However, BMI pattern among slum residents and lower social class seem to be comparable to the low BMI profile in rural areas.

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2 Evidence from WHO documents and other credible studies indicate that Non- communicable Diseases (NCD) are on the rise in developing countries, claiming increasing lives and contributing to morbidity and disability. This is attributed to changed life styles primarily in the form of diet change, decreased activity and adoption of habits not conducive to a healthy existence. This chain of events has led to the so- called Epidemiological transition of disease pattern. Bangladesh as a developing country is no exception to this menacing threat. The existing disease reporting and surveillance mechanism leave much to be desired. This scenario is hardly compatible with visions of a healthy society so instrumental for development of a nation. Against this backdrop a WHO sponsored study was undertaken to initiate a national health behavioral risk factors surveillance system in Bangladesh covering 5-64 years age groups of rural as well as urban populations. The WHO STEPwise approach (STEPS) to NCD risk factors, with modified indicators relevant to Bangladesh context, was employed for their study. According to WHO recommendation a total sample size of,49 were recruited representing different prescribed localities and age groups using systematic sampling technique. The data collection of the study started in September in the rural and in October in the urban areas respectively. Findings reveal remarkable diversity in lifestyle within urban, rural age groups and socioeconomic differentials. Rural respondents smoked more than their urban counterparts, while within the urban dwellers the smoking prevalence seemed to decrease with ascending social status. Despite this very high percentages of all type of respondents seemed to be aware of the hazards of smoking. Physical activity was markedly less in urban than rural inhabitants, while it is interesting to note that females had greater physical activity than males in rural areas. In urban situation the gender difference was not much noticeable, with females showing slightly less activity. Prevalence of greasy and fatty food intake again were lower among rural dwellers as well as low class and slum residents of urban areas. Perhaps in pursuance of the above, BMI of rural participants were lower than that of urban. There is an intra-urban increase in obesity with rise of social class. However, BMI pattern among slum residents and lower social class seem to be comparable to the low BMI profile in rural areas. The common NCDs in the study areas were found to correspond to the WHO list of Priority NCDs. The vast majority of these patients were treated by modern allopathic doctors with a preference for private facilities, this trait being more prominent among urban patients.

3 Principal Investigator: Professor Mahmudur Rahman, Ph.D Director Institute of Epidemiology, Disease control & Research (IEDCR) Mohakhali, Dhaka. Phone: (O), 89(R) Mobile: , fax: Co-Investigator: ) Professor ( Col) Mahmuduur Rahman Ex Director National Institute of Preventive and Social medicine (NIPSOM) ) Dr Meerjady Sabrina Flora Associate Professor of Epidemiology National Centre for Control of Rheumatic Fever & Heart Diseases ) Dr. Seikh Farid Uddin Akter, PhD Associate Professor of Epidemiology National Institute of Preventive and Social Medicine (NIPSOM) 4) Dr. Shaila Hossain Associate Professor of community Medicine National Institute of Preventive and Social medicine (NIPSOM) Consultant: Professor C G N Mascie-Taylor, Scd Professor & Head Dept. of Biological Anthropology University of Cambridge Drowning Street Cambridge CB DZ UK Tel: UK (Off) Fax: UK- -546

4 Content Introduction Background 4 Objective 8 Methodology 8 Sampling plan 8 Data collection method 9 Questionnaire design 9 Data analysis and quality assurance Findings Population characteristics Tobacco Usage Smoking Pattern Smokeless Tobacco Usage Pattern Knowledge and Attitude of the respondents 7 Physical Activity Status 7 Dietary Pattern 84 Health Seeking pattern Anthropometric Measurement Conclusions 4 Annxure List of the Interviewers 6 Questionnaire 7

5 Background The World Health Report 997 Conquering suffering, enriching humanity drew attention to the growing burden of non-communicable diseases (NCDs) in both the developed and developing countries. It is predicted that NCDs would come to dominate public health in the world in the twenty-first century. The emerging epidemic of non-communicable diseases is largely affected by population ageing and the rapidly increasing number of people who are at risk to different risk factors. The prevalence of non-communicable diseases (NCDs) is on the rise in the developed countries from the third decade of the twentieth century and for the last three decades in the developing countries. Singularly they have had an impact in the health situations of the respective countries giving rise to more morbidity and mortality. A few tips for controlling the NCDs expansion can be attributed to promotion of healthy life styles preferably in the areas of tobacco use, diet and physical activity. Due to improved health status and emphasis on the prevention and control of communicable diseases in the developed countries, the burden of NCDs is high in those countries whilst the double burden of communicable and non-communicable diseases is high in the developing countries. This apparent change in the disease trend can be attributed to the rapid socio-economic and life style changes that have taken place in these countries due to rapid industrialization, modernization and mechanization. Life style is a diffuse concept often used to denote the way people live signifying a whole range of social values, religious beliefs, attitudes and activities that drive men into action. New life style, traditions and customs has led to the change of people s attitudes towards life, dietary patterns, and living standards has resulted in the increased prevalence of sedentary workers, increased alcohol abuse, and increase in the number of smokers both male and female, and obesity. These changes have resulted in the increased prevalence of non-communicable diseases like coronary heart disease (CHD), hypertension, diabetes, stroke, chronic obstructive pulmonary disease (COPD) and cancer. NCDs caused an estimated 6 of deaths in the world and 4 of the global burden of diseases in 999. Based on current trends, by the year these diseases are predicted to account for 7 of deaths and 6 of the disease burden. Most of this increase will be due to the demographic and epidemiological transition in developing countries, although the burden of NCDs in developed countries continues to increase steadily. The two leading causes, CHD and stroke, will be responsible for.5 million deaths ( of the total 56 million deaths globally). A reduction of mean blood pressure in the whole population has the potential to prevent. million deaths from stroke and.6 million coronary deaths. Over the next years, the burden of disease from NCDs in developing and newly industrialized countries is expected to rise by more than 6 compared to only in the developed ones. Cardiovascular diseases (CVD) and cancer are at present the leading causes of death in the developed countries accounting for 7 to 75 percent of total deaths. The prevalence of chronic diseases is showing upward trend globally irrespective of rich and poor, developed or developing status. CHD is the cause of 5 to percent of deaths in most industrialized countries and World Health Organization (WHO) states it to be our modern epidemic. Hypertension is an ice-berg disease and in early 97s it was found that in developed countries half of the hypertensive subjects were aware of the disease and its consequences, half of those aware were treated and half of the treated were adequately treated. One can well imagine the gravity of the situation in the developing countries, which is easily understandable. In a study conducted in India the prevalence of hypertension was 59.9 and 69.9 per thousand in males and females in urban population and 5.5 and 5.9 in the rural population,. Different types of cancer are the cause of about percent of deaths globally. In the developed and economically sound countries, cancer is the second leading disease responsible for death after cardio-vascular disease causes, accounting for percent (.5 million) deaths of all mortality. In the developing and the least developed (LDCs) countries it is ranked third and responsible for 9.5 percent (.8 million) of deaths. Out of an estimated total of 5. million deaths in 996 in the world a sizable portion, 7.million deaths were implicated to cancer. In the South East Asia Region of WHO the great majority are cancer of the oral cavity and uterine cervix. 4

6 The rapid social, cultural and economic changes in the Bangladeshi society have also given rise to the number of deaths due to non- communicable diseases. The disease reporting in Bangladesh is poor and statistics are not easily available. There does not exist any effective surveillance system for monitoring disease and to think about NCD surveillance will be a very remote possibility. Hospital records show that death from cardiovascular diseases including intra-cerebral and other internal hemorrhagic diseases, acute myocardial infarction, hypertensive diseases and acute but ill-defined CVD together accounts for more than percent of all deaths in 997 making it number two killer disease in Bangladesh. The Cancer Control Program was started in 98 as a small non-communicable disease program and presently, The National Institute of Cancer and Hospital in Dhaka undertakes research activities in a very limited manner. Cancer patients in the above hospital rose from 47 in 98 to 5,669 in the year 997.This is the picture in one single hospital and can be rightly said to represent the tip of the iceberg in Bangladesh. The male to female cancer patient ratio in the hospital was constant from 99 to 997 varying from :.45 to :.58. It appears to be constant with the general idea that fewer women than men do suffer from cancer, due perhaps to the much lower prevalence rate of smoking among women 5. Lung cancer is the third most frequent cancer in the male population and smoking is thought to be the factor responsible. The rate of acute and chronic respiratory diseases is high and smoking probably aggravates this disease condition 6. No country, let alone Bangladesh, a LDC status country with a population more than million in an area size of fifty four thousand square miles can afford the burden of NCDs in addition to the communicable disease load. Risk factors related to non-communicable diseases are well established but the reasons for the causation and development of these conditions are less understood. The risk factors most epidemiologists accept are stated as cigarette use and other forms of smoking, alcohol abuse, life style changes (dietary patterns, physical activity, sedentary living etc.), environmental hazards (occupational hazards, air and water pollution etc.), s tress factors and failure or inability to obtain preventive health care services 7. The following gaps in the natural history of chronic diseases have added to the burden that calls for effective community based intervention programs in the form of education and advice to be undertaken. They are absence of a known agent, multifactorial causation, long latent period and indefinite onset. Smoking is an established risk factor of CHD, cancer, stroke, vascular complications of diabetes, hypertension etc. As stated earlier, research has identified a multitude of independent risk factors common to many NCDs. The conventional approach all too often focuses on the isolated contribution each one of them has on causality rather than on the totality of risk, showing the limitations of the risk factor paradigm. Preventive actions should be targeted to a given level of causation. For instance, at the physiological level, clinical interventions are appropriate, whereas in community interventions aiming at changes in the patterns of behavior, which predict disease occurrence, physical inactivity or smoking are in the center of the scale. Smoking, Alcohol, Physical Inactivity, Obesity, Raised Blood Pressure, Dietary fat/ Blood lipids and Blood glucose have been identified as common risk factors to major NCDs. There is strong evidence that smoking, blood pressure and cholesterol are the cause of at least two-thirds of heart attacks and strokes. The degree of risk of developing CHD is directly related to the number of cigarettes smoked per day and is not only an independent risk factor but also synergistic with hypertension and elevated serum cholesterol and obesity. The risk of death from CHD decreases after cessation of smoking. Ten to twenty years after cessation of smoking the status of an individual becomes the same as a non-smoker 8. In a consultative meeting of WHO held in Singapore identified smoking, unhealthy nutrition, obesity, sedentary life style, alcohol consumption, and unsafe practices as lifestyle factors related to non-communicable diseases. Unhealthy nutrition and obesity followed by smoking contributed as the most important risk factors for most of the high prevalent non-communicable disease 9. 5

7 Sedentary life and obesity has been stated to be the failure of mankind to the poor adoption to the modern and scientific industrialized and sedentary culture. The more serious the obesity the greater risk of developing the major noncommunicable diseases and over eating is the commonest cause of obesity. Gaining weight is easy but difficult to loose. Greater benefits can be achieved by persuading sedentary people to become more active. It has been proved beyond doubt through several studies in the last half a century that some major factors related to NCDs are modifiable and can be easily done by the countries and their health systems taking the people into confidence. Proper thinking and the right decision and community intervention is the need of the day and call for appropriate preventive measures to be taken against tobacco consumption and abuse, unhealthy diet, physical inactivity and other risk factors of non-communicable disease. Interventions have reduced the number of smokers, brought about healthy changes in the dietary intake, reduction in hypertension and cholesterol level saving the community from the dreadful affect. A -year follow up study in Goteborg Sweden showed a protective effect of leisure time physical activity but not work related activity on deaths from both CHD and all causes. The protective effect was independent of age, serum cholesterol, BMI, smoking, alcohol abuse and diabetes. Increasing physical activity during middle age could have important public health implication. Community intervention had a profound effect on the risk factors. In 97 a study carried out in California for two years in the form of education programs regarding risk factors of CHD like diet and smoking showed that in the control group the risk of cardiovascular diseases increased in the two year period. The net difference in estimated total risk between the two groups was to 8 percent. Intervention study carried out in Sweden shows both smokers and non-smokers who increased the exercise, other physical activity, improve the pattern of their diet intake, lowered their CHD risk. Before and after interventions smokers had a higher risk for CHD than non-smokers. The best CHD prevention action by smokers would of course be to quit smoking. Those who cannot stop should be encouraged to improve their dietary pattern and increase the amount of physical activity to decrease the health hazards of smoking. To care for a sick person is noble and the urgency and need of a desperately ill and agonized victim no doubt demands immediate attention and compassion but how many know that most of the disease, suffering and pre-mature death is from preventable causes. The best way to do this is to inspire everyone individually and collectively with will to remain healthy, as major health problems are preventable through changes in lifestyle, human behavior and improving the socio-economic status. The key to control of the global epidemics of NCDs is primary prevention. The aim must be to avert these epidemics wherever possible and to control them quickly as possible where they are entrenched. Surveillance of NCDs and their risk factors is an essential element in planning and evaluating programs that contribute to achievement of this aim. In a world of finite resources the priority is to collect essential and valid data. The WHO STEPwise approach to Surveillance for NCDs emphasizes that small amount of good quality data are more valuable than large amounts of poor quality data. The data must be collected, analyzed and used in a regular and systemic way. Data on major risk factors of NCDs are available in many developed countries but it is not the case in many developing nations. A critical definition of surveillance system includes the ongoing collection, analysis and use of health data. Public health surveillance is the epidemiological foundation of modern public health and an essential tool for measuring the impact of preventive measures. Surveillance is based on a public health agenda, to ensure that the data collected are timely and directly responsive to the health needs of the population. One of the objective of WHO s NCD surveillance strategy is to focus on the risk factors which predict the major NCDs. Intervening on risk factors is the basis of NCD prevention and surveillance of risk factors for disease has a high priority. The risk factors of today predict the disease of tomorrow. Knowledge about prevention through risk factor-focused interventions requires country specific data on risk factors so that priorities can be set, targeted programs developed and interventions monitored. 6

8 The 5 rd World Health Assembly (WHA) in has set a global strategy for the prevention and control of NCDs and the three main objectives are--- To map the emerging epidemics of NCDs and to analyze their social, economic, behavioral and political determinants to provide guidance for policy, legislation and finance; To reduce the risk of exposure of individuals and populations to the common risk factors of NCDs; To strengthen health care for people with NCDs. The WHO STEPwise approach developed for NCD risk factors is based on the concept that surveillance system requires standardized data collection as well as sufficient flexibility to be appropriate in a variety of country situation and settings. The key premise is that, by using the same standard questions, all countries can use the information not only for information within-country trends, but also for between-country comparisons. WHO STEP components are questionnaire-based assessment, physical measures and biochemical assessment. Creating awareness and necessary motivation for preservation and promotion of health including well-planned intervention programs and its successful implementation can do this. The present study is the Phase II of a WHO Pilot Projects For Community-Based Primary Prevention of The Major Non-communicable Diseases. This phase is a threeyear intervention program aimed at risk reduction in the intervention community. There are several key elements in the intervention program. An integral element is the community involvement; the community has to be mobilized, organized and motivated to take ownership of the program. Public policy initiatives and inter-sectoral coordination are equally important so that the environment is made conducive for people to adopt healthy life styles. Health education is the other key element and will impart knowledge and skill required for behavioral change. In addition to intervention activities during Phase II cross sectional health behavior surveys are conducted yearly in both communities to monitor progress. An important objective of the study is to develop and implement a pilot project on integrated communitybased NCD primary prevention projects in selected areas in Bangladesh. Data collected during the first phase will be used and applied. The first phase of the study would furnish us with new information based on which newer programs befitting the community can be under taken. The community has enormous potential to bring about changes. These qualities and potentials of the community should be explored. As already stated NCDs and other major chronic disease are diseases of life style. Life style is no longer purely conditioned by climate or culture only but is initiated as fast as ideas are transmitted. This calls for a change of human behavior and practice of a healthy life style. Ignorance has to be replaced by knowledge, prejudices removed and beliefs and attitudes changed in the direction favorable to healthful living. These cannot be thrust on people and must be won through their own efforts motivated from consciousness efforts on the parts of the individuals, family, community and the country. 7

9 Objective To initiate a national health behavioral risk factor surveillance system in Bangladesh covering both urban and rural adult (5-64 years of age) populations. Methodology The methodology described in the WHO STEPwise approach to surveillance (STEPS) of NCD risk factors guidelines were used for this study. Core, expanded and optional indicators in Step and core and expanded indicators of Step were included in the study. Some indicators were modified to reflect the local Bangladeshi lifestyle and therefore, questions added were on tobacco and betel nut chewing while questions on alcohol consumption were dropped since very few consume alcohol for religious reasons and questions on this topic would be culturally sensitive. Determination of energy expenditure was also omitted from the study. Sampling Plan The study focused on both urban and rural areas. Dhamrai Upazilla of Dhaka district was chosen as the rural site. Dhamrai is located 4 kilometers north-west of Dhaka, the capital of Bangladesh. The total population is about 4, and the Upazilla is divided administratively into 6 unions of which two unions were randomly selected for this study. The urban sample was selected from three locations to reflect low, intermediate and upper socio-economic strata of Dhaka Metropolitan City. Initially three sites were identified namely: Gulshan / Banani / Mohakhali DOHS / Dhanmondi RA., Mohammadpur and Mirpur (Rupnagar) to represent the Urban -Upper, Urban-Intermediate and Urban-Lower segment of the society respectively. House rent/estimated House-rent was also used as another indicator to categorize the households. Following criteria were used to categorize the sample: Urban-Upper Living in Gulshan or Banani or Mohakhali DOHS or Dhanmondi Residential Area; Rent of the house/apartment being Taka, or more ( US$ 7.4) if living in rented house. If living in own house then the rent was estimated. Urban-Intermediate Living in Mohammadpur area; Rent of the house/apartment being within Taka, to 9,999. (US$ 5.7 to 7.4) if living in rented house. If living in own house then the rent was estimated. Urban-Lower Living in Rupnagar, Mirpur area; Rent of the house/apartment being less than Taka, ( US$ 5.7) if living in rented house. If living in own house then the rent was estimated. Rural Living in Sanora or Kushora Union of Dhamrai upazilla. From each of the three urban locations systematic sampling were done until a minimum sample size of 5 (WHO recommendation) in each of the four age groups (5-4,5-44,45-54, 55-64) from each sex was reached. Therefore, the total sample size planned were 4x5 i.e. 6, in the Urban area. In the two rural areas the same sampling technique was used and the sample size estimated were be 6 x 5 i.e. 4,. So the total sample size calculated combining both urban and rural areas were,. Finally, at the end a total of,49 sample was included of which 7,8 was from the urban locations and 4,7 from the rural locations. 8

10 The following inclusion and exclusion criteria were followed to recruit the samples: Inclusion Criteria. Within the age range 5 to 64 years. Willingness to participate in the study Exclusion Criteria. Extremely ill (bedridden). Mentally handicapped. Pregnant Mothers Data Collection Method Information were collected by face-to-face interviews by 4 (twenty four) trained staff (list in annexure-) through a pre-tested questionnaire (annexure-). In addition height, weight, waist and hip circumferences and blood pressure were also measured. Two supervisors, one each for the urban and rural area were also recruited. Both the supervisors had postgraduate degrees in Public Health as well as research experience. The data collection started in September in the rural area and October in the urban areas. Details of the time frame are attached in annexure-. Data Collection Training The research staff received training (theoretical and practical) for 6 days (Training Schedule in annexure -4). They were taught how to (a) complete the questionnaire (b) food frequency tabulation (c) take anthropometric and blood pressure measurements accurately. Intra and inter-individual technical error of measurement (TEM) and reliability were assessed for anthropometric measurements (height, weight, waist, & hip circumferences) and blood pressures (Systolic and Diastolic). Questionnaire Design The questionnaire was developed based on the WHO STEPwise approach to surveillance as detailed in Annexes 6 9 of the document. Full details of the topics covered are presented in the table below: Core Expanded Optional Age (5-64: yrs gps) Highest level of education Household size, Marital Status, HH Risk factors at Step Demography Tobacco Use Nutrition Sex Education (years) Urban/Rural Current daily smoker (+ frequency, duration): Ex smoker (daily) Mean age starting pop sedentary during occupation and non-occupation Occupation Amount (pack yrs). Time since quitting Type of tobacco consumed pop very active during occupation and non-occupation. income Attempts to quit; beliefs, knowledge, attitude, behavior (KAB) Other Health service use Added Risk Factors at Step Obesity Blood Pressure Height, Weight, Waist Systolic Blood Pressure Diastolic Blood Pressure Hip Circumference 9

11 Data Analysis and Quality Assurance The research assistant after each interview checked for completeness and consistency of questionnaire. At the end of each working day the supervisor checked the questionnaires before the data were ready for entry in the computer. The respective supervisor for the urban and rural areas undertook planned supervisory visits and were responsible for undertaking random checks of anthropometric and blood pressure measurements on 5 of the daily sample. In addition the Principal and Co-Investigators took turns throughout the period of data collection to make on- site field checks. All the Weight, Blood Pressure and Height measuring equipment was checked every day for validation. The other measures which were taken in this project were meeting all the interviewers at the beginning and also at the end of the day initially everyday then twice a week for the rest of the data collection period. Feedback was given every morning on the data collected on the previous day. Data were entered into the computer using the SPSS Data Entry Package, which had, skip and fill rules. The data were analysed using SPSS for Windows version.5. The analyses included univariate, bivariate and multivariate approaches. The WHO STEPS guidelines for analysis were followed.

12 This study was conducted with the objective of initiating a national health behavioral risk factor surveillance system in Bangladesh in the urban and rural locations. Sample selection focused on the upper, intermediate and lower segments of the society in the urban area of Dhaka metropolitan city. A total of,49 sample was selected of which 7,8 was from the urban locations and 4,7 from the rural locations. This result chapter has been divided into following sections namely: Population characteristics. Tobacco usage. Knowledge and attitude towards tobacco use. Physical Activity. Food frequency. Health seeking pattern. Anthropometric measurements. Population Characteristics Study area Table. presents the distribution of the respondents in the urban and rural study areas. The number were slightly higher than the WHO guidelines with a total sample size of 49 compared with,. Gender More or less equal numbers of males (49.) and females (5.7) were studied in accordance with the protocol (Table.) Religion It appears from the Table. that most respondents were Muslim (9.9) while about in was Hindu. Only a minority was either Christian or Buddhist (.). Marital Status Table.4 shows the distribution of the respondents by their marital status. Most respondents (85.5) were married, 8. were unmarried while about one in seventeen were widowed (5.9). Only a negligible proportion was separated (.4), which reflects the very low separation rate in Bangladesh. Educational Status The respondents were asked about their educational status. Nearly a quarter reported having no formal education while the highest proportion (5.) was educated up to class level ten and.4 had either bachelor or master degree qualification (Table.5. through.5.6). Occupation Tables.6. through.6.6 show the distributions of the respondents by occupation. The wide variety of working categories reflects the different socio-economic strata of the population. The highest percentage of respondents (4.) was housewives, which reflects the predominance of male only earners in the country. Nearly a third of respondents were either professional (5.) or working in business (5.) while in were agricultural workers (8.5); very few were self-employed (.5), and rickshaw puller (.6).

13 Income Table.7 shows the monthly income of the respondents. The monthly overall mean income was about Taka in the urban areas and about Taka 545 in the rural areas. There was no marked variation in monthly average income among the different age groups both in the urban and rural areas. The wide disparity in monthly incomes between urban rural areas is noteworthy in all age groups, and reflects the poor financial status of the rural people of the country. Family Member The number of persons per house is partially indicative of the socio-economic status of the country. Table.8 shows that the mean households sizes of the respondents were around 5 irrespective of areas and urban strata. The overall mean family size was 5.44 persons.

14 Table. Distribution of the respondent by study area AREA Percentage Sanora 9 8. Kushora Urban upper Urban Intermediate Urban lower Table. Gender of the respondent SEX Percentage Male Female Table. Religion of the respondent RELIGION Percentage Islam Hinduism Christianity 9. Buddhism 5 Others 49 Table.4 Distribution of the respondent by marital status MARITAL STATUS Percentage Married Unmarried Widow Separated 45.4 Others. 49

15 Table.5. Educational status of the respondent: Rural Area Rural Education Table.5. Educational status of the respondent: Urban Area Urban Male Female Never attended Non-formal Up to class SSC HSC Graduates Professional others Education Male Female Never attended Non-formal Up to class SSC HSC Graduates Professional others

16 Table.5. Educational status of the respondent: Urban upper Area Education Never attended Male Female Urban Upper Non-formal Up to class SSC HSC Graduates+ Professional others Table.5.4 Educational status of the respondent: Urban Intermediate Area Urban Intermediate Education Male Female Never attended Non-formal Up to class SSC HSC Graduates Professional others

17 Table.5.5 Educational status of the respondent: Urban lower Area Urban lower Education Never attended Non-formal Up to class SSC HSC Graduates+ Professional others Male Female Table.5.6 Educational status of the respondent: Rural & Urban Area Urban & Rural Both total Education Never attended Non-formal Up to class SSC HSC Graduates+ Professional others Male Female

18 Table.6. Major occupation of the respondent: Rural Area Rural OCCUPATION Professional Bossiness Rickshaw Puller/Day Laborer Agricultural Worker Professional Housewife Self Employed Unemployed Other Male Female Table.6. Major occupation of the respondent: Urban upper Area Urban Upper OCCUPATION Professional Business Professional Housewife Self Employed Unemployed Others Male Female s

19 Table.6. Major occupation of the respondent: Urban intermediate Area Urban Intermediate OCCUPATION Professional Business Professional Housewife Self Employed Unemployed Others Male Female Table.6.4 Major occupation of the respondent: Urban lower Area Urban lower OCCUPATION Male Female Professional Business Rickshaw Puller/Day Labourer Professional Housewife Self Employed Unemployed Other

20 Table.6.5 Major occupation of the respondent: Rural & Urban Area Rural & Urban Table.6.6 Major occupation of the respondent: Urban Area Urban OCCUPATION Male Female Professional Business Rickshaw Puller/ Day Labourer Agricultural Worker Professional Housewife Self Employed Unemployed Other OCCUPATION Male Female Professional Business Rickshaw Puller/Day Labourer Agricultural Worker Professional Housewife Self Employed Unemployed Other

21 Table.7 Mean family size of the respondent Age Urban Rural Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T =

22 Table.8 Mean monthly family income in Taka Age Urban Rural Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T =

23 Tobacco Usage: Smoking Pattern Current Tobacco Smoking Pattern Current smoking pattern shows that the more rural people than urban smoke, 5.6 Vs. 9.6, with an overall smoking rate of.8 (Table.). In the urban areas there is an increasing smoking trend from lower urban, intermediate urban to upper urban (6, 7.7 and 4.4 respectively). The highest smoking prevalence rate was in the 5 to 44 year age group (4.8) with decreasing prevalence with increasing age. This age trend is more apparent in the urban than rural community. The most striking feature observed is that very few women smoke. Duration of Smoking Current smokers were asked to recall the age at which they started smoking first and the duration of smoking was then calculated (current age age at starting smoking). Table. shows the distribution of the means and standard error of means (SE) by age group, gender and residential status. The mean duration of smoking was found to be.8 years amongst the rural smokers and this figure was.7 years for the urban smokers. With few exceptions the mean duration of smoking was longer in males than females. The mean age of starting smoking was reported as about years in both the urban and rural areas (Table.). of Sticks smoked The severity of smoking was assessed by the number of sticks smoked per day and this was found to be.64 sticks per day per person on average for all the areas irrespective of age group and gender. People living in rural areas smoked slightly more cigarettes per day than urban dwellers (. versus., respectively). Within the urban areas the intermediate class reported the highest number of cigarettes smoked per day (.9), followed by the lower class (.6) and the upper class (.5; Table.4). Type of Smoke All reported smoking cigarettes only and none reported smoking bidi or hookah (Table.5). Quit Smoking Attempt Of the smokers 9 reported that they had tried to stop smoking (Table.6). About half the respondents from the urban location had tried to give up smoking at least once whereas only about tried to stop smoking in the rural areas. Attempts to stop smoking were highest in the urban-intermediate class (6 in the 5-4 year age group). Table.7 shows the distribution of the smokers concerning their willingness to stop smoking in the future. About half the respondents expressed their willingness to stop but urban smokers were more willing to stop (7.) than the rural smokers (7.5). About 8 respondents within the age group of years of urban-upper class expressed their keenness to give up smoking. Ever Smoking Status About 9 of respondents had experienced smoking at some time in their life (Table.8). This experience of smoking was almost similar in all the four areas (Urban-Upper: 8.7; Urban-Intermediate: 9.7; Urban: Lower: 9.6; and Rural= 9.) and 96 of them reported consuming at least cigarettes in their lifetime (Table.9).The overall prevalence of smoking cigarettes of 7.9 (urban and rural areas 7.5 and 8.6 respectively). The prevalence rates by gender and age groups are shown in Table..

24 Past Daily Smoking Habit Respondents who were not currently smoking were asked to give details of their previous smoking history. Table. shows the proportion of past daily smoking habit in the total population (urban + rural) is 4.9. Corresponding figures for the urban and rural are. and 6. respectively. Further analysis shows that the respondents within the age group of years in the upper-urban class reported past daily smoking history more that the other groups and also from the other segments of the society. This variable was further analysed by taking non-smokers as the denominator. The distribution of non-smoker respondents according to their past daily smoking habit is shown in Table.. About 99 of the rural non-smoker respondents reported that they were smoking daily in the past while in the urban area it was about 6 and within the urban population was more marked amongst the lower segment of the society (75.5). Duration of Quit Smoking The overall average duration of cessation of smoking was. years (Table.) while the duration increased with increasing age in both the urban and the rural areas and also in different segments of the society within the urban areas. Tobacco Usage: Smokeless Tobacco Usage Pattern The extent of chewing tobacco, use of Gul (powdered tobacco), use of snuff and use of khaini were also ascertained. Usually tobacco is chewed along with betel leaf. Betel Leaf Chewing Habit Overall, nearly a third () of respondents was regular betel leaf users, being higher in rural than the urban areas 9. and 5. respectively (Table.4). Betel leaf chewing was lowest in the urban-upper class. Females chewed betel more than the males and usage increased with age and 78. were chewing daily (Table.5) again with a higher proportion in rural than urban areas (86.7 versus 7.8 respectively). Tobacco Chewing Habit Of betel leaf users, about 85 were chewing with some form of tobacco (Table.6). This proportion ranged from 67.6 to 98. across the residential areas and urban social classes with the highest proportion in rural females (98.). Tobacco used for chewing is usually tobacco leaf and Jarda (the local blend of tobacco product). An attempt was made to ascertain the type of tobacco they consume most during chewing and it was found that about 6 of the respondents reported using Jarda alone, 4.6 tobacco leaf alone while.5 reported using both of these during chewing (Table.7). The greater use of Jarda was apparent in both urban and rural areas, particularly in urban areas. However women tended to use tobacco leaf rather than Jarda. The overall duration of chewing tobacco (leaf/jarda) was 4.8 years and as expected the mean durations were longer in the higher age-groups (Table.8). Table.9 shows the distribution of the tobacco chewers according to frequency of chewing tobacco per day. The average frequency of chewing tobacco was about 7 times per day for all the segments of the society. Current Use of Other forms of Tobacco As mentioned earlier other form/types of tobacco that have been included in the study were Gul (powdered tobacco), Snuff, and Khaini (Local blend of chewing tobacco). The prevalence rates of these types of smokeless tobacco and times they take these were analyzed separately and given in Tables. to.5. Prevalence rates of Gul, Snuff and Khaini were found to be.5, and 9 respectively. As regards Gul use prevalence rate was more pronounced in the lower class of urban area (.7).

25 Table. Prevalence of Current Smoking Status Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table. Duration of Smoking in Years Urban Rural Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T = 4

26 Table. Age at start of smoking Age Urban Upper Intermediate Lower Rural N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Table.4 Average number of sticks smoked per day Urban Rural Age Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T =

27 Table.5 Type of Smoke (Cigarette) Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table.6 History of stopped smoking anytime Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T = 6

28 Table.7 willing to stop smoking Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table.8 Smoking habit in life time Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T =

29 Table.9 Consumed sticks of cigarette among the ever smokers Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table. Prevalence of ever smoking status (at least sticks) Urban Age Upper Intermediate Lower Rural M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T =

30 Table. Past daily Smoker among all respondents Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table. Past daily Smoker among current non smokers Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T = 9

31 Table. Duration from Quit Smoking in Years Age Urban Rural Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Table.4 Current betel leaf chewer Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T =

32 Table.5 Frequency of betel leaf chewing Daily Age Occasionally Urban Upper Intermediate Lower N=87 M N=4 F N=99 N= M N=7 F N= N=55 M N=48 F N=566 N=984 M N=7 F N=898 N=69 Freq Freq Rural N=456 Table.6 Tobacco leaf / Jarda with betel leaf Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq N Freq N Freq N Freq Note: M = Male; F = Female; T =

33 Table.7 Type of chewing Tobacco Urban Age Upper Intermediate Lower N=959 Rural N= M N=6 F N=78 N=94 M N=76 F N=8 N=57 M N= F N=48 N=68 M N=56 F N=86 N=4 Tobacco Freq Jarda Freq Freq Both Note: M = Male; F = Female; T =

34 Table.8 Duration of use of chewing tobacco in years Age Urban Upper Intermediate Lower Rural N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE s Table.9 Times taken tobacco leaf in a day Age Urban Rural Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T =

35 Table. Current History of Gul (Powdered Tobacco) Use Urban Age Upper Intermediate Lower Rural M F M F M F M F N Freq N Freq N Freq N Freq N Freq Table. Times of Gul use Urban Rural Age Upper Intermediate Lower N Mean SE N Mean SE N Mean SE N Mean SE N Mean SE Note: M = Male; F = Female; T =

36 Table. Current History of Snuff Use Age Urban Rural Upper Intermediate Lower M F M F M F M F N Freq N Freq.. N Freq N Freq N Freq 4... Table. Times of Snuff use Tota l Age Urban Upper Intermediate Lower Rural N Mean SE N Mean... SE N Mean SE N Mean SE N 4 Mean SE Note: M = Male; F = Female; T = 5

37 Table.4 Current History of Khaini Use Age Urban Upper Intermediate Lower Rural M F M F M F M F N Freq.4.. N Freq N Freq N Freq N Freq. Table.5 Times of Khaini us Age Urban Rural Upper Intermediate Lower N Mean.... SE N Mean SE N Mean SE N Mean SE N Mean.. SE - - Note: M = Male; F = Female; T =

38 Reasons for smoking The participants were asked for their opinion on the reasons people smoke and the majority said that smoking was an addiction (overall 69.8). There was some variation between urban and rural areas and within the urban area (7.9 in rural area; 68.6, 75., 6.5 and 69 in all urban, urban upper, intermediate and lower class respectively). About 6 of rural participants, 9.6 of all urban participants (4.4 upper, 7.8 intermediate & 5.6 lower class) either did not know the reason or did not respond to the question (Table 4. to 4.6). The respondents were requested to give their opinion whether they completely agree, partially agree, completely disagree or did not know the following statements. Smoking is always good for health More than 99 of the participants completely disagree with the statement Smoking is always good for health. None in the rural area agreed with the statement. However, a small proportion (. -.4) of respondents in the urban areas agreed with this statement (Table ). Tobacco leaf, Jarda, Gul are always good for health Of all participants.5 partially, and another.4 completely, agreed with the statement while ninety-seven percent completely disagreed with the statement. In the rural area 9., in the urban area 97. were completely disagreed. The proportion varied a little between upper (99.8), intermediate (96.) and lower (96.) urban classes (Table ). Smoker s smoke can harm non-smoker Overall 9.4 of respondents completely agree with this statement but less agreed in rural than in urban areas (8.9 Vs respectively). The proportions were 99.7, 97.7 & 96.5 in upper, intermediate and lower urban area respectively (Table ). Every smoker should give up smoking forever The proportion agreeing with this statement was lower in rural (8.) than in urban areas (99.). The proportions were very similar in upper (99.7), intermediate (98.7) and lower (99.6) strata of urban area. The overall proportion completely agreeing was 9.8 (Table ). Smoking should be prohibited in transport and all public places A lower proportion of participants completely agreed in rural (8.8) than in urban areas (99.) and was lower in women than men in all age groups in the rural area. About of the rural participants did not agree and another 7.4 partially agreed. In the urban area the proportion completely agreeing was very similar in all strata (upper, intermediate and lower classes were 99.9, 98.8 & 99., respectively). Overall 9.6 completely agreed with the statement (Table ). 7