Pattern of Quitting Methods Used to Promote Tobacco Cessation in Bangladesh and Its Correlates

Papia Sultana^1*, Jahangir Alam¹, Jahanara Akter² and Tithi Rani Kundu^1
*Correspondence: Papia Sultana, Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh, Tel: +88-0721-711161, Email:

Keywords

Tobacco use • Quitting method • Prevalence • Cessation • Odds ratio • Logistic regression

Introduction

Tobacco is considered as the silent killer, which is a leading risk factor for disease globally. A study found that nearly 6 million premature deaths, 6.9% of years of life lost, and 5.5% disability-adjusted life-years (DALYs) occur in 2010 [1]. Global age-standardized prevalence of daily tobacco smoking was 31.1% in 2012 for men [2]. It has been observed that nearly 80% of the more than one billion smokers worldwide live in low- and middleincome countries including Bangladesh, where the burden of tobaccorelated illness and death is the heaviest. Bangladesh is one of the largest tobacco consuming countries in the world [2]. According to a previous study of Bangladesh, smoking causes about 25% of all deaths in Bangladeshi men aged 25 to 69 years and an average loss of life per smoker is seven years [3]. Tobacco use results in large and growing health care cost [4,5]. Among smokeless tobacco product, chewing tobacco (sadapata and zarda) is most commonly used by the Bangladeshi community which contains 28 cancer-causing agents (carcinogens). Smokeless tobacco is also highly associated with recession of the gums, gum disease, and tooth decay [6]. Due to its link with many chronic diseases various campaigns are going on worldwide to minimize tobacco use. Along with various national strategic policies, quitting methods are also initiated to cease tobacco use, such as medications, nicotine replacement therapy, telephone helpline, counselling etc. In a study of United States, Michael [7] had reported that cessation methods contributes about 23.6% people to succeed cessation. Hakim [8] had found that rate of unsuccessful quitter was higher (68%) among Bangladeshi smoker. Therefore, evolvement of cessation methods should be analyzed among Bangladeshi smokers who intended to quit.

In literature, some studies have been found to conduct in Bangladesh on tobacco use [9-16] which are limited to prevalence and predictors of tobacco use. Few studies address the issue of knowledge and attitude [17], marketing policy [18], tobacco use policy at home and offices [19] and cessation of tobacco smoking [8,20]. To our knowledge, no study has considered the issue of quitting methods of tobacco use in Bangladesh. Aims of the current study, therefore, are to obtain a nationally representative estimate of prevalence of methods used to quit tobacco use in Bangladesh and to identify significant correlates so that policy makers may find gap in existing quitting methods and get idea to make the cessation more successful.

Methods

Secondary data collected by the Global Adult Tobacco Survey (GATS), 2010 (http://www.who.int/tobacco/surveillance/survey/gats/en/) has been used for the current study. Details about the study design, survey method, questionnaire, and definitions of various terminologies can be found in literature [8,19,21-24]. The survey was conducted in 14 countries including Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam from 2008 to 2010. GATS used a global standard methodology for the survey. It included information on the respondents' background characteristics, tobacco use (smoking and smokeless), cessation, second-hand smoke, economics, media, knowledge, attitudes and perceptions of tobacco use. In Bangladesh, GATS was conducted in 2009 as a household survey of persons 15 years of age or older by the National Institute of Preventive and Social Medicine in collaboration with the Bangladesh Bureau of Statistics (BBS) and National Institute of Population Research and Training (NIPRT). A multi-stage (three-stage), geographically clustered sample design was used to produce nationally representative data. At the first stage 400 Primary Sampling Units (PSUs) (Mauza in rural and Mohalla in urban areas) were selected with probability proportional to size (PPS), followed by a random selection of one Secondary Sampling Unit (SSU) per selected PSU. At the third stage households were selected systematically within the listed households from a selected SSU. One individual was randomly chosen from each selected household to participate in the survey. Survey information was collected using handheld devices. The household response rate was 97.7%, the individual response rate was 95.8% and the overall response rate was 93.6%. There were a total of 9629 completed interviews (male=4468 and female=5161). Outcome variable was whether the quitting method(s) was (were) used by the tobacco user who tried to quit in the last 12 months of the survey. Therefore, the sample size reduces to 1058 tobacco smokers and 745 smokeless tobacco users for binary logistic regression analysis (Figure 1).

Descriptive analysis had been executed to know the characteristics of the study subjects. For the purpose frequency with percentage had been reported for categorical data and mean with standard deviation had been reported for continuous data. A comparison of prevalence of quitting methods had been carried out to confounding factors: gender and residence. Binary logistic regression [24] had been used to identify significant socio-demographic and economic correlates of quitting methods in Bangladesh. If a tobacco user who tried to quit tobacco use in the last 12 months of the survey followed at least one quitting methods was consider as 1 and 0 if didn’t follow any method. Logistic regression was suitable for such binary dependent variable. Therefore, two logistic regressions had been carried out: one was for tobacco smoker and another was for smokeless tobacco user. Therefore, the model estimated the Odds Ratio (OR) of using quitting methods among tobacco smokers who attempted to quit in the last 12 months of the survey versus no using any quitting method. The model for smokeless tobacco user estimates the similar OR. With 95% confidence interval had been reported. Statistical software StataSE version 13 (StataCorp, USA) has been used to carry out statistical analyses.

Results

It has been found that among the respondents, 23.19% are tobacco smokers and among them 47.38% tried to quit tobacco smoking in the preceding 12 months of the survey (Table 1). Of those intended smokers 27.13% used any one or multiple form of methods to quit: 13.71% used counseling, 0.76% used nicotine replacement therapy, 0.57% used traditional medicine, 0.09% used quit line or telephone support line, 7.47% used switching to smokeless tobacco and 6.85% used other methods (Figure 2). Among the respondents 24.26% used any form of smokeless tobacco product. Among the smokeless tobacco users 31.89% tried to quit in the preceding 12 months of the survey (Table 1). Among the intended group 24.83% followed any one or multiple form of methods to quit: 20.54% followed counseling, 0.67% followed nicotine replacement therapy, 0.54% used traditional medicine, 0.54% followed quit line or telephone support line and 4.90% followed other methods (Figure 3).

It has been also found that peoples who were using methods to quit tobacco smoking were more from urban area and were male (Table 2). On the other hand, peoples who were using methods to quit smokeless tobacco were more from rural area and were female.

From binary logistic regression (multiple) (Table 3) it had been found that rural people were 12% less likely to use methods to quit tobacco smoking than urban people with odds ratio (OR)=0.88 and 95% confidence interval (CI) = (0.65, 1.20). It had been also found that female were 26% more likely to use methods to quit tobacco smoking than male (OR=1.26, 95% CI=0.54, 2.95). Older peoples (age≥55 years) were two times more likely to use quitting methods to quit tobacco smoking than the youngest smokers of age 15-24 years (OR=2.24, 95% CI= 1.16, 4.32). Surprisingly, it has been found that more educated smokers were less likely to use quitting methods. Smokers who were employees (government or nongovernment), businessmen (small or large) and financially dependent peoples were more likely to use quitting methods than other occupation. Although it was not statistically significant. Intended smokers with higher wealth index were more likely to use quitting methods than the lowest and low wealth index.

On the other hand, for smokeless tobacco users it had been found that rural people were more likely to use quitting methods than urban people (OR=1.18 and 95% CI=0.81, 1.72). It was also found that female were 4 times more likely to use methods to quit smokeless tobacco use than male (OR=4.25, 95% CI=2.50, 7.24). Older peoples (age≥55 years) were two times more likely to use quitting methods to quit use of smokeless tobacco products than the youngest users of age 15-24 years (OR=2.57, 95% CI= 1.06, 6.22). Similar like tobacco smokers, it had been found that more educated smokeless tobacco users were less likely to use quitting methods. Among the intended group of smokeless tobacco users who were worker, daily laborer and self-employed were less likely to use quitting methods than government/non-government employees. Smokeless tobacco users with higher wealth index were more likely to use quitting policy than with low wealth index.

Discussion

This study tried to find pattern and correlates to quitting strategies of tobacco use in Bangladesh using nationally representative data. The study revealed that about 73% tobacco smokers didn’t use any method to quit and about 75% smokeless tobacco users didn’t use any methods to quit. There is evidence that smoker who tries to quit without any method, very few of quit attempts successful in the long-term [25]. It is also observed that combination of behavioral counseling and medications with other methods increase the rate of successfully quitting smoking, and a combination of behavioral counseling with a medication is more effective than any methods alone [26,27].

Counseling has been identified as the most used strategy to quit for both tobacco smokers and smokeless tobacco user. It has been found that age, education and wealth index were significantly associated to quitting methods used by tobacco smoker in Bangladesh. On the other hand, gender, age and wealth index were significantly associated with methods used to quit smokeless tobacco.

To quit both tobacco smoking and smokeless tobacco use, females used methods more than male. It might be one of the reasons that females were found to be more successful quitter than male [8]. In Bangladesh, due to social norm, tobacco smoking among females is not well accepted [14], but no restriction about smokeless tobacco use. Unregulated and unorganized marketing of smoking and smokeless products [18] and accessibility of varieties and attractive kind of the products [15] insists people to consume tobacco products more in Bangladesh than other developing countries. However, use some of the smoking (e.g, Bidi) and smokeless tobacco products (e.g, zarda, sadapata, gul, khoini, etc.) long time may make teeth and lips ugly looking. It might make the beauty aware females distressed and to take help of methods to quit. On the other hand, the prevalence of tobacco smoking among males in Bangladesh is higher than the neibouring country like Nepal [28] and Pakistan [29]. As the adverse effect of tobacco use is not prompt and as the males are not so beauty aware, they are less likely to quit tobacco use and hence they are not interested to take help of quitting methods.

Older peoples are more likely to use policy to quit tobacco use than the younger one. It might be due to the fact that after experiencing some tobacco related difficulties they realize necessity of quitting tobacco use. Moreover, older smokers experienced more health problems and visited healthcare professionals and received repeated advice to quit tobacco use (smoking and smokeless) which might encourage them to use quitting methods. Another reason might be that younger peoples are more confident in their decision which makes them less likely to use methods to quit tobacco use.

The study found that more educated peoples were less likely to use methods to quit tobacco use. Usually, educated peoples are more aware about health hazards and their adverse effect which makes them lower degree of fatalism and less risk taking behavior [30]. This is also true in India [31] and Sri Lanka [32]. Because of all these characteristics along with confidence in themselves, educated peoples might be able to quit tobacco use without using any method. Occupation was not found to have significant effect on using methods to quit tobacco use. Richest peoples were found more likely to use methods to quit tobacco use. It might be due to their dependency on wealth which encourages them to use of methods to quit tobacco use. Another reason might be that peoples in Bangladesh are eager in spending on treatment for any disease even leaving them poorer [33] rather than following preventive strategies. Alternatively, it suggests the need of target smoker with lower wealth index with quitting interventions. The major strength of the current study is the large sample size and coverage the nationally representative population which has already been discussed in literature [19]. In addition, to best of our knowledge, this is the first study that considered quitting methods that has been used by the intended group who tried to quit tobacco use in the past 12 months of the survey. However, there are several limitations that need to be addressed. Besides some common limitations of the data discussed in literature [8,19], the study could not find the trend of the quitting policies used over years, as the survey was cross-sectional. As the survey was based on self-reported information, the real pattern and prevalence of quitting methods used may be under or over reported. Addition, subtraction, or modification of any variable from (in) the model may change the result [34].

Conclusion

In conclusion, the study clearly found that a significant percentage of respondents who are higher educated, younger, of lower wealth index and male are less likely to use methods to quit tobacco use. Therefore, more active methods (e.g., “cold turkey” or, “self-help intervention”) to quit tobacco use should be intervened and implemented in Bangladesh to promote quitting, especially targeting male with higher educated, young and of lower wealth index. Additional proactive quitting intervention outreach program as discussed may be intervened in reaching tobacco user with lower wealth index. In addition, irrespective of all socio-demographic and economic conditions, a nationwide campaign is needed to increase quitting of tobacco use advocating use of medication and behavioral counselling along with other methods simultaneously.

References

1. Stephen S. Lim, Vos Theo, Flaxman Abraham D and Goodarz Danaei, et al. “A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010” a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380 (2012): 2224-2260.
2. Marie Ng, Michael K. Freeman and Thomas D. Fleming and Margaret Robinson, et al. “Smoking prevalence and cigarette consumption in 187 countries, 1980-2012” JAMA 311 (2014): 183-192.
3. Dewan S, AlamPrabhat Jha, Chinthanie Ramasundarahettige and Peter Kim Streatfield, et al. “Smoking-attributable mortality in Bangladesh: proportional mortality study” Bull World Health Organ 91 (2013): 757-764.
4. Fen Wu, Yu Chen, Faruque Parvez and Stephanie Segers, et al. “A prospective study of tobacco smoking and mortality in Bangladesh” PLOS One 8 (2013): e58516.
5. Nigar Nargis, Ummul H. Ruthbah, Geoffrey T. Fong and Iftekharul Huq, et al. “The price sensitivity of cigarette consumption in Bangladesh: evidence from the International Tobacco Control (ITC) Bangladesh Wave 1 (2009) and Wave 2 (2010) Surveys”. Tobacco Control 23 (2014): i39-i47.
6. “Centers for Disease Control and Prevention: Smokeless Tobacco Fact Sheets” (2019).
7. Michael C. Fiore, Homas E. Novotny, John P. Pierce and Gary A. Giovino, et al. “Methods used to quit smoking in the United States: Do cessation programs help” JAMA 263 (1990): 2760-2765.
8. Shariful Hakim, Muhammad Abdul, Baker Chowdhury and Md Jamal Uddin. “Correlates of unsuccessful smoking cessation among adults in Bangladesh” Preventive Medicine Reports 8 (2017): 122-128.
9. Abul Barkat, Ashraf Uddin Chowdhury, Nigar Nargis and Mashfiqur Rahman, et al. “The Economics of Tobacco and Tobacco Taxation, Bangladesh” (2012).
10. Mohammad Alamgir, KabirKim-Leng Goh, Sunny Mohammad Mostafa Kamal and Mobarak Hossain Khan. “Tobacco smoking and its association with illicit drug use among young men aged15-24 years living in urban slums of Bangladesh” PLoS One 8 (203): 68728
11. Kabir MohammadAlamgir, Goh Kim Leng, Khan Mobarak Hussain. “Adolescent Tobacco Use and Its Determinants: Evidence From Global Youth Tobacco Survey, Bangladesh” Asia Pac J Public Health 27 (2013).
12. Kabir MohammadAlamgir, Goh Kim Leng, Khan Mobarak Hussain. “Tobacco consumption and illegal drug use among Bangladeshi males association and determinants” Am J Mens Health 7 (2013): 128-137
13. Mobarak Hossian khan, Aklimunnessa khan, Alexande Kraemer and Mitsuru Mori. “Prevalence and correlates of smoking among urban adult men in Bangladesh slum versus non-slum comparison” BMC Public Health 9 (2019): 149
14. Papia Sultana, Shamima Akter, Mizanur Rahman and Samsul Alam. “Prevalence and Predictors of Current Tobacco Smoking in Bangladesh”. Journal of Biostatistics and Biometrics Applications 1 (2015): 102.
15. Munjila Begum, Papia Sultana. “Current pattern of product specific smokeless tobacco use in Bangladesh” Journal of Biometrics and Biostatistics 8 (2017): 4.
16. Munjila Begum, Papia Sultana. “Socioeconomic and demographic factors patterning smokeless tobacco use behavior in Bangladesh.A cross-sectional multilevel analysis”. Journal of Biometrics and Biostatistic 9 (2018): 4.
17. Md Tahidur Rahman, Dulal Chandra Roy, Papia Sultana. “Knowledge and attitude towards tobacco use in Bangladesh”Journal of Institute of Bangladesh Studies 38 (2016): 69-84.
18. Papia Sultana,   Md Tahidur Rahman, Dulal Chandra Roy. “Marketing policy that accelerate tobacco use in Bangladesh, A statistical investigation” Journal of Biometrics and Biostatistics 8 (2017): 6.
19. Papia Sultana, Md Tahidur Rahman, Dulal Chandra Roy and Shamima Akter, et al. “Tobacco control policies to promote awareness and smoke-free environments in residence and workplace to reduce passive tobacco smoking in Bangladesh and its correlates”. Plos One, (2018).
20. Pete Driezen., Abu S Abdullah, Anne CK Quah and Nigar Nargis, et al. “Determinants of intentions to quit smoking among adult smokers in Bangladesh findings from the International Tobacco Control (ITC) Bangladesh wave 2 survey” Global Health Research and Policy 1 (2016): 11
21. William D. Kalsbeek, Michael Bowling and Jason Hsia. “The Global Adult Tobacco Survey (GATS) sample design and related methods” (2010)
22. Gary A. Giovino, Sara A. Mirza, Jonathan M. Samet and Prakash C. Gupta, et al. “The GATS Collaborative Group. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys” Lancet 380 (2012): 668-679.
23. “Global Adult Tobacco Survey Collaborative Group” Global Adult Tobacco Survey(2008)
24. Kleinbaum, David G, Klein Mitchel. “Logistic regression, A self-learning text. Third edition” Springer, New York, London, (2010).
25. Nancy A. Rigott. “Strategies to help a smoker who is struggling to quit” JAMA 308 (2012): 1573-1580.
26. Stead LF, Lancaster T. “Combined pharmacotherapy and behavioural interventions for smoking cessation”. The Cochrane Database of Systematic Reviews 3 (2016): CD008286.
27. Laura J Rosen, Tal Galili, Jeffrey Kott and Mark Goodman, et al. “Diminishing benefit of smoking cessation medications during the first year: a meta-analysis of randomizedcontrolled trials” Addiction 113 (2018): 805–816. 
28. Sreeramareddy Chandrashekhar, Ramakrishnareddy N, Kumar Harsha and Sathian Brijesh, et al. “Prevalence distribution and correlates of tobacco smoking and chewing in Nepal a secondary data analysis of Nepal Demographic and Health Survey-2006”Substance Abuse Treatment, Preventionand Policy 6 (2011): 33.
29. Sara Ijaz Gilani, David A Leon. “Prevalence and sociodemographic determinants of tobacco use among adults in Pakistan: findings of a nationwide survey conducted in 2012” Population Health Matrics,11 (2013): 16.
30. World Health Organization. “The Millennium Development Goals and Tobacco Control. Geneva, Switzerland”. (2004).
31. Sansone Lalit J. Raute, Geoffrey T. Fong, Mangesh S. Pednekar and Anne CK. Quah, et al. “Knowledge of health effects and intensions to quit among smokers in India: Findings from Tobacco Control Policy (TBC) India Pilot Survey” Int. J. Environ. Res. Health 9 (2012): 564-578.
32. Manju Rani, Sekhar Bonu, Jha P and Nguyen, et al. “Tobacco use in India prevalence and predictors of smoking and chewing in a national cross sectional household survey” Tobacco Control, (2003): 12.
33. Md. Rashedul Islam, Md. Shafiur Rahman, Zobida Islam and Cherri Zhang B. Nurs. “Inequalities in finantial risk protection in Bangladesh: an assessment of universal health coverage” International Journal for Equity in Health 16 (2017): 59.
34. Hass Jasssebe, Linder Jincovit, Park Ereader and Gonzalez Isthad, et al. “Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial” JAMA Intern Med. 175 (2015): 218-226.