Supply chain actors' willingness to switch the business of smokeless tobacco: a mixed-methods study on Naswar business in Pakistan.

INTRODUCTION Provision of alternate livelihoods to smokeless tobacco (SLT) supply chain (SC) actors can help in curtailing SLT business and its consumption. We explored the reasons for SC actors' engagement in Naswar (SLT used in South Asia) business and their willingness to switch to other alternatives. METHODS We conducted an equal-status concurrent mixed-methods study in four districts of Khyber Pakhtunkhwa province of Pakistan. We surveyed 286 general points of sale (GPOS) and exclusive Naswar (EN) vendors through multistage cluster sampling. Additionally, we interviewed 15 tobacco farmers interpretively, being distinct from other SC actors. We assessed the association between vendors' willingness to switch and their awareness about tobacco-harms, profit margin, Naswar as a family business, length of business, education-level and shop-type using logistic regression. Qualitative data assessed the farmer's viable alternatives to switch and was analyzed using deductive-inductive thematic analysis. RESULTS Product demand-77% and profit margins-75% were the main drivers for selling SLT by EN vendors. Half of the GPOS and 25% EN vendors expressed willingness to stop Naswar's sale. Vendors aware of tobacco-harms were more willing to switch, but less likely to switch if Naswar was perceived to bring "good-profit". Farmers were mainly cultivating tobacco because of profitability, family-run farm, and perceived land-suitability for tobacco. Lack of government support was main constraint for farmers looking to switch. CONCLUSION A considerable portion of Naswar SC actors in Pakistan are willing to switch to viable alternatives, with profitability of alternatives, support from authorities, and social obligations as key considerations in doing so. IMPLICATIONS This study highlights that good profit margins in the Naswar business, lack of awareness of tobacco-related health harms, and absence of the Government's support are key detriments to switching to alternative businesses among Naswar supply chain actors in Pakistan. These findings are the first to come out in the context of both Pakistan and Naswar product, making a case for policy interventions focusing on tax increases, awareness campaigns about tobacco-harms, and a pro-active role by the government to provide support for the security of livelihoods to those tobacco supply chain actors who want to switch to other alternatives.