Simple random sampling method using the rotary technique was used to select the 430 study participants from the three markets. Each market contributed respondents equally that is 143 participants, these were picked by writing numbers 1 to 150 on small pieces of papers, and those who picked the 10^th number became the respondents until the sample target for the day was reached of 15. This was repeated on a daily basis until the sample size was reached.

The study included women aged 18 years and above available at the target settings who gave consent to participate in the study.

All females aged below the legal consent age (18 years) were excluded from the study. Traders and shoppers in the target markets who are non-residents of Kasama district were not included in the study. All respondents who did not pick the 10^th number using the simple random sampling method using rotary technique were also excluded.

The researcher started each data collection by introducing herself and participants were then asked to sign the consent form and thereafter given a questionnaire.

Data was analysed using version 26.0 of the Statistical Package for Social Sciences. Appropriate parametric or non-parametric statistical tests (Chi-squared or Fisher’s exact test) were adopted in testing for associations between variables. Univariable and multivariable binary logistic regression analysis were employed in identifying smokeless tobacco use among women using an investigator-led stepwise approach, guided by various fit statistics and the likelihood ratio test. All statistical analyses adopted a 5% significance level at 95% confidence interval.

Ethical Consideration: Since the study involved human subjects, written consent was sought from the study participants. Those who declined to take part in the research were not coerced. To ensure confidentiality and anonymity, the interview schedule did not bear any names so that the information could not be directly linked to a particular individual. In addition, ethical clearance was sought from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) (REF NO.3147-2022) and the National Health Research Authority (NHRA) (REF NO. NHRAR-R-162/16/2003). Further, a formal request was made to the Town Clerk, the Mayor and the markets where research was done to allow us to collect data.

The respondents’ decisions were respected and efforts were made to ensure their wellbeing throughout the data collection. In the study, justice was upheld, by ensuring that all respondents are treated equally and given equal opportunity to make individual decisions on whether to participate in the study or not. Respondents were not subjected to any harm as the research did not involve any invasive procedures. Respondents were protected from psychological harm by letting them answer the questions in a natural private setting with no public interference.

Table 1 shows that most of the respondents fell in the age groups of 18 - 25 years (45.6%) and 26 - 35 years (23.2%). About half, (49.8%) were Bemba, 52.8% were married and Christianity was the commonest religious affiliation (93.7%).

Most of the respondents (53.7%) lived in urban settlements, and the majority (80%) were unemployed. The majority of the respondents (79.1%) reported a monthly income of not more than K5000.

Table 2 shows that most respondents used smokeless tobacco daily (33%) and between 2 - 4 days (35.1%).

Over a third used smokeless tobacco twice (35.4%) and three (33.4%) times daily. Over half (52.6%) of the respondents first used smokeless tobacco aged between 18 and 25 years and about half (46.1%) had been using smokeless tobacco for over 5 years. Over half (54.5%) of the respondents were trying to cut down on smokeless tobacco use, mainly due to health reasons (40.5%) and experiences of stigma (30.9%).

As shown in Table 3 , the majority of respondents (83.5%) had a friend/relative who used smokeless tobacco and over half (53.5%) thought smokeless tobacco was beneficial to them. Commonly mentioned benefits of smokeless tobacco included body warmth (13.6%) and vaginal tightening (7.9%).

According to the findings of the current study, Figure 1 shows that the prevalence of current use of smokeless tobacco, the majority (71.6%) of the respondents reported current use of smokeless tobacco while over a quarter (28.4%) reported not using smokeless tobacco.

As shown in Table 4 , the majority of the respondents (95.1%) defined smokeless tobacco correctly and 88.4% agreed that it caused health problems. The majority agreed that smokeless tobacco contains nicotine that causes dependence (81.2%) and that users demonstrated signs of dependence similar to those of cigarette smokers (83.5%). The common effects of smokeless tobacco mentioned included addiction (20.7%) and causing cancer (22.3%). Overall, the majority (89.8%) of respondents expressed good knowledge of smokeless tobacco.

Table 5 indicates that most of the respondents attained the secondary level of education (38.4%) and (31.9%) attained the tertiary level of education. However, (23.7%) had been to primary school and (6.0%) had never been to school.

As shown in Table 6 , more than half of the respondents (57.2%) posses beliefs that promote the use of smokeless tobacco while (42.8) did not. Commonly mentioned beliefs about smokeless tobacco included makes you enjoy sex (36.9%), making the vagina warm (21.5%), treating flu (10.2%), controlling blood pressure (7.7%), colouring the mood (7.3%) and relives stress (7.3%). 1.6% of respondents mentioned that the use of smokeless tobacco can relieve an asthmatic attack.

Table 7 shows that the use of smokeless tobacco among women was significantly associated with the following demographic characteristics; age (p < 0.0001), education level (p = 0.050), and monthly income (p = 0.006). The table further shows that knowledge of smokeless tobacco (p = 0.003) and cultural beliefs (p < 0.0001) were significantly associated with the use of smokeless tobacco. It was noted that the use of smokeless tobacco was more common among women aged 36 - 45 years (86.6%) and over 45 years (92.3%), women with no formal education (80.8%), those with higher income (83.3%), women with poor knowledge (90.9%) and among women with cultural beliefs (84.9%).

Results in Table 8 shows that at univariable and multivariable analysis, age and cultural beliefs had an increasing effect on the odds of using smokeless tobacco. Adjusting for other variables, women aged 36 - 45 years (aOR = 3.85, 95% CI = 1.71, 8.68, p = 0.001) and those aged over 45 years (aOR = 6.00, 95% CI = 1.95, 18.4, p = 0.002) had significantly higher odds of using smokeless tobacco than women aged between 18 and 25 years. Similarly, women who reported having cultural beliefs towards smokeless tobacco use had 4.49 times higher odds of using smokeless compared to women with no cultural beliefs (aOR = 4.49, 95% CI = 2.76, 7.32, p < 0.0001).

At univariable analysis, women with good knowledge of smokeless tobacco had 77 percent reduced odds of using smokeless tobacco compared to those with poor knowledge (cOR = 4.39, 95% CI = 2.68, 7.18, p < 0.0001). At the same level of analysis, women with a monthly income of over K5000 compared to those with an income of not more than K5000 had higher odds of using smokeless tobacco (cOR = 2.30, 95% CI = 1.26, 4.18, p = 0.007). However, the effects of income and knowledge were not significant in multivariable analysis.

Ch = Chi-Square.

cOR = Crude Odds Ratio, aOR = adjusted Odds Ratio, CI = Confidence Interval, ST = Smokeless Tobacco.

The key background characteristics included age, tribe, marital status, religion, area of residence, employment status and monthly income.

Smokeless tobacco use may vary with age. In the current study, most of the respondents were in the age groups of 18 - 25 years 45.6% followed by the age group of 26 - 35 years 23.2% (100) which corresponds with the study conducted in Ndola-Zambia [6] , which revealed that the majority 39 (53%) of snuff users were between the age of 18 - 28 years with mean age of 33.92. The reason for this might be because the two towns are provincial headquarters of Zambia and women are exposed to social media and possibly getting the same information. This is also similar to the two studies done in Tanzania [9] which revealed that the peak age range of using snuff was around 15 - 40 years, though Warren and friends [10] revealed that the prevalence of using snuff starts as early as 12 years in young ladies because of peer pressure and envying their role models. However, the current findings are contrary to the study which was conducted in Lagos, Nigeria, where most of the respondents were aged between 21 - 40 years 5 (4.9%) [11] .

Table 1 shows that among respondents majority were Bembas 49.8% (214), Mambwe 17.9% Ngoni 7.2% (31), Tonga 7.0% and other tribes 18.1%. This is attributed to the nature of the study settings where the Bemba are the majority in the northern province hence the tribe is insignificant there making one tribe always prominent in one region than others. The majority of the respondents were not married 52.8% (227) Marital status may be associated with tobacco use this is in line with a study conducted in Nigeria where some current users of SLT were divorced/separated or widowed with the P-value of 0.002 [11] , and this finding was statistically significant. This might be because marital problems like divorce, separation or even the loss of a spouse may cause people to use ST products as a means of coping with marital challenges. In the 2014 Kenya demographic health survey, similar findings were noticed among men, but not among women [12] . This is contrary to the study that was conducted in Ndola-Zambia [6] , which revealed that most of the respondents (53%) were married. The current study is also contrary to the study that was conducted in Nigeria where half of the respondents were married [11] . The current study revealed that Christianity was the commonest religious affiliation 93.7% (403) according to Table 2 which is also in relation to the study conducted in Ndola-Zambia [6] , this could be due to the fact that Zambia is a Christian nation the majority of the citizens are Christians.

Over half, 53.7% (231) lived in urban settlements and the majority, 80% (344) were unemployed this could be as the fact that only 45% [13] of women are employed in Zambia. Majority, 79.1% (340) of the respondents reported a monthly income of not more than K5000 which could attribute to minimum wage set by the Zambian government. In the current study, at univariable analysis, women with a monthly income of over K5000 compared to those with an income of not more than K5000 had higher odds of using smokeless tobacco (cOR = 2.30, 95% CI = 1.26, 4.18, p = 0.007). This means that those with higher income have more access to smokeless tobacco or they have extra money to access the commodity. However, the effects of income and knowledge were not significant in multivariable analysis.

In the current study, 33% (142) of the respondents used smokeless tobacco daily and over a third used smokeless tobacco twice 35.4% (109) daily and this is contrary to the study which was done in Ndola-Zambia [6] , where most women had used snuff up to ten times (37.0%) per day; 11 to 20 times (34.2%) and 21 to 30 times (23.3%). Fewer women had used snuff for more than 31 times (2.7%) or not used it at all (2.7%). However, the findings of the current investigator reveal that the use of smokeless tobacco among women of Kasama is not as bad as women of Ndola, nevertheless, it could have an impact on the Zambian economy as urge amount of resources could be used if these women present with the health problems.

The current study further found that most respondents used smokeless tobacco daily 33% (142) and between 2 - 4 days 35.1% (151). Over a third used smokeless tobacco twice 35.4% (109) and three 33.4% (103) times daily. Over half, 52.6% (162) of the respondents first used smokeless tobacco between 18 and 25 years and about half, 46.1% (142) had been using smokeless tobacco for over 5 years compared to the study which was done in India where nearly 17% of women initiated ST use before the age of 15 (Global Adult Tobacco Survey (GATS) [14] ).

In the current study, over half, 54.5% (168) of the respondents were trying to cut down on smokeless tobacco use, mainly due to health reasons 40.5% (68) and stigma 30.9% (52). This is contrary to the study which was done in India where more than 50 per cent (54.4%) of women SLT users were not interested in quitting, only 2.7 per cent sought pharmacotherapy and 8.4 per cent underwent counselling at local cessation centers or through telephone Quitline/helpline (Global Adult Tobacco Survey GATS 2 [14] ). While only 4.3 per cent of the women opted for traditional methods to enable cessation, 71.6% attempted cessation without any assistance (Global Adult Tobacco Survey GATS 2 [14] ). This indicates an intrinsic issue with respect to access and willingness to enroll in cessation programmes or quitting practices as these centers often receive a low number of female ST users and participants. Low support for cessation, associated stigma and low access to cessation methods are some of the factors that may act as barriers to cessation among men and women. There is limited research on the intention to quit and barriers to cessation among women that need to be understood to facilitate quitting and awareness.

This clearly indicates that healthcare facilities and awareness about the very nature of their health soundness is very much lacking since it takes one to have a health problem to make a decision to quit. Besides, studies have reported that women have less success in quitting; therefore, more complex approaches may be needed to achieve better outcomes. Intensive counseling would address the circumstances that create obstacles to cessation. Awareness and advocacy are also needed.

However, these findings indicate clearly that women should be targeted in smoking cessation campaigns and it is important to target prevention messages to young people in schools and communities before they pick up tobacco smoking habits.

Knowledge is the information, understanding and skills that one gains through education or experience [15] . Section B of the questionnaire comprised the questions on knowledge of smokeless tobacco. The questions helped the researcher to assess whether respondents knew the definition of ST, whether ST can cause some health problems, content of ST and their health effects.

According to the global impact of tobacco control policies on smokeless tobacco [16] , an earlier systematic review highlighted that 138 parties to WHO’s Framework Convention on Tobacco Control defined smokeless tobacco in their statutes and in the current study majority of the respondents defined smokeless tobacco correctly 95.1% (409) and agreed that it caused health problems 88.4% (380). This is in line with the study which was conducted in India [17] , which states that SLT use among women has been inversely associated with increasing levels of education, wealth and knowledge about the health effects. Despite knowing the health problems women are going on and using the ST. Contrary to the international journal (2015) women hold a strong conception that tobacco does not only harm them but has also medicinal effects for the case of toothache, better digestion, acts as an anti-flatulence and also for smooth defection process. Therefore, development of awareness materials and using information, education and communication strategies on ST use is of utmost importance. Specific strategies such as enhanced health communication through the packaging of ST products depicting health risks are required.

The majority agreed that smokeless tobacco contains nicotine that caused dependence 81.2% (349) and that demonstrated signs of dependence similar to those of cigarette smokers 83.5% (359) this is in accordance with the European Journal of Public Health volume 26 (2016), which revealed that among current smokers, snus users had a similar cigarette consumption compared with non snus users, in contrast with a study from Norway showing that dual users smoked less than exclusive smokers [18] , (i.e. prevalence of 9%), suggesting that smokeless tobacco use may represent a gateway for nicotine addiction.

In this study, some of the common effects of smokeless tobacco are known including addiction 20.7% (89) and causing cancer 22.3% (96). This is in line with the study which was conducted in India [17] , that revealed that among women, SLT has been associated with the risk of oral cancers and pharyngeal cancers, cancer of the gums and buccal mucosa, oesophageal cancer, upper aero-digestive tract cancer, cervical cancer, ischaemic heart disease and osteoporosis. A meta-analysis revealed a higher risk for oral cancer among female SLT users with an odds ratio (OR) of 5.83 (95% CI: 2.93 - 11.58).

The other effects that were eluded to the current study included warming of the body temperature (12.1%) and tightening the vagina (3.9%) which is in line with the study carried out among South African young women demonstrated that women often insert snuff as a reference point of tightening the vagina and feeling tight like that of a child [19] . On the other hand, in the current study, some respondents expressed that the use of ST helped them to control their BP (6.1%). This is in harmony with a study that was conducted in Ndola [6] , where Snuff was significantly regarded as medicine for different diseases and conditions such as headache, flu, Blood pressure, toothache, stress and depression. 21.9% of the 73 participants affirmed the use of snuff for pharmacology purposes. This is also in agreement with the study done in Madagascar which revealed that snuff is a control measure of neuropsychological disorders such as stress, anxiety and depression giving 41% (Harrison et al., 2009), though not concurrent with the study done in South Africa (Global Adult Tobacco Survey (GATS) [14] ) which revealed that snuff does not reduce stress and Bp. levels.

However, in the current study, the majority 89.8% (386) of respondents expressed good knowledge of smokeless tobacco. As we know the level of knowledge of the ill effects of tobacco products, individual attitudes towards the use of tobacco and perception of social acceptance are the major determinants of tobacco use. On the other hand, the misconception that the use of smokeless tobacco has medicinal value for curing or reducing discomforts such as flu, BP, and lack of sleep could have led to the high prevalence of the use of smokeless tobacco. Despite having knowledge of ST and any form of tobacco products, knowledge and awareness of the adverse impact of tobacco use, women are still using it therefore, need to strengthen educating the public on the health benefits of quitting smoking and design gender-sensitive cessation centers, orientation of individuals engaged in cessation efforts on enabling a women-friendly environment for quitting is crucial.

SLT use among women has been inversely associated with increasing levels of education, wealth and knowledge about the health effects [20] . Most of the respondents in the current study attained secondary 38.4% (165) and tertiary 31.9% (137) level education. This corresponds to the study conducted in Nigeria which revealed that most of respondents had a high educational level or more (83.5%) [11] . However, the majority of the respondents in this 38.9% attained a secondary educational level this could be a result of opening/up-grading of basic schools to secondary schools and free education being offered in the country and this can help in changing the economic status of the country. The current study showed that 23.7% (102) attained primary educational level and 6.1% (18) never attended school, this coincides with the study conducted in India which revealed that adults with some primary school education showed the highest prevalence of dual-use (8.3%) of smokeless tobacco compared to individuals with other levels of education [21] . Education was independent significantly. Since knowledge is associated with education level, in the current study, women with no formal education have 80.8% chances of using ST as compared with those with formal education and this finding is contrary to the study conducted in Kaoma and Kasama where participants with no formal education were 49% (AOR=1.49, 95% CI [1.08, 2.06]) more likely to smoke than those with formal education [22] .

As shown in Table 5 the majority of respondents had a friend/relative that used smokeless tobacco 83.5% (359) this is in line with the international journal [23] a qualitative study that revealed that Peer influence is a very important factor reported by the participants (20%) for their chewing status of smokeless tobacco. People who have friends who chew tobacco are the most vulnerable group of people. Some participants reported cases of being compelled and forced to take up tobacco. They said, they are often under pressure from their peers to take up tobacco, and to refuse would not be pleasing to their friendship therefore, they have to take up.

Results in Table 7 show that at both univariable and multivariable analysis, age, religion and cultural beliefs had an increasing effect on the odds of using smokeless tobacco. Therefore, the use of smokeless tobacco and cultural beliefs are significant with the p-value < 0.0001. This is contrary to the study conducted in Ndola-Zambia, which showed social factors to be less significant in the use of snuff giving details of strengthening a bond as friends and being known in the world of snuff users [6] but in line with the study that was conducted in South Africa with 43 (19.5%) out of 220 participants who acknowledged that snuff usage helps women to form a strong bond of friendship, putting an invitation to a friend which they regard as sacred and family identification [24] . This is also concurrent with a study done in Congo DR. 27 (50.1%) of 53 [25] which revealed that peer/social networks are a strong risk factor for both the initiation and progression to regular use.

The current investigation found that over half, 53.5% (230) thought smokeless was beneficial to them. Commonly mentioned benefits of smokeless tobacco included body warmth 25.7% (59) and vaginal tightening 11.7% (27). Other benefits mentioned were: control of BP 7.7% (19), colour the mood 7.3% (19), relief of stress 7.3% (18), it makes sex enjoyable 4.9% (11), helps one to forget problems 8.3% (19), it helps in the treatment of flu 7.0% (16) and it is able to sedate 7.4% (17). This coincides with the study conducted among married women in Mumbai, India, SLT use was found to be attributed to reducing stress, providing pleasure, associated companionship with peers at the workplace and in the neighborhood, increasing energy for workload and suppressing hunger when dietary requirements were not met [26] .

Corresponding with the current study, a study carried out among South African young women demonstrated that women often insert snuff as a reference point of tightening the vagina and feeling tight like that of a child [19] . In another study carried out in Tanzania 70% and in South Africa 80% of women confirmed that vaginal temperature regulation is a very common use of snuff though the idea is uncommon in Western countries [16] who favour condoms. In Zimbabwe, 60% of women do not favour condoms as heat lubricant but snuff [27] .

In this study, over half, 57.2% possessed beliefs about the use of smokeless tobacco and making the vagina warm was the most common 21.5% reported belief among respondents. This is in line with a study done in South America, which confirmed that snuff usage is a preservative of culture and identity especially to women, like the South American Indian tradition (77%) use it for purification, connection with the divine, and recreation [14] . However, contrally with the study conducted in Ndola-Zambia where the study found that using snuff was not significantly culturally born as only 2 (2.7%) out of 73 participants agreed to this claim though it is a practice that has a long history in the Zambian rural set up among old women [6] .

Since the current study has shown that both univariable and multivariable analysis, age, religion and cultural beliefs had an increasing effect on the odds of using smokeless tobacco it is recommended that mass health campaigns concerning the effects of smokeless tobacco and education on the health hazards of smokeless tobacco are required to control and minimize its usage for long term healthy living.