|TOBACCO CONTROL ISSUE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 24-32
Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: Findings from the Global Adult Tobacco Survey
K Palipudi1, SA Rizwan2, DN Sinha3, LJ Andes1, R Amarchand2, A Krishnan4, S Asma1
1 Centers for Disease Control and Prevention, Atlanta, USA
2 The INCLEN Trust International, New Delhi, India
3 South East Asia Regional Office, WHO, New Delhi, India
4 Centre for Community Medicine, All India Institute of Medical Sciences, India
|Date of Web Publication||19-Dec-2014|
Centers for Disease Control and Prevention, Atlanta
Source of Support: None, Conflict of Interest: None
Introduction: Tobacco use is a leading cause of deaths and Disability Adjusted Life Years lost worldwide, particularly in South-East Asia. Health risks associated with exclusive use of one form of tobacco alone has a different health risk profile when compared to dual use. In order to tease out specific profiles of mutually exclusive categories of tobacco use, we carried out this analysis. Methods: The Global Adult Tobacco Survey (GATS) data was used to describe the profiles of three mutually exclusive tobacco use categories ("Current smoking only," "Current smokeless tobacco [SLT] use only," and "Dual use") in four World Health Organization South-East Asia Region countries, namely Bangladesh, India, Indonesia and Thailand. GATS was a nationally representative household-based survey that used a stratified multistage cluster sampling design proportional to population size. Prevalence of different forms of usage were described as proportions. Logistics regression analyses was performed to calculate odds ratios (OR) with 95% confidence intervals. All analyses were weighted, accounted for the complex sampling design and conducted using SPSS version 18. Results: The prevalence of different forms of tobacco use varied across countries. Current tobacco use ranged from 27.2% in Thailand to 43.3% in Bangladesh. Exclusively smoking was more common in Indonesia (34.0%) and Thailand (23.4%) and less common in Bangladesh (16.1%) and India (8.7%). Exclusively using SLT was more common in Bangladesh (20.3%) and India (20.6%) and less common on Indonesia (0.9%) and Thailand (3.5%). Dual use of smoking and SLT was found in Bangladesh (6.8%) and India (5.3%), but was negligible in Indonesia (0.8) and Thailand (0.4%). Gender, age, education and wealth had significant effects on the OR for most forms of tobacco use across all four countries with the exceptions of SLT use in Indonesia and dual use in both Indonesia and Thailand. In general, the different forms of tobacco use increased among males and with increasing age; and decreased with higher education and wealth. The results for urban versus rural residence were mixed and frequently not significant once controlling for the other demographic factors. Conclusion: This study addressed the socioeconomic disparities, which underlie health inequities due to tobacco use. Tobacco control activities in these countries should take in account local cultural, social and demographic factors for successful implementation.
Keywords: Global Adult Tobacco Survey dual use, prevalence, South-East Asia Region, socioeconomic determinants, tobacco use
|How to cite this article:|
Palipudi K, Rizwan S A, Sinha D N, Andes L J, Amarchand R, Krishnan A, Asma S. Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: Findings from the Global Adult Tobacco Survey. Indian J Cancer 2014;51, Suppl S1:24-32
|How to cite this URL:|
Palipudi K, Rizwan S A, Sinha D N, Andes L J, Amarchand R, Krishnan A, Asma S. Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: Findings from the Global Adult Tobacco Survey. Indian J Cancer [serial online] 2014 [cited 2021 Feb 27];51, Suppl S1:24-32. Available from: https://www.indianjcancer.com/text.asp?2014/51/5/24/147446
| » Introduction|| |
Tobacco use is responsible for six million deaths and 6.3% of Disability Adjusted Life Years (DALY) lost worldwide.  Despite decreases in tobacco smoking in the high-income regions, the global estimates remain stable due to compensating increase in the South-East Asia Region (SEAR).  The burden due to all forms of tobacco use (which also includes smokeless tobacco [SLT] use) would be much higher than these estimates. Majority of this burden due to tobacco use is borne by Low- and Middle-Income Countries, because of their large population size and widely prevalent tobacco use. ,
Dual tobacco use, popularly defined as the concurrent use of tobacco smoking and at least one other form of SLT,  has been perceived as a threat to global tobacco control efforts in recent times. This particular type of use has emerged at least partly as the tobacco industry's response to overwhelming scientific evidence of harm caused to human life by smoking. 
SLT products, which are cheaper and lack the disadvantage of violating smoking laws such as "use in public places" and which purportedly help in quitting smoking. They are likely to be co-adopted by those who are already smoking, in order to quit smoking or as a means of continued nicotine supply in public places. The question of dual tobacco use causing greater harm when compared to single product use is still open to debate. ,,,
Although many studies ,,,,, have described the sociodemographic profile of tobacco use in SEAR, very few have tried to examine exclusive categories of tobacco use such as smoking only, SLT use only and dual use. The need for such analyses arises from the fact that use of one type alone has a different health risk profile as compared to dual use.
To tease out the specific profile of these exclusive categories we needed to analyze them separately. In order to effectively plan for future tobacco control strategies we need to understand dual use and its determinants as opposed to studies, which focus on all tobacco use. The Global Adult Tobacco Survey (GATS) provided an excellent opportunity to examine the prevalence and determinants of exclusive categories of tobacco use.
| » Methods|| |
We used the GATS data to describe the profile of tobacco users in four World Health Organization (WHO) SEAR countries, namely Bangladesh, India, Indonesia and Thailand.
Detailed methodology of GATS in each country has been described elsewhere, ,,, but briefly GATS was a nationally representative household-based survey, designed to obtain data on tobacco use behaviors of civilian noninstitutionalised individuals aged ≥15 years. Each country used a stratified multistage cluster sampling design to produce nationally representative samples. The important survey details are given in [Table 1]. A minimum sample size of 8000 households was taken in each country, except India where 8000 households were chosen from each of six regions. Households were selected at random and in each selected household face-to-face interviews were done in the participant's local language. Efforts were taken to maintain confidentiality of information obtained. Ethical clearance was obtained from country specific health ministries and implementing institutions.
We defined three mutually exclusive groups of tobacco use: "Current smoking only," "Current SLT use only," and "Dual use" [Box 1 [Additional file 1]].
The prevalence of different forms of usage were described as proportions with 95% confidence intervals [CI] and also within categories of sociodemographic variables such as gender (male, female), age group (15-24, 25-44, 45-64, 65 or older), residence (rural, urban), education (no formal education, primary, secondary, college/university or above) and wealth index quintiles (lowest, low, middle, high, highest). Association between different forms of usage and sociodemographic variables were calculated by performing logistic regression and strength of association described in terms of odds ratios (OR) with 95% confidence interval (CI). Where a particular cell contained zero, adjacent categories of explanatory variables were combined to allow the model to converge. All analyses were weighted, accounted for the complex sampling design and conducted using Statistical Package for the Social Sciences (SPSS) version 18.
| » Results|| |
Prevalence of different forms of tobacco use [Figure 1]
The overall prevalence of current tobacco use was highest in Bangladesh (43.3%), followed by Indonesia (35.7%), India (34.6%) and lowest in Thailand (27.2%). Prevalence of current smoking only was highest in Indonesia (34%) followed by Thailand (23.4%), Bangladesh (16.1%) and India (8.7%). Prevalence of current SLT use was similar in India (20.6%) and Bangladesh (20.3%) followed by Thailand (3.5%) and Indonesia (0.9%). Prevalence of dual use was highest in Bangladesh (6.8%), followed by India (5.3%), Indonesia (0.8%) and Thailand (0.4%).
Prevalence of different forms of tobacco use by sociodemographic characteristics
Current tobacco use
Current tobacco use in males was highest in Indonesia (67.1%) and Bangladesh (58.0%) while the highest prevalence for females were in Bangladesh (28.7%) and India (20.3%). In all countries, a larger proportion of males used tobacco than females. Current tobacco use was also higher in rural areas (ranging from 29.2% in Thailand to 45.1% in Bangladesh) when compared to urban areas (ranging from 22.9% in Thailand to 38.1% in Bangladesh) in all four countries. There was a trend toward increasing prevalence with increasing age in all countries except in Indonesia, where the prevalence was slightly lower in the ≥ 65 years age group. Current tobacco use was lower with increasing education (except in Bangladesh) and with increasing wealth status (except in Indonesia) [Table 2].
Current smoking only
Prevalence of current smoking only was very high in males (ranging from 15.0% in India to 65.6% in Indonesia) as compared to females (ranging from 0.8% in Bangladesh to 2.8% in Thailand) in all four countries. With increasing age, the prevalence also increased reaching a peak in 45-64 years age group and declining thereafter, except in Thailand where the peak was earlier in the age group of 25-44 years. Rural areas had a higher prevalence but the difference was less prominent in Bangladesh and India. There was a general declining trend with increasing education, although in Bangladesh the prevalence was nearly the same across all education groups. In Thailand, the prevalence was lower in the no formal education group, whereas in other countries this group had the highest prevalence. The prevalence also declined with increasing wealth except in Indonesia where it was highest in middle wealth group [Table 3].
Current smokeless tobacco use only
In contrast with smoking only, SLT use only was higher in females in all countries except India where it was more common in males. In Indonesia and Thailand, the prevalence was almost negligible in males (0.0% and 0.8% respectively) and was very low for females (1.8% and 6.0%, respectively). In contrast, SLT prevalence in India was 23.6% for males and 17.3% for females; in Bangladesh, 13.3% for males and 27.2% for females. SLT use was markedly higher among people aged 65+ years, ranging from 6.4% in Indonesia to 47.3% in Bangladesh in this age group. SLT use was also more common in rural areas in all countries. The prevalence declined with increasing educational status (except in Bangladesh where it was slightly higher in college educated) and increasing wealth status [Table 4].
Prevalence of dual use was much lower in Indonesia (0.8%) and Thailand (0.4%) than in India (5.3%) and Bangladesh (6.8%). Males in all countries had a higher prevalence of dual use in all countries (except in Thailand where the difference was minimal). Dual use increased with age in Bangladesh up to 45-64 years age group after which it declined. In India it was lowest in the youngest category and nearly same in all other categories. In Indonesia and Thailand the prevalence gradually increased with age. Dual use was higher in rural areas of all countries, ranging from 0.5% in Thailand to 7.3% in Bangladesh. In Bangladesh, Indonesia and Thailand, dual use decreased with increase in educational status, but it was slightly higher in college educated as compared to secondary school educated in Bangladesh and the difference was minimal across groups in Thailand. In India, prevalence was lower in no formal education group when compared to primary school educated, which then decreased with increasing education [Table 5].
Association of different forms of tobacco use with sociodemographic variables
In [Table 2], current tobacco use is compared with never tobacco use in all four countries. Current tobacco use was significantly associated with male gender in all countries and the strength of association was much higher in Indonesia (OR: 119.4 vs. OR: 6.1 in India, 6.8 in Bangladesh and 27.7 in Thailand). The odds of being a tobacco user were significantly associated with age in all countries and increased as age increased. Rural residence was significantly associated only in India (OR: 1.3) and Thailand (OR: 1.2). With college-educated group as reference, current tobacco use was higher in the groups with lower education. The poorest wealth quintile had the highest association with current tobacco use and there was declining trend with increasing wealth in all countries.
Current smoking only is compared with never smoked tobacco in [Table 3]. Exclusive tobacco smoking was significantly associated with male gender in all countries, but the strength of association was much higher in Bangladesh (OR: 143.9) and Indonesia (OR: 193.0) compared with Thailand (OR: 68.3) and India (OR: 16.9). With regard to age group, there was an inverted 'U' shaped association with the strongest OR in 45-64 years age group. Residence was not significantly associated [Table 3].
Current SLT use only is compared with never used SLT in [Table 4]. SLT use was positively associated with female gender in all countries (expect India). SLT use increased with increasing age for all countries except India. It was significantly associated with rural residence only in India (OR: 1.2) and Thailand (OR: 2.9). The odd ratios decreased with increasing education in Bangladesh, India and Thailand; and with increasing wealth in India and Thailand.
In [Table 5], dual use is compared with never used tobacco. Dual use was significantly associated with male gender in all countries, however the strength of association was much higher in Bangladesh (OR: 64.9) and Indonesia (OR: 62.9). In Bangladesh and India, maximum association was seen in the 45-64 age group (OR: 24.0 and 3.7 respectively), whereas in Indonesia and in Thailand where the OR were the highest in ≥65 years age group (OR: 7.6 and 65.8 respectively). Significant association with rural residence was seen only in India (OR: 1.5). There was decrease in the OR for dual use with increasing education and with increasing wealth (except in Indonesia).
| » Discussion|| |
This study has provided a comparative social picture of different mutually exclusive categories of tobacco use in four countries of the SEAR. The strength of this analysis was the national representativeness of GATS data and depth of questions asked on tobacco use from the respondents. This stands apart from other social profiling studies because the tobacco use categories explored were mutually exclusive, which would provide a much clearer idea of social disparity without contamination of effects. It was found that there were within country and between country variations in the social determinants of tobacco use.
In general, tobacco use increased with increasing age, which can be explained by the increasing adoption of tobacco and reduced quitting with time so that by the time a particular age is reached, most adopt this habit. ,,, However, tobacco smoking presented a different picture, with maximum likelihood in the middle age and then decreasing in the elderly, but still remaining higher than younger age group levels (except in Thailand). This inverted "U" shaped relation might be due to the fact that by late middle age, effects of tobacco smoking become manifest forcing a proportion to quit and thereby less people beyond this age smoke tobacco or recourse to alternate forms such as SLT. However, this is only an assumption and needs verification by in-depth studies. SLT users were much more likely to be older persons except in India where the likelihood was fairly uniform across all ages. The profile of dual use was more heterogeneous across countries, with an inverted "U" shaped relation in Bangladesh, no age variation in India and Indonesia and rising with age in Thailand. A study carried out among United States (US) air force recruits showed that dual use was higher in younger males,  as did a couple of nationally representative US studies. 
As expected, men were more likely to use tobacco than women. Men were much more likely to smoke; however the likelihood was much higher in conservative Islamic nations like Bangladesh and Indonesia where women smoking would be very socially undesirable, which was also the case with dual use. It was interesting to observe that SLT use (not as undesirable as smoking) was more likely to be seen in women in all countries, except India. Similar findings have been reported elsewhere also. ,,
There was no specific association with residence, except in India where current tobacco use and dual use were more likely to be seen in rural areas. There was no significant rural-urban difference in tobacco smoking and SLT across all countries.
Increasing educational and wealth status (which are generally correlated with each other) had an overall protective effect for all forms of tobacco use with a few exceptions. SLT use seemed independent of education and wealth in Bangladesh. This was probably due to the social acceptability of some forms of SLT, which are culturally integrated with their lifestyle so that SLT was consumed irrespective of education and wealth. In India, SLT was independent of education but unlike in Bangladesh was associated with wealth. It is probable that SLT use, which is relatively a cheap product, is not a perceived social norm among the wealthy in India. In Indonesia, there was a nonsignificant decreasing trend in SLT use and an inconsistent association for tobacco smoking and dual use with respect to wealth. Another interesting observation was the independence of tobacco smoking with wealth in India. The likely explanation lies in the fact that " beedi" - a relatively cheap product - forms the major proportion of tobacco smoking in India. But this was not the case with education because " beedi" is likely to be considered socially undesirable in educated circles. Alternate explanations provided by some authors are also possible. ,
Strengths and limitations
The advantage of GATS over other national tobacco related surveys such as Demographic and Health Surveys and World Health Surveys, ,, is that GATS includes a wider age range and has in-depth questions on tobacco use types specifically designed for this purpose. Specifically this study was able to provide estimated adjusted ORs for sociodemographic correlates of mutually exclusive categories of tobacco use. Some of the limitations of this study are that of the GATS itself, such as inability to make temporal associations due to the cross-sectional nature of inquiry and social desirability bias in self-reported tobacco use.
| » Conclusion|| |
This study was able to address the socioeconomic disparities which underlie health inequities due to tobacco related morbidity and mortality. This analysis has raised several interesting hypotheses in the socioeconomic disparities of tobacco epidemic in these countries. It must be stressed that no one universal explanation can be offered for such anomalies, and that in-depth understanding of local cultural and lifestyle factors, industry factors, detailed product analysis, and economic analysis of tobacco trade is essential to obtain a better picture of the socioeconomic determinants of tobacco use.
Tobacco control activities in these countries can be based on the broader framework developed by the WHO but should take in account local cultural factors and trade dynamics and appropriately modified for successful implementation.
| » Acknowledgment|| |
Funding for the Global Adult Tobacco Survey (GATS) is provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies. The Government of India contributed to GATS implementation in India.
The author alone is responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]