Behcet’s Disease Research Committee of Japan: diagnostic criteria.
\r\n\tSynthetic zeolites can be formed from different raw materials and among these many wastes represent some interesting sources due to their chemical and mineralogical composition. Today, a large number of different types of waste resulting from many human activities are produced in the world (e.g. industrial, municipal, agricultural waste) and most of them are deposed of in landfills thus determining a great environmental problem.
\r\n\r\n\tThis book intends to provide the reader with a comprehensive overview of the current state-of-the-art on the possibility to transform the different types of waste materials into useful products, zeolites, through conventional processes and innovative methods. The aim is to demonstrate that waste can be a problem or a resource depending on how it is managed.
",isbn:"978-1-80356-426-5",printIsbn:"978-1-80356-425-8",pdfIsbn:"978-1-80356-427-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"3ed0dfd842de9cd1143212415903e6ad",bookSignature:"Dr. Claudia Belviso",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11561.jpg",keywords:"Structure, Properties, Natural Material, Synthetic Product, Type, Composition, Production, Disposal, Hydrothermal Method, Pre-fusion Process, Sonication, Multiple Steps",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 25th 2022",dateEndSecondStepPublish:"March 25th 2022",dateEndThirdStepPublish:"May 24th 2022",dateEndFourthStepPublish:"August 12th 2022",dateEndFifthStepPublish:"October 11th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"5 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Since 2002, Dr. Claudia Belviso has been carrying out research activity in the field of mineralogy and geochemistry aimed at environmental protection. She is responsible for the research activity on zeolite synthesis from waste materials and natural sources which has allowed her to be the inventor of an International Patent, publish numerous scientific articles in peer-reviewed journals, and carry out scientific research in national and international projects.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"61457",title:"Dr.",name:"Claudia",middleName:null,surname:"Belviso",slug:"claudia-belviso",fullName:"Claudia Belviso",profilePictureURL:"https://mts.intechopen.com/storage/users/61457/images/system/61457.jpg",biography:"Claudia Belviso is a researcher at the Institute of Methodologies of Environmental Analysis (IMAA) of CNR. After graduating in Geological Sciences and qualifying as a professional geologist, she earned a Ph.D. in Earth Sciences. Since 2002 has been carrying out her research activity in the field of mineralogy and geochemistry aimed at environmental protection. She is responsible for the research activity on zeolite synthesis from waste materials and natural sources as well as their application to solving environmental problems and as new raw material. These research activities have allowed her to be the inventor of an International Patent, publish numerous scientific articles in peer-reviewed journals, participate in national and international conferences, take part in the organization of international congresses, and carry out scientific research in national and international projects.",institutionString:"National Research Council",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"National Research Council",institutionURL:null,country:{name:"Italy"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"8",title:"Chemistry",slug:"chemistry"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"453622",firstName:"Tea",lastName:"Jurcic",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"tea@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"5306",title:"Zeolites",subtitle:"Useful Minerals",isOpenForSubmission:!1,hash:"eec7f864baf093058440c0f56072a7cf",slug:"zeolites-useful-minerals",bookSignature:"Claudia Belviso",coverURL:"https://cdn.intechopen.com/books/images_new/5306.jpg",editedByType:"Edited by",editors:[{id:"61457",title:"Dr.",name:"Claudia",surname:"Belviso",slug:"claudia-belviso",fullName:"Claudia Belviso"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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Even though almost all organs can eventually be involved, the compromise of the central nervous system (CNS) and eye makes the disease’s prognosis guarded and usually urges to start proper treatment.
There is no specific test to diagnose Behcet’s disease: by definition, its diagnosis is a clinical one. In 1990, the International Study Group for Behcet’s disease established a set of diagnostic criteria in an attempt to unify the five different ones used by that time [2]. They required the presence of oral ulcerations plus any two of genital ulcerations, typical defined eye lesions, typical defined skin lesions or a positive pathergy test.
Far from being solved, the debate on the diagnostic criteria is still active, and many other sets have been proposed. Among them, the Behcet’s Disease Research Committee of Japan defines the diagnosis as complete or incomplete upon the presence of major and minor symptoms (Table 1) [3]. The Dilsen criteria (revised in 2000) seems more suitable to the European patients suffering from Behcet’s disease (Table 2) [4, 5].
1. Major symptoms |
Recurrent aphthous oral ulcers |
Skin lesions: erythema nodosum-like lesions, thrombophlebitis, folliculitis, and cutaneous hypersensitivity |
Ocular symptoms: iridocyclitis, retinitis, and sequelae of uveitis |
Genital ulcers |
2. Minor symptoms |
Arthritis |
Intestinal Behcet’s disease |
Epididymitis |
Vascular lesions |
Neurologic lesions |
3. Examination |
Pathergy test |
4. Diagnosis |
Complete type: all four major symptoms present |
Incomplete type:
|
Behcet’s Disease Research Committee of Japan: diagnostic criteria.
Three out of the five following criteria are required to diagnose Behcet’s disease |
1. Recurrent oral ulcers |
2. Recurrent genital ulcers |
3. Skin lesions |
4. Eye lesions |
5. Thrombophlebitis |
(+) Skin pathergy test |
Always exclude other causative factors |
Behcet’s disease: the Dilsen criteria.
Almost every organ and system can eventually be affected by this severe vasculitis. Painful, recurrent oral and genital ulcers are so frequent that their presence is part of the diagnostic criteria [6]. Other skin manifestations are papulopustules, acneiform dermatitis, and erythema nodosum [7]. Arthritis is also a common manifestation of the disease [8]. Gastrointestinal involvement affects around 3–30% of cases with symptoms overlapping inflammatory bowel disease [9]. Central nervous system (CNS) involvement can touch almost 31% of patients and makes the prognosis guarded [10]. Venous thrombosis and arterial aneurysms are present in around 25% of cases [11].
The classic clinical picture is the one of recurrent, bilateral, non-granulomatous posterior or panuveitis with retinal vasculitis. This is the case for almost 80% of patients, while in around 10% disease manifests as anterior, non-granulomatous uveitis with hypopyon and eventually synechiae (Figure 1) [12].
Hypopyon and nasal synechiae in the left eye of a young patient suffering from acute reactivation of anterior uveitis related to Behcet’s disease.
Disease seems to be more severe in males, and ocular pain, redness, photophobia, and blurred vision are almost always present.
Retinitis is also a classic and sight-threatening manifestation of posterior segment involvement, leading most of the time to retinal atrophy. Indeed, Behcet’s disease is one of the differential diagnoses of macular atrophy related to uveitis (Figure 2) [13].
Horizontal OCT scan from the right eye of a patient with advanced Behcet’s disease posterior uveitis. Generalized retinal atrophy and retinal pigment hypertrophy are seen.
Retinal vasculitis is the hallmark of the disease, it is obliterative in nature, it affects both arteries and veins, and, most importantly, it involves the capillaries [14].
Behcet’s disease is mainly a capillaropathy, being fluorescein angiography (FA) essential to its proper diagnosis and management. FA will better delineate areas of non-perfusion (Figure 3), capillary leakage (Figure 4), and vascular remodeling. The “fern-leaf”-shaped leakage pattern from capillaries, even though not pathognomonic, is highly evocative of BD (Figure 5).
Late-frame fluorescein angiography showing extensive peripheral areas of retinal non-perfusion affecting the inferior temporal area of the right eye.
Early frame fluorescein angiography of the right eye of a patient suffering from Behcet’s disease retinal vasculitis. Areas of capillary leakage are present as well as peripheral ischemia and optic disc hyperfluorescence.
Late-frame fluorescein angiography of the right and left eye from a patient suffering from Behcet’s disease associated with retinal vasculitis. Typical “fern-leaf” pattern of capillary leakage is present.
Given the highly vascularized nature of choroidal tissue, it is not surprising to see choroidal involvement during active disease. Indocyanine green angiography (ICGA) shows irregular filling of the choriocapillaris, choroidal filling defects, and dye leakage from choroidal vessels [15]. Enhanced depth imaging optical coherence tomography (EDI-OCT) shows increased subfoveal choroidal thickness even in eyes without evident uveitis activity, making this finding a possible indicator of subclinical ocular inflammation in patients with BD [16].
Optic neuropathy (ON), although considered a rare manifestation of Behcet´s disease, might actually be overshadowed by uveitis’ complications. It can appear during the course of already known BD (and should be considered as part of the neuro-BD disease spectrum), or it can even be the first manifestation of the disease (BD should then be kept in mind as a differential diagnosis of optic neuropathy in regions where its prevalence is high) [17]. The prognosis of BD-associated ON seems not to be as poor as the one of BD uveitis, with excellent response to the combination of corticosteroids and immunosuppressants and recovery as the rule [18, 19]. However, the use of cyclosporine should be avoided in these cases since it could promote the development of neurologic involvement [20].
Despite years of research, BD remains idiopathic. Even though there are sporadic cases all around the world, disease is more prevalent along the ancient silk route and in countries located between 30 and 45 north latitude through the Mediterranean Basin, the Middle East, and Far East regions such as China and Japan [21]. This particular geographic distribution points toward a genetic predisposing factor. The high frequency of HLA-B51 among a wide range of affected ethnic populations highlights the importance of a special genetic background: even though not considered as part of the diagnostic criteria, the positivity of HLA-B51 increases the risk of BD in around six times [22].
Besides the classic and well-known predisposition to BD associated with HLA-B51 positivity, new insights on disease’s pathogenesis came out from genome-wide association studies (GWAS). The disruption of different biological pathways might determine the intrinsic biological process in multifactorial diseases, as BD. Six biologic pathways have been recently identified as possible mechanisms in the pathogenesis of BD:focal adhesion pathway, MAPK (mitogen-activated protein kinase) signaling, TGF (transforming growth factor) beta signaling, ECM-receptor interaction, complement and coagulation cascades and proteasome pathways [23].
Then, on this special genetic background, environmental factors might play a role as triggers for disease development. Infectious agents have been postulated as these triggering factors. Recently, a relationship between periodontal disease and specific polymorphisms of interleukin (IL)-1alpha and (IL)-1beta in Turkish patients with BD was reported, making periodontitis-induced autoinflammatory response a candidate for the development or severity of BD via IL-1 gene alteration [24]. Improvement of oral health among this high-risk population might affect BD course, leading to a better prognosis [25].
Neutrophils’ activation plays a predominant role in BD; this is evidenced through the positivity of pathergy test, one of the diagnostic criteria for the disease [2, 26]. The activation of the innate immune system against environmental and/or autoantigens in this particular genetic background is then perpetuated by the adaptive immune system [27].
As it was already stated, diagnosis is clinical and based on the presence of different combinations of symptoms and signs. In the acute attack, patients usually show raised inflammatory acute reactants (sedimentation rate and C-reactive protein) and high levels of white blood cells, mainly neutrophils [28, 29].
HLA-B51 is positive in around 50–70% of cases even though not necessary for the diagnosis [22, 30].
Differential diagnosis of hypopyon uveitis encompasses HLA-B27 associated, endogenous/exogenous endophthalmitis, toxic anterior segment syndrome (TASS) after cataract surgery, and masquerade syndromes [31, 32, 33, 34, 35]. BD-associated retinal vasculitis is unique in its predilection for capillaries but a similar picture can eventually be found in cases of HLA-B27 posterior uveitis with retinal vasculitis [36, 37, 38, 39].
Topical treatment is reserved for the minority of cases in which anterior uveitis is the only ocular disease manifestation. Prednisolone acetate with or without cyclopentolate is usually enough to stop episodes of anterior non-granulomatous uveitis. However, if these attacks are frequent or inflammatory quiescence requires more than three drops per day of prednisolone acetate for long periods, systemic treatment should be initiated.
The majority of cases presenting with posterior uveitis will require systemic treatment to control the sight-threatening manifestations of the disease.
High-dose systemic corticosteroids (1 g intravenous of Solu-Medrol or 1 mg/kg/day of oral prednisone) are useful in severe acute inflammatory attacks. However, they should not be administered alone given the high risk of flare up while tapering and the side effect profile of high doses [40].
Azathioprine and cyclosporine have both shown to be effective in BD’s uveitis in two different randomized clinical trials (RCT) [41, 42, 43]. In many cases, a single agent is not enough to control uveitis, and a combination of them is administered. Drugs are usually well tolerated in long term, providing the proper check of their own side effects’ profile is performed (liver toxicity for azathioprine, renal toxicity for cyclosporine). The likelihood of patients on cyclosporine to develop CNS complications should be kept in mind, and the drug is not recommended in the management of BD’s associated optic neuropathy [44].
High levels of tumor necrosis factor (TNF) alpha are present in BD’s uveitis [45]. The blockage of this inflammatory pathway is therefore a very effective approach to disease control. Infliximab (a chimeric monoclonal antibody against TNF alpha) and adalimumab (a fully humanized monoclonal antibody) are both widely used in the treatment of BD-associated posterior uveitis with high rates of success [46]. Adalimumab has the advantage of subcutaneous administration, theoretically improving patients’ quality of life [47].
Other anti-TNF alpha molecules, such as certolizumab pegol and golimumab, have also shown positive results in small case series of BD’s uveitis [48, 49].
Interferon alpha-2ª is a very effective biologic treatment for BD’s associated posterior uveitis [50]. Subcutaneously administered, it has rapid positive effect and also long relapse-free period making prophylactic maintenance treatment unnecessary [51, 52]. Drug is administered as a monotherapy after discontinuation of all previous immunosuppressive drugs (including corticosteroids). However, the associated flu-like syndrome limits the use of this important agent in the management of BD’s uveitis.
Cytotoxic agents (chlorambucil and cyclophosphamide) were in the past the drug of choice for this severe form of uveitis [53, 54]. Nowadays, however, given the more specific and less toxic agents available, they are only used in those settings
Intravitreal steroids (either triamcinolone acetonide, fluocinolone, or dexamethasone implant) are adjuvant rescue treatment in recalcitrant cases not responding to systemic medication or whenever systemic medication is contraindicated [55]. Their effect is always transitory and associated with the risk of local complications (mainly cataract and glaucoma).
Visual prognosis is directly related to anatomical location of inflammation and rapid introduction of proper treatment. The minority of cases manifesting only by anterior uveitis usually shows excellent visual prognosis. Posterior uveitis, however, might be sight-threatening even if only one acute attack involves the macula. The development of modern biologic agents has positively changed the natural guarded prognosis of this disease even though there is still a low proportion of cases that will not respond to different combinations of treatment.
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
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.
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
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
Smokeless tobacco products in Bangladesh.
Betel quid with
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.
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].
E-cigarettes.
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.
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.
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.
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
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.
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.
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,
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.
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.
The author declares no conflict of interest.
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