Current tobacco use and its associated factors among adults in a country with comprehensive ban on tobacco: findings from the nationally representative STEPS survey, Bhutan, 2014

Comparison of Laboratory and Non-Laboratory-Based 2019 World Health Organization Cardiovascular Risk Charts in the Bhutanese Population

The World Health Organization (WHO) recommends the use of color-coded cardiovascular disease (CVD) risk charts for CVD management. This study evaluated the agreement between the laboratory and non-laboratory 10-year CVD risks based on 2019 WHO CVD risk-prediction charts. The agreement of CVD risk scores among 40- to 69-year-old Bhutanese population stratified by gender and age groups (<60 and ≥60 years) was determined via weighted kappa statistics. In the general population, there was substantial agreement between the two CVD risk score charts for all ages and <60 years but a moderate agreement for participants aged ≥60 years. In males, substantial agreement was observed in all ages and in <60 years and moderate agreement in ≥60 years. In females, both the predictions showed substantial agreement in all ages and <60, but a moderate agreement for ≥60 years. The non-laboratory-based risk charts can be used interchangeably with laboratory-based charts for predicting 10-year CVD risk in resource-constrained countries like Bhutan.

Trends in behavioral and biological risk factors for non-communicable diseases among adults in Bhutan: results from cross-sectional surveys in 2007, 2014, and 2019

Background

The study aimed to evaluate trends in the prevalence and correlates of risk factors for non-communicable diseases (NCDs; low physical activity, insufficient fruit/vegetable intake, current tobacco use, problem alcohol use, diabetes, hypertension, increased total cholesterol, and obesity) in Bhutan.

Methods

Three repeat cross-sectional Bhutan STEPS surveys (N = 9,281) in 2007, 2014, and 2019 were analyzed.

Results

The proportion of people with 3-8 NCD risk factors significantly decreased from 62.8% in 2007 to 32.6% in 2019 (p < 0.001), and the mean number of NCD risk factors significantly decreased from 3.0 in 2007 to 2.1 in 2019 (p < 0.001). In linear regression analyses by study year, older age (p < 0.001) was positively associated with eight NCD risk factors across all study years. Furthermore, male subjects were negatively (p < 0.01) and positively (p < 0.001) associated with eight NCD risk factors, respectively. Higher education levels (p < 0.05) were positively associated with eight NCD risk factors in 2007 and negatively associated with eight NCD risk factors in 2019 (p < 0.05). Employment (p < 0.001) and urban residence (p < 0.001) were positively associated with eight risk factors for NCD in 2019, while urban residence (p < 0.001) was negatively associated with eight NCD risk factors in 2014.

Conclusion

The prevalence of eight NCD risk factors decreased in Bhutan over the past 13 years. Inadequate fruit and vegetable intake, problem alcohol use, and hypertension increased, current tobacco use, low physical activity, obesity, diabetes, and elevated total cholesterol decreased from 2007 to 2019. Several factors associated for eight and each individual NCD risk factor were identified, which can help guide interventions.

The global impact of tobacco control policies on smokeless tobacco use: a systematic review

BACKGROUND

Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use.

METHODS

In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946).

FINDINGS

14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%).

INTERPRETATION

Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use.

FUNDING

UK National Institute for Health Research.

Common assumptions in tobacco control that may not hold true for South-East Asia

Tobacco is a threat to public health in South-East Asia and its control should be a priority. However, many common assumptions about tobacco control may not hold true for the region and can misdirect policy. The substantial health risks associated with smokeless tobacco have been largely misunderstood and neglected. The syndemic association between tuberculosis and tobacco has also been overlooked. Similarly, less attention has been paid to address second-hand smoke exposure of pregnant women to indoor smoking (caused predominantly by men). On the other hand, our poor understanding of the diverse tobacco supply chain has been blocking progress in tobacco control. Finally, the rising popularity of electronic cigarettes has thrown new challenges; many governments, concerned for its youth, have banned such products. We argue for a nuanced approach to tobacco control in South-East Asia. We also encourage a wider debate in public health, where other established assumptions may be hampering progress.

Noncommunicable diseases risk factors in Bhutan: A secondary analysis of data from Bhutan's nationwide STEPS survey 2014

Background

Bhutan is facing an epidemic of noncommunicable diseases; they are responsible for 53% of all deaths. Four main modifiable risk factors, including tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet, are the causes of most noncommunicable diseases (NCDs). This study aimed to assess 1) the prevalence of NCDs modifiable risk factors in Bhutan’s adult population and 2) associations between the sociodemographic factors and the NCDs modifiable risk factors with overweight or obesity, hypertension, and diabetes.

Methods

We used the 2014 Bhutan WHO Stepwise Approach to NCD Risk Factor Surveillance (STEPS) Survey dataset in this study. Data were analyzed using multiple logistic regressions, constructed with overweight or obesity, hypertension, and diabetes as outcome variables and modifiable risk factors as independent variables.

Results

The prevalence of tobacco use, harmful use of alcohol, unhealthy diet (low fruits and vegetables intake) and physically inactive was 24.8% (95% CI: 21.5, 28.5), 42.4% (95% CI: 39.4, 45.5), 66.9% (95% CI: 61.5, 71.8), and 6.2% (95% CI: 4.9, 7.8), respectively. The prevalence of overweight or obesity, hypertension and diabetes was 32.9% (95%CI: 30.0, 36.0), 35.7% (95% CI: 32.8, 38.7) and 6.4% (95% CI: 5.1, 7.9), respectively. Multiple logistic regression showed that older age groups were more likely to be overweight or obese, hypertensive, and diabetic. Our analysis also found that tobacco users were less likely to be overweight or obese (aOR 0.71, 95% CI 0.52, 0.96), and to be hypertensive (aOR 0.74, 95% CI 0.56, 0.97); but they were more likely to be diabetic (aOR 1.64, 95% CI 1.05, 2.56). Alcohol users were more likely to be hypertensive aOR 1.41 (95% CI 1.15, 1.74). Furthermore, vigorous physical activity could protect people from being overweight or obese, aOR 0.47 (95% CI 0.31, 0.70), and those consuming more than five serves of fruits and vegetables per day were more likely to be overweight or obese, aOR 1.46 (95% CI 1.17, 1.82).

Conclusion

The prevalence of NCDs modifiable risk factors and overweight or obesity and hypertension was high in Bhutan. We found strong associations between tobacco use and diabetes, alcohol use, hypertension, physically inactive, and overweight or obesity. The results suggest that the government should prioritize NCDs prevention and control programs, focusing on reducing modifiable risk factors. The health sector alone cannot address the NCDs epidemic in Bhutan, and we recommend the whole of government approach to tackle NCDs through the Bhutan Gross National Happiness framework.

Prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu

BACKGROUND

According to WHO, the deaths due to NCDs in Nepal have soared from 60% of all deaths in 2014 to 66% in 2018. The study assessed the prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu.

MATERIALS AND METHODS

A community based cross-sectional study was conducted from September 2019 to February 2020 among 18-69 years adults residing in municipalities of Kathmandu district. Multi-stage random sampling technique was used to select 245 subjects who were interviewed using WHO NCD STEPS instrument. Chi-square test and logistic regression analysis were done to explore the determinants of NCD risk factors.

RESULTS

The prevalence of current smoking, alcohol consumption, low intake of fruits and vegetables and low physical activity was found to be 22%, 31%, 93.9% and 10.2% respectively. More than half (52.2%) of the participants were overweight or obese and the prevalence of raised blood pressure was 27.8%. Smoking was associated significantly with male gender (AOR = 2.37, CI: 1.20-5.13) and respondents with no formal schooling (AOR: 4.33, CI: 1.50-12.48). Similarly, the odds of alcohol consumption were higher among male gender (AOR: 2.78, CI: 1.47-5.26), people who were employed (AOR: 2.30, CI: 1.13-4.82), and those who belonged to Chhetri (AOR: 2.83, CI: 1.19-6.72), Janajati (AOR: 6.18, CI: 2.74-13.90), Dalit and Madhesi, (AOR: 7.51, CI: 2.13-26.35) ethnic groups. Furthermore, respondents who were aged 30-44 years (AOR: 5.15, CI: 1.91-13.85) and 45-59 years (AOR: 4.54 CI: 1.63-12.66), who were in marital union (AOR: 3.39, CI: 1.25-9.13), and who belonged to Janajati (AOR: 3.37, CI: 1.61-7.04), Dalit and Madhesi (AOR: 4.62, CI: 1.26-16.86) ethnic groups were more likely to be associated with overweight or obesity. Additionally, the odds of raised blood pressure were higher among people who were of older age (AOR: 6.91, CI: 1.67-28.63) and those who belonged to Janajati ethnic group (AOR: 3.60, CI: 1.46-8.87) after multivariate analysis.

CONCLUSION

The findings of the study highlighted high prevalence of behavioral and metabolic risk factors, which varied on different socio-demographic grounds. Thus, population specific health promotion interventions centered on public health interests is recommended to reduce risk factors of NCDs.

Factors influencing smoking behaviour of online ride-hailing drivers in China: a cross-sectional analysis

BACKGROUND

Online ride-hailing is a fast-developing new travel mode. However, tobacco control policies on its drivers remain underdeveloped. This study aims to reveal the status and determine the influencing factors of ride-hailing drivers' smoking behaviour to provide a basis for the formulation of tobacco control policies.

METHODS

We derived our cross-sectional data from an online survey of full-time ride-hailing drivers in China. We used a survey questionnaire to collect variables, including sociodemographic and work-related characteristics, health status, health behaviour, health literacy and smoking status. Finally, we analysed the influencing factors of current smoking by conducting chi-square test and multivariate logistic regression.

RESULTS

A total of 8990 ride-hailing drivers have participated in the survey, in which 5024 were current smokers, accounting to 55.9%. Nearly one-third of smokers smoked in their cars (32.2%). The logistic regression analysis results were as follows: male drivers (OR = 0.519, 95% CI [0.416, 0.647]), central regions (OR = 1.172, 95% CI [1.049, 1.309]) and eastern regions (OR = 1.330, 95% CI [1.194, 1.480]), working at both daytime and night (OR = 1.287, 95% CI [1.164, 1.424]) and non-fixed time (OR = 0.847, 95% CI [0.718, 0.999]), ages of 35-54 years (OR = 0.585, 95% CI [0.408, 0.829]), current drinker (OR = 1.663, 95% CI [1.526, 1.813]), irregular eating habits (OR = 1.370, 95% CI [1.233, 1.523]), the number of days in a week of engaging in at least 10 min of moderate or vigorous exercise ≥3 (OR = 0.752, 95% CI [0.646, 0.875]), taking the initiative to acquire health knowledge occasionally (OR = 0.882, 95% CI [0.783, 0.992]) or frequently (OR = 0.675, 95% CI [0.591, 0.770]) and underweight (OR = 1.249, 95% CI [1.001, 1.559]) and overweight (OR = 0.846, 95% CI [0.775, 0.924]) have association with the prevalence of current smoking amongst online ride-hailing drivers.

CONCLUSION

The smoking rate of ride-hailing drivers was high. Sociodemographic and work-related characteristics and health-related factors affected their smoking behaviour. Psychological and behavioural interventions can promote smoking control management and encourage drivers to quit or limit smoking. Online car-hailing companies can also establish a complaint mechanism combined with personal credit.

Key Drivers to Implement an Evidence-based Tobacco Control Programme in Schools of India: A Mixed-Methods Study

Background:

Adolescence is an influential stage in students’ lives when lifelong behaviours such as tobacco use are formed. During these years, school teachers are important role models for tobacco control among students. A study was conducted among school personnel and administrators to understand the key drivers for implementing an evidence-based school tobacco control program.

Methodology:

A cross-sectional, mixed-method study was conducted in five districts of Assam, India. The quantitative study was conducted among 565 school personnel across 40 Government-aided schools. Data was collected by means of an anonymous, self-administered questionnaire. Qualitative data was generated from 15 focus group discussions (FGDs) among 146 participants - District Program Officers, Block Education Officers, Cluster Coordinators, Headmasters and Teachers.

Results:

While the prevalence of smoked tobacco was low (3%), the use of smokeless tobacco was higher (40%), and the prevalence of use of areca nut without tobacco (65%) was still higher among school personnel. They were aware of the school policies prohibiting the use of tobacco among students within or outside school buildings or during school-sponsored activities (81%); they had rather limited knowledge about policy for themselves (58%). There was lack of access to training materials about prevention of tobacco use among youth. The FGDs amongst school personnel resulted in several constructive suggestions on tobacco control in schools mainly in training school teachers, monitoring the program and incentives for execution of the program. However, there was a reluctance to implement a smokeless tobacco control programme since many were current users of smokeless tobacco and areca nut.

Conclusion:

Tobacco control policies as well as training school personnel in schools need to improve and further measures must be taken to prohibit use of areca nut, which contains carcinogens. The existing system of the education department can be utilised to implement tobacco control programmes effectively.

Risk factors for non-communicable diseases in Bangladesh: findings of the population-based cross-sectional national survey 2018

OBJECTIVES

To determine the national prevalence of risk factors of non-communicable diseases (NCD) in the adult population of Bangladesh.

DESIGN

The study was a population-based national cross-sectional study.

SETTING

This study used 496 primary sampling units (PSUs) developed by the Bangladesh Bureau of Statistics. The PSUs were equally allocated to each division and urban and rural stratum within each division.

PARTICIPANTS

The participants were adults aged 18 to 69 years, who were usual residents of the households for at least 6 months and stayed the night before the survey. Out of 9900 participants, 8185 (82.7%) completed STEP-1 and STEP-2, and 7208 took part in STEP-3.

PRIMARY AND SECONDARY OUTCOME

The prevalence of behavioural, physical and biochemical risk factors of NCD. Data were weighted to generate national estimates.

RESULTS

Tobacco use was significantly (p<0.05) higher in the rural (45.2%) than the urban (38.8%) population. Inadequate fruit/vegetable intake was significantly (p<0.05) higher in the urban (92.1%) than in the rural (88.9%) population. The mean salt intake per day was higher in the rural (9.0 g) than urban (8.9 g) population. Among all, 3.0% had no, 70.9% had 1 to 2 and 26.2% had ≥3 NCD risk factors. The urban population was more likely to have insufficient physical activity (adjusted OR (AOR): 1.2, 95% CI: 1.2 to 1.2), obesity (AOR: 1.5, 95% CI: 1.5 to 1.5), hypertension (AOR: 1.3, 95% CI: 1.3 to 1.3), diabetes (AOR: 1.6, 95% CI: 1.6 to 1.6) and hyperglycaemia (AOR: 1.1, 95% CI: 1.1 to 1.1).

CONCLUSIONS

Considering the high prevalence of the behavioural, physical and biochemical risk factors, diverse population and high-risk group targeted interventions are essential to combat the rising burden of NCDs.

Prevalence and Correlates of Betel Quid Chewing among Bhutanese Adults

Background: Chewing of betel quid, popularly known as doma khamdo, is prevalent in Bhutan and is associated with Bhutanese customs and traditions. The objective of this paper was to determine the prevalence and explore the correlates of current betel quid use in Bhutan. Materials and methods: This is a retrospective study of secondary data from the National Health Survey 2012 (NHS 2012) of Bhutan. The outcome variable of interest was current betel quid use. The self-reported demographic characteristics were obtained using a questionnaire developed following the WHO STEPwise approach to the surveillance of non-communicable diseases (STEP). Univariate and multivariate logistic regression were performed to identify correlates for betel quid use. Results: The prevalence of current betel quid use in this study was 45.0%. The correlates associated with current betel quid use were: being female; having a primary, high school or a monastic education; being professionals in the armed forces, managers, technicians, service and sales workers, and machine operators; being current smokers; alcohol consumption; and intake of drugs. Correlates associated with decreased betel quid use were: having a diploma/certificate-level and non-formal education, and living in urban areas. Conclusion: The findings indicate that betel quid was consumed by nearly half of the Bhutanese population. Bhutan should immediately initiate national prevention programs targeting these correlates of betel quid use.

Educational and Wealth Inequalities in Smokeless Tobacco Use: An Analysis of Rural-Urban Areas of Bangladesh and India

This study aims to investigate the educational and wealth inequalities in smokeless tobacco (SLT) use in rural and urban areas of Bangladesh and India, the 2 largest global SLT users. Using the Global Adult Tobacco Survey, both absolute and relative measures of inequality were estimated. The analysis reveals that the educational inequalities in SLT use were higher in urban areas of India and in rural areas of Bangladesh, whereas the wealth inequalities in SLT use were higher in urban areas of both the countries. Moreover, the logit model showed that the odds of SLT use declined with an increase in the level of education and wealth in rural and urban areas of India. However, no consistent pattern was observed in rural and urban areas of Bangladesh. The findings clearly delineate the subgroups which require immediate attention for SLT cessation interventions in these 2 countries.

A review of trade practices of smokeless tobacco products in terms of prohibition on sale, manufacturing & importation in Framework Convention on Tobacco Control ratified Parties

BACKGROUND & OBJECTIVES

Over the past decade, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has served as a powerful tool to initiate and advance global tobacco control efforts. However, the control strategies have mainly targeted demand-side measures. The goal of a tobacco-free world by 2040 cannot be achieved if the supply-side measures are not addressed. This analysis was undertaken to examine the tobacco control legislations of various Parties ratifying WHO FCTC with an objective to ascertain the status of prohibition of importation, sale and manufacturing of smokeless tobacco products.

METHODS

All 180 Parties to WHO FCTC were included for the study. A comprehensive database of all the parties to FCTC was created and tobacco control legislations and regulations of all parties were studied in detail.

RESULTS

Overall, the sale of smokeless tobacco (SLT) products was prohibited in 45 Parties. Eleven Parties prohibited manufacturing of SLT products and six Parties imposed a ban on importation of SLT products. Australia, Bhutan, Singapore and Sri Lanka banned all three.

INTERPRETATION & CONCLUSIONS

Comprehensive tobacco control strategy with effective tobacco cessation programme should complement strong legal actions such as prohibition on trade in SLT products to meet the public health objective of such laws and regulations. In addition, multisectoral efforts are needed for effective implementation of such restrictions imposed by the governments.

Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey

BACKGROUND

Bhutan is currently facing a double burden of non-communicable (NCDs) and communicable diseases, with rising trends of NCDs. The 2014 STEPS survey identified high prevalence of several NCD risk factors; however, associations with socio-demographic characteristics as well as clustering of risk factors were not assessed. This study aimed to determine the distribution and clustering of modifiable NCD risk factors among adults in Bhutan and their demographic and social determinants.

METHODS

This was secondary analysis of data from NCD Risk Factors WHO STEPS Survey 2014 in Bhutan. A weighted analysis was conducted to calculate the prevalence of NCD risk factors, and associations were explored using weighted log-binomial regression models.

RESULTS

This study included 2822 Bhutanese aged 18-69 years; 52% were 18-39 years, 62% were female, and 69% were rural resident. Prevalence of high salt intake, unhealthy diet and tobacco use were 99, 67 and 25% respectively. Raised blood pressure was the commonest (36%) modifiable biological risk factor followed by overweight (33%). The median NCD risk factors per person was 3 (Inter Quartile Range: 2-4); 52.5%% had > = 3 risk factors. A statistically significant difference was found between male vs. female in alcohol consumption(aPR 0.71, 95% CI: 0.53-0.97), low physical activity(aPR 2.06, 95% CI: 1.54-2.75), impaired fasting glycaemia(aPR 1.24, 95% CI: 1.01-1.52), and being overweight(aPR 1.46, 95% CI: 1.31-1.63). Low physical activity was more common among those with secondary and above education level vs. those without any formal education(aPR 1.71, 95% CI: 1.24-2.35), and among those residing in urban areas vs. those in rural(aPR 3.43, 95% CI: 2.27-5.18). Older participants and urban residents were more likely to have > = 3 NCD risk factors compared to younger(aPR 1.46, 95% CI: 1.35-1.58) and rural residents(aPR 1.21, 95% CI: 1.10-1.32).

CONCLUSION

Lifestyle modifications at the population level are urgently required in Bhutan as several NCD risk factors such as high salt intake, unhealthy diet, overweight, and high blood pressure were alarmingly high and frequently clustered. Moreover there is a need to consider policy and socio-political and economic factors that have undermined global and national progress to address the rise of NCDs and their risk factors in Bhutan as elsewhere.