Background and challenges to implementation:
Inadequate attention has been paid to the significant harms arising from smokeless tobacco in Central Asia, both from a public health and regulatory perspective. Nasvai or nas is a finely ground, moistened dipping tobacco product found in Tajikistan, Kazakhstan, Kyrgyzstan, Uzbekistan, Pakistan, Afghanistan, Iran and India. Studies show that nasvai contains high- and varying- levels of nicotine and tobacco specific nitrosamines among other toxic constituents and carcinogens, and increases risks of cancer and cardiovascular disease. In Tajikistan, although cigarette prevalence is low (under 10%), nasvai use is significantly higher (up to 60% among certain populations). As far as we are aware, there are no examples of effective regulatory measures.

Intervention or response:
For the first time, a comprehensive tobacco control law that addresses nasvai use is being developed through a collaborative effort between civil society and the Tajikistan government. The initial draft law proposed regulating nasvai alongside other tobacco products. However, our legal analysis showed that measures developed to address combustible tobacco in the Framework Convention on Tobacco Control (FCTC) may not apply to nasvai regulation.

Results and lessons learnt:
Although some FCTC measures may be effective, we identified significant challenges that necessitate a novel regulatory approach. These include: lack of awareness that nasvai is harmful, or a tobacco product; cultural acceptance of nasvai use; lack of a formal market or industry; and the structure of the cottage industry. We assessed potential risks that could arise from regulation, including inadvertently attracting or creating a formal industry, and of nasvai users switching to combustible products.

Conclusions and key recommendations:
Further research into nasvai content, use and health harms is needed not only to enact much needed regulation, but also to educate target audiences (government, consumers, retailers, health professionals) and to develop cessation services. Our findings will support the development of policies that better address smokeless tobacco use in the region and beyond.