|Year : 2016 | Volume
| Issue : 3 | Page : 85-90
Prevalence of tobacco use and its contributing factors among adolescents in Bangladesh
Sheikh Mohammed Shariful Islam1, AKM Mainuddin1, Kamrun Nahar Chowdhury2
1 International Center for Diaroheal Disease Research, Dhaka, Bangladesh
2 National Centre for Control of Rheumatic Fever and Heart Disease, Dhaka, Bangladesh
|Date of Web Publication||16-Sep-2016|
Sheikh Mohammed Shariful Islam
CCCD, ICDDR, B Mohakhali, Dhaka 1212
Source of Support: None, Conflict of Interest: None
Background: Tobacco use is one of the major avoidable and recognized causes of noncommunicable diseases globally. Tobacco use among adolescents is considered as priority health risk behaviors that contribute to leading causes of morbidity and mortality among youth and adults and are often established at young age, extend into adulthood and are preventable. Aims: This study aimed to estimate the prevalence of tobacco use and its contributing factors among adolescents in Bangladesh. Settings and Design: We used data from the Global Youth Tobacco Survey Bangladesh 2007, which were a school-based survey of 2135 students aged 13-15 years in grades 7-10. Materials and Methods: A two-stage cluster sample design was used to produce representative data for Bangladesh. At the first stage, schools were selected with probability proportional to enrollment size. At the second stage, classes were randomly selected and all students in selected classes were eligible to participate. Statistical Analysis Used: We used SUDAAN for statistical analysis of correlated data, it computes standard errors of the estimates and produces 95% confidence intervals. We used t-tests to determine the differences between subpopulations. All analyses conducted in this study were gender stratified. Results: The overall prevalence of ever cigarette smokers in Bangladeshi students was about 9%, which was more than 3 times higher in boys compared to girls (15.8% vs. 4.8%). Almost four in ten students start smoking before the age of 10. In addition, another 6% students reported to use other tobacco products. About 70.7% students reported that they desired to stop smoking, and 85.0% tried to stop smoking during the past year but failed. About 42.2% students were exposed to smoke from other people in public places. Among current smokers, 97.8% reported that they were not refused cigarette purchase because of their age. Conclusions: Implementation and enforcement of tobacco control act are an urgent public health priority.
Keywords: Adolescents, Bangladesh, global youth tobacco surveillance, low- and -middle-income countries, prevalence, tobacco use
|How to cite this article:|
Islam SM, Mainuddin A, Chowdhury KN. Prevalence of tobacco use and its contributing factors among adolescents in Bangladesh. Heart India 2016;4:85-90
|How to cite this URL:|
Islam SM, Mainuddin A, Chowdhury KN. Prevalence of tobacco use and its contributing factors among adolescents in Bangladesh. Heart India [serial online] 2016 [cited 2021 Dec 2];4:85-90. Available from: https://www.heartindia.net/text.asp?2016/4/3/85/190727
| Introduction|| |
Tobacco use is one of the major avoidable and recognized causes of noncommunicable diseases such as cardiovascular diseases, respiratory diseases, diabetes, and cancers. , Tobacco use among adolescents (10-19 years) is considered as priority health risk behaviors that contribute to leading causes of morbidity and mortality among youth and adults and are often established at young age, extend into adulthood and are preventable.  Adolescents are the largest segment of population in South East Asian countries and are more susceptible to tobacco use epidemic.  It is estimated that in developing countries more than 50% of the adolescents who start smoking at an early age become regular tobacco users.  Moreover, adolescent smokers are more susceptible to alcohol and substance abuse and more likely to be engaged in unprotected sex.  Furthermore, those who uptake smoking below 18 years have a substantial chance to die prematurely from tobacco-related diseases and complications.  Recent studies in Bangladesh reported that smoking is a potential risk factor for hypertension, coronary artery disease, and acute myocaridal infarction in young adults. ,,
The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) reinforces the need for data on adolescent tobacco use by calling on countries to establish surveillance programs of "the magnitude, patterns, determinants, and consequences of tobacco consumption and exposure to tobacco smoke."  Bangladesh ratified the WHO FCTC in 2000, thus formally obligating the government of Bangladesh to follow the Articles of the WHO FCTC. Despite a legal ban on tobacco promotional activities in Bangladesh,  cigarette smoking and smokeless tobacco use have become an increasingly prevalent problem. , The prevalence of tobacco use among males (>15 years) was the second highest among the Global Adult Tobacco Survey countries. The WHO and the US Center for Disease Control and Prevention (CDC) pioneered the Global Youth Tobacco Survey (GYTS) in 151 countries which measures the prevalence of tobacco use among the school going children and their knowledge, attitudes, and perceptions on its use.  GYTS employs a single core questionnaire and a uniform methodology of sample collection, survey administration, and data analysis, which allows for national and international comparisons. 
Several social and cognitive factors influence tobacco use among adolescents, including parental smoking, best friend's smoking, peer pressure, and achieving a poor grade in school. , Previous studies have reported a higher prevalence of smoking among adolescents if their favorite movie star smokes, , if they have plenty of pocket money, and if any siblings smoke.  Furthermore, tobacco contents in movies are portrayed as societal support for tobacco consumption.  There is paucity on data for adolescent smoking in Bangladesh. The aim of this study was to estimate the prevalence of tobacco use and its contributing factors among adolescents of Bangladesh.
| Materials and methods|| |
The Bangladesh GYTS  includes data on the prevalence of cigarette and other tobacco use as well as information on five determinants of tobacco use: Access/availability and price, exposure to secondhand smoke (SHS), cessation, media and advertising, and school curriculum.
The 2007 Bangladesh GYTS is a school-based survey of defined geographic sites including subdistricts in a country.  The survey uses a two-stage cluster sample design that produces representative samples of students in secondary school grades 7-10, which are associated with ages 13-15 years. The sampling frame included all secondary level schools in Bangladesh containing any of the identified grades. At the first stage, the probability of schools being selected is proportional to the number of students enrolled in the specified grades. At the second sampling stage, classes within the selected schools are randomly selected. All the students in the selected classes attending school on the day of the survey were eligible to participate. Student participation was voluntary and kept anonymous by means of self-administered data collection procedures. The GYTS sample design produced representative, independent, cross-sectional estimates for Bangladesh.
The GYTS  used self-administered questionnaires in the classrooms and anonymous data collection procedures. Names of schools or students or personnel were not collected and participation in the survey was voluntary. Trained and experienced personnel conducted the survey. Written permission was obtained from all school authorities prior to data collection and all study participants provided written informed consent. The study protocol was approved by the Ethical Review Committee of Bangladesh Medical Research Council. The questionnaire was designed with no skip patterns to allow all respondents to answer all questions. In addition to the core GYTS questions, Bangladesh country-specific questions on the prevalence of bidi smoking and use of other tobacco products (e.g., chewing tobacco, cigars, pipes, etc.,) were also included in the questionnaire. The final Bangladesh questionnaires were translated into Bengali and translated back into English to check for accuracy and pretested. 
The GYTS enquired about several important tobacco-use indicators, including ever smoking; initiation of smoking before the age of 10; current cigarette smoking; dependency on cigarettes among current smokers; use of other tobacco products; exposure to SHS at home; exposure to SHS in public places; desire for a ban on smoking in public places; students who saw advertisements for cigarettes on billboards or newspapers or magazines; students who have an object with a cigarette brand logo on it; and smokers who want to stop, have tried to stop, and have ever received help to stop smoking. 
A weighting factor is applied to each student record to adjust for nonresponse (by school, class, and student) and variation in the probability of selection at the school, class, and student levels. A final adjustment sums the weights by grade and gender to the population of school children in the selected grades in each sample site. SUDAAN, a software package for statistical analysis of correlated data, was used to compute standard errors of the estimates and produced 95% confidence intervals which are shown as lower and upper bounds. We used t-tests to determine the differences between subpopulations. Differences between prevalence estimates were considered statistically significant if the t-test P < 0.05. Differences between prevalence estimates were considered statistically significant if the t-test P value is associated with gender and that gender most often acts as an effect modifier for smoking and related risk factors. All analyses conducted in this study were gender stratified.
In the 2007 national sample of GYTS, altogether 52 schools were selected, with a total of 3113 students participated in the survey.  The school response rate was 100%, while the student response rate was 88.9%, and the overall response rate (i.e. the school rate multiplied by the student rate) was 88.9%. The grades represented in the survey were 7, 8, 9, and 10, which are representatives of students aged 13-15 years.
| Results|| |
Overall 9% of the students reported that they had ever smoked cigarettes, even one or two puffs, which was significantly higher among boys compared to girls (15.8% vs. 4.8%) [Table 1]. Almost four in ten students (38.6%) smoked the first cigarette before the age of 10 years. Among the students, 2% were current cigarette smokers and there was no significant difference between boys (2.9%) and girls (1.1%). In addition to current cigarette smoking, another 6% also used other tobacco products at the time of the survey, which together showed that 8% of the students used tobacco products. There was no significant difference between boys (8%) and girls (4.2) in using other tobacco products during the survey period. Among students who currently smoked cigarettes, 1% reported that they felt like having a cigarette is the first thing in the morning (i.e., cigarette dependency). About 6.9% students reported that they used any tobacco product at the time of the interview (boy = 9.1% and girl = 5.1%). Among never smokers, 13.2% participants indicated that they were interested to initiate smoking within a year [Table 1].
|Table 1: Prevalence of tobacco use and interest in stopping smoking among students aged 13-15 years by gender, Bangladesh global youth tobacco survey, 2007|
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Almost three quarters of current smokers (70.7%) reported that they desired to stop smoking, and more than eight in ten (85.0%) tried to stop smoking during the past year but failed [Table 1]. Nine in ten current smokers (90.1%) reported that they had ever received help to stop smoking. There were no statistical differences by gender for any of these indicators of cessation.
More than three in ten students (34.7%) reported that they were exposed to smoke from other people in their home during the week before the survey [Table 2]. Moreover, more than four in ten students (42.2%) were exposed to smoke from other people in public places. A ban of smoking in enclosed public places was supported by 74.9% of students. About 83.3% participants considered that smoke from others was harmful to them, 41.1% had one or more parents who smoked, and 2.4% had most or all friends who smoke. There were no statistical differences by gender for any of these indicators.
|Table 2: Prevalence of factors influencing tobacco use among students aged 13-15 years by gender, Bangladesh Global Youth Tobacco Survey, 2007|
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Regarding direct advertisements, almost three-fourth of the students (73.5%) had seen several advertisements for cigarettes on billboards within the past month and more than six in ten (64.0%) had seen many advertisements for cigarettes in newspapers or in magazines. For indirect advertising, more than one in ten (12.8%) students reported having an object (e.g., t-shirt, cap, etc.,) with a cigarette or tobacco company logo on it, with no significant difference between boys (15.3%) and girls (10.9%). About 87.6% saw antismoking media messages during the past 30 days and 6.4% were offered free cigarettes by a tobacco company representative [Table 2].
Among current smokers, 38.3% reported that they usually buy tobacco in a store and of which 97.8% reported that they were not refused cigarette purchase because of their age. Moreover, about one in ten students reported that they had been offered free cigarettes by a tobacco company representative with no significant difference between boys (8.6%) and girls (4.6%). About 4.9% usually smoke at home [Table 2].
Students were asked if, during the past school year, they had been taught in school about the health effects on tobacco use. Fifty percent of the students (54.2%) reported that they were taught about the dangers of tobacco use in school. About one-third of the students (36.9%) reported that they discussed in class, during the past year, reasons why people of their age use tobacco [Table 2].
| Discussion|| |
The overall prevalence of ever cigarette smokers in Bangladeshi students was about 9%, which was more than 3 times higher in boys compared to girls (15.8% vs. 4.8%). The prevalence of smoking among students in our study was less compared to similar reports from other South East Asian countries where the prevalence was 17.5% in India  and 35% in Nepal.  Our study showed that the prevalence of tobacco use was higher among the adolescent boys in Bangladesh, which is similar to reports from India. The reason could be, the boys in this region have higher freedom than girls in both the family and society.  While the current smoking prevalence is 2%, about 13.2% never smokers expressed their willingness to initiate smoking within the next 1 year. The present study found all the contributing factors such as peer pressure, exposure to second-hand smoking, smoker parents or siblings, tobacco advertisement, and accessibility and availability of cigarette plays a critical role to transform an adolescent to be a smoker.
Willingness to quit smoking among adolescents was high (70.7%) in our study. A review of 66 cessation intervention trials showed that the actual quit rate is 12%.  A great majority of current smokers (85.0%) in our study tried to quit smoking during the past 1 year. A study from Czech Republic showed that 66.9% of the adolescent smokers tried to quit but remained unsuccessful.  Another study also reported that 88% of adolescent smokers were willing to quit,  which is in agreement with our study findings. Tobacco cessation programs using nicotine replacement therapy and smoking cessation support should be made available in the community in Bangladesh to help those who are willing to quit smoking.
Bangladesh has laws restricting smoking in public places, such as health care facilities, education facilities, university facilities, government facilities, indoor offices, restaurants, and other indoor workplaces. Studies from Spain and South Africa showed that among adolescents 27.8% and 25.7% were exposed to SHS at home and 33.6% and 34.2% outside home, respectively. , Our data showed that 34.7% participants were exposed to SHS at home and 42.2% were exposed in public places (42.2%) indicating that the scope and enforcement of these laws are not adequate.
The anti-tobacco legislation in Bangladesh prohibits any kind of direct and indirect advertisement of tobacco-related products.  A great number of our study participants reported observing tobacco advertisements in billboards (73.5%) and in magazines (64.0%). These high rates might be due to observing the advertisements at any time in the past. In addition, our participants might observe the large posters at the point of tobacco sale, which is not banned in Bangladesh. While Bangladesh has laws banning free distribution of tobacco products, nontobacco products identified with tobacco brand names, and events sponsored by tobacco companies. About 12.8% students reported that they have an object with a cigarette or tobacco logo on it, and 6.4% reported that they have been offered free cigarettes by a cigarette company representative. Tobacco advertisement has an effect on recruitment of new smokers, especially the adolescents.  A study conducted on pro-tobacco advertisement among adolescents in the low- and middle-income countries reported a high prevalence of tobacco advertisement exposure,  which is similar to our study findings. Such high exposure to pro-tobacco advertisement might influence adolescents to become regular smoker. 
Accessibility and availability play a critical role in influencing adolescents to become smokers.  In this study, 38.3% of the adolescents procured their cigarette supply from a store and 97.8% smokers were not refused cigarette purchase because of their young age. Only 2.2% of female respondent reported to buy tobacco from a store. Moreover, this study finds that cigarette company representatives offering cigarettes to the adolescents. Furthermore, deals offered by tobacco company influences the adolescents to be smokers.  These findings suggest the need for restricting the sale of tobacco products to minors in Bangladesh. 
The present study has features and limitations that should be kept in mind when using and interpreting its results. First, the GYTS results represent only school going population aged 13-15 years present on the day of survey and may not be representative of all population in this age group in Bangladesh. Second, our study findings are based on self-reports from students who may under- or over-report their use of tobacco, behavior, and knowledge. Cultural norms and the unacceptability of smoking by girls in Bangladeshi society might result in underreporting of tobacco use.
| Conclusion|| |
Results of this study suggest that the current tobacco control programs need to strengthen and enforcement of existing policies as well as expansion into additional programs are priority public health problems in Bangladesh, failing which, tobacco attributed morbidity and mortality will continue to rise. There is a need to develop the smoking cessation support at both the health facility and the community levels.
Authors sincerely acknowledge CDC and WHO for making the data publicly available for use.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]