Prevalence of Tobacco Use, Knowledge about Harmful Effects, Psychosocial Determinants of Tobacco Use, and Behavioral Patterns Among Patients with Cardiovascular Diseases in Pakistan: A Scoping Review

1. Introduction Cardiovascular diseases (CVDs) are the leading causes of death and disability globally and represent a major public health challenge (WHO, 2023; Romero et al., 2025). Worldwide, about 612.06 million people live with CVD. (Lindstrom et al., 2022; Martin et al., 2025; AHA, 2025; Zhu et al., 2025). In 2021, the global death toll from CVD was approximately 19.8 million (World Health Federation, 2023). In Pakistan, the CVD prevalence rate was 3850.8 per 100,000 individuals in 2019 (Raheem et al., 2022), and this burden is continuously increasing (Samad & Hanif, 2023). CVD burden is attributed to modifiable risk factors, including hypertension, diabetes, dyslipidemia, obesity, and tobacco use (Khan et al., 2020). Tobacco use is the most critical and well-established modifiable risk factor associated with recurrent cardiac events after CVD (Siddiqi et al., 2020). It is a leading global public health problem, accountable for approximately seven million deaths annually (WHO, 2023; Zhu et al., 2025). In Pakistan, approximately 22.7% of all deaths are caused by tobacco use (Pradhan et al., 2025). While continuing tobacco use worsens prognosis, quitting reduces CVD risk by ~39% (Wu et al., 2022; Rahman et al., 2025). Worldwide trends show an overall decline in tobacco product use (WHO, 2023). Disparities exist between high-income countries (HIC) and low- and middle-income countries (LMIC). About 20.9% of adults use tobacco in LMICs compared to 14.4% in HICs (Sathish et al., 2022). The reasons for high tobacco consumption in LMICs like Pakistan are that regulatory enforcement, public health infrastructure, understanding of behavioral patterns, psychosocial determinants, and cessation support are often not available or less robust than in HICs (Zubair et al., 2022; Reuters, 2025; WHO, 2025). Quitting smoking is critical for the secondary prevention of CVD. Despite this, achieving long-term abstinence is exceptionally difficult because of high nicotine dependence, prevalence of multiple tobacco products, lack of knowledge about harmful health effects, psychosocial determinants and behavioral patterns of tobacco use. Understanding tobacco use and cardiac events contributes to strengthening motivation to quit (Bhaumik et al., 2019). Tobacco-related health knowledge plays a significant role in tobacco cessation outcomes (Hussain et al., 2018). Although most CVD patients are aware that tobacco is harmful, many still do not completely understand the risks of continuing smoking (Elshatarat et al., 2013). Patients with CVD who are aware of the harmful effects of tobacco use are more likely to be motivated to quit (Siddiqui, et al., 2021; Benowitz & Liakoni, 2022). However, in many South Asian countries, particularly Pakistan, where a variety of local tobacco products are commonly used, especially smokeless (SLT) tobacco products (SLT), which are culturally accepted, little is known about the health concerns associated with them (CDC, 2024). Psychosocial determinants and behavioral patterns of tobacco use shape the initiation, maintenance, and cessation of tobacco use (Glanz et al., 2015) and influence quit attempts among patients with CVD (WHO, 2023). Nicotine dependence, and self-efficacy are key drivers for tobacco cessation (Hussain et al., 2018). Furthermore, depression, perceived benefits of tobacco use, social norms, and family or peer influence play a central role in continued use (Bandura, 1997; West & Brown, 2012). After CVD diagnosis, patients initially have high intention to quit tobacco but this is often undermined by the inability to sustain long-lasting abstinence (Iqbal et al., 2022). The exhibition and persistence of certain behaviors are influenced by the person’s belief in their capability to perform actions (Bandura, 1997). In the context of patients with CVD, self-efficacy plays a significant role in the initiation and successful maintenance of cessation attempts. Psychosocial and cultural factors may shape self-efficacy beliefs, thus influencing tobacco use behavior patterns. Cultural acceptance of certain types of tobacco, gender norms, and peer influence further shape tobacco use patterns. Understanding the psychosocial determinants and behavioral patterns of tobacco use is essential for developing effective prevention and cessation strategies. Despite the CVD burden, less is known about the prevalence of different types of tobacco products, behavioral patterns of their use, and the influence of psychosocial determinants in the Pakistani CVD population. Collectively, these trends underscore that tobacco behavior continues to evolve, necessitating ongoing research to understand its changing patterns and inform context-specific, evidence-based interventions. 1.2 Review’s Problem Statement Pakistan has a huge burden of CVD, with an incidence of 918.18 per 100,000 populations (Rahman et al., 2025a). While tobacco use is a critical modifiable risk factor, long-term cessation success is markedly low in Pakistani patients with CVD, as only 16.4% of patients sustain abstinence after a major cardiac event (Rahman et al., 2025a). This failure to quit is driven by a complex interplay of use of various tobacco types, a persistent lack of knowledge about harmful effects of tobacco, psychosocial determinants of tobacco use, and behavioral patterns of use. While the clinical consequences of using tobacco products are clear, there is a scarcity of evidence on these specific factor of tobacco product use that sustain their use and cause relapse among patients with CVD in Pakistan. Studying these factors is vital for developing culturally tailored cessation strategies that go beyond traditional approaches such as brief clinical advice. In particular, the regularization of SLT products is overlooked in ordinary clinical circumstances, leading to a lack of knowledge regarding its specific CVD risks. This scoping review aims to map and synthesize the available research evidence on the prevalence, knowledge regarding the harmful effects of different types of tobacco products, psychosocial determinants influencing tobacco use, and behavioral patterns of tobacco use among Pakistani patients with CVD. Through a comprehensive and critical assessment of the current Pakistani research landscape, we aim to identify the best approaches and research gaps. This scoping review will integrate data from several study designs in Pakistani contexts and can provide more solid inferences than individual studies. 1.3 Review Objectives To achieve the aims of this scoping review, the research objectives (RO) patients with CVD in Pakistan are as follows: 1. To map the available evidence on the prevalence of different types of tobacco products used. 2. To map the available evidence on knowledge about the harmful effects of various types of tobacco products. 3. To characterise the behavioural patterns of tobacco use. 4. To map the available evidence on psychosocial determinants influencing tobacco use (facilitating or hindering quitting).