Applied Research
Factors Influencing the Initiation of Smokeless Tobacco Consumption Among Low Socioeconomic Community in Bangladesh: A Qualitative Investigation
International Quarterly of Community Health Education 0(0) 1–7 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X17736244 journals.sagepub.com/home/qch
Md. Shahjahan1, Md. Golam Dostogir Harun1, A. B. M. Alauddin Chowdhury1, Kapil Ahmed2, and Hafiz T. A. Khan3
Abstract This study explored factors influencing the initiation of smokeless tobacco (SLT) consumption in a low socioeconomic urban community in Bangladesh. The study conducted four focus group discussions among 33 informants involves school teachers, community leaders, women, and betel-nut shops owners. The results were prepared by thematic analysis of the transcripts where informants mean age was 30 (SD 6.8) years with varying level of education. Tradition of hospitality, curiosity, offer from an elderly person, and avoiding nausea during pregnancy and at time of quitting smoking were key factors for the initiation of SLT consumption. The results also revealed most people were aware about the danger of SLT consumption but, in practice, consumed frequently. The research suggested that doctors might advise people not to use any form of SLT while they seeking health services. Furthermore, communitybased awareness program could minimize the wider use of SLT among low-income community in Bangladesh. Keywords smokeless tobacco, low socioeconomic community, focus group discussion, Bangladesh
Background Tobacco use is the leading cause of preventable deaths. It was revealed in the study that tobacco kills one person every 6 seconds and nearly six million people die in a year due to tobacco-related illness.1 Tobacco consumption is estimated to cause about 71% of all lung cancer deaths, 42% of chronic respiratory disease, and nearly 10% of cardiovascular disease.2 The use of smokeless tobacco (SLT) is a major health issue in the South Asian region.3 It is estimated that over 80% of the world’s SLT users live in the Southeast Asia.4 Over one third of tobacco consumed in these countries is smokeless. The use of SLT has been an emerging public health concern over the last few decades. SLT use in South Asia is believed to be a significant contributor to morbidity and mortality.4 SLT use is the leading preventable cause of premature death and disease worldwide, and its impact is even more pronounced in low- and middle-income countries.5 Increasing use of SLT has been reported not only among men but also among vulnerable groups, such as children, teenagers, and women of reproductive age. SLT increases the risk of premature birth and low birth weight.6 The major effects of SLT are also seen in the oral cavity, pharynx, and esophagus, which together account for a large proportion of tobacco-related cancers.7 Chewing of betel quid with tobacco is commonly practiced by both men and women in Bangladesh, India, Pakistan, and
Sri Lanka.8 It is more prevalent among people from lower socioeconomic (SE) groups in these countries. A study in Kerala, India, identified that tobacco use (in both form) is significantly more among the low SE groups compared with the high SE group.9 SLT is consumed predominantly by chewing in the form of pan (piper betel leaf filled with sliced areca nut, lime, catechu, and other spices chewed with or without tobacco), pan-masala or gutkha (a chewable tobacco containing areca nut), and mishri (a powdered tobacco rubbed on the gums as toothpaste). The use of SLT is also common in Bangladesh.8 World Health Organization country profiles report on tobacco consumption identified that overall consumption of SLT was 27.2% in Bangladesh.10 A vast number of adult males and females consume tobacco in one form or another.8 A multicountry study has shown a high prevalence of both smoking as well as use of SLT for Bangladesh,11 which has become a
1
Department of Public Health, Daffodil International University, Dhaka, Bangladesh 2 Bow Business Center, Agroni Research, London, UK 3 Department of Criminology and Sociology, Middlesex University, London, UK Corresponding Author: Md. Shahjahan, Department of Public Health, Daffodil International University, Dhaka 1207, Bangladesh. Email: [email protected]
2 major contributor to the country’s high morbidity rates. A study conducted in Bangladeshi revealed that use SLT with betel quid which is responsible for variety of diseases such as heart diseases, stroke, oral cancer, and so on.12 The distribution of tobacco consumption is disproportionately higher in the lower SE groups especially among the unemployed, semiskilled laborers, or those engaged in manual labor and among the less educate.13 Similarly, some results have also shown that SLT use is highest in industrial areas.14 A clear pattern was observed with respect to SLT use in Bangladesh where the prevalence decreased as education and SE status increased.15 Another study showed that an estimated 20% to 30% of women in rural areas of Bangladesh use SLT.16 There have been few studies conducted which identify the factors associated with SLT use among lower SE groups in industrial areas of Bangladesh. The country’s traditional values do not permit women to smoke, but there is no such taboo against use of SLT.17 A study conducted in Bangladesh indicated that prevalence of both smoking (cigarette, bidi, etc.) and SLT (zarda, gul, pan-masala, etc.) use is high in men.12 This qualitative research explored factors influencing the initiation of SLT consumption among these groups in an urban context.
Materials and Methods The Study Site The study conducted during February to November 2015 in Demra and Tongi industrial areas, adjacent to Dhaka metropolitan city of Bangladesh. The study selected these sites as of industrials and easy approachable areas with typical urban low-income community. Usually in the industrial areas, lowincome people live and supposed to use SLT more frequently than others.14
Participant Selection This study selected the informants purposively from two study sites. An equal number of informants participated from each study area, and a total of 33 informants were participated in the four focus group discussion (FGD) sessions with at least eight informants in each discussion session. Respondents were composed of different groups including school teachers, community leaders, women representatives, as well as owners of betel-nut shops. Both users and nonusers of SLT attended the FGD sessions.
Qualitative Tools and Data Collection The study employed FGDs to explore the influencing factors for initiation of SLT consumption including documentation of community’s perceptions, reported practices, and social norms related to consumption of SLT. Developed FGD guideline was pretested in the field and finalized before
International Quarterly of Community Health Education 0(0) conducting the sessions. A multidisciplinary team including public health specialists, social scientists, and statisticians were involved in developing the qualitative guideline in focusing the study objectives. Each discussion was happened within 90 to 120 minutes duration. The study used an guideline that started by asking people to list all of the SLTs they could consumed or observed to consume by the community people and the influencing factors of initiation of SLT consumption among low-income community. The investigators also asked about their perception on use of SLT, how people influenced to use it, knowledge of health hazard, existing social norms, current practices related to initiation of SLTs, and for suggestions of how to reduce SLT consumption in low-income community.
Data Analysis All FGDs were recorded and then translated into English. The team manually processed the information according to research objectives. The investigators have done thematic content analysis in order to provide a descriptive result. This analysis was done for each FGD separately and presented all together in the findings for reporting.
Ethical Considerations Institutional ethical clearance procedures were followed, and particular attention was addressed to the issue of informed consent, anonymity during presenting information, and confidentiality. Before starting the discussion sessions, researchers clearly explained the study objectives to the informants along with collecting their written informed consent. The study protocol was reviewed and approved by the National Ethics Review Committee of Bangladesh Medical Research Council.
Results SE Characteristics Among the informants from four FGD sessions, three quarters (25, 76%) were male and about one quarter (8, 24%) were female. The mean age of the informants was 30 years with a standard deviation of 6.8 years. About half were school or madrasah teachers, and the rest were SLT sellers, religious, and community leaders. The respondents had different levels of education: One tenth had primary education while those who were either teachers or women representatives had a higher educational background. The median monthly family income of the informants was Bangladeshi Taka 39,125.
SLT Use and Related Perceptions Consuming betel leaf with zarda was found to be a common form of tobacco addiction in the study area. In addition,
Shahjahan et al. shadapata, gul, and nossi were consumed as other forms of SLT. One of the SLT users said ‘‘Smokeless tobacco is less costly and easily accessible compared to cigarette which is more costly.’’ On the other hand, many of them perceived the harmful effects of SLT as one respondent said ‘‘We chew the tobacco directly, so, it is more harmful than smoking cigarette. Our appearance showed our weakness.’’ From the discussions, it was further revealed that of those who are selling SLT products, most perceived the adverse health effects of SLT use. An informant opined: ‘‘Gul and zarda are very harmful for health. Chewing SLT is more dangerous than smoking cigarette.’’ The informants claimed that peoples’ consumption of shadapata (raw tobacco leaf) is decreasing as zardas of various flavors were readily available and attracting more consumers. According to the informants, women consumed zarda more than men, although they may not be aware that zarda is raw form of tobacco. One female respondent said ‘‘My grandmother who has been using smokeless tobacco for a long time can live without food but cannot live without smokeless tobacco.’’ Some informants mentioned that gul is relatively cheaper and more available than other addictive substances. People find it is convenient to use gul for intoxication and become addicted to it. However, the uses of gul and consumption of the combination of zarda and gul were found to be more common among women than men.
Influencing Factors That Initiate Consumption of SLT The study results identified five most important influencing factors of SLT initiation and those are as follows: 1. Initiation during the process of quitting smoking: It is revealed from the FGDs that the most significant factor of initiation SLT was during the quitting process of smoking. Usually, smokers preferred SLT products instead of cigarettes during the quitting process. They often started to chew betel leaf with zarda in replacing the quitting process of smoking cigarettes. Some smokers started consuming gul during this time, although gul is known to produce severe addiction. A school teacher stated: ‘‘My father gave up smoking and started chewing betel leaf with zarda immediately. A few days afterwards, he started taking gul and shadapata with betel leaf, along with zarda.’’ 2. Initiation out of curiosity: Out of curiosity found another important factor of initiating STL. Some people started SLT use at a very young age, out of curiosity. Usually they started after being offered SLT by their friends and gradually became addicted. One participant who is a school teacher said ‘‘I found that many students from schools and colleges start it by the peer influence, and gradually become addicted. Initially, they might have had curiosities about how the smokeless tobacco products taste.’’
3 On the other hand, few informants mentioned that betel leaf alone was tasty to eat. To make it more delicious, zarda had to be added to it and then betel leaf with zarda consumption gradually increased the severity of their addictions. Sometimes SLT betel-nut sellers became annoyed with customers’ demands for much more zarda with a betel khili (betel leaf rolled into a cone). One shopkeeper said ‘‘If the quantity of zarda in a betel ‘Khili’ deemed less than the demand, the customers became angry.’’ 3. Initiation by accepting offers from an elderly person: Accepting offer from elderly person identified another important SLT initiation factor. Elderly women in the family influenced young people to use SLT by offering betel leaf with zarda, shadapata, and so on, during conversations. One study participant mentioned that young people started to take zarda and gul because they were influenced by the social environment and gradually became addicted. Smoking cigarette by the young people is not socially accepted but use of SLT does not have such social barrier in Bangladesh. One participant gave an example as: ‘‘If any person or even a young person chews smokeless tobacco in front of others, it does not look odd; but, if that person smokes a cigarette in front of others, it looks odd and is unacceptable as well.’’ Some elderly advised the pregnant women to chew betel leaf with zarda or shadapata to avoid nausea. Even taking advice from others, some people used gul for relief from a toothache and gradually became addicted to it. 4. Initiation through the traditions of hospitality: Traditionally, betel leaf is widely used as a symbol of hospitality in various social (engagements and wedding ceremonies), cultural, and religious events in Bangladesh. The majority of the informants opined that visiting neighbors, relatives, or friends were offered betel leaf with zarda by the host as a gesture to show respect to the guest. One respondent said ‘‘People love to offer betel leaf with zarda to their guests and visitors as a sign of hospitality; but no one offers a cigarette for smoking to their relatives or neighbors during their visits.’’ Betel leaf with zarda is a tradition of hospitality in most social event in Bangladesh such as wedding. Even if a young child consumes SLT openly, it is not viewed as an offensive act due to the existing cultural norms. 5. Initiation of SLT to avoid nausea during pregnancy: It is revealed from the discussion that many women started using SLT to avoid vomiting tendency during pregnancy period, especially at the first trimester. It is also revealed from the discussion that many women started taking SLT during their pregnancies by the influence of elderly family members. A women participant shared her initiation factor of SLT use ‘‘I had frequent vomiting tendency during the first trimester of my first pregnancy, my grandmother influenced me to use SLT (pan with Zarda) to get rid of this and
4
International Quarterly of Community Health Education 0(0) I started using SLT from that time.’’ Some informants mentioned that women with no formal education use more SLT during pregnancy. Regarding the perceived risks, many informants reported that SLT use increased the risk of bearing low birth weight babies and miscarriage. One of the informants stated, ‘‘In our cultural context, zarda, gul were used widely by the pregnant women to take away from nausea in that stage though many pregnant women aware about the risk of those SLT.’’ So many women started using SLT products during pregnancies became addicted eventually.
Knowledge of Health Effects of SLT Use When informants were asked about their knowledge of the health risks of SLT use, the majority of them mentioned numerous risks such as oral cancer, tooth decay, cardiovascular diseases, tongue infections, mouth infections, vision loss, mouth ulcer, and so on. They emphasized that though zarda and gul are more flavorful, they contain nicotine and addictive substances, which increase health risks that are similar to smoking. The majority of the informants again mentioned that use of SLT had no health benefits and caused huge economic losses as large amounts of money is spent on purchasing SLT products and then treatment costs for the associated health problems. A SLT business man stated: My wife has suffered from a stroke once and is paralyzed and lost her ability to walk properly but she is still using smokeless tobacco. I have tried my level best to stop by informing all health risks involved with SLT, but it was in vain.
SLT Business and Shifting Paradigm The participanting SLT sellers were asked if they are requested by community members to shift from selling SLT to other business or whether they will change their occupation. Most of them replied that they would be willing to do so, if they received adequate support from the local community leaders to establish their alternative businesses. All the SLT sellers participating in the discussions were found to be aware of the harmful health effects of SLT products. Some of the informants opined that if they were required to give up the business due to government policies, the government should take the responsibility to rehabilitee them through business opportunities. One of the respondents claimed: ‘‘To reduce the number of smokeless tobacco users we have to make the community people aware of the health hazards and bad effects of the chewing betel quid with tobacco.’’ Another participant said ‘‘Discouraging the production of tobacco can reduce the number of smokeless tobacco users effectively.’’
Community Base Informant’s Perception on SLT It is revealed from the FGDs that most of the community members were aware about the health hazard of using SLT and they also had positive perception to reduce the use of SLT at community level. The informants have provided the following suggestions to reduce the number of SLT users in their localities: . The informants suggested that people should be informed about the adverse health effects of SLT use. If people understand the hazards of tobacco use and its risks that lead to nicotine addiction, oral cancer, gum diseases and increased the risk of cardiovascular disease, they must change their habits. Proper information about the risks of SLT can help to discourage its use. . Initiatives can be taken by the local youth to make their localities SLT free zones, with the support of advocacy groups or nongovernmental organizations operating in the areas. Arranging group meetings, distributing posters, and hosting banners and billboards can be used for alerting people in the community. Religious leaders (Imam) of the local mosque can play an important role to reduce the number of SLT users and they can highlight the serious health effects of SLT use during Jummah-prayers. . The informants emphasized that the government should introduce better policies to control use of SLT products, which would raise public awareness regarding the adverse health effects of SLT use through mass media campaigns. Betel leaf sellers or shop owners should be brought under a registration system. The license or registration will be canceled, and a penalty will be imposed if they sell any form of tobacco (zarda, gul, shadapata, etc.) products. One participant said ‘‘Like alcohol sellers, SLT sellers should have registrations or licenses; and some necessary laws should be introduced restricting them from selling such harmful SLT products.’’ . The informants again pointed out that there should be special advertisements in the printed and electronic media against SLT use. The media should frequently advertise the severe health effects of SLT use at peak hours when everybody will be watching. Doctors should particularly advise pregnant women coming for antenatal checkups not to use any form of tobacco including SLT.
Discussion The study informants were mostly young comprises men and women from different background, particularly from low SE groups and various levels of education. SLT consumers were found to be more common in the study area as it is less costly and easily accessible compared with smoking tobacco. Studies identified that a larger proportion of women from low SE backgrounds use SLT compared with men; and
Shahjahan et al. rural areas have a higher prevalence of SLT use compared with urban areas.18 Consumption of SLT in the study area appeared to be more widespread than in others parts of Bangladesh.19 The study also explored some features of SLT business and the overall views of informants on how to reduce SLT practice. According to the informants’ opinion, most of the people with low-income communities had some awareness but were not fully aware of about the adverse effects of use of SLT. Nowadays, consumption of raw tobacco leaf (sadapata) is being gradually replaced by various flavored ingredients of SLT, which are readily available and attracting more consumers. From the discussion sessions, it was also revealed that many of these informants including those who are selling SLT products perceived the adverse effects of SLT consumption. Development of community-based organizations with mobilization programs as well as advocacy programs with the aim of raising awareness of people on the adverse effects of using SLT. Strategic campaigns through tobacco control programs should be increased against all kinds of SLT use by involving community leaders, young people, and women volunteers. The government should formulate better policies to control the use of SLT products and to raise public awareness through mass media campaigns on its adverse health effects. It is again documented from the discussion that the most important influencing factors of SLT initiation were the process of quitting smoking, curiosity, offers from elderly persons, traditional hospitality, and to avoid nausea during pregnancy. The majority of informants agreed that visiting neighbors, relatives, or friends were offered betel leaf with zarda by the host, as a gesture to show respect to the guest. Most of the informants illustrated that SLT is easily available, cheap, and still viewed as socially acceptable as chewing betel quid with sliced betel nut, and dried tobacco leaf is considered a normal social behavior. The aforementioned SLT initiation pattern is comparable with other study results. Like other South Asian countries, the traditional values of Bangladesh do not widely permit women and young people to smoke cigarettes openly20 but SLT is an exception. Besides, it is considered a symbol of hospitality in the study areas. This was also similar in a study in Kerala (India) which reported that offering raw tobacco to the children was a part of their culture of hospitality.21 With regard to the health effects of SLT use, the majority of informants opined that SLT users faced numerous health risks. They further mentioned that SLT, especially zarda and gul, contains nicotine, an addictive substance and its use carries health risks that are similar to smoking. The government should impose high taxes on mentioned tobacco products to rein in the soaring rate of consumption. Many of the study informants perceived health risks of SLT among women, and majority of the informants viewed that the use of SLT during pregnancies increased the risk of bearing low birth weight babies and is also a major cause of premature death. A study from India documented similar information with
5 increases in stillbirth and 100 to 400 g decrease in birth weights in offspring of women who applied or chewed tobacco during pregnancy.22 When women informants visiting medical doctors for antenatal checkups, health practitioners should specifically advise not to use any forms of tobacco, including SLT during pregnancy. Finally, a majority of FGD informants mentioned that the use of SLT had no health benefits and caused huge economic losses in the forms of money spent on buying SLT products, as well as treatment costs for the associated health problems. In response to shifting SLT to other businesses among the product sellers, the many of the SLT sellers would be willing to do so, if they get adequate support from the community to establish their new businesses. It is recommended that incentives system should be given to the tobacco farmers to encourage them to leave tobacco farming and switch to alternatives, such as cash-crop farming.
Conclusion The identified key influencing factors of tobacco incitation suggest that people are not very much aware of the negative health impact of using SLT. People of any age can easily purchase all smokeless products and use SLT. So advocacy campaigns to strengthen and enforce policies restricting SLT needed. Policies to raise awareness of these interventions and increase the accessibility of cessation counseling with behavior therapy are still needed to reduce the use of SLT in Bangladesh. The study revealed that consuming betel leaf with Zarda was found to be common form of tobacco addiction among low SE population. Considering the public health consequences of SLT in Bangladesh, the amended act has addressed SLT adequately. Acknowledgments The authors are grateful to FGDs informants for their active participant and discussion in the study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Bangladesh Center for Communication which was collaborative research grant from Johns Hopkins Bloomberg School of Public Health, Institute for Global Tobacco Control.
References 1. Peto R, Boreham J, Lopez AD, et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 339: 1268–1278.
6 2. Murray CJ and Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet 1997; 349: 1498–1504. 3. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31: 3–24. 4. Gupta PC and Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003; 8: 419–431. 5. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization, 2009. 6. Benowitz NL. Nicotine replacement therapy during pregnancy. JAMA 1991; 266: 3174–3177. 7. Rodu B and Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants. Crit Rev Oral Biol Med 2004; 15: 252–263. 8. Gupta P and Ray C. Epidemiology of betel quid usage. Ann Acad Med Singapore 2004; 33: 31–36. 9. Thankappan K and Thresia C. Tobacco use & social status in Kerala. Indian J Med Res 2007; 126: 300. 10. World Health Organization. Noncommunicable diseases country profiles 2011. Geneva: World Health Organization, 2013. 11. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet 2006; 368: 647–658. 12. Zaman MM, Bhuiyan MR, Karim MN, et al. Clustering of noncommunicable diseases risk factors in Bangladeshi adults: an analysis of STEPS survey 2013. BMC Public Health 2015; 15: 1. 13. Richardson K. Smoking, low income and health inequalities: thematic discussion document. Atlanta: ASH, 2001. 14. Gilani SI and Leon DA. Prevalence and sociodemographic determinants of tobacco use among adults in Pakistan: findings of a nationwide survey conducted in 2012. Popul Health Metr 2013; 11: 1. 15. Sinha DN, Palipudi KM, Rolle I, et al. Tobacco use among youth and adults in member countries of South-East Asia region: review of findings from surveys under the Global Tobacco Surveillance System. Indian J Public Health 2011; 55: 169. 16. Islam N. Challenges and opportunities for tobacco control in Islamic countries. In: Slama K (ed.) Tobacco and health. Boston: Springer, 1995, pp.177–180. 17. Flora MS, Mascie-Taylor C and Rahman M. Gender and locality differences in tobacco prevalence among adult Bangladeshis. Tob Control 2009; 18: 445–450. 18. Sarker MAB, Rahman M, Harun-Or-Rashid M, et al. Association of smoked and smokeless tobacco use with migraine: a hospital-based case-control study in Dhaka, Bangladesh. Tob Induc Dis 2013; 11: 1. 19. King BA, Mirza SA and Babb SD. A cross-country comparison of secondhand smoke exposure among adults: findings from the Global Adult Tobacco Survey (GATS). Tobacco Control, http:// dx.doi.org/10.1136/tobaccocontrol-2012-050582 (2012, accessed 26 September 2017). 20. Bush J, White M, Kai J, et al. Understanding influences on smoking in Bangladeshi and Pakistani adults: community based, qualitative study. BMJ 2003; 326: 962. 21. Bhonsle RB, Murti PR and Gupta PC. Tobacco habits in India. In: Gupta PC, Hamner JE III and Murti PR (eds.) Control of
International Quarterly of Community Health Education 0(0) Tobacco-related Cancers and Other Diseases. Bombay: Oxford University Press, 1992, pp.25–46. 22. Rogers JM. Tobacco and pregnancy. Reprod Toxicol 2009; 28: 152–160.
Author Biographies Md. Shahjahan is an associate professor of the Department of Public Health at Daffodil International University, Bangladesh, who has long experience on teaching, planning, and coordinating training courses on biostatistics, research methodology and epidemiology at graduate and post graduate institutes. He has been also conducting research activities covering the issues of public health, population, reproductive health and family planning along with reviewing Project proposals, monitoring and evaluation of research activities. He performed many key responsibilities in different organizations in various capacities and gained substantial knowledge on classroom teaching and supervising student’s dissertation. Md. Golam Dostogir Harun is currently project research manager at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) also assistant professor (part time) at the Department of Public Health, Daffodil International University, Bangladesh. Dostogir Harun is social graduate from Dhaka university, also completed his Master degree in Women and Gender Study from Dhaka university and Master of Public Health in Epidemiology from Dhaka University and Daffodil International University respectively. Dostogir Harun published numbers of article on public health issues in the peer reviewed journals, he also presented more than 20 papers on public health issues in the international seminar and conferences. A. B. M. Alauddin Chowdhury is currently working as an assistant professor in the Department of Public Health at Daffodil International University, Bangladesh. He accomplished PhD degree from the Department of Global Health and Epidemiology under Social Medicine Cluster at Hokkaido University, Japan. He was research fellow in the Department of Health for Senior Citizens at the same university of Japan. Dr Chowdhury is involved with researches in the area of public health, sociology, psychology, anthropology, etc. He is also serving as associate manager in the Editorial Board of the DIUJAHS journal. Kapil Ahmed with the basic training in Statistics (B.Sc. & M.Sc.) and advance degree (PhD) in Demography, Dr. Md. Kapil Ahmed have several years of working experiences with the capacity of demographer/statistician, monitoring and evaluation specialist, Population/Public Health researcher and data analyst in Bangladesh and United Kingdom. He has also been regular exposed to remote works (Consultancy) in European, Asian and African Countries with responsibilities
Shahjahan et al. of methodological support for implementing formative, baseline, midterm, and end-line, as well as impact evaluation. More specifically, designing sampling strategy, development of survey questionnaire/topic guides, personal capacity building by distance learning on Program/Project Monitoring & Evaluation, Data Analyses using advance software and Report Writing. Hafiz T. A. Khan is professor of Public Health at University of West London and is also an associated research fellow at
7 the Oxford Institute of Population Ageing, University of Oxford in the United Kingdom. He trained as health statistician and developed his academic career in the area of public health over the last 25 years. His current research interests include healthy ageing, co-morbidity in later life, long-term care and support provisions for elderly. He has published important articles in health and population related issues. He has co-authored two books ‘‘Research Methods for Business and Social Science’’, Sage, 2007 & 2014.
Factors Influencing the Initiation of Smokeless Tobacco Consumption Among Low Socioeconomic Community in Bangladesh: A Qualitative Investigation
International Quarterly of Community Health Education 0(0) 1–7 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X17736244 journals.sagepub.com/home/qch
Md. Shahjahan1, Md. Golam Dostogir Harun1, A. B. M. Alauddin Chowdhury1, Kapil Ahmed2, and Hafiz T. A. Khan3
Abstract This study explored factors influencing the initiation of smokeless tobacco (SLT) consumption in a low socioeconomic urban community in Bangladesh. The study conducted four focus group discussions among 33 informants involves school teachers, community leaders, women, and betel-nut shops owners. The results were prepared by thematic analysis of the transcripts where informants mean age was 30 (SD 6.8) years with varying level of education. Tradition of hospitality, curiosity, offer from an elderly person, and avoiding nausea during pregnancy and at time of quitting smoking were key factors for the initiation of SLT consumption. The results also revealed most people were aware about the danger of SLT consumption but, in practice, consumed frequently. The research suggested that doctors might advise people not to use any form of SLT while they seeking health services. Furthermore, communitybased awareness program could minimize the wider use of SLT among low-income community in Bangladesh. Keywords smokeless tobacco, low socioeconomic community, focus group discussion, Bangladesh
Background Tobacco use is the leading cause of preventable deaths. It was revealed in the study that tobacco kills one person every 6 seconds and nearly six million people die in a year due to tobacco-related illness.1 Tobacco consumption is estimated to cause about 71% of all lung cancer deaths, 42% of chronic respiratory disease, and nearly 10% of cardiovascular disease.2 The use of smokeless tobacco (SLT) is a major health issue in the South Asian region.3 It is estimated that over 80% of the world’s SLT users live in the Southeast Asia.4 Over one third of tobacco consumed in these countries is smokeless. The use of SLT has been an emerging public health concern over the last few decades. SLT use in South Asia is believed to be a significant contributor to morbidity and mortality.4 SLT use is the leading preventable cause of premature death and disease worldwide, and its impact is even more pronounced in low- and middle-income countries.5 Increasing use of SLT has been reported not only among men but also among vulnerable groups, such as children, teenagers, and women of reproductive age. SLT increases the risk of premature birth and low birth weight.6 The major effects of SLT are also seen in the oral cavity, pharynx, and esophagus, which together account for a large proportion of tobacco-related cancers.7 Chewing of betel quid with tobacco is commonly practiced by both men and women in Bangladesh, India, Pakistan, and
Sri Lanka.8 It is more prevalent among people from lower socioeconomic (SE) groups in these countries. A study in Kerala, India, identified that tobacco use (in both form) is significantly more among the low SE groups compared with the high SE group.9 SLT is consumed predominantly by chewing in the form of pan (piper betel leaf filled with sliced areca nut, lime, catechu, and other spices chewed with or without tobacco), pan-masala or gutkha (a chewable tobacco containing areca nut), and mishri (a powdered tobacco rubbed on the gums as toothpaste). The use of SLT is also common in Bangladesh.8 World Health Organization country profiles report on tobacco consumption identified that overall consumption of SLT was 27.2% in Bangladesh.10 A vast number of adult males and females consume tobacco in one form or another.8 A multicountry study has shown a high prevalence of both smoking as well as use of SLT for Bangladesh,11 which has become a
1
Department of Public Health, Daffodil International University, Dhaka, Bangladesh 2 Bow Business Center, Agroni Research, London, UK 3 Department of Criminology and Sociology, Middlesex University, London, UK Corresponding Author: Md. Shahjahan, Department of Public Health, Daffodil International University, Dhaka 1207, Bangladesh. Email: [email protected]
2 major contributor to the country’s high morbidity rates. A study conducted in Bangladeshi revealed that use SLT with betel quid which is responsible for variety of diseases such as heart diseases, stroke, oral cancer, and so on.12 The distribution of tobacco consumption is disproportionately higher in the lower SE groups especially among the unemployed, semiskilled laborers, or those engaged in manual labor and among the less educate.13 Similarly, some results have also shown that SLT use is highest in industrial areas.14 A clear pattern was observed with respect to SLT use in Bangladesh where the prevalence decreased as education and SE status increased.15 Another study showed that an estimated 20% to 30% of women in rural areas of Bangladesh use SLT.16 There have been few studies conducted which identify the factors associated with SLT use among lower SE groups in industrial areas of Bangladesh. The country’s traditional values do not permit women to smoke, but there is no such taboo against use of SLT.17 A study conducted in Bangladesh indicated that prevalence of both smoking (cigarette, bidi, etc.) and SLT (zarda, gul, pan-masala, etc.) use is high in men.12 This qualitative research explored factors influencing the initiation of SLT consumption among these groups in an urban context.
Materials and Methods The Study Site The study conducted during February to November 2015 in Demra and Tongi industrial areas, adjacent to Dhaka metropolitan city of Bangladesh. The study selected these sites as of industrials and easy approachable areas with typical urban low-income community. Usually in the industrial areas, lowincome people live and supposed to use SLT more frequently than others.14
Participant Selection This study selected the informants purposively from two study sites. An equal number of informants participated from each study area, and a total of 33 informants were participated in the four focus group discussion (FGD) sessions with at least eight informants in each discussion session. Respondents were composed of different groups including school teachers, community leaders, women representatives, as well as owners of betel-nut shops. Both users and nonusers of SLT attended the FGD sessions.
Qualitative Tools and Data Collection The study employed FGDs to explore the influencing factors for initiation of SLT consumption including documentation of community’s perceptions, reported practices, and social norms related to consumption of SLT. Developed FGD guideline was pretested in the field and finalized before
International Quarterly of Community Health Education 0(0) conducting the sessions. A multidisciplinary team including public health specialists, social scientists, and statisticians were involved in developing the qualitative guideline in focusing the study objectives. Each discussion was happened within 90 to 120 minutes duration. The study used an guideline that started by asking people to list all of the SLTs they could consumed or observed to consume by the community people and the influencing factors of initiation of SLT consumption among low-income community. The investigators also asked about their perception on use of SLT, how people influenced to use it, knowledge of health hazard, existing social norms, current practices related to initiation of SLTs, and for suggestions of how to reduce SLT consumption in low-income community.
Data Analysis All FGDs were recorded and then translated into English. The team manually processed the information according to research objectives. The investigators have done thematic content analysis in order to provide a descriptive result. This analysis was done for each FGD separately and presented all together in the findings for reporting.
Ethical Considerations Institutional ethical clearance procedures were followed, and particular attention was addressed to the issue of informed consent, anonymity during presenting information, and confidentiality. Before starting the discussion sessions, researchers clearly explained the study objectives to the informants along with collecting their written informed consent. The study protocol was reviewed and approved by the National Ethics Review Committee of Bangladesh Medical Research Council.
Results SE Characteristics Among the informants from four FGD sessions, three quarters (25, 76%) were male and about one quarter (8, 24%) were female. The mean age of the informants was 30 years with a standard deviation of 6.8 years. About half were school or madrasah teachers, and the rest were SLT sellers, religious, and community leaders. The respondents had different levels of education: One tenth had primary education while those who were either teachers or women representatives had a higher educational background. The median monthly family income of the informants was Bangladeshi Taka 39,125.
SLT Use and Related Perceptions Consuming betel leaf with zarda was found to be a common form of tobacco addiction in the study area. In addition,
Shahjahan et al. shadapata, gul, and nossi were consumed as other forms of SLT. One of the SLT users said ‘‘Smokeless tobacco is less costly and easily accessible compared to cigarette which is more costly.’’ On the other hand, many of them perceived the harmful effects of SLT as one respondent said ‘‘We chew the tobacco directly, so, it is more harmful than smoking cigarette. Our appearance showed our weakness.’’ From the discussions, it was further revealed that of those who are selling SLT products, most perceived the adverse health effects of SLT use. An informant opined: ‘‘Gul and zarda are very harmful for health. Chewing SLT is more dangerous than smoking cigarette.’’ The informants claimed that peoples’ consumption of shadapata (raw tobacco leaf) is decreasing as zardas of various flavors were readily available and attracting more consumers. According to the informants, women consumed zarda more than men, although they may not be aware that zarda is raw form of tobacco. One female respondent said ‘‘My grandmother who has been using smokeless tobacco for a long time can live without food but cannot live without smokeless tobacco.’’ Some informants mentioned that gul is relatively cheaper and more available than other addictive substances. People find it is convenient to use gul for intoxication and become addicted to it. However, the uses of gul and consumption of the combination of zarda and gul were found to be more common among women than men.
Influencing Factors That Initiate Consumption of SLT The study results identified five most important influencing factors of SLT initiation and those are as follows: 1. Initiation during the process of quitting smoking: It is revealed from the FGDs that the most significant factor of initiation SLT was during the quitting process of smoking. Usually, smokers preferred SLT products instead of cigarettes during the quitting process. They often started to chew betel leaf with zarda in replacing the quitting process of smoking cigarettes. Some smokers started consuming gul during this time, although gul is known to produce severe addiction. A school teacher stated: ‘‘My father gave up smoking and started chewing betel leaf with zarda immediately. A few days afterwards, he started taking gul and shadapata with betel leaf, along with zarda.’’ 2. Initiation out of curiosity: Out of curiosity found another important factor of initiating STL. Some people started SLT use at a very young age, out of curiosity. Usually they started after being offered SLT by their friends and gradually became addicted. One participant who is a school teacher said ‘‘I found that many students from schools and colleges start it by the peer influence, and gradually become addicted. Initially, they might have had curiosities about how the smokeless tobacco products taste.’’
3 On the other hand, few informants mentioned that betel leaf alone was tasty to eat. To make it more delicious, zarda had to be added to it and then betel leaf with zarda consumption gradually increased the severity of their addictions. Sometimes SLT betel-nut sellers became annoyed with customers’ demands for much more zarda with a betel khili (betel leaf rolled into a cone). One shopkeeper said ‘‘If the quantity of zarda in a betel ‘Khili’ deemed less than the demand, the customers became angry.’’ 3. Initiation by accepting offers from an elderly person: Accepting offer from elderly person identified another important SLT initiation factor. Elderly women in the family influenced young people to use SLT by offering betel leaf with zarda, shadapata, and so on, during conversations. One study participant mentioned that young people started to take zarda and gul because they were influenced by the social environment and gradually became addicted. Smoking cigarette by the young people is not socially accepted but use of SLT does not have such social barrier in Bangladesh. One participant gave an example as: ‘‘If any person or even a young person chews smokeless tobacco in front of others, it does not look odd; but, if that person smokes a cigarette in front of others, it looks odd and is unacceptable as well.’’ Some elderly advised the pregnant women to chew betel leaf with zarda or shadapata to avoid nausea. Even taking advice from others, some people used gul for relief from a toothache and gradually became addicted to it. 4. Initiation through the traditions of hospitality: Traditionally, betel leaf is widely used as a symbol of hospitality in various social (engagements and wedding ceremonies), cultural, and religious events in Bangladesh. The majority of the informants opined that visiting neighbors, relatives, or friends were offered betel leaf with zarda by the host as a gesture to show respect to the guest. One respondent said ‘‘People love to offer betel leaf with zarda to their guests and visitors as a sign of hospitality; but no one offers a cigarette for smoking to their relatives or neighbors during their visits.’’ Betel leaf with zarda is a tradition of hospitality in most social event in Bangladesh such as wedding. Even if a young child consumes SLT openly, it is not viewed as an offensive act due to the existing cultural norms. 5. Initiation of SLT to avoid nausea during pregnancy: It is revealed from the discussion that many women started using SLT to avoid vomiting tendency during pregnancy period, especially at the first trimester. It is also revealed from the discussion that many women started taking SLT during their pregnancies by the influence of elderly family members. A women participant shared her initiation factor of SLT use ‘‘I had frequent vomiting tendency during the first trimester of my first pregnancy, my grandmother influenced me to use SLT (pan with Zarda) to get rid of this and
4
International Quarterly of Community Health Education 0(0) I started using SLT from that time.’’ Some informants mentioned that women with no formal education use more SLT during pregnancy. Regarding the perceived risks, many informants reported that SLT use increased the risk of bearing low birth weight babies and miscarriage. One of the informants stated, ‘‘In our cultural context, zarda, gul were used widely by the pregnant women to take away from nausea in that stage though many pregnant women aware about the risk of those SLT.’’ So many women started using SLT products during pregnancies became addicted eventually.
Knowledge of Health Effects of SLT Use When informants were asked about their knowledge of the health risks of SLT use, the majority of them mentioned numerous risks such as oral cancer, tooth decay, cardiovascular diseases, tongue infections, mouth infections, vision loss, mouth ulcer, and so on. They emphasized that though zarda and gul are more flavorful, they contain nicotine and addictive substances, which increase health risks that are similar to smoking. The majority of the informants again mentioned that use of SLT had no health benefits and caused huge economic losses as large amounts of money is spent on purchasing SLT products and then treatment costs for the associated health problems. A SLT business man stated: My wife has suffered from a stroke once and is paralyzed and lost her ability to walk properly but she is still using smokeless tobacco. I have tried my level best to stop by informing all health risks involved with SLT, but it was in vain.
SLT Business and Shifting Paradigm The participanting SLT sellers were asked if they are requested by community members to shift from selling SLT to other business or whether they will change their occupation. Most of them replied that they would be willing to do so, if they received adequate support from the local community leaders to establish their alternative businesses. All the SLT sellers participating in the discussions were found to be aware of the harmful health effects of SLT products. Some of the informants opined that if they were required to give up the business due to government policies, the government should take the responsibility to rehabilitee them through business opportunities. One of the respondents claimed: ‘‘To reduce the number of smokeless tobacco users we have to make the community people aware of the health hazards and bad effects of the chewing betel quid with tobacco.’’ Another participant said ‘‘Discouraging the production of tobacco can reduce the number of smokeless tobacco users effectively.’’
Community Base Informant’s Perception on SLT It is revealed from the FGDs that most of the community members were aware about the health hazard of using SLT and they also had positive perception to reduce the use of SLT at community level. The informants have provided the following suggestions to reduce the number of SLT users in their localities: . The informants suggested that people should be informed about the adverse health effects of SLT use. If people understand the hazards of tobacco use and its risks that lead to nicotine addiction, oral cancer, gum diseases and increased the risk of cardiovascular disease, they must change their habits. Proper information about the risks of SLT can help to discourage its use. . Initiatives can be taken by the local youth to make their localities SLT free zones, with the support of advocacy groups or nongovernmental organizations operating in the areas. Arranging group meetings, distributing posters, and hosting banners and billboards can be used for alerting people in the community. Religious leaders (Imam) of the local mosque can play an important role to reduce the number of SLT users and they can highlight the serious health effects of SLT use during Jummah-prayers. . The informants emphasized that the government should introduce better policies to control use of SLT products, which would raise public awareness regarding the adverse health effects of SLT use through mass media campaigns. Betel leaf sellers or shop owners should be brought under a registration system. The license or registration will be canceled, and a penalty will be imposed if they sell any form of tobacco (zarda, gul, shadapata, etc.) products. One participant said ‘‘Like alcohol sellers, SLT sellers should have registrations or licenses; and some necessary laws should be introduced restricting them from selling such harmful SLT products.’’ . The informants again pointed out that there should be special advertisements in the printed and electronic media against SLT use. The media should frequently advertise the severe health effects of SLT use at peak hours when everybody will be watching. Doctors should particularly advise pregnant women coming for antenatal checkups not to use any form of tobacco including SLT.
Discussion The study informants were mostly young comprises men and women from different background, particularly from low SE groups and various levels of education. SLT consumers were found to be more common in the study area as it is less costly and easily accessible compared with smoking tobacco. Studies identified that a larger proportion of women from low SE backgrounds use SLT compared with men; and
Shahjahan et al. rural areas have a higher prevalence of SLT use compared with urban areas.18 Consumption of SLT in the study area appeared to be more widespread than in others parts of Bangladesh.19 The study also explored some features of SLT business and the overall views of informants on how to reduce SLT practice. According to the informants’ opinion, most of the people with low-income communities had some awareness but were not fully aware of about the adverse effects of use of SLT. Nowadays, consumption of raw tobacco leaf (sadapata) is being gradually replaced by various flavored ingredients of SLT, which are readily available and attracting more consumers. From the discussion sessions, it was also revealed that many of these informants including those who are selling SLT products perceived the adverse effects of SLT consumption. Development of community-based organizations with mobilization programs as well as advocacy programs with the aim of raising awareness of people on the adverse effects of using SLT. Strategic campaigns through tobacco control programs should be increased against all kinds of SLT use by involving community leaders, young people, and women volunteers. The government should formulate better policies to control the use of SLT products and to raise public awareness through mass media campaigns on its adverse health effects. It is again documented from the discussion that the most important influencing factors of SLT initiation were the process of quitting smoking, curiosity, offers from elderly persons, traditional hospitality, and to avoid nausea during pregnancy. The majority of informants agreed that visiting neighbors, relatives, or friends were offered betel leaf with zarda by the host, as a gesture to show respect to the guest. Most of the informants illustrated that SLT is easily available, cheap, and still viewed as socially acceptable as chewing betel quid with sliced betel nut, and dried tobacco leaf is considered a normal social behavior. The aforementioned SLT initiation pattern is comparable with other study results. Like other South Asian countries, the traditional values of Bangladesh do not widely permit women and young people to smoke cigarettes openly20 but SLT is an exception. Besides, it is considered a symbol of hospitality in the study areas. This was also similar in a study in Kerala (India) which reported that offering raw tobacco to the children was a part of their culture of hospitality.21 With regard to the health effects of SLT use, the majority of informants opined that SLT users faced numerous health risks. They further mentioned that SLT, especially zarda and gul, contains nicotine, an addictive substance and its use carries health risks that are similar to smoking. The government should impose high taxes on mentioned tobacco products to rein in the soaring rate of consumption. Many of the study informants perceived health risks of SLT among women, and majority of the informants viewed that the use of SLT during pregnancies increased the risk of bearing low birth weight babies and is also a major cause of premature death. A study from India documented similar information with
5 increases in stillbirth and 100 to 400 g decrease in birth weights in offspring of women who applied or chewed tobacco during pregnancy.22 When women informants visiting medical doctors for antenatal checkups, health practitioners should specifically advise not to use any forms of tobacco, including SLT during pregnancy. Finally, a majority of FGD informants mentioned that the use of SLT had no health benefits and caused huge economic losses in the forms of money spent on buying SLT products, as well as treatment costs for the associated health problems. In response to shifting SLT to other businesses among the product sellers, the many of the SLT sellers would be willing to do so, if they get adequate support from the community to establish their new businesses. It is recommended that incentives system should be given to the tobacco farmers to encourage them to leave tobacco farming and switch to alternatives, such as cash-crop farming.
Conclusion The identified key influencing factors of tobacco incitation suggest that people are not very much aware of the negative health impact of using SLT. People of any age can easily purchase all smokeless products and use SLT. So advocacy campaigns to strengthen and enforce policies restricting SLT needed. Policies to raise awareness of these interventions and increase the accessibility of cessation counseling with behavior therapy are still needed to reduce the use of SLT in Bangladesh. The study revealed that consuming betel leaf with Zarda was found to be common form of tobacco addiction among low SE population. Considering the public health consequences of SLT in Bangladesh, the amended act has addressed SLT adequately. Acknowledgments The authors are grateful to FGDs informants for their active participant and discussion in the study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Bangladesh Center for Communication which was collaborative research grant from Johns Hopkins Bloomberg School of Public Health, Institute for Global Tobacco Control.
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Author Biographies Md. Shahjahan is an associate professor of the Department of Public Health at Daffodil International University, Bangladesh, who has long experience on teaching, planning, and coordinating training courses on biostatistics, research methodology and epidemiology at graduate and post graduate institutes. He has been also conducting research activities covering the issues of public health, population, reproductive health and family planning along with reviewing Project proposals, monitoring and evaluation of research activities. He performed many key responsibilities in different organizations in various capacities and gained substantial knowledge on classroom teaching and supervising student’s dissertation. Md. Golam Dostogir Harun is currently project research manager at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) also assistant professor (part time) at the Department of Public Health, Daffodil International University, Bangladesh. Dostogir Harun is social graduate from Dhaka university, also completed his Master degree in Women and Gender Study from Dhaka university and Master of Public Health in Epidemiology from Dhaka University and Daffodil International University respectively. Dostogir Harun published numbers of article on public health issues in the peer reviewed journals, he also presented more than 20 papers on public health issues in the international seminar and conferences. A. B. M. Alauddin Chowdhury is currently working as an assistant professor in the Department of Public Health at Daffodil International University, Bangladesh. He accomplished PhD degree from the Department of Global Health and Epidemiology under Social Medicine Cluster at Hokkaido University, Japan. He was research fellow in the Department of Health for Senior Citizens at the same university of Japan. Dr Chowdhury is involved with researches in the area of public health, sociology, psychology, anthropology, etc. He is also serving as associate manager in the Editorial Board of the DIUJAHS journal. Kapil Ahmed with the basic training in Statistics (B.Sc. & M.Sc.) and advance degree (PhD) in Demography, Dr. Md. Kapil Ahmed have several years of working experiences with the capacity of demographer/statistician, monitoring and evaluation specialist, Population/Public Health researcher and data analyst in Bangladesh and United Kingdom. He has also been regular exposed to remote works (Consultancy) in European, Asian and African Countries with responsibilities
Shahjahan et al. of methodological support for implementing formative, baseline, midterm, and end-line, as well as impact evaluation. More specifically, designing sampling strategy, development of survey questionnaire/topic guides, personal capacity building by distance learning on Program/Project Monitoring & Evaluation, Data Analyses using advance software and Report Writing. Hafiz T. A. Khan is professor of Public Health at University of West London and is also an associated research fellow at
7 the Oxford Institute of Population Ageing, University of Oxford in the United Kingdom. He trained as health statistician and developed his academic career in the area of public health over the last 25 years. His current research interests include healthy ageing, co-morbidity in later life, long-term care and support provisions for elderly. He has published important articles in health and population related issues. He has co-authored two books ‘‘Research Methods for Business and Social Science’’, Sage, 2007 & 2014.
