Abstract
Introduction
To examine predictors of current tobacco smoking and smokeless tobacco use among the adult population in Bangladesh.
Materials and Methods
We used data from the 2009 Global Adult Tobacco Survey (GATS) in Bangladesh consisting of 9,629 adults aged ≥15 years. Differences in and predictors of prevalence for both smoking and smokeless tobacco use were analyzed using selected socioeconomic and demographic characteristics that included gender, age, place of residence, education, occupation, and an index of wealth.
Results
The prevalence of smoking is high among males (44.7%, 95% confidence interval [CI]: 42.5-47.0) as compared to females (1.5%, 95% CI: 1.1-2.1), whereas the prevalence of smokeless tobacco is almost similar among both males (26.4%, 95% CI: 24.2-28.6) and females (27.9%, 95% CI: 25.9-30.0). Correlates of current smoking are male gender (odds ratio [OR] = 41.46, CI = 23.8-73.4), and adults in older age (ORs range from 1.99 in 24-35 years age to 5.49 in 55-64 years age), less education (ORs range from 1.47 in less than secondary to 3.25 in no formal education), and lower socioeconomic status (ORs range from 1.56 in high wealth index to 2.48 in lowest wealth index. Predictors of smokeless tobacco use are older age (ORs range from 2.54in 24-35 years age to 12.31 in 55-64 years age), less education (ORs range from 1.44 in less than secondary to 2.70 in no formal education), and the low (OR = 1.34, CI = 1.0-1.7) or lowest (OR = 1.43, CI =1.1-1.9) socioeconomic status.
Conclusion
Implementation of tobacco control strategies needs to bring special attention on disadvantaged group and cover all types of tobacco product as outlined in the WHO Framework Convention on Tobacco Control (FCTC) and WHO MPOWER to protect people’s health and prevent premature death.
Keywords: Bangladesh, global adult tobacco survey, social determinants tobacco use, smokeless tobacco, use tobacco smoking
Introduction
Tobacco use is the leading preventable cause of premature death and disease worldwide, and its impact is even more pronounced in low-and middle-income countries.[1] In Bangladesh, tobacco use has become not only a major contributor to the country’s high morbidity[2] but also the biggest drains to the nation’s economy.[3] Several national and sub-national studies in Bangladesh have shown high prevalence of both smoking (e.g., cigarettes, bidis) and use of smokeless tobacco (e.g., betel quid with tobacco, khoini, gul, zarda).[4–10]
Surveys in Bangladesh have shown that males and individuals with no education, lower household income, and a lower standard of living have higher smoking prevalence.[4,5] These surveys, however, were multi-topical and thus not designed solely to collect information on tobacco use. The Global Adult Tobacco Survey (GATS)[10] offered an opportunity to focus on the prevalence of tobacco use in Bangladesh using a globally standardized methodology. A study based on GATS finding analyzed the social determinants of tobacco use as a whole.[11] The present paper examines predictors’ of smoking and smokeless tobacco use using data from the GATS conducted in 2009.
Materials and Methods
The GATS is a nationally representative household survey that uses a standardized questionnaire, sample design, and procedures for data collection and management. The survey provides cross-sectional estimates for the country as a whole as well as by urban city (rural/urban residence) and gender.[10]
Variables included in the analyses
In accordance with the guidelines for GATS indicators,[12,13] current smoking and smokeless tobacco use, the dependent variable in this analysis, were defined as smoking or the use of any smokeless tobacco product either daily or occasionally. The following two questions were used—(1) “Do you currently smoke tobacco on a daily basis, less than daily, or not at all?” and (2) “Do you currently use smokeless tobacco on a daily basis, less than daily, or not at all?” The information on the use of tobacco smoking products included cigarettes (both manufactured and hand rolled), bidis, hookahs, pipes, cigars, cheroots, cigarillos, or any other unspecified smoked tobacco products. For smokeless tobacco, the products included were betel quid with tobacco (zarda, zarda with supari, sada pata, and pan masala with tobacco), sada pata chewing, gul, khoinee, or any other unspecified smokeless tobacco products.
The variables related to social determinants used in this analysis were age, place of residence (urban/rural), gender (male/female), education (highest level completed), occupation, and wealth index (described below). For this analysis, educational level had five categories: No formal schooling, less than primary, primary completed, less than secondary, and secondary school or above completed (including high school, college/university, and postgraduate and above). Occupational categories were based on a question that asked about the primary work status of the respondent in the past 12 months. The responses to this question were recorded into five mutually exclusive categories: Employed, self-employed, homemaker, student, and unemployed/retired. The wealth index, a proxy measure for the respondents’ socioeconomic status, was constructed using principal component analysis[13,14] applied to information on household ownership of assets. The index used here, which was similar to the one that has been developed and tested in a large number of countries in relation to inequities in household income,[6,14,15] is an indicator of the level of wealth that is consistent with measures of expenditures and income.[14,15] Information on assets collected in GATS included household ownership of a number of items, such as electricity, flush toilet, fixed telephone, cell telephone, television, radio, refrigerator, automobile, moped/scooter/motorcycle, washing machine, bicycle, sewing machine, almirah/wardrobe, table, bed or cot, chair or bench, watch or clock, as well as the type of main material used for the roof of the main house (cement, tin, or katcha such as bamboo/thatch/straw). The sample was categorized into quintiles of wealth from 1 (lowest) to 5 (highest).
The GATS data used in the analysis consisted of 9,629 completed interviews of adults aged ≥15 years, with an overall response rate of 93.6%. All data collected on adults was used for this analysis; the estimates for prevalence were reported as percentages with 95% confidence intervals (CIs). Chi-square test was used to test associations between the prevalence and various socioeconomic and demographic categories. A P value of <0.05 was considered statistically significant. The effects of these social determinants on the prevalence of both smoking and smokeless tobacco use were estimated using a multivariate logistic regression model using SPSS 17.0 software for complex samples.
Results
Tobacco smoking
The prevalence of tobacco smoking was higher among males. The prevalence of smoking by age group among adults aged 15+ ranged from 12.0% (15-24 years) to 32.9% (45-54 years). There was no significant variation by place of residence for prevalence of tobacco smoking. In contrast, there was a strong gradient in smoking prevalence by educational level. Among adults, the rate of smoking was highest among those with no formal education and lowest among those with a secondary education or more. In addition, the prevalence of smoking was highest among those in the lowest quintile of the wealth index (29.2%) and lowest among those in the highest quintile (13.6%). Tobacco smoking was more prevalent among self-employed (46.7%) and employed (43.3%) adults than in the other occupational categories [Table 1].
Table 1. Pattern of current tobacco use among adults in Bangladesh by type of use and socioeconomic and demographic characteristics.
| Socioeconomic or demographic characteristic | Tobacco use | Tobacco smoking | Smokeless tobacco use | Sample size n | |||
|---|---|---|---|---|---|---|---|
| % | (95% CI) | % | (95% CI) | % | (95% CI) | ||
| Overall | 43.3 | (41.7, 45.0) | 23.0 | (21.9, 24.2) | 27.2 | (25.5, 28.9) | 9,629 |
| Gender | P<0.05 | P<0.05 | P>0.05 | ||||
| Male | 58.0 | (55.9, 60.1) | 44.7 | (42.5, 47.0) | 26.4 | (24.2, 28.6) | 4468 |
| Female | 28.7 | (26.7, 30.8) | 1.5 | (1.1, 2.1) | 27.9 | (25.9, 30.0) | 5161 |
| Age (years) | P<0.05 | P<0.05 | P<0.05 | ||||
| 15–24 | 16.9 | (14.7, 19.4) | 12.0 | (10.2, 14.1) | 6.6 | (5.1, 8.6) | 2,073 |
| 25–34 | 36.3 | (33.6, 39.1) | 22.6 | (20.3, 25.1) | 19.9 | (17.7, 22.3) | 2,665 |
| 35–44 | 55.0 | (51.7, 58.2) | 29.8 | (27.3, 32.4) | 35.0 | (31.8, 38.4) | 2,232 |
| 45–54 | 67.6 | (63.9, 71.1) | 32.9 | (29.6, 36.3) | 46.7 | (42.4, 51.0) | 1,329 |
| 55–64 | 70.7 | (66.4, 74.6) | 31.6 | (27.3, 36.3) | 49.3 | (44.6, 54.0) | 755 |
| 65+ | 70.8 | (66.2, 75.1) | 23.5 | (19.5, 28.0) | 56.4 | (51.3, 61.4) | 575 |
| Place of residence | P<0.05 | P>0.05 | P<0.05 | ||||
| Urban | 38.1 | (35.6, 40.7) | 21.3 | (19.8, 22.9) | 22.5 | (20.3, 24.8) | 4,857 |
| Rural | 45.1 | (43.2, 47.1) | 23.6 | (22.2, 25.1) | 28.8 | (26.8, 30.9) | 4,772 |
| Education | P<0.05 | P<0.05 | P<0.05 | ||||
| No formal education | 62.9 | (60.7, 65.1) | 31.1 | (29.1, 33.3) | 42.3 | (39.8, 44.9) | 3,416 |
| Less than primary | 47.2 | (43.0, 51.4) | 26.6 | (23.6, 29.8) | 28.7 | (25.0, 32.8) | 1,487 |
| Primary | 37.6 | (34.0, 41.3) | 17.5 | (14.7, 20.6) | 24.9 | (21.4, 28.7) | 1,115 |
| Less than secondary | 26.2 | (23.5, 29.0) | 16.7 | (14.6, 19.0) | 13.5 | (11.5, 15.7) | 1,937 |
| Secondary or above | 21.7 | (18.7, 25.0) | 14.3 | (11.9, 17.2) | 10.2 | (8.1, 12.7) | 1,610 |
| Occupation | P<0.05 | P<0.05 | P<0.05 | ||||
| Employed | 57.6 | (54.6, 60.6) | 43.3 | (40.3, 46.3) | 26.5 | (23.6, 29.7) | 2,326 |
| Self-employed | 62.5 | (59.6, 65.3) | 46.7 | (44.0, 49.4) | 30.7 | (28.0, 33.5) | 2,271 |
| Homemaker | 30.4 | (28.1, 32.8) | 1.4 | (1.0, 2.0) | 29.6 | (27.3, 32.0) | 4,132 |
| Student | 4.4 | (2.3, 8.3) | 3.4 | (1.5, 7.5) | 1.0 | (0.4, 2.6) | 461 |
| Unemployed/retired | 49.8 | (43.3, 56.4) | 22.1 | (17.1, 28.2) | 32.4 | (26.6, 38.8) | 435 |
| Wealth index | P<0.05 | P<0.05 | P<0.05 | ||||
| Lowest | 55.6 | (52.7, 58.5) | 29.2 | (26.4, 32.2) | 36.1 | (32.6, 39.8) | 1,866 |
| Low | 48.1 | (45.2, 51.0) | 26.3 | (24.0, 28.7) | 30.3 | (27.4, 33.3) | 2,068 |
| Middle | 43.1 | (39.6, 46.6) | 23.2 | (20.6, 26.1) | 26.3 | (23.2, 29.6) | 1,732 |
| High | 38.4 | (35.6, 41.4) | 20.5 | (18.2, 22.9) | 23.8 | (21.4, 26.3) | 2,040 |
| Highest | 28.1 | (25.1, 31.2) | 13.6 | (11.8, 15.7) | 17.3 | (14.8, 20.1) | 1,923 |
CI=Confidence interval
Use of smokeless tobacco
The use of smokeless tobacco by age was highest among older adults (≥65 years), and the age gradient was significant (P < 0.05). The proportion of adults consuming smokeless tobacco was higher among rural adults than among urban adults of both genders (P < 0.05). Among adults, only 10.2% of those at the highest educational level used smokeless tobacco as compared to 42.3% of those with no formal education. In terms of the wealth index, there was a notable gradient, with the percentage of adults consuming smokeless tobacco decreasing from 36.1% in the lowest quintile to 17.3% in the highest. By occupation, prevalence of smokeless tobacco use among adults was highest among the unemployed/retired (32.4%) as compared to a prevalence of 29.6% among homemakers [Table 1].
Predictors of smoking and smokeless tobacco use
Table 2 presents the multivariate logistic regressions that predict the socioeconomics and demographic correlates of both smoking and smokeless tobacco use. The strongest correlates of current smoking are male gender (odds ratio [OR] = 41.46, CI = 23.8-73.4), and adults in older age (ORs range from 1.99 in 24-35 years age to 5.49 in 55-64 years age), less education (ORs range from 1.47 in less than secondary to 3.25 in no formal education), and the lower socioeconomic status (ORs range from 1.56 in high wealth index to 2.48 in lowest wealth index).
Table 2.
Predictors of current tobacco smoking and smokeless tobacco use among adults age 15 years and above in Bangladesh using logistic regression analysis
| Selected socioeconomic and demographic characteristics | Tobacco smoking | Smokeless tobacco use | ||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Gender | P<0.001 | P<0.01 | ||
| Male | 41.76 | (23.8, 73.4)*** | 0.81 | (0.6, 1.1) |
| Female (RC) | 1.00 | 1.00 | ||
| Age | P<0.001 | P<0.001 | ||
| 15-24 (RC) | 1.00 | 1.00 | ||
| 25-34 | 1.99 | (1.5, 2.7)*** | 2.54 | (1.8, 3.5)*** |
| 35-44 | 2.80 | (2.1, 3.8)*** | 5.18 | (3.8, 7.1)*** |
| 45-54 | 4.17 | (3.0, 5.9)*** | 8.52 | (6.0, 12.0)*** |
| 55-64 | 5.49 | (3.7, 8.2)*** | 9.75 | (6.8, 14.0)*** |
| 65+ | 3.55 | (2.1, 6.1)*** | 12.31 | (8.6, 17.5)*** |
| Place of residence | P>0.05 | P>0.05 | ||
| Urban (RC) | 1.00 | 1.00 | ||
| Rural | 0.86 | (0.7, 1.0) | 1.09 | (0.9, 1.3) |
| Education | P<0.001 | P<0.001 | ||
| No formal education | 3.25 | (2.3, 4.6)*** | 2.70 | (2.0, 3.6)*** |
| Less than primary | 1.90 | (1.3, 2.8)*** | 2.23 | (1.6, 3.1)*** |
| Primary completed | 1.49 | (1.0, 2.3) | 2.28 | (1.6, 3.2)*** |
| Less than secondary | 1.47 | (1.0, 2.1)* | 1.44 | (1.1, 2.0)* |
| Secondary or above (RC) | 1.00 | 1.00 | ||
| Occupation | P<0.001 | P<0.001 | ||
| Employed (RC) | 1.00 | 1.00 | ||
| Self-employed | 0.99 | (0.8, 1.2) | 1.09 | (0.9, 1.3) |
| Homemaker | 0.27 | (0.1, 0.5)*** | 0.85 | (0.7, 1.1) |
| Student | 0.19 | (0.1, 0.4)*** | 0.17 | (0.1, 0.5)*** |
| Unemployed/retired | 0.69 | (0.4, 1.3) | 0.83 | (0.6, 1.2) |
| Wealth index | P<0.001 | P>0.05 | ||
| Lowest | 2.48 | (1.7, 3.6)*** | 1.43 | (1.1, 1.9)* |
| Low | 1.72 | (1.3, 2.4)*** | 1.34 | (1.0, 1.7)* |
| Middle | 1.64 | (1.2, 2.3)** | 1.18 | (0.9, 1.5) |
| High | 1.56 | (1.1, 2.1)** | 1.16 | (0.9, 1.5) |
| Highest (RC) | 1.00 | 1.00 | ||
| Sample size | 8999 | 9327 | ||
***P<0.001.**P<0.01.*P<0.05. ‡P values shown for test of linear trend. OR=Odds Ratio. CI=Confidence interval. RC=Reference category. Dependent variable: 1=Current smokers/users. 0=Never smokers/users (former smokers/users excluded)
Similarly, the significant predictors of smokeless tobacco use are older age (ORs range from 2.54 in 24-35 years age to 12.31 in 55-64), less education (ORs range from 1.44 in less than secondary to 2.70 in no formal education), and the low (OR = 1.34, CI = 1.0-1.7) or lowest (OR = 1.43, CI = 1.1-1.9) socioeconomic status.
Discussion
The high prevalence of tobacco use in Bangladesh reported here is consistent with most of the national and sub-national surveys among the adult population in this nation of more than 145 million people located in northeastern south Asia.[4–8] This analysis indicated that, in Bangladesh, the use of tobacco is more common among older adults aged 35+ years, living in rural areas, with lower socioeconomic status, and less education for both genders.[16] The socioeconomic gradient for tobacco use, in this case using a previously developed wealth index, is similar to the ones reported in other national[5,6] and sub-national surveys[4,8] for this Bangladesh. The prevalence pattern of both tobacco smoking and smokeless tobacco use was similar to that of overall tobacco use. Though the current study describes the pattern of tobacco smoking and smokeless tobacco use among various socioeconomic and demographic sub-groups, attention should be given to further investigating reasons for tobacco use in Bangladesh to develop an evidence base for interventions. These patterns of use are also consistent with six previous studies[2,3,5,6,11,16,17] that reported that a large proportion of household income among poor families is spent on tobacco in Bangladesh. Given our findings and based on earlier research,[11,12,18] it would likely be advantageous to develop appropriate public health interventions to reduce tobacco use in Bangladesh with a focus on the disadvantaged populations. Given the morbidity and mortality associated with tobacco use,[1,3,16] regulating the production, sales, and marketing of tobacco in Bangladesh could be considered. More resources for effective public health education and interventions may be created by raising taxes on tobacco and then earmarking part of the funds for public health initiatives.
The fact that over one-fourth of men and women in Bangladesh used smokeless tobacco in some form or other is also a source of concern. For women smoking cigarettes or bidis is considered socially unacceptable in the South-East Asian community, but using smokeless tobacco is socially acceptable. Unfortunately, there are common misconceptions among different socio-demographic sectors of population in South-East Asia that smokeless tobacco is less harmful than cigarettes and actually good for the teeth and gums, resulting in it being often used in the form of a dentifrice. An estimated 5% of Bangladeshi adults use tobacco as dentifrice.[9]
Among women, the use of smokeless tobacco has dual health implications particularly in the reproductive years, affecting both mothers and fetuses (due to increased risk for low birth weight and preterm deliveries).[19] Because of the greater use of smokeless tobacco in women as well as the exposure of both women and children to second-hand smoke, integration of tobacco control programs that focus on smokeless tobacco and second-hand smoke into the maternal and child health program could be a cost-effective strategy to educate people, particularly women, about dangers of tobacco use and benefits of quitting;[12] further research is needed to determine if it would be feasible to do this. Interestingly, none of the earlier studies had captured comprehensive information on use of smokeless tobacco; the present study provides results related to the use of smokeless tobacco across various demographic subgroups and identified important predictors such as education and socioeconomic status that may have bearing on public health policy. In Bangladesh, tobacco control legislation at present does not cover smokeless tobacco[20] and, thus, it may prove beneficial to include smokeless tobacco into tobacco policies addressing marketing, packaging, sales, and investing in effective educational or media campaigns to educate the public about harmful effectsof smoking as well as using smokeless tobacco.
Bangladesh ratified the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) in 2004, formulated national tobacco control legislation in 2005,[20] and issued further regulations in 2006.[21] GATS data for the first time offered an opportunity to study some critical elements of the WHO FCTC[22] and monitoring component of WHO MPOWER.[23] To prevent premature morbidity and mortality associated with smokeless tobacco use, it is desirable to revise the tobacco control policy in Bangladesh to include provisions for prevention and control of smokeless tobacco in national tobacco control policies and programs.
The present study found no statistically significant difference in the prevalence of smoking between the urban and rural populations, but did find that the use of smokeless tobacco was statistically higher in the rural population. Providing health warningson all tobacco products has been demonstrated to be a cost-effective health education tool.[20] Bangladesh has implemented a textual health warning on smoking products, but it has done this only on cigarette packs, not on packs of bidis and smokeless tobacco products. In view of low literacy rate in Bangladesh, pictorial health warnings likely would provide a more effective public health message. The WHO Framework Convention has called for graphic health warnings covering 50% or more of the front and back of all tobacco products, and providing such warnings should contribute to prevent and reduce initiation, and promote cessation.
There are limitations in the study. We note that the findings in this report are subject to the limitation that estimates that prevalence was based on self-reports. In certain settings, social norms (e.g., the unacceptability of smoking by women) might result in underreporting. Furthermore, both the education and occupational categories had only five subcategories each, which could have contributed to biased estimates in terms of the pattern of results observed. Nonetheless, these groupings were more specific than those used in earlier research on tobacco use in Bangladesh. Finally, the construction of the wealth index for this study was based on a limited number of asset variables. Essentially predictors are same for male and female. In addition, although we observed huge differences in smoking between males and females, the number of female smokers was very less to carry out logistic regression with many variables in the model.
Conclusion
In Bangladesh, tobacco smoking and the use of smokeless tobacco individually are strongly associated with social disadvantage (e.g., low socioeconomic status, less education), indicating an important association between tobacco use and social determinants. Findings from GATS indicate that rural residence and having less education and wealth are predictors of smoking and use of smokeless tobacco. We also found that the prevalence of use increased as age increased for all forms of tobacco use. Implementation of tobacco control strategies drawn from the standards outlined in the WHO Framework Convention on Tobacco Control (FCTC) and WHO MPOWER could have benefits in reducing tobacco use and preventing premature death.
Acknowledgments
The authors thank Bangladesh Ministry of Health and Family Welfare, Bangladesh Bureau of Statistics (BBS), National Institute of Preventive and Social Medicine (NIPSOM), and National Institute of Population Research and Training (NIPORT), which, in collaboration with WHO (SEARO and Country Office for Bangladesh) and Centers for Disease Control and Prevention (Atlanta, Georgia, USA), made completion of the GATS possible. The authors would also like to thank Mr. Edward Rainey from the Global Tobacco Control, Office on Smoking Health, CDC for providing support with technical editing and formatting of the manuscript. Funding for GATS was provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies.
Source of Support: Funding for GATS was provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies.
Footnotes
Disclaimer
The views expressed in this article are solely those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the GATS partner organizations."
Conflict of Interest: None declared.
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