|TOBACCO CONTROL ISSUE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 50-53
Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region
DN Sinha1, KM Palipudi2, CK Jones2, BB Khadka3, PD Silva4, M Mumthaz5, NNN Shein6, T Gyeltshen7, K Nahar8, S Asma2, NN Kyaing1
1 World Health Organization, Regional Office for South-East Asia New Delhi, India
2 Global Tobacco Control, Office on Smoking and Health, Centre for Disease Control and Prevention, Atlanta, Georgia, USA
3 National Health Education, Information Communication Center, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
4 Ministry of Health and Nutrition, Colombo, Sri Lanka
5 Ministry of Education, Republic of Maldives, Myanmar
6 Ministry of Health, Government of Myanmar, Myanmar
7 Ministry of Health, Government of Bhutan, Bhutan
8 National Centre for Control of Rheumatic Fever and Heart Disease, Dhaka, Bangladesh
|Date of Web Publication||19-Dec-2014|
D N Sinha
World Health Organization, Regional Office for South-East Asia New Delhi
Source of Support: None, Conflict of Interest: None
Background: At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time. Methods: This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software. Results: According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011. Conclusion: The findings call for countries to implement corrective measures through strengthened policy and enforcement.
Keywords: Global Youth Tobacco Survey, smokeless tobacco use, trends, World Health Organization South-East Asia region, youth
|How to cite this article:|
Sinha D N, Palipudi K M, Jones C K, Khadka B B, Silva P D, Mumthaz M, Shein N, Gyeltshen T, Nahar K, Asma S, Kyaing N N. Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region. Indian J Cancer 2014;51, Suppl S1:50-3
|How to cite this URL:|
Sinha D N, Palipudi K M, Jones C K, Khadka B B, Silva P D, Mumthaz M, Shein N, Gyeltshen T, Nahar K, Asma S, Kyaing N N. Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region. Indian J Cancer [serial online] 2014 [cited 2021 Mar 9];51, Suppl S1:50-3. Available from: https://www.indianjcancer.com/text.asp?2014/51/5/50/147472
| » Introduction|| |
Prevalence of smokeless tobacco (SLT) use among youth in countries in the World Health Organization (WHO) South-East Asia region (SEAR) has been reported sporadically for different population sub-groups, though data is not comparable due to the use of varying methodologies. ,
For the first time, the Global Youth Tobacco Survey (GYTS) provides an opportunity to report levels and trends in prevalence of current SLT use among students aged 13-15 years. We included findings from the nationally representative GYTS conducted in countries in WHO SEAR between 2006 and 2013 using a consistent and standardized methodology, making the data comparable across countries and within the country, across time. 
| » Methods|| |
GYTS is a nationally representative school-based survey that collects data from students aged 13 to 15 years using a standardized methodology. The survey uses a two-stage cluster sample design. At the first stage, the probability of a school 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 students in the selected classes attending school on the day the survey is administered are eligible to participate. Student participation is voluntary.
GYTS was conducted at least once in 10 member states of the region between 1999 and 2013, using a standardized protocol that includes a standard questionnaire with anonymous self-administered, machine-readable answer sheets; field implementation; and analysis. However, we included data from nine countries (Bangladesh, Bhutan, India, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) with availability of nationally representative data between 2006 and 2013.
Current use of SLT is defined as the use of any forms of smokeless products (such as chewing betel quid with tobacco, dipping tobacco, and snuff tobacco) in the last 30 days preceding the survey.
Sample sizes for the surveys in these countries varied from 1764 in Sri Lanka in 2007 to 12,086 in India in 2006. Response rates were reported at over 80% in all countries except for India (79.6% in 2009), Maldives (75.4% in 2011), and Nepal (73.9% in 2011) [Table 1]. A weighting factor was applied to each student record accounting for variation in the probability of selection at the school and class levels and adjusting for nonresponse (by school, class, and student). A final adjustment was made to the weights by grade and sex of all school-aged children in each country. SUDAAN, a software package for statistical analysis of correlated data, was used to calculate weighted prevalence estimates and standard errors (SEs) of the estimates; the 95% confidence intervals were calculated from the SEs. A two-sample t-test was used to assess the significant difference between sub-groups (boys and girls) as well as between and within countries over time. Differences in proportions are considered statistically significant if the P value of the difference is < 0.05.
|Table 1: Sample size and response rates by country and year of the survey in selected member countries of the WHO South - East Asia Region, GYTS, 2006-2013|
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| » Results|| |
Prevalence of smokeless tobacco use
By comparing the most recent survey in each country, prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan. Among boys, SLT prevalence ranged from 7.1% in Bangladesh to 27.2% in Bhutan and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Significantly higher proportions of boys than girls reported using SLT products in Bhutan (2013) (boys 27.2%; girls 19.8%), India (2009) (boys 11.1%; girls 6.0%), Maldives (2011) (boys 9.2%; girls 2.9%), Myanmar (2011) (boys 15.2%; girls 4.0%), and Sri Lanka (2011) (boys 13.0%, girls 4.1%). Conversely, there was no difference in prevalence of SLT use among boys and girls in Bangladesh (2013), Nepal (2011), Thailand (2009), and Timor-Leste (2013) [Figure 1].
|Figure 1: Prevalence of smokeless tobacco use in the countries of the World Health Organization South - East Asia region: Global Youth Tobacco Survey 2009-2013|
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Prevalence of specific smokeless tobacco products use
Prevalence of betel quid chewing was reported from Myanmar, Nepal, and Sri Lanka in 2011, ranging from 7.1% in Sri Lanka to 9.6% in Nepal. In Myanmar and Sri Lanka, boys were more likely to use betel quid than girls were. However, there was no difference in betel quid chewing among boys and girls in Nepal [Figure 2]. In Nepal, chewing pan masala with zarda was reported by 7.6% of youths (boys 9.3%; girls 6.3%). Khaini chewing was reported (3.3%) by boys and girls. Prevalence of chewing SLT products other than betel quid was reported in Nepal (10.9%) and Sri Lanka (2.5%) with much less differences among boys and girls [Figure 3]. In Nepal, prevalence of chewing betel quid with tobacco was similar to that of chewing other SLT products. However, prevalence of chewing betel quid with tobacco was reported higher than chewing other SLT products among boys and girls in Sri Lanka [Figure 2] and [Figure 3].
|Figure 2: Prevalence of chewing betal quid with tobacco in selected member countries of the World Health Organization South - East Asia region in 2011|
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|Figure 3:Prevalence of chewing tobacco other than betal quid in selected member countries of the World Health Organization South - East Asia region, Global Youth Tobacco Survey 2011|
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Trends of smokeless tobacco use
Prevalence of current SLT use did not change in Bangladesh between 2007 and 2013, Bhutan-between 2006 and 2009, India-between 2006 and 2009, Myanmar-between 2007 and 2011, and in Sri Lanka-between 2007 and 2011. A significantly increase in trend was noted, however, in Bhutan from 9.4% in 2009 to 23.2% in 2013 and in Nepal from 6.1% in 2007 to 16.2% in 2011 [Table 2].
|Table 2: Trends in prevalence of current SLT use among youth ages 13-15 years in the selected member countries of the WHO South - East Asia Region, GYTS, 2006-2013|
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| » Discussion|| |
The present study findings reveal that prevalence of SLT use was unacceptably higher among boys in India (11.1% in 2009), Myanmar (15.2% in 2011), Nepal (19.7% in 2011), Sri Lanka (13.0% in 2011), Timor-Leste (12.1% in 2013) and Bhutan (27.2% in 2013). SLT use among boys in countries of SEAR is one of the highest reported from anywhere in the world. 
The present study results show that prevalence of current SLT use did not change in Bangladesh between 2007 and 2013, Bhutan between 2006 and 2009, India between 2006 and 2009, Myanmar between 2007 and 2011, and Sri Lanka between 2007 and 2011. However, a significant increase was noted in Bhutan from 9.4% in 2009 to 23.2% in 2013 and in Nepal from 6.1% in 2007 to 16.2% in 2011.
All countries, with the exception of Timor-Leste, have national tobacco control legislation. ,,,,,,,, In many countries, this legislation focuses on SLT control. ,,,,,,,,, In addition, allied rules,  regulations, and judicial orders have also helped to advance SLT control in countries of the region. High prevalence of SLT use reported in the present paper in countries of SEAR may be due to the absence of proper policies focusing on SLT control or a lack of enforcement.
The royal government of Bhutan enacted legislation banning the manufacture and sale of tobacco products in 2010.  However, there is an indication from other studies that the ban on sale of tobacco products is not well implemented and that tobacco products are still available and accessible in Bhutan.  Earlier GYTS results also indicated that tobacco products were available in Bhutan's local market and that youths had access to such items. , High and increasing prevalence of SLT use among boys and girls in Bhutan is a wake-up call for stricter enforcement of existing policies.
In Nepal, tobacco control legislation was enacted in 2010  with regulations in place by 2011.  However, before implementation of the different provisions, the tobacco industry initiated litigation against the legislation. In 2014, the Nepal apex court ultimately gave direction to the government to enforce the tobacco control law, and various provisions have now been implemented, including graphic health warning labels covering 75% of the front and back of smoked and SLT products.
India has had a policy in place to address SLT control since 2003. However, a number of provisions could not be implemented for several years due to court cases. India has taken bold steps in last 4 years, such as considering gutka to be a food product, which is not permitted to have nicotine by law. As a result, the production and sale of gutka has been banned in almost all states of India. Some states have also banned the production of SLT products with any additives or flavorings. Furthermore, state governments in India have increased the value added tax on SLT products. 
Bangladesh responded late in 2013 to include SLT control in their tobacco control legislation. 
Countries in SEAR need to use GYTS data to assist in the development of their National Programme for Tobacco Control as recommended by WHO in the "Regional Strategy for Utilization of GYTS Data."  Strengthening health systems, building information systems, and integrating tobacco control efforts with population and personal services under national non-communicable disease programmes are required. Development of an effective comprehensive tobacco control program will require careful monitoring, enforcement, and evaluation of existing programs and the likely expansion of new efforts.
GYTS data presented here are limited to school-going students aged 13-15 years only and may not be representative to all youths of this age. These data apply only to youths who were in school on the day of survey implementation and completed the survey questionnaire. Finally, data were based on self-reports from students who might under-report or over-report their behaviors.
| » Conclusion|| |
SLT use in the member countries of WHO SEAR does not show any downward trend. In fact, trends show an increase in Bhutan and Nepal. This may be due to delayed policy response with respect to SLT control, partly caused by tobacco industry interference and also due to the inadequate strategy to implement existing policies. It is vital for countries to plan intense SLT control measures, and then robustly enforce and monitor them. The findings presented here call for the implementation of corrective measures through strengthening policy and enforcement.
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.
| » References|| |
Gupta PC, Ray CS. Tobacco and youth in the South East Asian region. Indian J Cancer 2002;39:1-33.
Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003;8:419-31.
Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste JP, Costa de Silva V, et al.
Global youth tobacco surveillance, 2000-2007. MMWR Surveill Summ 2008;57:1-28.
Asma S, Palipudi K, Sinha DN. Smokeless Tobacco and Public Health in India, A Scientific Monograph Presented During Stakeholders Meeting; New Delhi, India; October 17, 2011.
Ministry of Health and Family Welfare, Government of the People′s Republic of Bangladesh, Smoking and Tobacco Products Usages (Control) (Amendment) Act (16); 2013.
Ministry of Health, Royal Government of Bhutan, Tobacco Control Act of Bhutan, 2010, 6 June 2010; The Tobacco Control Rules and Regulations 2011; Ministry of Health, Royal Government of Bhutan, Tobacco Control (Amendment) Act of Bhutan 2012; Bhutan, Tobacco Control Rules and Regulations 2013, 1 Jan 2013.
Ministry of Law and Justice, (Legislative Department), Government of India, Cigarettes and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act; 2003.
Maldives Ministry of Health, Male, Regulation for Designating Tobacco Consumption Prohibited Places; 1 January, 2013.
The Union of Myanmar, The State Peace and Development Council, Control of Smoking and Consumption of Tobacco Product Law (Law No. 5/2006); 4 May, 2006.
Ministry of Health and Nutrition, Government of Nepal-Tobacco Product (Control and Regulation) Act, 2010, 8 Aug 2011; and Directives for Printing and Labeling of Warning Message and Graphics in the Boxes, Packets, Wrappers, Carton, Parcels and Packaging of Tobacco Products, 4 Nov 2011; and Tobacco Products (Control and Regulation) Regulation - 2068 (2011), 7 May 2012.
The Democratic Socialist Republic of Sri Lanka, Notification Establishing the Effective Date of the National Authority on Tobacco and Alcohol Act, No. 27 of 2006; 3 Nov, 2006.
The Gazette of the Democratic Socialist Republic of Sri Lanka, Tobacco Products (Labelling and Packaging) Regulations, No. 01 of 2012; 8 August, 2012.
The Gazette of the Democratic Socialist Republic of Sri Lanka, Regulation Amending the Effective Date of the Tobacco Products (Labelling and Packaging) Regulations, No. 01 of 2012; 26 Oct, 2012.
The Gazette of the Democratic Socialist Republic of Sri Lanka, 2013 Regulation Amending the Tobacco Products (Labelling and Packaging) Regulations, No. 01 of 2012; 15 Feb, 2013.
The Gazette of the Democratic Socialist Republic of Sri Lanka, 2014 Regulation Amending the Tobacco Products (Labelling and Packaging) Regulations, No. 01 of 2012; 27 May, 2014.
Ministry of Public Health, Royal Government of Thailand, Tobacco Products Control Act, B.E. 2535 (1992), 29 Mar 1992 and subsequent several notifications of Ministry of public health and latest Ministry of Health Notice of Rules, Procedures, and Conditions for the Display of Images, Warning Statements, and Contact Channels for Smoking Cessation on Cigarette Labels, 2013; 2 Oct, 2013.
ITC Bhutan Project Report. Thimphu, Bhutan: University of Waterloo, Ontario, Canada, and Ministry of Health; 2011.
World Health Organization. Regional Strategy for Utilization of Global Youth Tobacco Survey Data. New Delhi: Regional Office for South-East Asia; 2008.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]