Award Title: NIHR Global Health Research Group on Addressing Smokeless Tobacco and building Research capacity in south Asia (ASTRA) at the University of York
Funder: Department of Health and Social Care

Abstract: Smokeless tobacco (ST) refers to tobacco products that are consumed without being burnt.  Smokeless tobacco has historically been assumed to be less harmful than cigarettes; however, most ST products are highly addictive and are known to cause cancers of the mouth, pharynx and oesophagus, as well as leading to cardiovascular deaths and pregnancy problems._x000D_
The types of ST used worldwide vary greatly and products used in South Asia usually contain higher levels of cancer-producing chemicals than those used in Europe and the US. There are 300 million ST users in the world, with the vast majority (85%) living in South Asia. Despite almost 350,000 people dying every year due to ST-related cancers and other diseases, ST remains largely neglected by policy makers and researchers. Policies to reduce tobacco use are mainly based on research carried out on cigarettes and/or in high-income countries. Furthermore, most South Asian institutions do not have enough researchers or funds to carry out high quality research in this area. Based on the principles of equality and respect, we have set up ASTRA; a collaboration begun in 2018 between six leading UK universities, a WHO Global Knowledge Hub on ST and six institutions in Bangladesh, India and Pakistan. ASTRA is conducting world-class research to prevent ST-related deaths in South Asia. Our research is providing information on how to prevent young people from starting to use ST and how to help adults to stop using it. ASTRA is also helping to train and support new and existing researchers in South Asia, now and in the future. ASTRA’s research activities are guided by talking to stakeholders (people who will be affected by our research, including ST users, health workers, and policymakers). _x000D_
We have organised our activities into five work-streams, as follows: 1. ASTRA-Youth; assessing the impact of tobacco control policies on uptake of ST in adolescents: 2. ASTRA-Sellers; examining the implementation of tobacco control policies in the ST supply chain: 3. ASTRA-Cessation; evaluating interventions to help adults to quit ST: 4. ASTRA-Policy; measuring gaps in ST control policies, to inform policy makers; and 5. ASTRA- Economics; estimating the economic impact of ST use. Scientific evidence from the above studies will provide a sound basis for policy recommendations to improve ST control. Another key feature of ASTRA is to enhance capacity in applied health research in South Asia, and use this capacity to support wider tobacco control efforts in this region._x000D_
Since ASTRA began, we have set ourselves up as a strong international team, able to deliver world-class research on ST. Despite the global pandemic, our research studies are progressing well and we have been granted a one-year extension to enable us to complete them fully, and to maximise the impacts of our research. We have already published 14 articles and a factsheet, and launched a video to raise awareness of ST. We have also put ourselves in a good position to be able to apply successfully for Unit status and new funding for further large-scale studies.

Lay Abstract: The University of York (henceforth York) has an excellent research reputation and a vision to become a global leader in research - its key strategic objective. In its strategic plan (2014-2020), York is committed to expand its research activity and continue to build its international alliances and collaborations. The strategy states Research excellence defines York and further strengthening and improving our research, to be dynamic, inspirational and life-changing in its impact, is an absolute priority. Ranked 28th for International Outlook in the latest THE World University Rankings, York is ideally placed to respond to the global challenges of our time. York's seven research themes (https://www.york.ac.uk/research/themes/), including health and well-being, align its academic strengths with both the United Nation's sustainability goals and the four strategic objectives of the UK Aid Strategy (gov.uk). York's response to the Global Challenges Research Fund (GCRF) is ambitious. Supported by several recent grants (e.g. GCRF, European Union [EU], Research Councils UK [RCUK], Wellcome Trust) and strategic investments (posts, research office support, pump-prime funding), York's research in international development is thriving. Recently, York was successful in securing several GCRF grants in the fields of global health histories, tobacco control, environment, agriculture, human rights and biology. Consequently, York's researchers are already in partnership with communities across the global South and are addressing some of the world's most pressing health, environmental and social challenges. York has created a vibrant and multidisciplinary International Development Network (https://www.york.ac.uk/idn/). York has recently made a strategic investment by creating a Centre for Global Development, which will bring academics from different disciplines together to create innovative solutions to address key global challenges. York is now a growing hub for excellent global health research. Its research centres such as: Centre for Immunology & Infection (CII), Centre for Novel Agricultural Products (CNAP), York Environmental Sustainability Institute (YESI), Centre for Health Economics, Centre for Global Health Histories and Department of Health Sciences are bringing excellent researchers from diverse disciplines together to create innovative solutions to tackle global health challenges. Through its efforts, York is determined to leave a legacy for research in the UK and for its partners in the global South. York's excellence in research was recognised in the Research Excellence Framework (REF 2014), where York was joint first for its research environment. The impact of its research was ranked as predominately world leading (i.e. 80% 4*, 20% 3*). York was also rated 7th nationally in public health, health services and primary care. The University is also committed to Athena SWAN (current status bronze) and the Concordat to support the career development of researchers. The Department of Health Sciences host for ASTRA - has over 130 active multi-disciplinary research staff, including clinical academics in public health, primary care, health policy and mental health, which together position York as a premier provider of applied health research. Its six core research groups (https://www.york.ac.uk/healthsciences/research/research-in-healthsciences/) are poised to build on its established world-leading research excellence. The Department's annual research income exceeds £7m per year with a diverse portfolio of funders. York has been increasingly recognised as a global leader for its tobacco control research in South Asia. Over recent years, York has established extensive research collaborations within South Asia. These have led to the foundation of two research organisations in the region, the securing of competitive research grants of more than £10 million, the publication of more than 60 scientific papers and a significant research impact within tobacco control. In Pakistan and Bangladesh, York's commitment to build applied health research capacity has culminated in establishing The Initiative (http://theinitiative.org.pk/) and The ARK Foundation (http://arkfoundationbd.org/) research organisations with capacity to conduct large multicentre trials and a national reputation in tobacco control research. In response, the University of York has invested in two new posts; a Professor and a Lecturer in Global Health. ASTRA is harnessing institutional support from both within and outside its host Department. Within the Department, ASTRA is  drawing upon the expertise of its six research groups; Cancer Epidemiology, Cardiovascular Health, Health Services and Policy, Mental Health and Addictions, Public Health and Society and York Trials Unit and Statistics. York's recent and significant investment in Mental Health and Addictions is helping to widen ASTRA's expertise in health psychology, addiction science, psychometrics (new appointments), and in understanding industries' interference in public health policy (Wellcome Trust's Senior Investigator Award). ASTRA's research is embedded within York's Trial's Unit (a NIHR recognised Clinical Trials Unit) - internationally recognised for conducting large and efficient trials in health and social care. ASTRA is supported by York's Centre for Health Economics (CHE), which has recently secured £8 million in grants from RCUK and NIHR to improve health systems and evaluate health policies in low- and middle-income countries (LMICs). We benefit from the infrastructure provided by York's Research Centre for the Social Sciences (ReCSS) for research and dissemination activities. To build and sustain its research activities, the group has taken advantage of several internal funding initiatives. For example: ReCSS network grants enable early career researchers (ECRs) to develop innovative and interdisciplinary ideas. The Centre for Future Health - a multimillion-pound investment by the University of York and Wellcome Trust - offers a variety of funding schemes to prime new ideas to address global health challenges. These include pump-priming, collaboration, career establishment and impact grants. York's ESRC Impact Acceleration Account offers support for knowledge transfer and fostering new and existing collaborations. We are also able to draw upon York's national and international links e.g. membership of the White Rose University Consortium, Russell Group and Worldwide Universities Network, which allow us to use a wider pool of experts, funds, and collaborations. We are driven by the NIHR/GCRF principles for global research partnerships to ensure equity and equality in priority setting.  ASTRA is a result of York's efforts, spanning over several years, to bring together a group of scientists, policy makers and advocates from South Asia and the UK together to address priority research topics in tobacco control. At a two-day summit in York in 2013, our South Asian partners proposed the establishment of a consortium to advance research for strong and evidence-based policies to reduce use of ST(2) and agreed on key knowledge gaps.(3) These needs were reiterated in September 2017 in New Delhi at another meeting organised by the WHO Framework for Convention for Tobacco Control (FCTC) Secretariat and WHO Global Knowledge Hub on ST. Our research plan reflects priorities identified by our South Asian partners and stakeholders, and we retained scope to amend this following ASTRA's inception meeting and through planned stakeholder workshops in each country at the start. Through these workshops, and pre- and post-workshop surveys, we are sharing our research plans with stakeholders and co-create/refine our research questions and approaches.

Research Activity Codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;5.9 RESOURCES AND INFRASTRUCTURE (TREATMENT DEVELOPMENT);6.9 RESOURCES AND INFRASTRUCTURE (TREATMENT EVALUATION)
Health Categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;MENTAL HEALTH;STROKE;GENERIC HEALTH RELEVANCE