Smokeless tobacco's hidden price: The cultural tradition costing South Asia billions in healthcare

A passion for public health and economics

Subhash’s journey into public health economics was driven by a desire to make a tangible difference in people’s lives. He evaluates public health interventions to work out their health and economic benefits, aiming to provide decision-makers with the best strategies for utilising scarce resources. This passion is fuelled by the potential to influence decisions that can lead to significant health gains and economic returns.

One of the most significant challenges in Subhash’s recent research study is the deep cultural roots of smokeless tobacco use in South Asia.

Subhash

Subhash Pokhrel

Smokeless tobacco is typically chewed or placed between the gum and cheek or lip, rather than being inhaled or burned.

It’s not just a habit; it’s a cultural staple, celebrated at family gatherings and social events. This cultural acceptance makes it difficult for current users to quit, or for those who have, to not start again, as well as for non-users to resist starting altogether. “Our research needed to capture this challenging scenario so we could model the entire lifetime trajectory of this habit,” explains Subhash.

The economic costs associated with smokeless tobacco are staggering. In India alone, the habit costs an estimated 19 billion US dollars annually. To communicate this effectively to policymakers, Subhash translated the figures into relatable terms, emphasising the cost burden on young adolescents to drive home the urgency of policy action.

“We said, if India did not do anything further, each 15-year-old male adolescent would have to contribute INR 1,500 to its national treatment pot to treat diseases caused by smokeless tobacco,” he elaborates.

The study, funded by the UK's National Institute for Health and Care Research and published in the journal Nicotine & Tobacco Research, predicted the lifetime costs of treating four common diseases among smokeless tobacco users: oral, pharyngeal, and oesophageal cancers, and stroke. The researchers developed a Markov-based state-transition model (later named as ASTRAMOD) to estimate these costs and the disability-adjusted life years (DALYs) attributable to current and future smokeless tobacco use in India, Bangladesh, and Pakistan.

The findings revealed that if current policies and their implementation levels stay as they are, the lifetime healthcare costs attributable to smokeless tobacco use would exceed $19 billion in India, $1.5 billion in Bangladesh, and $3 billion in Pakistan. The study highlighted that the greatest health impacts fall on young people who have not yet taken up the habit, emphasising the urgent need for policy changes.

Collaboration and cultural understanding

Subhash’s work stands out not only for its rigorous economic evaluations but also for its emphasis on effective communication with stakeholders. By engaging with service users, decision-makers, and wider stakeholder groups early in the research process, he ensures that his findings are both relevant and actionable. Tools like the NICE Tobacco Control ROI, the EQUIPTMOD, ASTRAMOD and Affordability Calculators are designed to help stakeholders understand the value-for-money arguments behind tobacco control interventions.

The success of Subhash’s research is also a testament to the importance of international and local collaboration. Working with local researchers in South Asia helped pinpoint the specific needs and cultural nuances essential for the study. This collaboration ensured that the research questions were relevant and the findings useful for local policymakers.

Paving the way for a healthier future

Subhash is expanding his research a step further. He aims to explore the cost-effectiveness of interventions to stop smoking in specific sub-populations, such as individuals with significant mental illnesses and those receiving services outside traditional healthcare settings. This next phase of research promises to further enhance our understanding of how to effectively combat tobacco use in diverse contexts.

This study is a powerful example of how understanding cultural nuances and engaging with stakeholders can lead to impactful public health interventions. Subhash’s work not only highlights the health and economic benefits of tobacco control but also underscores the human element, making a compelling case for urgent policy action.

"When I see our findings influencing policies that improve the lives of hundreds, thousands, or even millions of people, it motivates me to keep going."

Subhash Pokhrel

Through his innovative approaches and collaborative efforts, Subhash is paving the way for a healthier future, one informed decision at a time. His commitment to producing practical, impactful research offers hope in the battle against tobacco-related harm, while also addressing the deep cultural roots of smokeless tobacco use.

Learn more about Subhash and his work