Tobacco Use in Bangladesh

Abstract

Bangladesh is rich in cultural inheritance and tobacco use is an integral part of the culture in the country. Bangladesh is a tobacco-producing country and one of the most consuming countries. Traditionally, Bangladeshi male tobacco users mostly smoke cigarettes and bidi, and chew tobacco leaves such as zarda, sadapata, gul, and khaini. However, females usually do not smoke tobacco but chew tobacco leaves. According to Global Adult Tobacco Survey (GATS) Bangladesh, 2017, 40.0% of males and 25.2% of females use tobacco; among them, 36.2% of males and 0.8% of females smoked cigarettes or other forms of smoking tobacco such as bidi or hukkah; and 16.2% of males and 24.8% of females use smokeless tobacco (betel quid with zarda, gul, sadapata, etc.). This chapter has presented a description of tobacco use and its socio-demographic and economic correlates, secondhand tobacco exposure, tobacco use policies in workplaces and residences, awareness, quitting methods, and management of marketing and media coverage in Bangladesh.

1. Introduction

Bangladesh has a rich cultural inheritance. Tobacco use is an integral part of the culture in the country. Bangladesh has an extended history of tobacco use and, smoked and smokeless tobacco is used in different ways. Bangladesh is also a tobacco-producing country. About 46,472 hectares of land is used for cultivating tobacco and about 87,628 tons of tobacco leaf is produced every year [1]. Bangladesh stands at 14th position in area under tobacco production, 12th position for production in quantity, and contributes 1.3% of global tobacco production [1]. Usually, males in Bangladesh smoke cigarettes and bidi, and use raw or formatted tobacco leaves such as zarda, sadapata, gul, khoinee, etc. Although tobacco smoking among females is not well accepted in the country, chewing tobacco leaf is acceptable. Tobacco-related death and illness hamper the social and economic progression of a country. Early death or disability from tobacco use decreases the living standards and obstructs the financial condition of the family [2]. A prospective study of ten years with twenty thousand adult participants in Bangladesh has discovered that smoking was accountable for 25% of male deaths and 7.6% of female deaths directly or indirectly [3], which clearly visualize that Bangladesh has experienced a large number of tobacco-related deaths and illnesses that authorized national as well as global attention to this massive delinquent. It is also estimated that about 1.2 million people became ill due to tobacco use. The economic cost of tobacco is enormous, which is about 863 million USD each year [4].

Recently Bangladesh has been going through health and economic evolution, and has experienced a dual burden of communicable and noncommunicable diseases. Tobacco is identified as the key risk factor for noncommunicable diseases. Deaths due to tobacco are projected to be declined by 9% from 2002 to 2030 in developed countries, but increased to double in low- and middle-income countries. Like many other countries, the Government of Bangladesh has executed some steps to minimize tobacco use. Recently, the National Strategic Plan of Action for Tobacco Control (2007-2010) has been executed in the country. The MPOWER package is a series of six recognized strategies, which had been launched in Bangladesh in December 2008. But, Government has failed to make the acts 100% in action. On the other hand, teenagers are getting more prevalent to tobacco use. Smoking affects adversely the individual smoker, in some cases his/her family and society as a whole. A significant amount of costs is being used for medicinal purposes, leaving the family in poorer economic condition. It also reduces the individuals’ working capacity. All these are alarming to Bangladesh.

This chapter will provide a detailed description of tobacco use and its socio-demographic and economic correlates, secondhand tobacco exposure, tobacco use policies in workplaces and residences, awareness, quitting methods, and management of marketing and media coverage in Bangladesh.

2. Tobacco use and its correlates

Tobacco is used in various forms and patterns in Bangladesh. There are different types of tobacco, e.g., smoked tobacco and smokeless tobacco. Main tobacco smoking products are manufactured cigarettes and bidi. Water pipe (hookah), pipe, cigars, e-cigarettes, shisha, hand-rolled cigarettes, etc. are also available. Global Adult Tobacco Survey (GATS) Bangladesh 2017 reported that overall 18.0% (19.2 million) adults currently smoke some form of tobacco, with 36.2% men and 0.8% women [5]. Among the smokers, 77.1% smokes manufactured cigarettes, 29.0% smokes bidis, 0.5% smokes water pipe (hookah), 0.4% smokes hand-rolled cigarette, 0.3% smokes cigar, cheroot, or cigarillo, 0.2% smokes tobacco in pipe, and 0.2% smokes tobacco in other way (Figure 1). Various studies have reported that tobacco smoking is associated with male gender, middle age, low education, low paid jobs and lower economic condition [6]. However, some studies also identified that peer smoking, higher grades in academic results, higher amount of pocket money, etc. are positively associated with tobacco smoking in teenagers [7].

Figure 1.

Prevalence of tobacco smoking in Bangladesh, GATS 2017.

There are many types of smokeless tobacco (SLT) products that have traditionally been used in Bangladesh. Smokeless tobacco ranges from unprocessed to processed with various attractive flavors and forms including Zarda, Gul, Sada Pata, Pan Masala, and Khaini (Figure 2).

Figure 2.

Smokeless tobacco products in Bangladesh.

Zarda is the most common smokeless tobacco product used in Bangladesh. It is a processed tobacco leaf. Usually, tobacco leaf is boiled, baked, or roasted and flaked. The flakes of tobacco leaf are then mixed with other spices, sweeteners, and flavors, especially menthol and camphor, herbs, fragrances, saffron, and silver flakes (Figure 3). It is usually used with betel quid with slaked lime paste and chopped areca nut (Figure 4), and is very popular among older men and women.

Figure 3.

Zarda.

Figure 4.

Betel quid with Zarda.

Gul is the powdered tobacco product with the ash of tendu leaves, usually sold in small containers or sachets (Figure 5). It is used to clean teeth, but sometimes it is placed in mouth between the gums and lips for few minutes before cleaning teeth.

Figure 5.

Gul.

Sada Pata is the raw tobacco leaf (Figure 6), which is dried and is usually used for chewing among low-socioeconomic people.

Figure 6.

Sada Pata.

PanMasala with tobacco (PM-T) is a mixture of crushed tobacco leaf, chopped areca nut, lime, catechu, and spices (Figure 7). It is used in betel leaf and is very popular among teenagers due to its nice flavor.

Figure 7.

PanMasala.

Khaini is made from crushed sun-dried tobacco leaves (Figure 8). A small amount of crushed and fermented tobacco is taken in the palm and a pinch of slaked lime paste is added to it. The mixture becomes ready to use after it is rubbed thoroughly with the thumb. Traditionally, a user prepares this at the time of use. It is put in the mouth and sucked or chewed slowly. Users may add areca nut if they like. Usually, a special group of people in Bangladesh use Khaini.

Figure 8.

Khaini.

According to GATS Bangladesh 2017, overall 20.6% of adults use smokeless tobacco products with 16.2% males and 24.8% females. Among the smokeless tobacco users, 71.8% use Betel leaf with zarda, only zarda, or zarda with superi, 28.0% use Betel leaf with Sada Pata, 8.1% use Gul, 3.6% use Pan Masala with tobacco, 2.3% chew only Sada Pata, 0.7% use Khaini, and 0.2% use smokeless tobacco products in other forms (Figure 9). Smokeless tobacco use is associated with the female gender, middle age and older people, and people with low education, low-paid jobs, and low economic conditions.

Figure 9.

Prevalence of smokeless tobacco use in Bangladesh, GATS 2017.

E-cigarettes (electronic-cigarettes) [8, 9] are still fairly new in Bangladesh. E-cigarette is an electronic device that mimics tobacco smoking. E-cigarettes are available in many shapes and sizes in Bangladesh (Figure 10). Common structure of the device is to have a battery, a heating component, and a chamber to hold a liquid with nicotine, flavorings, and other chemicals. E-cigarettes produce vapor by heating the liquid. Smokers inhale this vapor of nicotine into their lungs. Nearby nonsmokers can also be exposed to this vapor when it is exhaled. Using an e-cigarette is sometimes called “vaping.” It has been found that 4.4% of adults in Bangladesh are addicted to e-cigarettes with 5% males and 1.8% females [GATS, Bangladesh, 2017].

Figure 10.

E-cigarettes.

3. Passive smoking

Passive smoking causes due to secondhand tobacco exposure. It is also termed as Second-hand tobacco smoke (SHS), or environmental tobacco smoke. Passive smoking is the inhalation of tobacco smoke by nonsmoker. It occurs when the smoke drift from a lit cigarette or tobacco smoke exhaled by an active smoker in an environment and a nonsmoker nearby the active smoker inhales it. Many studies have revealed that exposure to SHS is linked to a number of noncommunicable health consequences among nonsmoker adults, including lung cancer, heart disease, and asthma [10], and among children including coughs and wheezing, acute lower respiratory infections, exacerbated asthma, middle ear infections, meningococcal meningitis, and sudden infant death syndrome [11, 12, 13, 14]. GATS Bangladesh 2017 [5] has reported that 39.0% of adults were exposed to SHS at home, 42.7% of adults who worked indoors were exposed to SHS in enclosed areas at their workplace, 44.0% were exposed when using public transportation, 49.7% exposed while visiting restaurants, 12.7% exposed at health care facilities, 21.6% exposed at government buildings or offices, and 8.2% exposed to SHT at schools.

4. Tobacco use policies in workplaces and residences

Like many other countries, smoking is forbidden in enclosed public places and workplaces, with a slight exemption for restaurants with fewer walls in Bangladesh. But no clear smoking law is declared for residences. This produces a huge number of passive smokers, especially female and child passive smokers whose primary source of SHS exposure is in their own homes with at least one tobacco smoker. From GATS Bangladesh 2009, it has been found that among the female passive smokers, 21.4% were exposed in their residences and 18.9% were exposed at offices/workplaces [15]. The most common policy in home was that smoking was never allowed in home (30.97%), followed by no rules (29.82%), and smoking was allowed (22.15%). On the other hand, the most common policy in workplace was that smoking was prohibited (29.62%), followed by no rules (27.50%), and smoking was allowed (26.03%). However, 26.0% of passive tobacco smokers informed that smoking was allowed at their job place and 27.5% informed that there was no such smoking rule at the place.

5. Quitting methods

Besides various national strategies, some popular and useful quitting methods are also initiated to quit tobacco use, such as medications, nicotine replacement therapy, telephone helpline, counseling, etc. In two ways, prevalence of tobacco use can be minimized: (i) stopping initiation of new tobacco users, and (ii) quitting tobacco smoking. Successful quitting smoking is a continuous process, it may involve several attempts to quit and need to follow several methods. From GATS Bangladesh 2010, it has been found that among the tobacco smokers, 47.38% tried to quit smoking in the immediate past year of the survey [16]. Among them, 27.13% used anyone or compound form of quitting methods: 13.71% followed counseling, 0.76% followed nicotine replacement therapy, 0.57% followed traditional medication, 0.09% followed quitline or telephone helpline, 7.47% followed switching to smokeless tobacco, and 6.85% followed some other methods. Among the smokeless tobacco users, 31.89% tried to quit in the immediate past year of the survey. Among them, 24.83% used any one or compound form of quitting methods: 20.54% used counseling, 0.67% used nicotine replacement therapy, 0.54% used traditional medicine, 0.54% used quitline or telephone helpline, and 4.90% used other methods.

It has been found that male smokers, younger smokers, and smokers with lower wealth index were significantly and less likely to use one or more quitting methods at cessation attempts than their counterparts [16]. However, the study also investigated rural-urban inequities, educational inequities, and job inequities in using quitting methods. But, those were not found to be significant. The study also showed similar socio-demographic and economic behavior in using quitting methods to quit smokeless tobacco use.

6. Management of marketing and media coverage

Marketing and media play an important role in minimizing (or promoting) tobacco use. No doubt that the mass media and social media campaigns in the context of adverse effects of tobacco use can promote quitting or reducing tobacco smoking as well as smokeless tobacco use. On the other hand, advertisement of cigarette or bidi in mass media or in social media, signs promotion of bidi or cigarette, sponsorship of bidi or cigarette company in sports or sporting events, bidi or cigarette at sale price, free gifts, discount offers on other products, etc. may promote tobacco use and may initiate new users. Therefore, the Government and policymakers should monitor marketing and media coverage of tobacco products. A study found that 85.77% of adults noticed cigarette advertisements in the last 30 days of the survey [17]. The most common spot for observing cigarette advertisements was in a store (49.90%) and in other spots was 35.87%. In last 30 days of the survey, 2.07% noticed sport promotional events that encouraged tobacco users and 31.00% noticed other promotional events that encouraged them. It has also been found that 48.58% of people observed bidi advertisements. The most common spot for observing such advertisements was in stores (26.25%), and in other spots was 22.33%. Sport promotional events were observed by 0.65% of people and other promotional events were observed by 13.14% of people. The percentage of people who observed smokeless tobacco product advertisements was 22.49%. The most common spot was in a store (13.97%), and in other spots was (8.52%). Sport promotional event was observed by 0.21% and other promotional event was observed by 4.02% of people.

It has been identified that smokers, rural respondents, male respondents, younger respondents, higher educated respondents, and respondents with low-paid jobs or students were significantly and more likely to be inspired to smoke by observing such marketing policies for smoking-tobacco products. On the other hand, nonusers, rural respondents, male respondents, younger respondents, higher educated respondents, and respondents with middle economic status were significantly and more likely to be inspired to use by observing such marketing policy for smokeless-tobacco product.

7. Knowledge and attitude toward tobacco use

One of the most important strategies in reducing tobacco use prevalence is to increase knowledge about adverse effects of tobacco use in the population. It has been found that 94.8% of adults in Bangladesh know that tobacco smoking causes lung cancer, 89.5% know it causes heart attack, and 88.9% know it causes stroke [5]. On the other hand, 91.0% of adults know that smokeless tobacco use causes oral cancer, 82.5% know that it causes heart attack, and 82% know that it causes stroke. However, 93.1% of adults know that passive tobacco smoking causes serious illness. Another study has reported that female respondents are significantly less knowledgeable about the adverse effect of tobacco smoking and passive smoking [18]. Females are also less knowledgeable about the adverse effect of smokeless tobacco use but not statistically significant. Poorest people are significantly less knowledgeable about the adverse effect of passive smoking and smokeless tobacco use, and insignificantly less knowledgeable about tobacco smoking. Rural peoples are less knowledgeable about tobacco smoking, passive smoking, and smokeless tobacco use, but statistically insignificant. Respondents with less than secondary school completed are significantly more knowledgeable about the adverse effect of passive smoking and smokeless tobacco use than respondents with no formal schooling. Respondents with other educational levels are more knowledgeable but not statistically significant. However, education has not been found to play any significant role in the knowledge about the effect of tobacco smoking. Other common socio-demographic variables including age and profession are not significant to the knowledge about the effect of tobacco smoking, passive tobacco smoking, and smokeless tobacco use.

The study also analyzed tobacco use behavior of Bangladeshi respondents. It has been found that 11.48% of tobacco smokers smoke within 5 minutes after wakeup, 33.37% smoke between 6 and 30 minutes after wakeup, 25.37% smoke between 31 and 60 minutes after wakeup, and 29.54% smoke after one hour after wakeup [18]. Among the smokeless tobacco product users, 8.35% use within 5 minutes after wakeup, 25.30% use between 6 and 30 minutes after wakeup, 23.16% use between 31 and 60 minutes after wakeup, and 43.02% use after one hour after wakeup.

8. Discussion

Tobacco use, like many other addicted substances, is generally initiated as a result of an individual’s social involvement with tobacco-using age-mates: The adolescent who is ready to access and living in a socio-cultural milieu attitudinally tolerant of tobacco use, in contrast to his or her nonuser, motivationally mature fellows, experiences the tremendous adjustive value of tobacco once overcoming its initial unpleasant consequences or side effects, Hence, initiation occurs almost without exception, from established users to novices, in a densely branched network.

In the cultural or endemic addictions, the intoxicant is socially accepted, e.g., smoking among males, and zarda with pan, sadapata, gul, etc. among females. Many studies reported that most of the addictions are initiated in late teens. However, 16 seemed to be the most common age according to the researchers.

The prevalence of tobacco smoking among adult males in Bangladesh is found to be very high and higher than neighboring countries like Pakistan [19] and Nepal [20], although lower than India [21]. It is hoped that tobacco smoking among females is not well accepted due to social customs in Bangladesh. But, large proportion of male smokers may cause passive smoking among females [22] as well as among children and nonsmoker males.

Smoking (or passive smoking) during gestation has long been linked to prenatal damage and subsequent antisocial behavior in adolescence. One study found that exposure to smoke was associated with increased psychopathology in offspring and that exposure to secondhand tobacco smoke during pregnancy predicted later conduct disorder [23]. Having a tobacco-smoking parent had a greater effect on behavior than other influences, including prematurity, low birth weight, and poor parenting practices. This in turn may be generated as an important component of ill-health causation. Therefore, the biosocial theory is highly tangled with tobacco use in sociology [24, 25]. As such, public policy implications to trait theory including family therapy, substance abuse hospitals, and mental health associations are helpful as primary prevention programs. However, services are dependent on the evidence that if a person’s problems can be treated before they become devastating; some future smoking-related health problems can be prevented. Secondary prevention programs provide treatment such as psychological counseling to youths and adults who are at high risk of violating law of “smoking is prohibited in public places.” Tertiary prevention programs may be a requirement of a visible amount of fine (say, tk 2000) to smoke first time at public places and gradually increase the amount of fine for the subsequent smoking at public places. More controversial has been the use of antismoking medications in fancy and fashionable packages. Some available antismoking medications in the world are Chantix, Bupropion, Topiramate, Naltrexone, Nicotine, Topamax, etc. Beximco Pharma Ltd. (BPL), Bangladesh’s largest pharmaceutical company is manufacturing antismoking drug Zybex-SR (Bupropion Hydrochloride) since 2005.

Numerous psychologically based treatment methods range from individual counseling to behavior modification. Therapeutic interventions designed to make young adults better problem solvers may include methods that improve:

• coping and problem-solving abilities,

• relationships with peers, parents, and other juniors (or seniors),

• communication skills, and measures for resisting peer pressure,

• substantial thinking and decision-making skills,

• prosocial manners, including cooperation with others, self-responsibility, respecting elders, and public-speaking ability, and

• responsiveness.

E-cigarette is popular among teenagers (both males and females). E-cigarette is new in Bangladesh, but the prevalence is higher than in Japan [26]. British American Tobacco, Bangladesh first launched e-cigarettes in 2013 in Bangladesh [27]. Although the company overwhelming of its low-toxicants and fewer harmful substances compared to conventional cigarettes, the public health community has been divided over the possible benefits of e-cigarettes [28]. As it has been recently induced and its long-term effect has not been evaluated yet [29], the Government of Bangladesh should ban e-cigarettes. E-cigarette may not help in reduction of tobacco use; rather it will increase prevalence of the user.

Bangladesh is also a tobacco-cultivating country; the topmost is China, followed by India and Brazil [30]. Studies had identified that Company’s incentives, profitability, guaranteed market for the tobacco crop, and economic viability encouraged farmers to cultivate tobacco [31] and sixty percent of household were found in shifting cultivation to tobacco in the last decade [32]. Government should also take some initiative to minimize tobacco cultivation.

9. Conclusion

Tobacco use not only affects health but also affects the user economically, which is enormous and upward. Due to its social acceptability and easy availability, more teenagers and young women are having access to it; some consider it as a part of their fashion and hence get addicted. As the effect of tobacco use is not immediate, very few people aim to quit. When the effect is visualized, it is too late to quit. Hence, successful cessation is lower. Some studies discussed the issues and challenges of tobacco control in Asia [33, 34] and policymakers should pay attention more keenly.

Therefore, besides strengthening the tobacco reduction acts, the government of Bangladesh should implement some infrastructure including establishment of smoking zones in educational institutions, government buildings/offices, and other crowded areas to reduce initiation of new users. Banning smoking in enclosed public places is not enough. Smoking should be banned in open crowded places, including “bus stoppage,” train station, and public gatherings; in workplaces and home to minimize passive smoking. The government may prohibit attractive packaging and flavored tobacco products, and limit licensing retailers with number and location, especially nearby schools and colleges. In addition, government may take some initiative to renormalize the industries by continuously monitoring inclusion of child labor, and comprehensive banning advertisement, promotion, and sponsorship.

Conflict of interest

The author declares no conflict of interest.