Patterns and Predictors of Smokeless Tobacco Use among Adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey

<div><p>Background</p><p>Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.</p><p>Methods</p><p>The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.</p><p>Results</p><p>Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18–3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73–9.21) or non-tribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94–6.03), being illiterate (OR = 3.37; 95% CI: 1.99–5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38–10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53–4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51–5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36–3.62).</p><p>Conclusion</p><p>The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.</p></div

Smokeless tobacco use by demographic characteristics among Bangladeshi residents (weighted), Bangladesh 2011.

<p>Smokeless tobacco use by demographic characteristics among Bangladeshi residents (weighted), Bangladesh 2011.</p

Characteristics of the ITC Bangladesh Wave 3 sample (unweighted), Bangladesh 2011 (N = 5522).

<p>*those who use both cigarettes and bidi; **those who use cigarette, bidi and SLT.</p>#<p>Due to the missing values, the total may not add up to the same in some variables.</p

Odds of being a current smokeless tobacco user (weighted; n = 4702), Bangladesh 2011.

<p>*Omnibus test.</p

Additional file 2: Table S2. of An examination of the effectiveness of health warning labels on smokeless tobacco products in four states in India: findings from the TCP India cohort survey

GEE analysis examining differences in awareness and salience of health warning labels on smokeless tobacco between pre- and post-policy periods (Waves 1 and 2) among all pre-and post-policy completers (N = 5142) those that quit SLT by post-policy (n = 508). (DOC 40 kb

Additional file 1: Table S1. of An examination of the effectiveness of health warning labels on smokeless tobacco products in four states in India: findings from the TCP India cohort survey

Type of products used by SLT respondents by state among those who reported using only one product. (DOC 50 kb

Description of the study population by sample type, International Tobacco Control (ITC) Study Bangladesh Enumeration.

<p>Source: ITC Bangladesh Enumeration, 2009 and 2012 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0141135#pone.0141135.s001" target="_blank">S1 File</a>).</p><p>Description of the study population by sample type, International Tobacco Control (ITC) Study Bangladesh Enumeration.</p

Crude adult prevalence of tobacco use in Bangladesh by socio-economic status, 2009–2012.

<p>Source: ITC Bangladesh Enumeration, 2009 and 2012 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0141135#pone.0141135.s001" target="_blank">S1 File</a>).</p><p>Note: Point estimates, standard errors and confidence intervals are obtained from logistic regression models accounting for complex sampling design estimated using SAS. Chi-square and p-values refer to the difference in the point estimates between wave 1 and wave 3.</p><p>Crude adult prevalence of tobacco use in Bangladesh by socio-economic status, 2009–2012.</p

Adjusted prevalence of tobacco use in Bangladesh by gender across sample types, 2009–2012.

<p>Source: ITC Bangladesh Enumeration, 2009 and 2012 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0141135#pone.0141135.s001" target="_blank">S1 File</a>).</p><p>Note: Prevalence estimates are adjusted for age group, gender and socio-economic status and control for the complex sampling design. Point estimates, standard errors and confidence intervals are obtained from logistic regression models accounting for complex sampling design estimated using SAS -callable SUDAAN.</p><p>Adjusted prevalence of tobacco use in Bangladesh by gender across sample types, 2009–2012.</p

Prevalence and Patterns of Tobacco Use in Bangladesh from 2009 to 2012: Evidence from International Tobacco Control (ITC) Study

<div><p>Background</p><p>Smoking and passive smoking are collectively the biggest preventable cause of death in Bangladesh, with major public health burden of morbidity, disability, mortality and community costs. The available studies of tobacco use in Bangladesh, however, do not necessarily employ nationally representative samples needed to monitor the problem at a national scale. This paper examines the prevalence and patterns of tobacco use among adults in Bangladesh and the changes over time using large nationally representative comparable surveys.</p><p>Methods</p><p>Using data from two enumerations of the International Tobacco Control (ITC) Bangladesh Project conducted in 2009 and 2012, prevalence estimates are obtained for all tobacco products by socio-economic determinants and sample types of over 90,000 individuals drawn from over 30,000 households. Household level sample weights are used to obtain nationally representative prevalence estimates and standard errors. Statistical tests of difference in the estimates between two time periods are based on a logistic regression model that accounts for the complex sampling design. Using a multinomial logit model, the time trend in tobacco use status is identified to capture the effects of macro level determinants including changes in tobacco control policies.</p><p>Results</p><p>Between 2009 and 2012, overall tobacco use went down from 42.4% to 36.3%. The decline is more pronounced with respect to smokeless tobacco use than smoking. The prevalence of exclusive cigarette smoking went up from 7.2% to 10.6%; exclusive bidi smoking remained stable at around 2%; while smoking both cigarette and bidi went down from 4.6% to 1.8%; exclusive smokeless tobacco use went down from 20.2% to 16.9%; and both smokeless tobacco use and smoking went down from 8.4% to 5.1%. In general, the prevalence of tobacco use is higher among men, increases from younger to older age groups, and is higher among poorer people. Smoking prevalence is the highest among the slum population, followed by the tribal population, the national population and the border area population, suggesting greater burden of tobacco use among the disadvantaged groups.</p><p>Conclusions</p><p>The overall decline in tobacco use can be viewed as a structural shift in the tobacco market in Bangladesh from low value products such as bidi and smokeless tobacco to high value cigarettes, which is expected with the growth in income and purchasing power of the general population. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37%. The world average of daily smoking among men is 31.1%. The Tobacco Control Act 2005 and the Amendment have yet to make a significant impact in curbing tobacco usage in Bangladesh. The findings in this paper further suggest that the tobacco control policies in Bangladesh need to include targeted interventions to restrain the use of particular types of tobacco products among specific demographic and socio-economic groups of the population, such as smoked tobacco among men, smokeless tobacco among women, and both smoked and smokeless tobacco among those living in rural areas, those in low socio-economic status and those belonging to the tribal and the slum population.</p></div