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Addressing smokeless tobacco and building research capacity in South Asia

ASTRA is a world-class, international and interdisciplinary group, aiming to reduce the substantial burden of disease caused by smokeless tobacco. Smokeless tobacco is responsible for thousands of deaths per year, but has so far been neglected in policy and research. ASTRA’s international teams will carry out policy research and develop interventions to address the problems caused by smokeless tobacco use in South Asia. Our focus is on Bangladesh, India and Pakistan, where 80% of the world’s 300 million smokeless tobacco users live, and where the most harmful types of smokeless tobacco are favoured. ASTRA is a three-year programme, with a budget of £2M. Dr Subhash Pokhrel and Ms Kathryn Coyle from Health Economics Theme are leading Economics study within ASTRA with an aim to quantify the healthcare costs of smokeless tobacco use in Bangladesh, India and Pakistan.

Aims of ASTRA:

  • To gather evidence about how the policies recommended by the WHO-FCTC are being developed and implemented for smokeless tobacco in LMICs. This part of the programme will focus on young people, since 90% of ST users start their habit during adolescence.
  • To develop and evaluate interventions, such as behavioural support or medicines, to help adult ST users to quit.
  • To build capacity, by training research teams at LMIC institutions to conduct high quality applied health research in Bangladesh, Pakistan and India.
  • To use this capacity to support wider tobacco control efforts in the South Asia region.

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Meet the Principal Investigator(s) for the project

Professor Subhash Pokhrel
Professor Subhash Pokhrel - Subhash Pokhrel, PhD is a professor of health economics and the Lead, Health Economics Research Group (HERG). Most recently, he was the Head of Department of Health Sciences (2018-2023), an academic department comprising allied health professions, nursing, social work, health economics and public health. Prior to that, he was the Founding Divisional Lead of (now) the Division of Global Public Health (2016-18). From 2013-16, he developed and led a large-scale, multi-country (n=11), multi-disciplinary research project, EQUIPT, providing European policymakers with the decision-support evidence and tools around tobacco control.  In addition to the UK and EU, Subhash has research experience in several low- and middle-income countries (LMICs) including Nepal, India, Bangladesh, Pakistan, Burkina Faso, Ghana, Brazil and Indonesia. Working together with the World Health Organisation, Subhash co-designed and is currently leading the implementation of the WHO-Brunel Framework Agreement to strengthen National Health Research Systems (NHRSs), particularly in LMICs.      Subhash's research is focussed on two complementary themes: supporting 'health systems' to deliver efficient healthcare as well as strengthening 'health research systems' to support more research into healthcare. As such, his research has contributed to several public health policies. The two REF2021 impact case studies - Supporting tobacco control decision making for improved health and economic productivity and Informing policies and debates on breastfeeding promotion describe Subhash's approach to developing a programme of research and generate significant impact from them. His learning about how researchers can engage with and support goverments and wider stakeholders to make investment decisions in public health is underpinned by his and colleagues' earlier work around the suite of NICE Public Health ROI Tools. These ROI tools provided the basis for many public health investment decisions in England and were informed by the work on tobacco control led by Subhash. The ROI tools are practical, customisable models to help make real-world decisions in context of local, regional and national government decision-making. Economic arguments are needed to make the business case for public health investments. Subhash led the roll out of ROI work to several European nations through a €2 million multi-centre European Commission funded study, EQUIPT. He has been the coordinator of a large scale inter-disciplinary collaboration of national and international expertise. Subhash is the lead author of a book, ROI in Public Health Policy: Supporting Decision Making (Palgrave Macmillan). Subhash’s work in public health research has been as diverse as the discipline itself – from developing a household decision making pathway for child health care in low- and middle income countries (LMICs) to quantifying the economic impact of breastfeeding promotion in industrialised countries; from evaluating health insurance for its population health impact in LMICs to finding out what interventions could improve physical activity globally. His doctoral researchers have investigated whether integrated care models, particularly in a local area in England, are effective; what determines obesity in West Africa and particularly the role of physical activity and dietary habits to reduce obesity among adults in Ghana; and what the correlates of COVID-19 hospitalisations and long-COVID in Ghana were. His visiting student from Sri Lanka has investigated the economics of physical activity in LMICs. Such research evidence, particularly in LMICs, is key to developing and evaluating public health measures for their value for money.   Subhash is intrigued not only by "health systems" questions (e.g. In LMICs and industrialised countries, what works to improve population health outcomes and at what cost?) but also by "health research systems" questions. Subhash worked with the WHO Euro to review the evidence on policies, interventions and tools for establishing and/or strengthening national health research systems and their effectiveness. In particular, Subhash and colleagues have investigated the extent of integration of research (particularly economic evaluations) into policymaking in Spain and what implications the Spanish experience could have globally for strenthening both systems. As a member of various external committees (NICE Technology Appraisal, NIHR PGfAHR and SPI-B), Subhash has contributed to decision making processes around funding of medical technologies, research in applied health, and behavioural measures to tackle public health emergencies.        Google Profile Orcid Profile ResearchGate BURA Profile

Related Research Group(s)


Health Economics (HERG) - Our strategic focus is on economic evaluation and systematic reviews of a broad range of clinical and health service technologies by providing high-quality, applied, policy-relevant research, as well as developing and refining methods to increase the rigour and relevance of such studies.

Partnering with confidence

Organisations interested in our research can partner with us with confidence backed by an external and independent benchmark: The Knowledge Exchange Framework. Read more.

Project last modified 02/10/2023