, and the perception that they are easy to acquire influenced 22.8%. The appeal of flavors was also significant, affecting 27.0% of individuals. Furthermore, the absence of offensive odors or pleasant smells was motivating for 26.4% of participants. Social factors played a role, as having friends or family members using these products (26.0%) and the perception of looking "cool" (22.9%) were noted to be significantly impactful for the participants. Positive media portrayals (25.4%) and the perception of being an alternative to cigarettes (24.4%) also significantly contributed to motivation. However, the perception that it makes one look “cool” (51.5%) and the affordability (56.2%) were the only two factors which had no impact on the intent to pursue for a majority of participants. Table 1: General Knowledge regarding NCSTP Variable N(%) Before this survey, had you heard about NCSTPs other than cigarettes? Yes No 1115(93.3) 80(6.7) What do you think is contained in NCSTPs? Nicotine Tobacco Nicotine plus tobacco Neither Other 299(25.0) 149(12.5) 682(57.1) 31(2.6) 34(2.8) How do you think NCSTPs compares to traditional cigarettes? Smoked tobacco is not harmful. Smoked tobacco is less harmful. Smoked tobacco is equally harmful. Smoked tobacco is more harmful. 22(1.8) 288(24.1) 606(50.7) 279(23.3) Do you think NCSTPs are prohibited by law? Yes No Maybe 304(25.4) 518(43.3) 373(31.2) NCSTP: Non Cigarette Smoked Tobacco Product We also assessed the impact of various deterrents on the pursuit of smoked tobacco products ( Fig. 4 ) . Among the deterrents, the most significant impact was attributed to the negative health effects of the product, with 61.4% of participants reporting it had a significant impact in discouraging them. Similarly, the social unacceptability or stigma associated with it had a significant impact on 41.3% of respondents. The cost factor also played a role, with 37.7% indicating that the expense had a significant impact. Negative taste and smell (45.4%), environmental pollution (41.8%), and the potential spread of secondhand smoke to family and friends (45.1%) were other significant deterrents. Additionally, a substantial percentage, 57.5%, expressed that the fear of addiction had a significant impact on discouraging use of these products. Table 2: Usage of NCSTPs N(%) Have you ever used any of these types of smoked tobacco products, even one time? Yes No 366(30.6) 829(69.4) Past Users (N=180) How often did you use NCSTP in the past? Daily Less than daily Weekly 27(15) 144(80) 9(5) Active Users (N=186) How much do you currently spend on it on a weekly basis? Less than Rs 1000 Rs. 1000-2000 Rs. 2000-3000 More than Rs. 3000 72(38.7) 33(17.7) 29(15.6) 52(28.0) What kind of smoked tobacco do you use? [Select all that apply] Manufactured cigarettes Hand-rolled cigarettes Kreteks Pipes full of tobacco Cigars, cheroots, or cigarillos Waterpipes/Shisha/Nargile/Hookah Other 161(86.6) 39(21.0) 17(9.1) 30(16.1) 45(24.2) 146(78.5) 16(8.6) How often do you use NCSTP currently? Daily Less than daily Weekly 60(32.2) 103(55.4) 23(12.4) Do you plan on quitting? Yes 186(100) A total of 30.6% of respondents reported having used smoked products at least once, while the majority (69.4%) had not (Table 2) . Among those who had used these products, the current spending habits varied with most respondents (56.4%) spending less than 2000 Rupees (USD 7.10). In terms of frequency of use, only 32.3% reported daily use. A vast majority of these respondents (86.6%) were also users of traditional manufactured smoked cigarettes. Regarding intentions to quit, all of the respondents planned on quitting. . Table 3: Logistic Regression to Determine Significant Motivators towards Use of Smoked Tobacco Even Once P Value Odds Ratio Easy to acquire Not Impactful Reference Impactful 0.232 1.266 Enjoyable experience Not Impactful Reference Impactful 0.908 1.024 Gets rid of stress Not Impactful Reference Impactful 0.434 0.864 It comes in flavors I like Not Impactful Reference Impactful 0.006 1.788 No offensive odor/smells good Not Impactful Reference Impactful 0.158 1.313 A friend or family member uses them Not Impactful Reference Impactful 0.654 1.088 It makes one look “cool.” Not Impactful Reference Impactful 0.006 0.542 It is positively portrayed in the media/ by a celebrity. Not Impactful Reference Impactful 0.289 0.801 Alternative to cigarettes Not Impactful Reference Impactful 0.000 2.623 It is cheaper than other tobacco products Not Impactful Reference Impactful 0.015 0.587 *Adjusted for Age, Gender, Province, Ethnicity, Marital Status, Level of Education and Monthly Family Income and all Deterring Factors Among significant motivators ( Table 3 ) , appealing flavors (OR: 1.788, p = 0.006) and usage as a cigarette alternative (OR: 2.623, p = 0.000) were the only factor significantly related to an increased odds of consumption of these products. On the other hand, those who found the fact that using these products would make them look “cool” (OR: 0.542, p = 0.006) or the supposedly cheaper price point (OR: 0.587, p = 0.015) as being impactful motivators were significantly less likely to have actually ever used NCSTPs. Among deterring factors (Table 4 ), those who found social stigma (OR: 0.576, p = 0.004), bad taste or smell (OR: 0.663, p = 0.018), and environmental pollution (OR: 0.493, p = 0.000) to be impactful deterring factors were significantly less likely to have ever used NCSTPs. On the other hand, those who found the high price point to be a deterrent were more likely to be users than non-users (OR: 1.687, p = 0.002). Table 4: Logistic Regression to Determine Significant Deterrents towards Use of Smoked Tobacco Even Once P-Value Odds Ratio Negative health effects of product Not Impactful Reference Impactful 0.356 0.850 Not socially acceptable/social stigma Not Impactful Reference Impactful 0.004 0.576 Expensive Not Impactful Reference Impactful 0.002 1.687 Bad taste and/or smell Not Impactful Reference Impactful 0.018 0.663 Environmental pollution Not Impactful Reference Impactful 0.000 0.493 Second hand spread to my family and friends Not Impactful Reference Impactful 0.742 1.063 Do not want to get addicted Not Impactful Reference Impactful 0.534 1.117 Negative portrayal of non-cigarette smoked tobacco in media Not Impactful Reference Impactful 0.061 0.688 Non-cigarette smoked tobacco is difficult to acquire Not Impactful Reference Impactful 0.814 1.048 Opposed by family + friends Not Impactful Reference Impactful 0.561 1.106 *Adjusted for Age, Gender, Province, Ethnicity, Marital Status, Level of Education and Monthly Family Income and all Motivating Factors Discussion Using the data collected through an online survey, we assessed the knowledge, attitude, and usage of the NCSTP in Pakistan. 93.3% of the respondents revealed that they had heard about smoked products other than cigarettes while nearly 30.6% admitted to using them at least once. Among the users who admitted to having used NCSTP, motivating factors included utility in relieving stress and the flavors that they were available in while the frequently reported discouraging factors were negative impact on health and potential of getting addicted. 15.6% of the sample were active users, all of which agreed that they planned on quitting. An overwhelming 85.5% agreed that NCSTP can lead to serious illnesses like cancer and stroke. Various negative health effects are associated with the use of NCSTP. Hyperglycemia, hypertriglyceridemia, low birth weight, and heart rhythm fluctuations are all strongly linked to exposure to shisha smoking. Furthermore, there is an increased risk of cancer, with the lung and pancreas being the most common sites involved( 22 ). The understanding within our respondent population is in line with developed countries such as the United States where a survey found 88% of participants recognize the health risks associated with hookah tobacco, with 69% attributing cardiovascular disease and cancer to its usage ( 23 ). NCSTP has been in use among the public for decades now and an established knowledge base calls for greater investigation into motivators and deterrents to curb usage. Often, it is the public's perception regarding NCSTP's being relatively safer than cigarettes in terms of health effects that contributes to their use. Our study findings indicate that 24.1% of participants believed NCSTPs to be less harmful than cigarettes, although there is limited data from the health authorities to establish this claim( 24 ). This finding echoes the result from prior research, where 34.06% of shisha users shared this misconception ( 25 ). These results indicate the presence of misperceptions surrounding shisha smoking and highlight the pressing need for targeted interventions to address these misconceptions effectively. A different Pakistani survey revealed that the median age at which people started smoking shisha was 20 years old. Shisha smoking was deemed less harmful to health than cigarette smoking by 69% of respondents ( 26 ). 57.1% of the population correctly identified the presence of nicotine and tobacco in NCSTPs. In a crossover study on water-pipes, it was observed that peak nicotine levels in water-pipe tobacco were comparable to those in cigarettes (water-pipe M = 10.2 ng/mL; cigarette M = 10.6 ng/mL), furthermore, the study also revealed that water-pipe smoking produced more CO and greater exposure to smoke thereby posing a similar health hazard as cigarette smoking ( 27 ). Therefore, the health effects are comparable and future interventions should clarify this congruency in impact between the products. Waterpipe smoking was the most popular form of NCSTPs. A population-based systematic review found that waterpipe use was surprisingly high among students and was 33% among Pakistani university students( 28 ). While a 2016 study among medical students in Pakistan found that waterpipe smoking was common and although the majority were aware of its harmful effects, many lacked awareness on legislation( 14 ). It is likely this behavior that started during early years that has led to waterpipe smoking being favored in our public survey. Young people are especially vulnerable to the temptation of water-pipe smoking since it is a pleasant and highly social behavior. as seen in local sheesha bars ( 29 ). As shown in our study, 26% of participants were significantly influenced if their friend or family member used NCSTP. This highlights a concerning pattern of social influence contributing to tobacco consumption across different age groups. Moreover, our study shed light on public awareness of legislation regarding NCSTP. Since 2017, smoking sheesha has been prohibited in Pakistan; nevertheless, the rules have not been effectively enforced, leading to a lack of awareness among the general public ( 30 , 31 ). The inconsistency in policy implementation has contributed to a legal gray area. Surprisingly, only 25.4% of participants in our study were aware of the legal prohibition on NCSTP smoking. This finding resonates with similar research, where many students demonstrated a lack of awareness regarding legislation prohibiting shisha smoking (63.74%), and most were unaware of the consequences of violating such laws (83.9%)( 25 ). These comparative observations underscore a consistent lack of awareness regarding legislation related to shisha use and emphasize the necessity for educational initiatives to enhance public understanding of regulatory frameworks governing shisha consumption. Among significant deterrents, bad taste, environmental pollution and lack of social acceptability resulted in lower odds to use while the expensive nature of the product had greater odds to use. The dislike towards taste is likely attributable to smoked tobacco such as cigars and less likely due to shisha/waterpipe which credits itself on a variety of flavors. Along with social acceptability as a discouraging factor, our findings showed that 41.3% of participants agreed that negative stigma played a role in discouraging their use of NCSTP. Cultural or societal factors may have a greater influence on non-cigarette tobacco product consumers than health risks( 32 ). Literature demonstrates that the stigma surrounding tobacco use can significantly influence behavior ( 33 ). For instance, research has shown that a notable percentage of individuals feel devalued or experience differential treatment due to their smoking habits. These findings underscore the powerful, yet often overlooked, impact of societal attitudes towards smokers( 33 ). In summary, our study indicates that societal attitudes, coupled with concerns about health risks and social stigma, play pivotal roles in shaping individuals' decisions regarding NCSTP use. Addressing these factors is crucial for effective tobacco control efforts and promoting healthier behaviors. The most commonly reported factor discouraging NCSTP use among our participants was negative health effects and risk of getting addicted. It is well-documented in previous studies that negative effects tend to be significant deterrents to tobacco use ( 34 ). Research found that there were numerous substances in water pipe smoke that were identical to those in cigarette smoke, including nicotine, CO, VOCs, and polycyclic aromatic hydrocarbons (PAH), as well as chrysene, phenanthrene, and fluoranthene—the latter of which is known to cause cancer. Although a single aliquot of waterpipe smoke contained less nicotine than a cigarette, the amount of nicotine-free dry particle matter was comparable. It's interesting to note that lead, chromium, and arsenic levels were higher( 35 ). These comparable harmful substances act as major deterrents for water-pipe smoking when properly emphasized as this also underscores the misconception that water-pipe is safer than cigarette smoking. Regarding patterns of use, both past and current users cited use on a weekly basis. More importantly, an increase in daily use from past to current users was seen. This could be due to taxes imposed on cigarettes and other varieties( 36 ), leading to increased selling and use of non-smoked kinds of tobacco. Our motivators analysis echoes the same notion where use as an alternative to cigarettes has been associated These shifts suggest changing patterns in tobacco use behaviors over time, with a reduction in less-than-daily use and an increase in daily consumption indicating a trend towards more frequent consumption of NCSTP among certain segments of the population, as this uptick in daily consumption raises concerns regarding potential increases in dependence and associated health risks. Understanding these trends is crucial for informing targeted interventions aimed at reducing tobacco-related harm and promoting healthier behaviors. Limitations Being an online survey with a closed-ended multiple-choice questionnaire, there were limitations in the responses received, notably there was selection bias where individuals without internet access or those less inclined to engage online may have been excluded from the study. Moreover, our study, being cross-sectional, captured only a single snapshot at a given time, which hindered our ability to explore long-term perceptions and attitudes towards tobacco use. Furthermore, our study was not able to target equal representation across all provinces, especially Azad Kashmir, Balochistan, and Gilgit Baltistan, which have unique socio-cultural dynamics and tobacco use behaviors. This limited our understanding of the broader population's perspectives on tobacco use within these regions. Study Recommendations Being a product which has been in the public space for a long time, the majority of our population is aware of NCSTP. Therefore, future campaigns should address motivators and deterrents to use. To address this targeted education campaigns in age groups where it initially starts such as schools, colleges, universities, and workplaces should be implemented to enhance awareness and understanding of NCSTP. Considering subjective enjoyment as a significant motivator for NCSTP use in our study population, it is imperative to monitor their marketing closely. Additionally, given the observed prevalence of NCSTP use in social gatherings, exploring alternative healthy activities to minimize their consumption becomes crucial. Lastly, taxation has played a crucial role in the curbing of traditional kinds of tobacco and so should be explored for this socially conducted kind- waterpipe/shishas. Conclusion The findings from our study shed light on the varied knowledge, attitudes, and usage patterns regarding non-cigarette smoked tobacco products (NCSTP) among our study population. Despite a high level of awareness, misconceptions persist regarding their contents and harm perception. Furthermore, while a substantial proportion have experimented with NCSTPs, the majority have not, with deterrents such as health concerns and social unacceptability playing significant roles. Notably, the appeal of flavors and the potential for stress relief emerged as motivating factors among users. These insights emphasize the importance of comprehensive strategies aimed at both discouraging use and promoting accurate knowledge about NCSTP. Abbreviations NCSTP: Non-Cigarette Smoked Tobacco Products PAH : Polycyclic Aromatic Hydrocarbons AKUH : Aga Khan University Hospital ERC : Ethical Review Committee GATs: Global Adult Tobacco Surveys CVI: Content Validity Index SPSS: Statistical Package for Social Sciences Declarations Supplementary information None Availability of data and materials Available only on request. Ethics Statement The Aga Khan University Ethical Review Committee (ERC) granted ethical clearance for our work (ID: 2023-8608-24823). This study was conducted in accordance with the Declaration of Helsinki (1975) and its future amendments. Competing interests The authors declare that they have no competing interests. Consent for publication All authors have consented to the publication of the manuscript. Funding None. Acknowledgments The authors would like to thank all participants for their time in filling out the questionnaire and Muhammad Ali Akbar Khan (AKU) for reviewing the final manuscript. Authors’ contributions HAI, and JAK conceptualized the study and, along with NI had major contributions in devising the methodology. US, WAS, SR, and KKR were instrumental in the data collection and recruitment of participants by disseminating the questionnaire, while HAI, HJ, and MAJ were the major contributors in analyzing and interpreting data. HAI, US, and WAS contributed to the initial draft while HAI, HJ and MAJ were major contributors in editing the manuscript. HAI, NI, HJ, WHK, and MAJ authors critically reviewed the results and suggested changes. All authors approved of the final manuscript. References Dai X, Gakidou E, Lopez AD. 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Social and cultural influences on tobacco-related health disparities among South Asians in the USA. Tob Control. 2012 Jul;21(4):422–8. Golan R, Muthigi A, Ghomeshi A, White J, Saltzman RG, Diaz P, et al. Misconceptions of Vaping Among Young Adults. Cureus. 2023 Apr 27; Memon JA, Nasir M, Nayab D, Siddique O, Kishwar S. Economic burden of tobacco use in Pakistan. Tob Control. 2022 Dec 15;tc-2022-057726. Barolia R, Iqbal S, Virani SS, Khan F, Petrucka P. Cigarette smokers’ perceptions of smoking cessation and associated factors in Karachi, Pakistan. Public Health Nurs. 2022 Mar 21;39(2):381–9. Hameed A, Malik D, Mohamed H. Barriers to Cigarette Smoking Cessation in Pakistan: Evidence from Qualitative Analysis. J Smok Cessat. 2021 Jan 1;2021:e4. Zavery A, Qureshi F, Riaz A, Pervez F, Iqbal N, Khan JA. Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan. J Community Health [Internet]. 2017 Jun 1 [cited 2024 Jun 19];42(3):461–5. Available from: https://link.springer.com/article/10.1007/s10900-016-0277-4 WHO [Internet]. Noncommunicable Disease Surveillance, Monitoring and Reporting. Martins RS, Junaid MU, Khan MS, Aziz N, Fazal ZZ, Umoodi M, et al. Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country. BMC Public Health. 2021 Dec 18;21(1):1419. Irfan M, Riaz N, Sirang Z, Haque A, Khan J, Shaikh S. Why do women use tobacco? A cross sectional survey from a developing country. European Respiratory Journal. 2013; Ali NS, Khuwaja AK, Ali T, Hameed R. Smokeless tobacco use among adult patients who visited family practice clinics in Karachi, Pakistan. Journal of Oral Pathology & Medicine. 2009 May 13;38(5):416–21. Davis LL. Instrument review: Getting the most from a panel of experts. Applied Nursing Research. 1992 Nov;5(4):194–7. OpenEpi Menu [Internet]. [cited 2024 Jan 7]. Available from: https://www.openepi.com/Menu/OE_Menu.htm The DHS Program - Pakistan: DHS, 2017-18 - Final Report (English) [Internet]. [cited 2024 Jan 7]. Available from: https://dhsprogram.com/publications/publication-fr354-dhs-final-reports.cfm Aslam H, Saleem S, German S, Qureshi W. Harmful effects of shisha: literature review. Int Arch Med. 2014;7(1):16. Braun RE, Glassman T, Wohlwend J, Whewell A, Reindl DM. Hookah Use Among College Students from a Midwest University. J Community Health. 2012 Apr 31;37(2):294–8. Husain H, Al-Fadhli F, Al-Olaimi F, Al-Duraie A, Qureshi A, Al-Kandari W, et al. Is Smoking Shisha Safer than Cigarettes: Comparison of Health Effects of Shisha and Cigarette Smoking among Young Adults in Kuwait. Medical Principles and Practice. 2016;25(2):117–22. Zavery A, Qureshi F, Riaz A, Pervez F, Iqbal N, Khan JA. Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan. J Community Health. 2017 Jun 17;42(3):461–5. Sameer-ur-Rehman, Sadiq MA, Parekh MA, Zubairi ABS, Frossard PM, Khan JA. Cross-sectional study identifying forms of tobacco used by Shisha smokers in Pakistan. J Pak Med Assoc. 2012 Feb;62(2):192–5. Eissenberg T, Shihadeh A. Waterpipe Tobacco and Cigarette Smoking. Am J Prev Med. 2009 Dec;37(6):518–23. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. BMC Public Health [Internet]. 2011 Apr 19 [cited 2024 Jun 19];11(1):1–12. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-244 Hecht SS, Hatsukami DK. Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention. Nat Rev Cancer. 2022 Mar 3;22(3):143–55. Sheesha smoking. Dawn News [Internet]. 2020 [cited 2024 May 26]; Available from: https://www.dawn.com/news/1528847 Federal govt bans Sheesha smoking across Pakistan. Dawn News [Internet]. 2023 [cited 2024 May 31]; Available from: https://www.nation.com.pk/17-Jan-2023/federal-govt-bans-sheesha-smoking-across-pakistan Saeed S, Khan JA, Iqbal N, Irfan S, Shafique A, Awan S. Cancer and how the patients see it; prevalence and perception of risk factors: a cross-sectional survey from a tertiary care centre of Karachi, Pakistan. BMC Public Health. 2019 Dec 1;19(1):360. Stuber J, Galea S, Link BG. Stigma and Smoking: The Consequences of Our Good Intentions. Social Service Review. 2009 Dec;83(4):585–609. Yang J, Hammond D, Driezen P, Fong GT, Jiang Y. Health knowledge and perception of risks among Chinese smokers and non-smokers: findings from the Wave 1 ITC China Survey. Tob Control. 2010 Oct 1;19(Supplement 2):i18–23. Hecht SS, Hatsukami DK. Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention. Nat Rev Cancer. 2022 Mar 3;22(3):143–55. Masud H, Sekalala S, Gill P, Oyebode O. Critical analysis of tobacco taxation policies in Pakistan after two decades of FCTC: Policy gaps and lessons for low- and middle-income countries. Tob Induc Dis [Internet]. 2023 Nov 24 [cited 2024 Jun 19];21(November):1–14. Available from: https://www.tobaccoinduceddiseases.org/Critical-analysis-of-tobacco-taxation-policies-in-Pakistan-after-two-decades-of-FCTC,173389,0,2.html Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4625171","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321502187,"identity":"38e06223-0bb7-4573-a600-ce8d7103d6a1","order_by":0,"name":"Hammad Atif Irshad","email":"","orcid":"","institution":"Medical College, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Hammad","middleName":"Atif","lastName":"Irshad","suffix":""},{"id":321502188,"identity":"9c5b5d02-296c-4e2c-ab17-b1c1e56abfa5","order_by":1,"name":"Umair Saleem","email":"","orcid":"","institution":"Medical College, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Umair","middleName":"","lastName":"Saleem","suffix":""},{"id":321502189,"identity":"ea7f3b54-8baa-4188-b71f-85bad3f53e77","order_by":2,"name":"Hamzah Jehanzeb","email":"","orcid":"","institution":"Medical College, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Hamzah","middleName":"","lastName":"Jehanzeb","suffix":""},{"id":321502190,"identity":"2339bf85-5896-43b7-acab-e1e4d3b55d40","order_by":3,"name":"Wamiq Ali Shaikh","email":"","orcid":"","institution":"Medical College, Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Wamiq","middleName":"Ali","lastName":"Shaikh","suffix":""},{"id":321502192,"identity":"8aa86c6c-5877-441c-8f51-68932c72846a","order_by":4,"name":"Sajjan Raja","email":"","orcid":"","institution":"Medical College, Aga Khan 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Khan University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Javaid","middleName":"Ahmed","lastName":"Khan","suffix":""}],"badges":[],"createdAt":"2024-06-23 12:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4625171/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4625171/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60619967,"identity":"6d20fcfa-5822-4943-ac1c-67edacf9b230","added_by":"auto","created_at":"2024-07-18 20:47:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":231663,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHealth-related knowledge of the public towards NCSTPs\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/5515666511cd0c074df368a9.png"},{"id":60619970,"identity":"abbb1b94-37c3-43f4-a74e-439080f5ed90","added_by":"auto","created_at":"2024-07-18 20:47:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":358207,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGeneral Attitudes towards NCSTPs\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/71778a2e3a6c1a8e91f0e9d3.png"},{"id":60619969,"identity":"e809a7a0-6c57-4be0-a590-543522418bdc","added_by":"auto","created_at":"2024-07-18 20:47:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":327278,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFactors motivating NCSTP use among respondents.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/756d8c0de8d43679dc5df6a8.png"},{"id":60619972,"identity":"ccebbd87-53b5-4a01-a3e2-a8ad55ea52b5","added_by":"auto","created_at":"2024-07-18 20:47:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":325409,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFactors deterring NCSTP use among respondents.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/2dcdd77228728da60114ff81.png"},{"id":72839403,"identity":"2e32935c-66d1-4082-98e1-ad10b8c60df1","added_by":"auto","created_at":"2025-01-02 17:31:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2222751,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/01b7ae6c-4372-4d64-8624-ab4e8425cd97.pdf"},{"id":60620877,"identity":"643c9df8-6262-480f-ace4-4a7c8d6f3eb1","added_by":"auto","created_at":"2024-07-18 20:55:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17647,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4625171/v1/1f757330c673e04ce3da0d0c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Cigarettes- Insights into Public Knowledge, Attitudes and Patterns of Use of Non-Cigarette Smoked Tobacco Products (NCSTPs): A National Cross-Sectional Study from Pakistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite increasing public health awareness, consumption of tobacco products is still one of the leading causes of otherwise preventable, and premature deaths worldwide(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While cigarette smoking accounts for the predominant form of smoked tobacco consumption, the development and emergence of non-cigarette smoked tobacco products (NCSTP) in the form of bidis, chillum, cigars, water-pipes (hookah), kreteks have been one of the major reasons for the evolving patterns of usage among the regular smokers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile there is proven evidence of the deleterious health effects of various carcinogens found in smoked tobacco, the use of smoked tobacco has only grown exponentially, contributing to significant morbidity and mortality with an estimated 8\u0026nbsp;million deaths annually by the year 2030 (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe consumption of various types of smoked tobacco products can be categorized geographically; cigarettes and cannabis are used globally while bidis, chillum, and kreteks are predominantly a part of Southeast Asian culture(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Particularly, in countries like Pakistan, prevalence is fueled not only by addiction but also by cultural norms and societal acceptance of tobacco use in its various forms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Moreover, increasing use of smoked tobacco products can also be attributed to factors like widespread availability, peer pressure, and certain common misconceptions such as hookah being relatively less hazardous than cigarettes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe growing consumption of smoked tobacco products causes health and social dilemmas and imposes a dramatic economic burden. One of the studies estimated a total of \u003cspan\u003e$\u003c/span\u003e3.85\u0026nbsp;billion smoking-attributable economic cost of all health complications in Pakistan(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). While there is substantial data available highlighting existing behaviors of cigarette smokers as well as the execution of tobacco control measures targeting cigarettes, there is very limited information available from developing countries like Pakistan where the landscape of smoked tobacco consumption is evolving, with newer forms of NCSTP gaining popularity among different demographics (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). It is therefore critical to understand people\u0026rsquo;s perception towards the NCSTP forms to alleviate its consumption at the grassroot level.\u003c/p\u003e \u003cp\u003eIn addition, although there have been localized studies on NCSTPs(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), a national study is needed to inform public policy. Our comprehensive study aims to fill the existing gap, and understand the public\u0026rsquo;s perceptions, knowledge, attitudes, and patterns of usage of NCSTP. We believe that findings of this study hold long-term implications to develop targeted interventions aimed at reducing the overall tobacco-related morbidity and mortality through clinical practice, tobacco control initiatives, and public health policies in Pakistan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting and Population\u003c/h2\u003e \u003cp\u003e This cross-sectional study was approved by the Aga Khan University Hospital's (AKUH) Ethical Review Committee (ERC) and was conducted throughout Pakistan using an online questionnaire. This questionnaire was intended for adults living in Pakistan who were at least eighteen years old.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Tool\u003c/h2\u003e \u003cp\u003eA comprehensive questionnaire was created combining components from the Global Adult Tobacco Surveys (GATs) and other instruments that have previously been used in Pakistan because there was no previous questionnaire appropriate for our designated population (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). An independent translator with experience translating questionnaires and fluency in both English and Urdu, the native language of Pakistan, translated the English version of the questionnaire.\u003c/p\u003e \u003cp\u003eThe questionnaires in Urdu and English were pilot tested with 50 respondents in order to guarantee face validity. Pilot testing involved the use of questionnaires with seven knowledge, twenty-seven attitude, and five usage questions. The internal consistency of each of these domains was assessed by calculating the Cronbach's alpha value, which came out to be 0.8597, 0.9503, and 0.86 for the knowledge, attitudes, and usage domains, respectively. These results showed, in order, good, exceptional, and good consistency.\u003c/p\u003e \u003cp\u003eThe finalized questionnaire underwent a thorough examination in close collaboration with AKUH faculty members who specialize in tobacco research in the Section of Pulmonary and Critical Care Medicine. Based on the evaluations of two subject matter experts, a content validity index (CVI) for this survey's relevance, essentiality, and clarity was calculated. Davis (1992)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) determined that a CVI of 0.942, 0.942, and 0.8986 was computed for each of these three values, respectively.\u003c/p\u003e \u003cp\u003eThe final survey started with a consent form explaining the study and then contained the following four sections: Sociodemographic, Knowledge, Attitudes (with Motivators and Deterrents) and Patterns of Use.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample Size Calculation\u003c/h2\u003e \u003cp\u003eThe sample size was calculated using OpenEpi(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). According to the Pakistan Demographic and Health Survey 2017-18, the current smoking prevalence among men ages 15\u0026ndash;49 is 31.8%(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Using that statistic, at least 334 participants aged 18 years and above were determined to be recruited. An additional 10% margin of error was taken for a minimum required sample size of 367.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSampling Technique and Data Collection Procedure\u003c/h2\u003e \u003cp\u003eFor this study, both convenience sampling and snowball sampling were used to reach adults across the country, with convenience sampling being our primary technique. Multistage cluster sampling technique was also used. The online questionnaire was shared on social media platforms and circulated from person to person.\u003c/p\u003e \u003cp\u003eA questionnaire that was available in Pakistan's official language of Urdu as well as English was used to gather responses. Adults (\u0026ge;\u0026thinsp;18) were asked to complete our questionnaire, which was distributed as a Google Form on private social media networks including Facebook groups and WhatsApp groups.\u003c/p\u003e \u003cp\u003eAs the data was collected, it was compiled into a Google Sheet. This Google Sheet was password protected and accessible only to members of the research team. Upon completion of data collection, the Google Sheet was downloaded as an Excel sheet, which was password protected. The Google Sheet and individual questionnaire responses were available to the research team for 3 months after data collection was complete, after which they were erased. The data, in the form of the password protected Excel sheet, will be stored for 7 years to meet the requirements of Ethical Review Committee (ERC) audits.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e The Aga Khan University Ethical Review Committee (ERC) granted ethical clearance for our work (ID: 2023-8608-24823). The original form used to acquire informed consent included information about the study's objectives, the participant's right to withdraw from the study at any time, and how the participants' confidentiality would be maintained. The other portions of the questionnaire could be completed by the subject if they consented to participate in the study. In order to protect the participants' privacy, identifiers like names weren't requested. Furthermore, the poll did not capture respondents' emails to preserve anonymity. It was explained to the participants that there are no incentives, dangers, or quick rewards for taking the survey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were run using Statistical Package for Social Sciences (SPSS) version 26. Continuous data such as age was reported using mean and standard deviation. Categorical data consisting of the results of the Likert scales and multiple-choice questions have been reported as frequencies (gross numbers) and percentages (n; %). Logistic regression was used to determine significant motivators and deterrents for use of NCSTPs. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn our research study, we collected data from a total of 1,195 participants (\u003cstrong\u003eSupplementary Table\u0026nbsp;1\u003c/strong\u003e). The mean age of the sample was 33.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 years, consisting of 41.8% male and 58.2% female participants. Most participants hailed from either of the two most populous provinces, Sindh (42.1%) and Punjab (32.3%). In terms of ethnicity, the largest group was Urdu-speaking (29.3%), followed by Punjabi (22.5%), and Pashtun (17.5%). Participants in our study came from a wide range of socioeconomic backgrounds, with the most common reported monthly income being 100,000\u0026ndash;500,000 Rupees (360\u0026ndash;1,800 US Dollars) (43.4%), and an additional 42.4% of respondents having a monthly family income of less than 100,000 Rupees (360 US Dollars). Additionally, most participants reported visiting a doctor or healthcare provider 1\u0026ndash;2 times in the past 12 months (50.6%).\u003c/p\u003e\n\u003cp\u003eMost participants (93.3%) had heard about smoked products other than cigarettes (\u003cstrong\u003eTable\u0026nbsp;1\u003c/strong\u003e). When asked about the contents of these products, 57.1% believed they contained both nicotine and tobacco, while 25.0% thought they contained only nicotine. Concerning harm perception, 50.7% believed that smoked tobacco is equally harmful as traditional cigarettes, while 24.1% considered it less harmful, and 23.3% considered it more harmful. Notably, 43.3% thought these products were not prohibited by law and 31.2% were unsure if these products were prohibited by law.\u003c/p\u003e\n\u003cp\u003ePerceptions of health-related knowledge of NCSTPs are outlined in Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e. Regarding health risks, 52.7% strongly agreed that these products can cause serious illnesses like cancer and stroke. Additionally, 41.2% believed these products had added chemicals. Interestingly, the majority either disagreed (36.3%) or strongly disagreed (19.3%) with the statement that occasional use of these products is not addictive or harmful. Lastly, a major proportion, 72.2%, strongly disagreed that these products are safe to use during pregnancy, and 72.1% strongly disagreed that they are safe for individuals with underlying medical conditions such as heart disease, blood pressure, and diabetes.\u003c/p\u003e\n\u003cp\u003eThe greatest proportion, 57.0%, responded \u0026quot;Don\u0026apos;t know\u0026quot; when asked about the satisfaction level of using smoked tobacco compared to traditional cigarettes. When exploring the attitudes of our participants towards NCSTPs, a major proportion disagreed or strongly disagreed that they make one feel happy (33.6%), young (50.7%), or evoke a sense of shame or guilt (34.3%). Additionally, many also disagreed or strongly disagreed with the notion that these products are exclusively for adults (45.1%) and that health effects are genetic and don\u0026apos;t happen to everyone (73.4%). On the other hand, a significant number of participants, 64.0%, believed that more research is needed on these products, while 54.3% agreed or strongly agreed that NCSTPs make one feel unwell. The general attitudes of the public towards NCSTPs are depicted in Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eWe examined the impact of various motivators on encouraging individuals to consider or pursue smoked tobacco products \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Among these motivators, the most substantial impact in encouraging their use was their potential to alleviate stress, with 29.8% of participants reporting a significant impact. Additionally, the enjoyable experience offered by NCSTPs had a notable impact on 26.8% of respondents, and the perception that they are easy to acquire influenced 22.8%. The appeal of flavors was also significant, affecting 27.0% of individuals. Furthermore, the absence of offensive odors or pleasant smells was motivating for 26.4% of participants. Social factors played a role, as having friends or family members using these products (26.0%) and the perception of looking \u0026quot;cool\u0026quot; (22.9%) were noted to be significantly impactful for the participants. Positive media portrayals (25.4%) and the perception of being an alternative to cigarettes (24.4%) also significantly contributed to motivation. However, the perception that it makes one look \u0026ldquo;cool\u0026rdquo; (51.5%) and the affordability (56.2%) were the only two factors which had no impact on the intent to pursue for a majority of participants.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: General Knowledge regarding NCSTP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003cp\u003eN(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore this survey, had you heard about NCSTPs other than cigarettes?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e1115(93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e80(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat do you think is contained in NCSTPs? \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Nicotine\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Tobacco\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Nicotine plus tobacco\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Neither\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e299(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e149(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e682(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e31(2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e34(2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow do you think NCSTPs\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecompares\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;to traditional cigarettes? \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSmoked\u0026nbsp;tobacco is not harmful.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Smoked\u0026nbsp;tobacco is less harmful.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Smoked\u0026nbsp;tobacco is equally harmful.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Smoked\u0026nbsp;tobacco is more harmful.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e22(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e288(24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e606(50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e279(23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you think\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNCSTPs are\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eprohibited by law?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Maybe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e304(25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e518(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e373(31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNCSTP: Non Cigarette Smoked Tobacco Product\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWe also assessed the impact of various deterrents on the pursuit of smoked tobacco products \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Among the deterrents, the most significant impact was attributed to the negative health effects of the product, with 61.4% of participants reporting it had a significant impact in discouraging them. Similarly, the social unacceptability or stigma associated with it had a significant impact on 41.3% of respondents. The cost factor also played a role, with 37.7% indicating that the expense had a significant impact. Negative taste and smell (45.4%), environmental pollution (41.8%), and the potential spread of secondhand smoke to family and friends (45.1%) were other significant deterrents. Additionally, a substantial percentage, 57.5%, expressed that the fear of addiction had a significant impact on discouraging use of these products.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Usage of NCSTPs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003cp\u003eN(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you ever used any of these types of smoked\u0026nbsp;tobacco products, even one time?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e366(30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e829(69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePast Users (N=180)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often did you use NCSTP in the past?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDaily\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLess than daily\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eWeekly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003cp\u003e27(15)\u003c/p\u003e\n \u003cp\u003e144(80)\u003c/p\u003e\n \u003cp\u003e9(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eActive Users (N=186)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow much do you currently spend on it on a weekly basis?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLess than Rs 1000\u003c/p\u003e\n \u003cp\u003eRs. 1000-2000\u003c/p\u003e\n \u003cp\u003eRs. 2000-3000\u003c/p\u003e\n \u003cp\u003eMore than Rs. 3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e72(38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e33(17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e29(15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e52(28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat kind of smoked tobacco do you use? [Select all that apply]\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eManufactured cigarettes\u003c/p\u003e\n \u003cp\u003eHand-rolled cigarettes\u003c/p\u003e\n \u003cp\u003eKreteks\u003c/p\u003e\n \u003cp\u003ePipes full of tobacco\u003c/p\u003e\n \u003cp\u003eCigars, cheroots, or cigarillos\u003c/p\u003e\n \u003cp\u003eWaterpipes/Shisha/Nargile/Hookah\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003cp\u003e161(86.6)\u003c/p\u003e\n \u003cp\u003e39(21.0)\u003c/p\u003e\n \u003cp\u003e17(9.1)\u003c/p\u003e\n \u003cp\u003e30(16.1)\u003c/p\u003e\n \u003cp\u003e45(24.2)\u003c/p\u003e\n \u003cp\u003e146(78.5)\u003c/p\u003e\n \u003cp\u003e16(8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you use NCSTP currently?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003cp\u003eLess than daily\u003c/p\u003e\n \u003cp\u003eWeekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e60(32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e103(55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e23(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.2182985553772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you plan on quitting?\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.781701444622794%\" valign=\"top\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"184\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"bottom\"\u003e\n \u003cp\u003e186(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA total of 30.6% of respondents reported having used smoked products at least once, while the majority (69.4%) had not \u003cstrong\u003e(Table\u0026nbsp;2)\u003c/strong\u003e. Among those who had used these products, the current spending habits varied with most respondents (56.4%) spending less than 2000 Rupees (USD 7.10). In terms of frequency of use, only 32.3% reported daily use. A vast majority of these respondents (86.6%) were also users of traditional manufactured smoked cigarettes. Regarding intentions to quit, all of the respondents planned on quitting.\u003c/p\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"679\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLogistic Regression to Determine Significant Motivators towards Use of Smoked Tobacco Even Once\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003eP Value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.091310751104565%\" valign=\"top\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEasy to acquire\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnjoyable experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.908\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGets rid of stress\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIt comes in flavors I like\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo offensive odor/smells good\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.313\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eA friend or family member uses them\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIt makes one look \u0026ldquo;cool.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.542\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIt is positively portrayed in the media/ by a celebrity.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.801\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlternative to cigarettes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e2.623\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIt is cheaper than other tobacco products\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.015\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e*Adjusted for Age, Gender, Province, Ethnicity, Marital Status, Level of Education and Monthly Family Income and all Deterring Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong significant motivators \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e, appealing flavors (OR: 1.788, p\u0026thinsp;=\u0026thinsp;0.006) and usage as a cigarette alternative (OR: 2.623, p\u0026thinsp;=\u0026thinsp;0.000) were the only factor significantly related to an increased odds of consumption of these products. On the other hand, those who found the fact that using these products would make them look \u0026ldquo;cool\u0026rdquo; (OR: 0.542, p\u0026thinsp;=\u0026thinsp;0.006) or the supposedly cheaper price point (OR: 0.587, p\u0026thinsp;=\u0026thinsp;0.015) as being impactful motivators were significantly less likely to have actually ever used NCSTPs.\u003c/p\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cp\u003eAmong deterring factors (Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e), those who found social stigma (OR: 0.576, p\u0026thinsp;=\u0026thinsp;0.004), bad taste or smell (OR: 0.663, p\u0026thinsp;=\u0026thinsp;0.018), and environmental pollution (OR: 0.493, p\u0026thinsp;=\u0026thinsp;0.000) to be impactful deterring factors were significantly less likely to have ever used NCSTPs. On the other hand, those who found the high price point to be a deterrent were more likely to be users than non-users (OR: 1.687, p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"679\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLogistic Regression to Determine Significant Deterrents towards Use of Smoked Tobacco Even Once\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003eP-Value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.091310751104565%\" valign=\"top\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative health effects of product\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot socially acceptable/social stigma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpensive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.687\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBad taste and/or smell\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.663\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvironmental pollution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.493\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond hand spread to my family and friends\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo not want to get addicted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative portrayal of non-cigarette smoked tobacco in media\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-cigarette smoked tobacco is difficult to acquire\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.09720176730486%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpposed by family + friends\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.440353460972016%\" valign=\"top\"\u003e\n \u003cp\u003eNot Impactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.46244477172312%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.0655737704918%\" valign=\"top\"\u003e\n \u003cp\u003eImpactful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003e0.561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e1.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e*Adjusted for Age, Gender, Province, Ethnicity, Marital Status, Level of Education and Monthly Family Income and all Motivating Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing the data collected through an online survey, we assessed the knowledge, attitude, and usage of the NCSTP in Pakistan. 93.3% of the respondents revealed that they had heard about smoked products other than cigarettes while nearly 30.6% admitted to using them at least once. Among the users who admitted to having used NCSTP, motivating factors included utility in relieving stress and the flavors that they were available in while the frequently reported discouraging factors were negative impact on health and potential of getting addicted. 15.6% of the sample were active users, all of which agreed that they planned on quitting.\u003c/p\u003e \u003cp\u003eAn overwhelming 85.5% agreed that NCSTP can lead to serious illnesses like cancer and stroke. Various negative health effects are associated with the use of NCSTP. Hyperglycemia, hypertriglyceridemia, low birth weight, and heart rhythm fluctuations are all strongly linked to exposure to shisha smoking. Furthermore, there is an increased risk of cancer, with the lung and pancreas being the most common sites involved(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The understanding within our respondent population is in line with developed countries such as the United States where a survey found 88% of participants recognize the health risks associated with hookah tobacco, with 69% attributing cardiovascular disease and cancer to its usage (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). NCSTP has been in use among the public for decades now and an established knowledge base calls for greater investigation into motivators and deterrents to curb usage.\u003c/p\u003e \u003cp\u003eOften, it is the public's perception regarding NCSTP's being relatively safer than cigarettes in terms of health effects that contributes to their use. Our study findings indicate that 24.1% of participants believed NCSTPs to be less harmful than cigarettes, although there is limited data from the health authorities to establish this claim(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This finding echoes the result from prior research, where 34.06% of shisha users shared this misconception (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These results indicate the presence of misperceptions surrounding shisha smoking and highlight the pressing need for targeted interventions to address these misconceptions effectively. A different Pakistani survey revealed that the median age at which people started smoking shisha was 20 years old. Shisha smoking was deemed less harmful to health than cigarette smoking by 69% of respondents (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e57.1% of the population correctly identified the presence of nicotine and tobacco in NCSTPs. In a crossover study on water-pipes, it was observed that peak nicotine levels in water-pipe tobacco were comparable to those in cigarettes (water-pipe M\u0026thinsp;=\u0026thinsp;10.2 ng/mL; cigarette M\u0026thinsp;=\u0026thinsp;10.6 ng/mL), furthermore, the study also revealed that water-pipe smoking produced more CO and greater exposure to smoke thereby posing a similar health hazard as cigarette smoking (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Therefore, the health effects are comparable and future interventions should clarify this congruency in impact between the products.\u003c/p\u003e \u003cp\u003eWaterpipe smoking was the most popular form of NCSTPs. A population-based systematic review found that waterpipe use was surprisingly high among students and was 33% among Pakistani university students(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). While a 2016 study among medical students in Pakistan found that waterpipe smoking was common and although the majority were aware of its harmful effects, many lacked awareness on legislation(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is likely this behavior that started during early years that has led to waterpipe smoking being favored in our public survey.\u003c/p\u003e \u003cp\u003eYoung people are especially vulnerable to the temptation of water-pipe smoking since it is a pleasant and highly social behavior. as seen in local sheesha bars (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). As shown in our study, 26% of participants were significantly influenced if their friend or family member used NCSTP. This highlights a concerning pattern of social influence contributing to tobacco consumption across different age groups.\u003c/p\u003e \u003cp\u003eMoreover, our study shed light on public awareness of legislation regarding NCSTP. Since 2017, smoking sheesha has been prohibited in Pakistan; nevertheless, the rules have not been effectively enforced, leading to a lack of awareness among the general public (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The inconsistency in policy implementation has contributed to a legal gray area. Surprisingly, only 25.4% of participants in our study were aware of the legal prohibition on NCSTP smoking. This finding resonates with similar research, where many students demonstrated a lack of awareness regarding legislation prohibiting shisha smoking (63.74%), and most were unaware of the consequences of violating such laws (83.9%)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These comparative observations underscore a consistent lack of awareness regarding legislation related to shisha use and emphasize the necessity for educational initiatives to enhance public understanding of regulatory frameworks governing shisha consumption.\u003c/p\u003e \u003cp\u003eAmong significant deterrents, bad taste, environmental pollution and lack of social acceptability resulted in lower odds to use while the expensive nature of the product had greater odds to use. The dislike towards taste is likely attributable to smoked tobacco such as cigars and less likely due to shisha/waterpipe which credits itself on a variety of flavors.\u003c/p\u003e \u003cp\u003eAlong with social acceptability as a discouraging factor, our findings showed that 41.3% of participants agreed that negative stigma played a role in discouraging their use of NCSTP. Cultural or societal factors may have a greater influence on non-cigarette tobacco product consumers than health risks(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Literature demonstrates that the stigma surrounding tobacco use can significantly influence behavior (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). For instance, research has shown that a notable percentage of individuals feel devalued or experience differential treatment due to their smoking habits. These findings underscore the powerful, yet often overlooked, impact of societal attitudes towards smokers(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In summary, our study indicates that societal attitudes, coupled with concerns about health risks and social stigma, play pivotal roles in shaping individuals' decisions regarding NCSTP use. Addressing these factors is crucial for effective tobacco control efforts and promoting healthier behaviors.\u003c/p\u003e \u003cp\u003eThe most commonly reported factor discouraging NCSTP use among our participants was negative health effects and risk of getting addicted. It is well-documented in previous studies that negative effects tend to be significant deterrents to tobacco use (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Research found that there were numerous substances in water pipe smoke that were identical to those in cigarette smoke, including nicotine, CO, VOCs, and polycyclic aromatic hydrocarbons (PAH), as well as chrysene, phenanthrene, and fluoranthene\u0026mdash;the latter of which is known to cause cancer. Although a single aliquot of waterpipe smoke contained less nicotine than a cigarette, the amount of nicotine-free dry particle matter was comparable. It's interesting to note that lead, chromium, and arsenic levels were higher(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These comparable harmful substances act as major deterrents for water-pipe smoking when properly emphasized as this also underscores the misconception that water-pipe is safer than cigarette smoking.\u003c/p\u003e \u003cp\u003eRegarding patterns of use, both past and current users cited use on a weekly basis. More importantly, an increase in daily use from past to current users was seen. This could be due to taxes imposed on cigarettes and other varieties(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), leading to increased selling and use of non-smoked kinds of tobacco. Our motivators analysis echoes the same notion where use as an alternative to cigarettes has been associated\u003c/p\u003e \u003cp\u003eThese shifts suggest changing patterns in tobacco use behaviors over time, with a reduction in less-than-daily use and an increase in daily consumption indicating a trend towards more frequent consumption of NCSTP among certain segments of the population, as this uptick in daily consumption raises concerns regarding potential increases in dependence and associated health risks. Understanding these trends is crucial for informing targeted interventions aimed at reducing tobacco-related harm and promoting healthier behaviors.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eBeing an online survey with a closed-ended multiple-choice questionnaire, there were limitations in the responses received, notably there was selection bias where individuals without internet access or those less inclined to engage online may have been excluded from the study. Moreover, our study, being cross-sectional, captured only a single snapshot at a given time, which hindered our ability to explore long-term perceptions and attitudes towards tobacco use. Furthermore, our study was not able to target equal representation across all provinces, especially Azad Kashmir, Balochistan, and Gilgit Baltistan, which have unique socio-cultural dynamics and tobacco use behaviors. This limited our understanding of the broader population's perspectives on tobacco use within these regions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy Recommendations\u003c/h2\u003e \u003cp\u003eBeing a product which has been in the public space for a long time, the majority of our population is aware of NCSTP. Therefore, future campaigns should address motivators and deterrents to use. To address this targeted education campaigns in age groups where it initially starts such as schools, colleges, universities, and workplaces should be implemented to enhance awareness and understanding of NCSTP. Considering subjective enjoyment as a significant motivator for NCSTP use in our study population, it is imperative to monitor their marketing closely. Additionally, given the observed prevalence of NCSTP use in social gatherings, exploring alternative healthy activities to minimize their consumption becomes crucial. Lastly, taxation has played a crucial role in the curbing of traditional kinds of tobacco and so should be explored for this socially conducted kind- waterpipe/shishas.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings from our study shed light on the varied knowledge, attitudes, and usage patterns regarding non-cigarette smoked tobacco products (NCSTP) among our study population. Despite a high level of awareness, misconceptions persist regarding their contents and harm perception. Furthermore, while a substantial proportion have experimented with NCSTPs, the majority have not, with deterrents such as health concerns and social unacceptability playing significant roles. Notably, the appeal of flavors and the potential for stress relief emerged as motivating factors among users. These insights emphasize the importance of comprehensive strategies aimed at both discouraging use and promoting accurate knowledge about NCSTP.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eNCSTP:\u0026nbsp;\u003c/strong\u003eNon-Cigarette Smoked Tobacco Products\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePAH\u003c/strong\u003e: Polycyclic Aromatic Hydrocarbons\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAKUH\u003c/strong\u003e: Aga Khan University Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eERC\u003c/strong\u003e: Ethical Review Committee\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGATs:\u0026nbsp;\u003c/strong\u003eGlobal Adult Tobacco Surveys\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;CVI:\u0026nbsp;\u003c/strong\u003eContent Validity Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;SPSS:\u0026nbsp;\u003c/strong\u003eStatistical Package for Social Sciences\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailable only on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Aga Khan University Ethical Review Committee (ERC) granted ethical clearance for our work (ID: 2023-8608-24823). This study was conducted in accordance with the Declaration of Helsinki (1975) and its future amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have consented to the publication of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants for their time in filling out the questionnaire and Muhammad Ali Akbar Khan (AKU) for reviewing the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHAI, and JAK conceptualized the study and, along with NI had major contributions in devising the methodology. US, WAS, SR, and KKR were instrumental in the data collection and recruitment of participants by disseminating the questionnaire, while HAI, HJ, and MAJ were the major contributors in analyzing and interpreting data. HAI, US, and WAS contributed to the initial draft while HAI, HJ and MAJ were major contributors in editing the manuscript. HAI, NI, HJ, WHK, and MAJ authors critically reviewed the results and suggested changes. All authors approved of the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDai X, Gakidou E, Lopez AD. Evolution of the global smoking epidemic over the past half century: strengthening the evidence base for policy action. Tob Control [Internet]. 2022 Mar 1 [cited 2024 Jun 19];31(2):129\u0026ndash;37. Available from: https://tobaccocontrol.bmj.com/content/31/2/129\u003c/li\u003e\n\u003cli\u003eSzymański J, Ostrowska A, Pinkas J, Giermaziak W, Krzych-Fałta E, Jankowski M. 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J Community Health. 2012 Apr 31;37(2):294\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHusain H, Al-Fadhli F, Al-Olaimi F, Al-Duraie A, Qureshi A, Al-Kandari W, et al. Is Smoking Shisha Safer than Cigarettes: Comparison of Health Effects of Shisha and Cigarette Smoking among Young Adults in Kuwait. Medical Principles and Practice. 2016;25(2):117\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eZavery A, Qureshi F, Riaz A, Pervez F, Iqbal N, Khan JA. Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan. J Community Health. 2017 Jun 17;42(3):461\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eSameer-ur-Rehman, Sadiq MA, Parekh MA, Zubairi ABS, Frossard PM, Khan JA. Cross-sectional study identifying forms of tobacco used by Shisha smokers in Pakistan. J Pak Med Assoc. 2012 Feb;62(2):192\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eEissenberg T, Shihadeh A. Waterpipe Tobacco and Cigarette Smoking. Am J Prev Med. 2009 Dec;37(6):518\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eAkl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. BMC Public Health [Internet]. 2011 Apr 19 [cited 2024 Jun 19];11(1):1\u0026ndash;12. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-244\u003c/li\u003e\n\u003cli\u003eHecht SS, Hatsukami DK. Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention. Nat Rev Cancer. 2022 Mar 3;22(3):143\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eSheesha smoking. Dawn News [Internet]. 2020 [cited 2024 May 26]; Available from: https://www.dawn.com/news/1528847\u003c/li\u003e\n\u003cli\u003eFederal govt bans Sheesha smoking across Pakistan. Dawn News [Internet]. 2023 [cited 2024 May 31]; Available from: https://www.nation.com.pk/17-Jan-2023/federal-govt-bans-sheesha-smoking-across-pakistan\u003c/li\u003e\n\u003cli\u003eSaeed S, Khan JA, Iqbal N, Irfan S, Shafique A, Awan S. Cancer and how the patients see it; prevalence and perception of risk factors: a cross-sectional survey from a tertiary care centre of Karachi, Pakistan. BMC Public Health. 2019 Dec 1;19(1):360. \u003c/li\u003e\n\u003cli\u003eStuber J, Galea S, Link BG. Stigma and Smoking: The Consequences of Our Good Intentions. Social Service Review. 2009 Dec;83(4):585\u0026ndash;609. \u003c/li\u003e\n\u003cli\u003eYang J, Hammond D, Driezen P, Fong GT, Jiang Y. Health knowledge and perception of risks among Chinese smokers and non-smokers: findings from the Wave 1 ITC China Survey. Tob Control. 2010 Oct 1;19(Supplement 2):i18\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eHecht SS, Hatsukami DK. Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention. Nat Rev Cancer. 2022 Mar 3;22(3):143\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eMasud H, Sekalala S, Gill P, Oyebode O. Critical analysis of tobacco taxation policies in Pakistan after two decades of FCTC: Policy gaps and lessons for low- and middle-income countries. Tob Induc Dis [Internet]. 2023 Nov 24 [cited 2024 Jun 19];21(November):1\u0026ndash;14. Available from: https://www.tobaccoinduceddiseases.org/Critical-analysis-of-tobacco-taxation-policies-in-Pakistan-after-two-decades-of-FCTC,173389,0,2.html\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cigar, smoked tobacco, developing country, public health","lastPublishedDoi":"10.21203/rs.3.rs-4625171/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4625171/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePakistan has over 30\u0026nbsp;million active adult smokers, making it one of the most vulnerable low-and middle-income nations. The problem deepens with the popularity of non-cigarette smoked tobacco products (NCSTPs) such as cigars, pipes, and shisha. While studies have been conducted evaluating regular cigarette usage, there is a gap in literature exploring other means of smoked tobacco in these regions. Our study aims to analyze the public\u0026rsquo;s knowledge, attitudes, and patterns of usage regarding NCSTP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing an online questionnaire, we conducted a nationwide web-based cross-sectional survey in Pakistan. Convenience sampling was used to disseminate and validate the questionnaire. The participants' knowledge, attitudes, and use of NCSTP were evaluated using this questionnaire. The responses of the participants were described using descriptive statistics, and SPSS Version 26 was used to perform logistic regression at a p-value of less than 0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn our sample of 1195 respondents with a mean age of 33 years, 93.3% of respondents had heard of NCSTP before with 57.1% believing they contained both tobacco and nicotine. 45.1% disagreed when asked if NCSTP are exclusively for adults. Removal of stress (29.8%) was the most cited motivator for use while negative health effects (61.4%) was the most selected deterrent. The vast majority of respondents (86.6%) who had used NCSTPs were also users of conventional cigarettes. On accounting for demographic and other variables, our regression analysis revealed that appetizing flavors (OR: 1.788, p\u0026thinsp;=\u0026thinsp;0.006) and usage as cigarette alternatives (OR: 2.623, p\u0026thinsp;=\u0026thinsp;0.000) were the two factors significantly associated with usage. On the other hand, social stigma (OR: 0.576, p\u0026thinsp;=\u0026thinsp;0.004), bad taste (OR: 0.663, p\u0026thinsp;=\u0026thinsp;0.018), and environmental pollution (OR: 0.493, p\u0026thinsp;=\u0026thinsp;0.000) were the deterrents significantly associated with decreased usage.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings demonstrate the varied knowledge, attitudes, and usage patterns regarding non-cigarette smoked tobacco products (NCSTP) among participants in an LMIC. Despite a high level of awareness, misconceptions persist regarding their contents and associated risks. While a substantial proportion of the participants have experimented with NCSTPs, the majority have not, citing deterrents such as health concerns and social unacceptability playing significant roles. Notably, the appeal of flavors and the potential for stress relief emerged as the most prevalent motivating factors among users. These insights emphasize the importance of comprehensive strategies aimed at both discouraging use and promoting accurate knowledge about NCSTP.\u003c/p\u003e","manuscriptTitle":"Beyond Cigarettes- Insights into Public Knowledge, Attitudes and Patterns of Use of Non-Cigarette Smoked Tobacco Products (NCSTPs): A National Cross-Sectional Study from Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:47:36","doi":"10.21203/rs.3.rs-4625171/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5f9d654-d012-4819-8dae-26527104cd75","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-02T17:23:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:47:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4625171","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4625171","identity":"rs-4625171","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}