Introduction: Dual use of tobacco (using smoking and smokeless forms) in Bangladesh is uncommon in women but common in men. Dual users are at additional risk of cancers and heart diseases compared with a single form of tobacco use. Knowledge about their socioeconomic background is necessary for planning appropriate interventions. We report here socioeconomic background of the dual users of tobacco from a nationally representative survey. Methods: The study adopted a probability proportionate to size sampling technic of divisional population stratified into urban and rural areas to recruit men aged 25 years or older from their households. A total of 4312 men were recruited. Variables included questions on 20 household assets, tobacco use and other behavioral risk factors, and measurement of body weight and height. Results: The average age of dual users was 46.7 years old compared to 43.4 and 52.3 years for smokers and smokeless tobacco users. Prevalence of "smoking only," "smokeless only" and "dual use" of tobacco was 40.6%, 15.2%, and 14.2%, respectively. Among all tobacco users, dual users constituted 20%. These dual users had lower educational achievement, rural residence, lower intake of fruit, and higher intake of alcohol. They were more undernourished as indicated by a thin body mass index compared to nonusers and smokers. Dual users were of socioeconomically deprived as measured by wealth quartiles constructed out of household assets. Conclusion: Dual use of tobacco is common in Bangladesh, and it is intimately linked with socioeconomic deprivation. Poverty reduction strategy and campaigns should address tobacco control not only tobacco in general, but its dual use in particular.

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Introduction: The developing world, including countries like India, has become a major target for the tobacco industry to market its products. This study examines the influence of the marketing (advertising and promotion) of tobacco products on the use of tobacco by adults (ages 15 and over) in India. Method: Data from Global Adult Tobacco Survey 2009-2010 was analyzed using methods for complex (clustered) sample designs. Multivariate logistic regression was employed to predict the use of different tobacco products by level of exposure to tobacco marketing using adults who have never used tobacco as the reference category. Odds ratios (ORs) were adjusted for education, gender, age, state of residence, wealth index, and place of residence (urban/rural). Results: Adults in India were almost twice as likely to be current smokers (versus never users) when they were exposed to a moderate level of bidi or cigarette marketing. For bidis, among adults with high exposure, the OR for current use was 4.57 (95% confidence interval [CI]: 1.6, 13.0). Adults were more likely to be current users of smokeless tobacco (SLT) with even a low level of exposure to SLT marketing (OR = 1.24 [95% CI: 1.1, 1.4]). For SLT, the ORs showed an increasing trend (P for trend < 0.001) with greater level of exposure (moderate, OR = 1.55 [95% CI: 1.1, 2.2]; high, OR = 2.05 [95% CI: 0.8, 5.1]). The risk of any current tobacco use rose with increasing level of exposure to any marketing (minimum, OR = 1.25 [1.1-1.4]; moderate, OR = 1.38 [1.1-1.8]; and high, OR = 2.73 [1.8-4.2]), with the trend highly significant (P < 0.001). Conclusion: Exposure to the marketing of tobacco products, which may take the form of advertising at the point of sale, sales or a discounted price, free coupons, free samples, surrogate advertisements, or any of several other modalities, increased prevalence of tobacco use among adults. An increasing level of exposure to direct and indirect advertisement and promotion is associated with an increased likelihood of tobacco use.

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Context: A high prevalence of tobacco use, even among educated professionals like teachers, has been reported from Bihar. After passing of the Cigarette and Other Tobacco Products Act (COTPA) in 2003, there have been major improvements in tobacco control nationwide. Aims: To compare tobacco use prevalence among school teachers in Bihar reported in 2000 with a survey in 2008 and investigate correlates of current and past tobacco-use. Methods: Data from the baseline survey of a cluster random sample of 72 government schools conducted during the beginning of two consecutive school years was analyzed. Results: The prevalence of current tobacco use was 35.5% and past use, 11.3%. Likelihood of current use compared with no use increased with age (odds ratio [OR] =3.27 for > 50 years compared to < 30, 95% confidence interval [CI]: [1.50, 7.13]); whereas that of past use compared to current use decreased (OR = 0.25, 95% CI: [0.09-0.68] for age > 50 years compared to < 30 years). Discussion: Compared to the tobacco use prevalence among Bihar school teachers reported from a survey in the year 2000 (77.4%), the prevalence in this survey in 2008 was much lower and past use, much higher. In the earlier survey, lal dantmajan was counted as a tobacco product. If we do the same in the current survey, and consider ever use, the prevalence even then was 53.9%, lower than the earlier figure. Although the tobacco use among teachers in Bihar is still high, it has decreased after the implementation of COTPA and the cessation has increased.

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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.

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Introduction: Smokeless tobacco use occupies a significant portion of overall tobacco consumption in Bangladesh. Yet very little is known about the effectiveness of tax and price policy in controlling the use of smokeless tobacco use in the country. Methods: The paper examines the price distribution of various smoked (cigarette, bidi) and smokeless tobacco products (zarda, gul) using the univariate Epanechnikov kernel density function. It estimates the own and cross price elasticity of demand for the most widely used smokeless tobacco product zarda using two-step regression analysis. The analysis is based on data from the ITC Bangladesh Wave 3 Survey which is a nationally representative cohort survey of tobacco users and nonusers conducted in in Bangladesh during 2011-12. Results: The price elasticity of lower price brands of zarda is estimated at −0.64 and of higher priced brands at −0.39, and the cross price elasticity of zarda with respect to cigarette price at 0.35. The tax increase on smokeless tobacco needs to be greater than the tax increase on smoked tobacco to bridge the wide price differential between the two types of products that currently encourages downward substitution from smoked to smokeless tobacco and discourages quitting behavior. Conclusions: This paper argues that increasing tax on smokeless tobacco simultaneously with the tax increase on smoked tobacco can have significant negative impact on the prevalence of smokeless tobacco use in Bangladesh. Finally, a specific excise system replacing the existing ad valorem excise tax can substantially contribute to the revenue collection performance from smokeless tobacco products.

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Background: Global Adult Tobacco Survey India 2009-2010 revealed that more than one-third (35%) of adults in India use tobacco in some form: 21% use smokeless tobacco, 9% smoke, and 5% are mixed users (they smoke and use smokeless tobacco), and the quit rate is very low. In an effort to decrease prevalence of tobacco use, it is thus important to understand the factors that are related to intention to quit among Indian tobacco users. Research has shown consistently that intention to quit is a strong predictor of future quitting. The present study reports the factors encouraging quitting tobacco products in India. Subjects and Methods: Cross-sectional data from Wave 1 of the International Tobacco Control Policy Evaluation India Survey conducted in four cities and surrounding rural areas (i.e. Mumbai [Maharashtra], Patna [Bihar], Indore [Madhya Pradesh], and Kolkata [West Bengal]) between August 2010 and December 2011 were analyzed. A total of 8051 tobacco users (15+ years) were randomly sampled from 8586 households: 1255 smokers, 5991 smokeless users, and 805 mixed (smoke and smokeless) users. Validated, standardized questions were asked about current tobacco use, intention to quit, and factors encouraging quitting. Results: Overall, 19.6% of tobacco users intended to quit. Smokers had less intention to quit as compared to smokeless tobacco users whereas mixed users had more intention to quit (odds ratio [OR] =1.48, 95% confidence interval [CI] =1.12-1.97) compared to smokeless tobacco users. Highly educated people were more likely to report intention to quit (OR = 1.82, 95% CI = 1.09-3.02) compared to less educated. Advice by doctors to quit tobacco had a strong impact on intention to quit (OR = 1.68, CI = 1.29-2.15). Tobacco users who were exposed to antitobacco messages at work places (OR = 1.74, CI = 1.23-2.46), at restaurants (OR = 1.65, CI = 1.12-2.43), bars (OR = 1.81, CI = 1.07-3.06), on public transportation (OR = 2.14, CI = 1.49-3.08) and on tobacco packages (OR = 1.77, CI = 1.29-2.14) also expressed greater intention to quit tobacco use. Conclusion: Around one-fifth of tobacco users in India intended to quit tobacco use. Higher education, doctor's advice, and antitobacco messages were positively associated with users' intention to quit tobacco.

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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.

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Background: Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low- and middle-income countries. Tobacco is addictive; hence, tobacco users need support in quitting. Aims: Providing tobacco cessation services to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable "model tobacco cessation program." Settings and Design: This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India. Subjects and Methods: It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow-up. Statistical Analysis: Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco. Results: The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. Conclusions: Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India.

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Background: Cigarettes and other tobacco products act 2003 (COTPA) is the principal law governing tobacco control in India. Government of Maharashtra in one of its landmark decisions also banned manufacturing, sale and distribution of gutka and pan masala since July 2012. The desired impact and level of enforcement of the COTPA legislation and the gutka and pan masala ban in Maharashtra State, however, needs assessment. Among the many provisions within COTPA, the present study seeks to assess compliance to implementation and enforcement of Section 5 and 6 of COTPA including compliance to gutka and pan masala ban in Mumbai, India. Methodology: Six educational institutes (EI) within the Mumbai metropolitan region were selected in a two stage random sampling process. Area around each EI was manually mapped and all the tobacco products selling outlets with in the 100 yards distance were listed by trained Field Social Investigators and were observed to determine compliance for Section 5 and Section 6 of the COTPA legislation and for gutka and pan masala ban. The vendors/shop owners manning these outlets were also interviewed for their personal sociodemographic details, self-tobacco use, awareness and perception about ill-effects of tobacco and existing tobacco control legislation in the country. Results: A total of 222 tobacco retail outlets were listed within 100 yards of the EI in violation to the provisions of Section 6 of COTPA, of which 72 (32.4%) were selling tobacco products on mobile structures. About 53.2% of the tobacco vendors were also users of some form of tobacco. Whereas, nearly 217 (97.7%) vendors were aware about the gutka and pan masala ban in the State, only 48.2% were aware about the existence of COTPA legislation. None of the EI had a display board prohibiting the sale of tobacco products within a radius of 100 yards of their EI. Only 56.3% tobacco outlets had complied with the mandatory warning display boards indicating tobacco products will not be sold to people below 18 years of age. With regards to point of sale advertisement only 25.2% compliance was noted for display of health warning boards at the point of sale. Nearly 48.6% tobacco outlets exhibited >2 display boards and another 43.2% exhibited hoardings with brand pack photo, brand name in violation to the provision under Section 5. Violation by visible stacking and open display of tobacco products for sale was observed at 51.3% of tobacco outlets. While 41% of tobacco outlets were found displaying gutka and pan masala packets in violation to the ban. Conclusions: Enacting of the law without robust measures for enforcement has led to widespread noncompliance to the provisions with in the tobacco control legislation in the metropolitan city of Mumbai. Strong and sustainable measures needs to be incorporated both by civic administration and public health departments for its forceful implementation.

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Context: In 1999, an increase in mouth cancer incidence among young men (<50 years) in urban Ahmedabad was reported to be occurring along with decreasing mouth cancer incidence in older age groups and increasing oral submucous fibrosis incidence associated with areca nut consumption among young men in Gujarat. The aim was to investigate whether the increase in the incidence mouth cancer that had started among young men in the 1990s was continuing. Settings and Design: Ahmedabad urban population, comparison of reported mouth cancer cases in the population across four time period. Methods: Age-specific incidence rates of mouth cancer (International Classification of Diseases [ICD]-9:143-5; ICD-10:C03-06) in five year age groups among men aged ≥15 years for the city of Ahmedabad for years 1985, 1995, 2007 and 2010 were extracted from published reports. For comparison, lung cancer (ICD-9:169; ICD-10:C33-C34) rates were also abstracted. Statistical Analysis Used: A cohort approach was used for further analysis of mouth cancer incidence. Age adjusted incidence rates of mouth and lung cancer for men aged ≥15 years were calculated and compared. Results: The age specific incidence rates of mouth cancer among men increased over the 25-year period while lung cancer rates showed a net decrease. Using a cohort approach for mouth cancer, a rapid increase in younger age cohorts was found. Conclusions: Mouth cancer incidence increased markedly among men in urban Ahmedabad between 1985 and 2010, apparently due to increasing consumption of areca nut products, mawa and gutka. Gutka has now been banned all over India, but a more vigorous implementation is necessary.

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Background: Use of smokeless tobacco (SLT) is widely prevalent in India and Indian subcontinent. Cohort and case-control studies in India and elsewhere report excess mortality due to its use. Objective: The aim was to estimate the SLT use-attributable deaths in males and females, aged 35 years and older, in India. Materials And Methods: Prevalence of SLT use in persons aged 35 years and older was obtained from the Global Adult Tobacco Survey in India and population size and deaths in the relevant age-sex groups were obtained from UN estimates (2010 revision) for 2008. A meta-relative risk (RR) based population attributable fraction was used to estimate attributable deaths in persons aged 35 years and older. A random effects model was used in the meta-analysis on all-cause mortality from SLT use in India including four cohort and one case-control study. The studies included in the meta-analysis were adjusted for smoking, age and education. Results: The prevalence of SLT use in India was 25.2% for men and 24.5% for women aged 35 years and older. RRs for females and males were 1.34 (1.27-1.42) and 1.17 (1.05-1.42), respectively. The number of deaths attributable to SLT use in India is estimated to be 368127 (217,076 women and 151,051 men), with nearly three-fifth (60%) of these deaths occurring among women. Con Clusion: SLT use caused over 350,000 deaths in India in 2010, and nearly three-fifth of SLT use-attributable deaths were among women in India. This calls for targeted public health intervention focusing on SLT products especially among women.

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Background: Tobacco is a leading risk factor for different types of diseases globally. Tobacco smoking by women is culturally unacceptable in India, but still women smoke tobacco at various times of their life. Aims: The aim was to estimate the prevalence and pattern of tobacco use among women and to study the associated sociodemographic factors. Settings And Design: This cross-sectional study was conducted among women aged 30 years or over in an urban resettlement colony for the migrant population at Chandigarh, India. Methodology: The study included women used tobacco products on one or more days within the past 30 days. Through systematic random sampling, 262 women were studied. As a part of the study 144 bidi smoking women were interviewed using detailed semi-structured questionnaire. Statistical Analysis: Descriptive statistics and hypothesis testing with Chi-squared test and logistic regression were done using SPSS 16.0 version. Results: Overall, the prevalence of tobacco use was 29.4% and that of bidi, zarda and hookah were 19.8%, 8.8%, and 2.7%, respectively. Around 6.2% women used tobacco during pregnancy. Teenage was the most common age of initiation of bidi smoking. Logistic regression analysis showed that the prevalence of tobacco use was high among Hindu unemployed women with no formal education belonged to scheduled caste, and those having grandchildren. Conclusions: This study highlighted high rates of tobacco use and explored both individual and family factors related to tobacco use among women. Affordable, culturally acceptable, sustainable and gender-sensitive individual and community-specific interventions will reduce the prevalence and effects of tobacco use.

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Background: The role of fiscal policy, especially taxation, though has been proved to be an effective instrument of tobacco control, its application is limited in India due to several reasons. This paper examines the tax structure, price and affordability of SLT products in order to provide evidence on how to strengthen the role of fiscal policy in tobacco control. Method: Secondary data on tax structure and revenue from tobacco products were collected from the Ministry of Finance, Government of India. In order to measure the rise of prices corresponding to the increase in tax rate, the retail price index (RPI) and Whole Price Index (WPI) of SLT products were compared with the price index for all commodities for the period 2006-2012. The affordability of tobacco products is calculated by dividing prices of tobacco products by per capita income. Results: During the last 6 years, the tax rate on SLT has gone up leading to a rise in the prices of SLT products more than the general price rise. However, the price rise is less than the per capita income growth indicating increasing affordability. The study observed a decline in the consumption of zarda and kahini due to the price increase during 2008-2013. However, the decline in the consumption of zarda is less compared with khaini due to a very low rise in its price. Conclusion: The prices should be raised more than the growth in income to influence consumption. Tax administration is a major challenge for SLT products and strengthening it could enhance revenue collection from SLT products.

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Context: In India, 14% of the population use smoked tobacco products. Increasing prices of these products is one of the measures to curb their consumption. Aims: This study analyzes "unit price" and "daily consumption" of cigarettes and bidis and investigates their relation with each other. Settings And Design: A cross-sectional survey was conducted in four states of India (Bihar, West Bengal, Madhya Pradesh and Maharashtra) as a part of the International Tobacco Control Policy (TCP) Evaluation Project (the TCP India Project) during 2010-2011. Methods: Information was collected from adult (aged ≥15) daily exclusive smokers of cigarette/bidi regarding (a) last purchase (purchase in pack/loose, brand and price) and (b) daily consumption. Average unit price and daily consumption was calculated for different brands and states. Regression model was used to assess the impact of price on daily consumption. Results: Bidis were much less expensive (₹0.39) than cigarettes (₹3.1). The daily consumption was higher (14) among bidi smokers than cigarette smokers (8). The prices and daily consumption of bidis (₹0.33-0.43; 12-15) and cigarettes (₹2.9-3.6; 5-9) varied across the four states. The unit prices of bidis and cigarettes did not influence their daily consumption. Smokers purchasing bidis in packs paid substantially less per unit and purchase of bidis and cigarettes in packs influenced their consumption positively. Conclusions: Cigarettes although more expensive than bidis, seem very cheap if compared internationally. Hence, prices of both cigarettes and bidis do not influence their consumption.

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Myanmar Tobacco Control Law of 2006 covers the control of all forms of tobacco use. After 7-year, tobacco use among adults did not see a decrease. The paper aimed to study the prevalence, details of the products, trade, legislation, tax, marketing, advertising and evidence on morbidity and mortality, and to make recommendations for policy options. Personal communications by authors and colleagues, and searches by keywords in PubMed and on Google, literature review and research from published reports, and various studies and surveys conducted in Myanmar and other countries. Smokeless tobacco use in Myanmar is the highest among ASEAN countries. A variety of SLT products used together with betel chewing poses a challenge; betel quid chewing has been accepted as a cultural norm in both rural and urban areas. Betel quid chewing usually starts at younger ages. Sale, marketing, and advertising of SLT are not under control and thus, road-side kiosks selling betel quid with SLT are mushrooming. Considerable trade of SLT products by illegal and legal means created an increase in access and availability. Low cost of SLT product enables high volume of use, even for the poor families. Taxation for raw tobacco and tobacco products is half the values of the tax for cigarettes. Effective enforcement, amendment of the law, and action for social change are needed.

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