Policy perspective on the global use of Smokeless Tobacco (ST): a literature review

Background Globally, Smokeless Tobacco (ST) is consumed by over 300 million people. ST is addictive and most products cause cancers of the oral cavity, pharynx and oesophagus. The aim of this review was to identify knowledge gaps in the implementation of key demand-reduction measures with regard to ST. Methods A series of focused literature reviews was conducted and findings were synthesized by relevant Articles (6 - 14) of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Results We found sufficient evidence to support implementation of key demand-reduction measures for ST. For example, raising taxes can reduce ST consumption, with price elasticity on a par with, or sometimes higher than, cigarettes. Similarly, graphic pictorial warnings on ST packaging are far more effective than text-only warning labels. But despite supportive evidence, countries have either not implemented measures or have kept the bar much lower than that for cigarettes. For example, very few countries regulate the contents of ST products. Some have raised ST taxes but not to the extent of cigarette taxes, risking product substitution. Similarly, health-warning requirements for ST are less strict than those for cigarettes. Even where strong policies exist, compliance has been poor. For example, despite bans on ST advertising, most suppliers continue to promote products, especially at points of sale and via print and digital media. Consequently, ST demand-reduction measures have had limited impact. Conclusions The full implementation of FCTC Articles 6-14 is likely to reduce the global demand for ST, but their current state of implementation lags behind that for cigarettes. The existing policy gaps can be addressed through better knowledge of ST products, setting unambiguous standards, innovative systems for tax administration, building capacity in testing ST products and undertaking targeted research