Cultural Drivers, Modes of Use, and Perceived Harms of Traditional and Non-Traditional Smokeless Tobacco Use in South Africa: A Qualitative Study.

Introduction: Smokeless tobacco (SLT) is used not only for recreation, but also for traditional healing, spiritual practices, and medicinal purposes. Understanding the motivations and lived experiences underlying these diverse forms of use is important for developing culturally-appropriate tobacco control interventions. This study explored the drivers, mode of use, perceived harms and lived experiences associated with traditional and non-traditional SLT use among adults in KwaZulu-Natal, South Africa. Methods: A qualitative phenomenological design was used. In-depth interviews were conducted with 25 adults who used SLT primarily for traditional purposes (traditional health practitioners [THPs] and trainees/initiates [n=12]) or non-traditional purposes (n=13). Participants were recruited using convenience, purposive and snowball sampling. All interviews were audio-recorded, transcribed verbatim, translated where necessary, and analysed thematically using Braun and Clarke's six-phase framework aided by NVivo v12. Results: Four key themes emerged: motivations for SLT use, modes and practices of use, experienced harms, and perceptions of harmfulness. Traditional users described SLT use as part of ancestral communication, initiation into traditional healing, ritual practices, and traditional treatment. Non-traditional users reported using SLT for stress relief, perceived medicinal benefits, sexual enhancement, affordability compared with smoking, and social influence. Multiple modes of use were reported, including oral, nasal, intravaginal, and external ritual use. Participants described health-related, social, and financial harms associated with SLT use. However, some traditional users perceived SLT used within traditional healing contexts as protected from harm through ancestral or spiritual authority. Conclusion: SLT use in KwaZulu-Natal is shaped by cultural, spiritual, medicinal, psychological, sexual, and economic motivations. Although participants reported multiple harms, cultural beliefs and perceptions of spiritual protection may influence risk perceptions and continued use. Public health interventions should address both the health risks of SLT and the cultural meanings attached to its use while engaging THPs and communities in developing culturally-acceptable prevention and cessation approaches.