BACKGROUND: Smokeless tobacco (SLT) use is highly prevalent in India, posing a significant public health threat. This study aimed to develop a framework for prioritizing hazardous SLT constituents based on toxicity, attractiveness, and addictiveness to inform regulatory policies.
METHODS: A comprehensive database of SLT constituents was compiled through a literature review (2005-2024) adhering to PRISMA guidelines, encompassing PubMed, Scopus, and Web of Science databases. The review integrated recommendations from the WHO Study Group on Tobacco Product Regulation, IARC monographs, and the US FDA's list of harmful and potentially harmful constituents. A multidisciplinary expert panel (n=24) evaluated 120 identified constituents using a structured digital evaluation form and a 10-point Likert scale. Constituent prioritization was conducted using the Analytic Hierarchy Process, equally weighting toxicity, addictiveness, and attractiveness criteria.
RESULTS: The analysis identified over 120 hazardous SLT constituents, including 65 classified as carcinogenic by the IARC (5 Group 1, 10 Group 2A, and 24 Group 2B). Nicotine emerged as the highest priority constituent (priority vector = 0.218), followed by tobacco-specific nitrosamines NNN (0.187) and NNK (0.167), and heavy metals lead (0.165), cadmium (0.162), and arsenic (0.158). Strong inter-rater agreement was observed across all criteria (Kendall's W = 0.83, p < 0.001), with a particularly high consensus for toxicity assessments (W = 0.88).
CONCLUSIONS: This evidence-based prioritization framework provides a crucial tool for advancing SLT regulation in India by identifying key constituents requiring monitoring and control. Policy recommendations include mandatory disclosure of priority chemicals on product packaging, establishing maximum permissible limits for priority toxicants, developing a network of accredited testing laboratories, and implementing standardized testing protocols aligned with WHO FCTC Articles 9 and 10. These measures aim to mitigate SLT-related morbidity and mortality through enhanced tobacco product regulation.