Dual use of tobacco among Bangladeshi men

Dual Burden of Smoked and Smokeless Tobacco Use in India, 2009-2017: A Repeated Cross-Sectional Analysis Based on Global Adult Tobacco Survey

INTRODUCTION

The dual use of smoked and smokeless tobacco (SLT) poses a serious challenge to tobacco control efforts. This article examines the trends and patterns of this usage in India during the period 2009-2010 and 2016-2017.

METHODS

Data from two rounds of nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009-2010 and 2016-2017 have been used. Dual use was assessed based on current smokers and SLT users in both rounds.

RESULTS

Findings reveal that dual use in India has dropped from 5.3% during 2009-2010 to 3.4% during 2016-2017, a decline of nearly 10 million dual users. However, some states have added nearly 4.6 million new dual users during this period. While dual use continues to remain high in rural areas, there has been a manifold increase in urban areas. Findings revealed that intention to quit tobacco was lower among dual tobacco users as compared to single users with considerable difference between urban and rural areas.

CONCLUSION

Easy availability and affordability of SLT products compared to smoking products and restrictions on smoking in public places may have pushed current smokers and dual users to take to or intensify their SLT consumption. Measures relating to awareness, pricing, taxation, and enforcement of tobacco control laws should focus on all forms of tobacco, especially targeting high dual burden in rural and urban settings.

IMPLICATIONS

Dual form of tobacco users represent 12% of all tobacco users in the country. The study reveals that intention to quit tobacco among dual users is significantly lower than that among single tobacco product users. This requires improving public awareness about the morbidity and mortality that arises from the use of all forms of tobacco products. Efforts to restrict the availability of tobacco products should focus on licensing the sale of all tobacco products. Reduction in dual tobacco use will not only result in multiplied health benefits but also help in achieving the Non-Communicable Diseases targets under the United Nations Sustainable Development Goals.

Prevalence and determinants of dual and poly-tobacco use among males in 19 low-and middle-income countries: Implications for a comprehensive tobacco control regulation

Despite their implications for tobacco control, data on concurrent dual (using two tobacco products) and poly-tobacco use (using more than two products) are relatively scarce globally. This study aimed to estimate the prevalence of dual and poly-tobacco use among men in 19 low-and middle-income countries (LMICs) and assess potential associations with individual and country level factors. Data from 19 LMICs were obtained from the most recent wave of the Demographic and Health Survey (DHS), collected between 2015 and 2016 comprising 235,975 men aged 15-49 years. The prevalence of current single, dual and poly-tobacco use were estimated using available sample weights. Mixed-effect multilevel models were used to estimate associations of individual and country level factors with tobacco use. Results showed that the prevalence of dual or poly-tobacco use among men was highest in Timor Leste (27.1%), Nepal (18.3%), Lesotho (13.2%) and India (9.3%). Factors associated with dual and poly-tobacco use were older age, low academic achievement, low income status, being divorced, living in urban areas and high frequency of media use. Among country-level characteristics, national wealth was not associated with dual and poly-tobacco use. Implementation of MPOWER measures was inversely associated with single tobacco use; this was not the case for dual and poly-tobacco use. Findings suggest that dual and poly-tobacco use are common among men especially in South-East Asian countries. This study highlights the need for MPOWER measures to be expanded and strengthened to address all tobacco products and explicitly consider dual and poly use.

Social determinants of dual tobacco use in India: An analysis based on the two rounds of global adult tobacco survey

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First study from India and south Asia examining trends and socioeconomic predictor of dual tobacco use.

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Considerable disparity in dual tobacco use across socioeconomic groups evident.

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Time adjusted result show various factors that determined dual tobacco use.

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There is a need for targeted cessation interventions among dual tobacco users as no proven pharmocological or behavioural cessation model exists for them.

This study examines the socioeconomic determinants of dual use of smoked and smokeless tobacco (SLT) in India between 2009–10 and 2016–17. Data from two rounds of the nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009–10 and 2016–17 was used. Complete sample size from both rounds of survey covering 143,333 individuals (GATS I: 69,296 and GATS II: 74,037) from 153,239 households (GATS I: 76,069 and GATS II: 77,170) included in the study. Dual use was assessed based on current smoked and SLT users in both rounds. Bivariate analysis was applied to assess differences in dual tobacco use by socioeconomic status (SES) and across regions, whereas, pooled sampled analysis was conducted to examine the determinants of dual use applying multinomial logistic regression model. Findings reveal that dual use has declined in India from nearly 5% in 2009–10 to 3.4% in 2016–17. Considerable regional and SES differences in dual use are evident. Multivariate results indicate, while age is positively associated with dual use, education and household wealth was negatively associated. Dual use of tobacco was found to be considerably higher among men as compared to women (RRR: 15.66, 95%CI 14.20–17.27). Awareness about the adverse health consequences of tobacco was also negatively associated with dual tobacco use (RRR: 0.56, 95%CI 0.50–0.64). Future awareness and enforcement efforts should focus on all forms of tobacco, especially targeting vulnerable SE groups.

Smokeless tobacco and public health in Bangladesh

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Epidemiology of hypertension among Bangladeshi adults using the 2017 ACC/AHA Hypertension Clinical Practice Guidelines and Joint National Committee 7 Guidelines

In 2017, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines on the definition of hypertension, and blood pressure thresholds for initiation of antihypertensive medication. Our objective was to assess the change in prevalence of hypertension, risk factors, and identify populations recommended for treatment among Bangladeshi adults, based on the 2017 ACC/AHA guidelines. Data for this analysis were collected from a population-based nationally representative sample of 1843 Bangladeshi adults, aged ≥18 years in 2015. Hypertension was defined based on two definitions: the JNC 7 guidelines (SBP ≥ 140 or DBP ≥ 90 mmHg), and the 2017 ACC/AHA guidelines (SBP ≥ 130 mmHg, or DBP ≥ 80 mmHg), or a self-reported diagnosis of hypertension. Based on the 2017 ACC/AHA guidelines, the prevalence of hypertension was 40.7% (95% CI: 38.5-43.0). The prevalence of JNC 7 definition of hypertension was 17.9% (95% CI: 16.2-19.7), indicating a 22.8% increase in prevalence. Based on both definitions, urban residents, older adults, adults with low physical activity, obese, abdominally obese, and diabetic adults were more likely to have hypertension. Based on current JNC 7 guidelines, only half of hypertensive adults were aware of having hypertension. Among those aware of their condition, 75% were taking medication based on self-report. Using the 2017 ACC/AHA guidelines, the prevalence of hypertension will more than double in Bangladesh. Newly diagnosed hypertensive adults will be considered high-risk for cardiovascular disease leading to a larger burden on Bangladesh's health system. However, implementation of the ACC/AHA guidelines may improve prevention efforts where lifestyle changes are appropriate.

Alcohol consumption among adults in Bangladesh: Results from STEPS 2010

Background Alcohol use is a risk factor for the development of noncommunicable diseases. National data are needed to assess the prevalence of alcohol use in the Bangladeshi population. The objective of this study was to describe the prevalence and patterns of alcohol use among men and women of rural and urban areas of Bangladesh. Additionally, predictors of ever alcohol use were also identified. Methods A nationally representative cross-sectional survey (STEPS 2010) was conducted on 9275 adults between November 2009 and April 2010. Participants were selected using multi-stage random cluster sampling. Data on several risk factors for noncommunicable diseases, including alcohol use, were collected by an interviewer-administered questionnaire. Results Among the total population, 5.6% (n = 519) reported to have ever drunk alcohol and 94.4% (8756) were lifetime abstainers; 2.0% (n = 190) of participants reported to have drunk alcohol within the last 12 months. Of these, 94.7% (n = 180) were men. Only 0.9% (n = 87) of the total population had drunk alcohol within the last 30 days and were categorized as current drinkers. Among current drinkers, 77.0% (n = 67) were defined as binge drinkers, having had at least one episode of heavy drinking in this time period; 92.0% (n = 80) were current smokers and 59.8% (n = 52) had either no formal education or less than primary school education. Ever alcohol use was more common among men, those who live in urban areas and smokers. Conclusion Alcohol use is low in Bangladesh; however, those who do use alcohol frequently binge drink, which is a public health concern. Targeted efforts should be made on these specific groups, to control and prevent the continued use of alcohol in Bangladesh.

Socio-demographic characteristics and tobacco use among the adults in urban slums of Dhaka, Bangladesh

BACKGROUND

Use of tobacco has become one of the major causes of premature deaths in most developing countries, including Bangladesh. The poorest and most disadvantaged populations, such as those living in slums, are considered to be extremely vulnerable to non-communicable diseases and their risk factors, especially tobacco use. The objective of this study was to assess the current status of tobacco consumption among slum dwellers and its association with socio-demographic factors.

METHODS

A cross-sectional study was conducted in three slums of Dhaka city. Information about tobacco use as well as socio-demographic characteristics was collected from adult slum dwellers via face to face interviews using WHO STEPS questionnaire.

RESULT

Overall proportion of smoking, smokeless tobacco consumption and dual use of tobacco was 35% [95% CI: 31.6-39.8], 40.6% [95% CI: 36.5-45.2] and 12% [95% CI: 9.3-15.0] respectively. Elderly people (55-64 years) were more likely to smoke (OR: 2.34, 95% CI: 1.21-4.49) than younger people (aged 25-34 years). On the other hand, those who had no schooling history (OR: 2.95, 95% CI: 1.66-5.25) were more likely to consume smokeless tobacco than those who had higher education (secondary or above). At the same time, manual workers were more likely to indulge in dual use of tobacco (OR: 5.17, 95% CI: 2.82-9.48) as compared to non-manual workers.

CONCLUSION

The urban slum population of Dhaka city has a high prevalence of tobacco use, which increases their likelihood of developing non-communicable diseases. Proper attention needs to be directed towards addressing the risk factors related to non-communicable diseases within this vulnerable population.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

BACKGROUND

Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs.

METHODS

We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604.

FINDINGS

After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings.

INTERPRETATION

Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4-reducing premature non-communicable disease mortality by a third by 2030-should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases.

FUNDING

WHO.

Trends of Smokeless Tobacco use among Adults (Aged 15-49 Years) in Bangladesh, India and Nepal

BACKGROUND

Smokeless tobacco (SLT) has long been realized as an important component of the fight for global tobacco control. It still remains a major problem in countries like India, Bangladesh and Nepal. The objective of this study was to estimate the trends of SLT use in three countries of the SEARO WHO office.

MATERIALS AND METHODS

We used data from national surveys in three countries (Bangladesh, India and Nepal) to estimate trends in prevalence of current SLT use. All available nationally representative data sources were used. Estimates were weighted, age standardized and given along with 95% confidence intervals. Significance of linear trend in prevalence over time was tested using the Cochrane-Armitage test for trend. A p value of less than 0.05 was considered statistically significant.

RESULTS

We identified three surveys for Bangladesh, three for India and four for Nepal that met the selection criteria (such as Demographic and Health Surveys, WHO-STEPwise approach to Surveillance and Global Adult Tobacco Surveys). A significantly increasing trend was noticed in the prevalence of current SLT use among Bangladeshi men (20.2% to 23%, p=0.03). In India, a similar significantly increasing trend was seen among men (27.1% to 33.4%, p<0.001) and women (10.1% to 15.7%, p<0.001). In Nepal, there was a no significant trend among both men (39.1% to 31.6%, p=0.11) and women (5.6% to 4.7%, p=0.49).

CONCLUSIONS

In the study countries SLT use has remained at alarmingly high levels. Usage trends do not show any signs of decline in spite of control efforts. Tobacco control measures should focus more on controlling SLT use.

Prevalence and Sociodemographic Determinants of Any Tobacco Use and Dual Use in Six Countries of the WHO South-East Asia Region: Findings From the Demographic and Health Surveys

BACKGROUND

Tobacco control is an important strategy to reduce the disease burden caused by several noncommunicable diseases. An in-depth understanding of the sociodemographic variations in tobacco use is an important step in achieving effective tobacco control.

AIMS

We aimed to estimate the age-standardized prevalence of any tobacco use and dual tobacco use and determine their association with sociodemographic variables in six countries (Bangladesh, Indonesia, India, Maldives, Nepal, and Timor Leste) of the WHO South-East Asia Region.

METHODS

The main outcome variables "any tobacco use" and "current dual use" were created from the latest available Demographic and Health Surveys data for each country. The prevalence estimates were weighted using sample weights and age standardized using the WHO standard population. Associations between the sociodemographic variables and tobacco use were calculated by performing multivariable logistic regression analysis. Analyses were performed in Stata 12 using "svyset" and "svy" commands.

RESULTS

The highest prevalence of any tobacco use among men was in Indonesia (76.4%) and among women in Nepal (15.7%). Also, Nepal had the highest prevalence of dual tobacco use in both men (17.9%) and women (1.5%). With regard to sociodemographic determinants, despite the inter-country variations, any and dual tobacco use were significantly associated with age, higher education, greater wealth, rural residence, and ever-married marital status. The poor and uneducated had a higher odds ratio for these practices.

CONCLUSION

Prevalence of dual tobacco use and its underlying socioeconomic disparities should be taken into account for the planning of tobacco control activities in the region.

IMPLICATIONS

The dual tobacco use phenomenon is being increasingly recognized as a distinct entity in the fight against tobacco addiction. When compared with single product users, dual users have a greater risk of developing tobacco related diseases and are less likely to quit their habits. However, this phenomenon has not been studied adequately in the South-East Asia region. In this context, this study has provided a detailed and comprehensive view of dual tobacco use and its sociodemographic determinants in six countries of the region. This study recommends that tobacco control interventions should be targeted specifically at the disadvantaged sections of the society, such as the poor and the uneducated, who are more likely to engage in "dual" as well as "any" tobacco use. This study could prove as an important reference and tool for policy making in the South-East Asia region.

Clustering of non-communicable diseases risk factors in Bangladeshi adults: An analysis of STEPS survey 2013

Background

Non-communicable diseases (NCDs) have already become major killers in Bangladesh. Once NCDs are developed, they become chronic health and economic problems. Their primary prevention is linked to their common risk factors. This study was conducted to determine the prevalence of NCD risk factors with a focus on their clustering in Bangladeshi adults.

Methods

This nationally representative study was done in 4,073 (1,812 men and 2,261 women) adults aged 25 years or older selected from rural and urban households. Multistage cluster sampling design was used. Selected variables were in line with steps I and II of WHO stepwise surveillance except alcohol.

Results

Forty-four percent used tobacco in any form. Almost 93 % did not consume adequate fruit and vegetables (5 servings or more). Thirty eight percent had low physical activity level (<600 MET-minutes/week). One-quarter (26 %) were overweight (body mass index > =25 kg/m^2). Twenty-one percent had hypertension (blood pressure > =140/90 mmHg or medication) and about 5 % had documented diabetes.

Upon examination of risk factor clustering, we observed that 38 % had at least three risk factors. After this threshold, clustering suddenly dropped down to a fairly low level. Using this threshold as a cut-off, clustering of risk factors was associated with age, male gender, urban residence, educational levels and quality of house in multivariate analysis.

Conclusion

Prevalence of NCD risk factors is fairly high in Bangladeshi adults with a tendency of clustering. If a risk factor such as hypertension is detected, a closer look for other risk factors has to be given in both at clinical and public health settings. Clustering raises risk by more than a summation of risk factors. Our findings, therefore, suggest that Bangladesh could expect a significant increase in NCDs in near future.