Acceptability of Female Smoking and Smokeless Tobacco Use in Bangladesh and India

Background: Smokeless tobacco has a long history in Bangladesh and India, where it has become normalized as a socially acceptable behaviour, but the same level of social acceptance does not apply to smoking, especially among females. As a result, there is a large gender gap in smoking rates but the gender difference in smokeless tobacco use is much narrower or even in the opposite direction. Explanations for the higher prevalence and social acceptability of female smokeless tobacco use in this region range from cultural factors to tobacco industry practices and tobacco control policies. Objectives: This study aims to examine acceptability of female smoking and smokeless tobacco use in Bangladesh and India, and to identify factors that might distinguish female tobacco use from male tobacco use and influence behavior such as quitting, including different types of social norms (descriptive and injunctive), beliefs about tobacco, and awareness of tobacco control policies. Methods: Data are from the International Tobacco Control (ITC) Policy Evaluation Project in India and Bangladesh, longitudinal cohort surveys of tobacco users and non users conducted using face-to-face interviews. This dissertation uses data from Wave 1 of the TCP India Project (2010-2011; N=10,585) and Waves 2-3 of the ITC Bangladesh Project (2010, N=4,379; and 2011-2012, N=4,225). Respondents were categorized as either smokers (of cigarettes and/or bidis), smokeless tobacco users, mixed users (currently smoke and use smokeless tobacco), or non users of tobacco. The primary measures of interest for this study were behaviours relevant to quitting (quit intentions and quit attempts), perceived social acceptability of tobacco use in general and of female tobacco use in particular, awareness of selected tobacco control policies, and sociodemographics. Results: While rates of female tobacco use were low in each country, females were much more likely to use smokeless tobacco than to smoke, compared to males. In both countries, smokeless tobacco was perceived to be more acceptable than smoking, especially for females. Social acceptability measures were predicted by a few of the measures of awareness of tobacco control policies, including warning labels and smoke-free laws. The majority of respondents were aware that any form of tobacco use is harmful and is not an acceptable behaviour overall, indicating a negative injunctive norm; however, people who use either smoked or smokeless tobacco were more likely to say that their own product is socially acceptable, a sign of justification effects. This effect was strongest for female smokers – only 75-83% said it is not acceptable for females to smoke, compared to 93-97% of male smokers. The influence of descriptive norms on behaviour was seen from the finding that tobacco users were more likely to have friends and parents who shared the same habit. However, most tobacco users also said close others disapproved of their habit, creating a negative subjective norm that may be stronger for females. Very few tobacco users expressed a desire to quit, and a minority had made a quit attempt by Wave 3 in Bangladesh. Social acceptability predicted quit intentions only for smokers in Bangladesh: smokers who perceived greater society disapproval of smoking were more likely to intend to quit. Conclusions: Most research on smoking has focused on men and specifically on the harms of cigarettes; less attention has been paid to other tobacco products or the factors explaining their use, specifically for female tobacco users. It is important to study patterns of tobacco use among females in countries such as Bangladesh and India in order to reduce health risks and improve cessation rates for women who currently use smokeless tobacco, while at the same time preventing more women in these countries from taking up smoking. A better understanding of the ways that social norms influence tobacco use behaviour and quitting can have a valuable impact on designing and implementing more effective tobacco control strategies and health interventions in these countries and other LMICS

Time perspective as a predictor of smoking status: findings from the International Tobacco Control (ITC) Surveys in Scotland, France, Germany, China, and Malaysia

BACKGROUND: Prior studies have demonstrated that time perspective-the propensity to consider short-versus long-term consequences of one\u27s actions-is a potentially important predictor of health-related behaviors, including smoking. However, most prior studies have been conducted within single high-income countries. The aim of this study was to examine whether time perspective was associated with the likelihood of being a smoker or non-smoker across five countries that vary in smoking behavior and strength of tobacco control policies. METHODS: The data were from the International Tobacco Control (ITC) Surveys in five countries with large probability samples of both smokers (N=10,341) and non-smokers (N=4,955): Scotland, France, Germany, China, and Malaysia. The surveys were conducted between 2005-2008. Survey respondents indicated their smoking status (smoker vs. non-smoker) and time perspective (future oriented vs. not future-oriented) and provided demographic information. RESULTS: Across all five countries, non-smokers were significantly more likely to be future-oriented (66%) than were smokers (57%), χ(2)(1, N = 15,244) = 120.64, p < .001. This bivariate relationship between time perspective and smoking status held in a multivariate analysis. After controlling for country, age, sex, income, education, and ethnicity (language in France), those who were future-oriented had 36% greater odds of being a non-smoker than a smoker (95% CI: 1.22 to 1.51, p<.001). CONCLUSION: These findings establish time perspective as an important predictor of smoking status across multiple countries and suggest the potential value of incorporating material to enhance future orientation in smoking cessation interventions

From Research to Impact: A Toolkit for Developing Effective Policy Briefs

This toolkit provides an informative guide for researchers on the development of effective policy briefs to communicate research findings to policymakers, with the aim of supporting evidence-informed decision-making. Relevant examples, tips, resources, and checklists are also provided to maximize the impact of the policy brief

Evidence of the continuing weak impact of China's health warnings: longitudinal findings over nine years (2006 to 2013 - 15) from the ITC China project

Background China's health warnings do not meet the FCTC Article 11 guidelines. They are small (< 35% of the pack) and do not include pictorial images, which research has shown to have greater impact. Four rounds of warnings have been implemented between 1992-2016. This study examines warning impact over 9 years (2006-15), including the third round (April 2012), which increased font size while maintaining overall warning size and replaced the English text with Chinese on the back. Methods Data are from Waves 1-5 (2006-15) of the International Tobacco Control (ITC) China Survey, a cohort survey of 800 adult smokers in each of five cities, adding five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes in key indicators of warning impact over time. Results Over 9 years, there has been little change in impact of the Chinese warnings. Indeed, the percentage of smokers who noticed warnings 'often' actually DECREASED from 51% (2006) to 38% (2013-15) ( p < .001), and fewer than one-third of smokers reported cognitions or behaviours related to quitting because of the warnings. The April 2012 revision did not improve any of the warning impact indicators. Warning noticing/salience did not differ between cities and rural areas, but rural smokers were more likely to think 'a lot' about harms of smoking (17% vs 11%, p < .001) and about quitting (14% vs 6%, p < .001) because of the warnings. Conclusions China's text-only warnings continue to be extremely weak. The minor changes in 2012 did not increase warning impact. Global evidence is clear that large pictorial warnings depicting specific harms of cigarettes would greatly enhance warning impact in China, including increasing knowledge and motivation to quit among the 300M Chinese smokers. These benefits would be especially important for the large rural population, where there are fewer other sources of health information

Trends in SHS exposure and smokers' support for smoke-free laws in China: findings from the ITC China survey, 2007 - 15

Background Secondhand smoke (SHS) poses a major public health threat in China, causing over 100,000 deaths/year. China, however, has not yet implemented a national comprehensive smoke-free law, and the few subnational laws are only partial. This study presents trends in selected cities from 2007 to 2015 in: (1) exposure to SHS in key public places (workplaces, restaurants, bars), and (2) smokers' support for comprehensive smoke-free laws, comparing cities and rural areas in 2013-15. Methods Data are from Waves 2 to 5 of the International Tobacco Control (ITC) China Survey (2007-15), a face-to-face cohort survey of 800 smokers in each of five cities (Beijing, Guangzhou, Kunming, Shanghai, Shenyang), plus five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes over time. Results At the latest wave (2013-15), the majority of respondents reported being exposed to SHS in public places. Smoking was most prevalent in bars, with little reduction over time across cities (from 93% overall in 2007 to 86% in 2013-15). Smoking in other venues decreased over time, but remained very high in 2013-15 (from 94% to 67% for restaurants; and 75% to 51% for workplaces). In rural areas, smoking prevalence was higher in workplaces (73% vs 56%, p < .001) and lower in bars (73% vs 88%, p < .05) compared to cities; there was no difference in restaurants. Support for complete smoking bans among smokers in cities increased over time for each venue and is higher than nearly all other 20+ ITC countries. Support did not differ between cities and rural locations. Conclusions Partial smoke-free laws in China are failing to protect both urban and rural residents from SHS, demonstrating the urgent need for a comprehensive national smoke-free law, as called for by the FCTC. Such a law would be supported by the majority of the Chinese public

Children Aging Out of Care

Studies have consistently shown that youth who age out of care face numerous challenges and poorer life outcomes compared to their peers. The aim of this literature scan was to explore research on interventions or policies that might improve the transition process and outcomes for children and youth aging out of care in Ontario and any evidence on their effectiveness

Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: Findings from the Tobacco Control Policy (TCP) India Pilot Survey

Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India