Smoking in Chakaria, Bangladesh: A study of its trend and determinants S. M. A. Hanifi Shehrin Shaila Mahmood Abbas Bhuiya Chakaria HDSS,ICDDR,B Bangladesh
Outline Background Objective Study design Data analysis Findings Conclusion
Background Smoking killed 100 million people in the 20 th century. Smoking could kill 1 billion people by the end of the 21st century and if trends continue. More than 80% of these deaths will occur in developing countries. Unprecedented levels of disease and early death are expected in the developing world where population growth is high and health care services are least available.
Bangladesh profile Nearly half of its 138 million population are living below the poverty line and are addicted to smoking. Annual population growth rate is 1.4%. Health care services are least available, especially for the poor.
Smoking Prevalence in Bangladesh About two-thirds of males and one-third of females are smoking. Males smoke more than females. Rate of smoking tends to increase with age. Smoking varies by socioeconomic group. The poor smoke more than the rich. The illiterate are more likely to smoke than the literate.
Smoking related illness and deaths in Bangladesh Over 1.2 million cases of tobacco-attributable illness each year. Each year around 9% of all deaths (57,000 deaths) are a result of tobacco use. Exposure to secondhand smoke kills tens of thousands of non-smoker every year.
Anti Smoking Regulation Public awareness of the adverse effects of smoking through mass media, posters, leaflets, billboards and seminars have been in effect since 1987. Bangladesh banned tobacco advertisement through radio and television in 1997. Prohibition of smoking in public places and transports are in place since 2006. World No-Tobacco Day is celebrated annually. Health warnings are also mandatory on packaging of cigarettes and bidis from 2006.
Health warnings messages on packaging of cigarettes and bidis Smoking is harmful to health
Objectives Examine the changes in smoking over time Whether the changes are uniform for all Whether the changes are uniform for all socioeconomic groups?
Study Design Data were collected from the Chakaria HDSS area in two surveys in 1994 and 2008. 12% of 17,608 households in 1994 and 25% of 21,659 households in 2008 were systematically randomly chosen. The questionnaire was administered to the head of the household and data were collected for the members of households aged 10 years and above. The respondents were asked whether individuals smoked; if the response was yes, details of what they smoked were asked. Smoking prevalence was compared between 1994 and 2008.
Study area The study was carried out in Chakaria under Cox s Bazar district in the south of Bangladesh. The population comprises mainly of Muslims (89.9%) followed by Hindus (6.8%), Buddhists (3.3%). Around half of the population aged 6 years and above have never been to school. Main economic activities are agriculture, forestry, and sea fishing. Tobacco cultivation is practiced in around one-fifth of the villages in Chakaria.
Variables Dependent variable: Smoking status of the individuals (dichotomous) Independent variables: Background characteristics of individuals (age, sex, education, religion, socioeconomic status) Literate: who have completed at least one year of schooling Illiterate: who have had no schooling Socioeconomic status of individual was classified combining the occupation of main earner and ownership of household-land.
Univariate and Bivariate analysis Data were analyzed for all individuals aged 15 years and above Smoking prevalence was calculated by background characteristics of individuals for 1994 and 2008. For each group, the difference in smoking prevalence between 1994 and 2008 was tested to investigate whether the difference was statistically significant. the difference was statistically significant. Two data sets from 1994 and 2008 were combined. Background characteristics were cross-tabulated by smoking status. Chi2-test was performed to investigate the relationship between smoking and the background characteristics of individuals.
Multivariate analysis A forward-stepwise selection method was applied for identifying the important independent variables associated with smoking (at 5% level of significance) The interaction effects between time of survey and others independent variables were examined at 5% level of significance Finally, a model with all important independents variables and significant-interaction terms was fitted Standard error was adjusted for clusters (households) Probability of smoking was predicted from the final model for the significant interaction-terms.
Findings
Study Population 1994 6,474 individuals aged 15 years and above 2008 20,398 individuals aged 15 years and above Total 26,872 individuals aged 15 years and above
Univariate and Bivariate analysis
Smoking pattern Bidi smoking was the most popular form in 1994, around one-third of all males and one-sixth of all females smoke in this form. Cigarettes was the second most common habit among men (27%); however, only 3% of all females reported smoking cigarettes. In 2008, the scenario of tobacco consumption was different from 1994. Cigarette was the predominant form of smoking; 32% of all males and 4% of all females consumed tobacco in this form. The second most common habit was Bidi, 15 % of all males and 9% of all females consumed tobacco in this form.
Smoking pattern
Smoking trend over time by sex Sex 1994 (%) 2008 (%) Difference between 1994 and 2008 (% points) Male 59.8 40.5 19.3 Female 20.0 12.3 7.7 Total 40.8 26.7 14.1
Smoking trend over time by age Age (years) 1994 (%) 2008 (%) Difference between 1994 and 2008 (% points) 15-24 10.4 6.2 4.2 25-34 43.0 20.5 22.5 35-44 62.9 41.6 21.3 45 and above 68.5 54.5 14.0
Smoking trend over time by education Education 1994 (%) 2008 (%) Difference between 1994 and 2008 (% points) Illiterate 46.9 44.2 2.7 Literate 31.2 16.8 14.4
Smoking trend over time by religion Religion 1994 (%) 2008 (%) Difference between 1994 and 2008 (% points) Muslim 41.3 27.0 14.3 Non-Muslim 36.4 24.1 12.3
Smoking trend over time by socioeconomic status Socioeconomic status 1994 2008 Difference between 1994 and 2008 (% points) Poor 46.3 31.9 14.4 Middle class 40.9 24.4 16.5 Rich 31.0 17.5 13.5
Multivariate analysis
Differentials in smoking Males were 13.3 times more likely to smoke than their female counterparts. Smoking prevalence increased with increasing age. The illiterates were three times more likely to smoke than the literates. The Muslims were 1.4 times more likely to smoke than the non-muslims. The poor were 2.4 times more likely to smoke than the rich.
Predicted proportion of smoker by age and year Proport tion of smoker 70 60 50 40 30 20 10 0 1994 2008 34% 52% 40% 15-24 25-34 35-44 45+ Age in years 20%
Predicted proportion of smoker by education and year Proportion of smoker 50 40 30 20 10 0 Illiterate 14% Literate 51% 1994 2008
Predicted proportion of smoker by socioeconomic status and year 50 1994 2008 of smoker Proportion 40 30 20 10 39% 51% 55% 0 Poor Middle class Rich
Conclusion Why currently the poor and the illiterate people smoke more and the reduction in smoking over time is lower among these groups remains a complex question that deserves further research.