Abstract
Despite scientific evidence about the harmful effects of smokeless tobacco (SLT), it is widely used in Bangladesh. This study explored perceptions about health effects of SLT use. Semistructured interviews were conducted with 1812 nonsmoking adults. About 40% of the participants were current SLT users or had used SLT in the past. Family members’ influence was the main factor for initiation. The participants believed that people continued using SLT because of addiction (52%) and as a part of their lifestyle (23%). The majority of participants (77%) did not mention any benefit, but SLT users considered it to be a remedy for toothache (P < .05). Almost all participants mentioned that SLT was harmful and causes heart disease, cancer, and tuberculosis. Doctors’ advice was the common motivating factor to quit. Health promotion interventions should highlight the adverse effects of SLT use, which outweigh the perceived benefits, and should consider addressing the role of family in SLT initiation and use.
Keywords
Introduction
Chewing betel leaf, known as paan in the subcontinent, is a cultural tradition of Bangladeshi people extending back over centuries. 1 Smokeless tobacco (SLT) products are added to betel leaf during chewing by many Bangladeshi adults. The prevalence of SLT use is 27% (26 million adult people) with a similar distribution across genders in Bangladesh. 2 SLT use is associated with several adverse health effects, including oral and dental diseases, 3 cancers, 4 cardiovascular diseases, 5 hypertension, 6 diabetes, 7 poor reproductive outcomes, 8 genetic damage, 9 and addiction. 10 Studies from India 11 and Pakistan 12 report that many people believe that some of the SLT products are beneficial to health, relieving toothache, headache, and stomach ache.
In Bangladesh, tobacco studies focused on the prevalence of tobacco use,2,13 association between tobacco use and cardiovascular disease,14,15 and other tobacco-related issues such as sociodemographic characteristics of tobacco users 16 and socioeconomic determinants of tobacco use. 17 Two studies have explored perceptions of tobacco use among Bangladeshi adults thus far; one study 18 did not report perceptions separately among SLT users, and the other study 2 only explored the perceived health effects of SLT use but not the perceived benefits or the initiation factors related to SLT use.
Understanding perceptions is important because they are strongly associated with behavior. The Health Belief Model 19 hypothesizes that perceived susceptibility, perceived severity of a disease, and perceived benefits outweighing costs are all preludes to healthy behavior change. 20 According to this model, SLT users would be more likely to change their chewing habits if they perceived themselves as vulnerable to diseases as a result and if they perceived that quitting SLT use would ensure better health. 21 A cohort study 22 of current smokers from the United States, United Kingdom, Canada, and Australia reported that perceived benefits from smoking were large enough to inhibit quitting. Therefore, it is important to identify whether the perceived benefits of SLT use outweigh the harmful effects on health. The aim of this study was to describe the patterns of SLT use among the Bangladeshi adults and to explore their perceptions about the effects of SLT use on health.
Methods
Study Design and Study Sites
This study was a component of a large case-control study that explored the association between coronary heart disease (CHD) and use of SLT products among nonsmoking Bangladeshi adults. 23 In line with the protocol of that case-control study, we collected data from CHD-positive individuals and CHD-negative individuals. CHD-positive individuals were recruited from cardiac inpatient facilities of the National Institute of Cardiovascular Diseases and the National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh. CHD-negative individuals were recruited from cardiac outpatient facilities of the same hospitals and from the neighborhood households of CHD-positive individuals within Dhaka City Corporation areas.
Study Population
Inclusion criteria were as follows: age 40 to 75 years, nonsmoker, residence within Dhaka City Corporation areas, and well enough to undertake a 20-minute interview. Nonsmokers were defined as either (1) never smokers or (2) ex-smokers who had not smoked a single puff in the past 10 years. Selection criteria for CHD-positive and CHD-negative individuals are reported elsewhere. 23 For this study, we reclassified the study participants into SLT users and non–SLT users. SLT users included current SLT users and past SLT users.
Sample Size
A total of 1812 participants were interviewed for the original study and formed the sample for this study. It included 302 CHD-positive individuals and 1208 CHD-negative individuals.
Data Collection
Data were collected through semistructured interviews by four trained interviewers during January to July 2010 in Bangladesh. Interviewers described the study objectives prior to obtaining written consent from each study participant. Interviewers collected information on the variables described below.
Sociodemographic variables
Information on age, sex, residence, marital status, highest level of education achieved, primary occupation, and monthly house rent were collected from the participants.
Use of SLT products
Detailed information on SLT use such as current use and quitting, types of SLT products used, frequency and duration of SLT use for current users, and duration since stopping SLT use for quitters was collected. Neither betel leaf nor areca nut alone were included as SLT products because they do not contain tobacco. If a respondent used any SLT product with/without betel leaf or areca nut in the past 1 year, he/she was categorized as a current SLT user. If a respondent had stopped using SLT products for at least the past 12 months, he/she was categorized as a quitter of SLT products. We categorized frequency into light use (less than once a day) and heavy use (at least once a day), and duration into short duration (<10 years) and long duration (>10 years).
Perceptions of SLT use
Perceptions of the participants about health effects of SLT use were collected through a semistructured questionnaire. Some of the questions were chosen from prior tobacco research in Bangladesh1,2 and perception studies in India 11 and Pakistan. 12 Respondents, irrespective of usage status, were asked to offer possible reasons as to why Bangladeshi adults would use SLT products. All participants were interviewed regarding their perceptions of beneficial and harmful effects of SLT use on health. Only the SLT users, either current or past, were asked about the factors, persons, or events those influenced them to start using SLT. They were also asked whether they had ever tried to quit, reasons for quitting attempts or successfully quitting SLT use, and an estimate of weekly or daily expenditure on SLT products.
Data Analysis
Descriptive statistics were used to describe the sociodemographic variables (age, sex, residence, marital status, education, occupation, and monthly house rent) and main exposure variable (prevalence, types, frequency, and duration of SLT use) among the study participants. Open-ended responses were recorded and categorized under each item of perceptions. First, the perceptions among all participants were analyzed, then the differences in perceptions between SLT users and non–SLT users were analyzed. We also compared the differences in perceptions between CHD-positive individuals and CHD-negative individuals. For each item of perceptions, SLT users and non–SLT users were first compared using cross-tabulations. McNemar’s χ2 tests were used when the frequency in all the cells of the cross-tabulation was ≥5, and Fisher’s exact tests were used otherwise to determine statistical significance at .05 level. Univariate logistic regression models were fitted to determine the strength of perception differences between SLT users and non–SLT users as well as between CHD-positive individuals and CHD-negative individuals. Then, multivariate logistic regression models were fitted to adjust for potential confounding variables. To avoid complexity, because this is a descriptive article, results of logistic regression analyses are not shown, and results of significance are shown in a simple way in Table 1.
Perceptions of Smokeless Tobacco (SLT) Use Among the Study Participants. a
Multivariate analyses were done to compare the difference in perceptions between SLT users and non–SLT users, considering age, gender, marriage, education, occupation, and house rent as potential confounders.
Indicates the categories that show a statistically significant difference between SLT users and non–SLT users.
Results
Study Participants
Out of 1920 eligible participants, 1812 (94%) took part in this study. The mean age of participants was 53 years (±8.5 years), and 70% were in the age range of 40 to 57 years. Half of the participants were women. More than two thirds (78%) were married, and 76% had completed formal education. The majority (81%) of female participants were housewives, whereas half (47%) of the male participants were either government or private service holders. Based on the monthly house rent, half (51%) of the participants were categorized as belonging to the middle socioeconomic group (monthly house rent 5000-10 000 Bangladeshi Taka; Table 2)
Sociodemographic Characteristics of the Study Participants.
Abbreviations: SLT, smokeless tobacco; SD, standard deviation; BDT, Bangladeshi Taka; SES, socioeconomic status; HR, house rent.
Indicates categories that show a statistically significant (P < .01) difference using χ2 tests between SLT users and non–SLT users.
Use of SLT Products
Among the 1812 participants, 704 (39%) were current SLT users or had used SLT in the past. The majority (92%) of them were current SLT users. Use of any one SLT product exclusively was more common compared with the use of more than one SLT product, which suggests some degree of product loyalty. Among individual types of SLT products, jarda was used most commonly (64%), followed by sada-pata (6%) and gul (7%). The majority of exclusive jarda, sada-pata, and gul consumers were heavy users and long-duration users (Table 3).
Status of Smokeless Tobacco (SLT) Use Among the Study Participants.
Comparing Sociodemographic Variables Between SLT Users and Non–SLT Users
Table 2 shows that there was a statistically significant difference (P < .05) between SLT users and non–SLT users in terms of age, gender, marital status, highest level of education achieved, primary occupation, and monthly house rent. SLT users were more likely to be from older age groups, women, widowed, less educated, housewives, and of lower socioeconomic status compared to non–SLT users (Table 2).
Perceptions of SLT Use
Reasons for use of SLT products by Bangladeshi adults
Half (52%) of the participants, irrespective of their status of SLT use, believed that ongoing use of SLT products was a result of addiction. Another 23% believed that SLT users exhibited a lifestyle habit. Table 1 shows the differences in perceptions between SLT users and non–SLT users. SLT users were more likely to believe that the common reasons for using SLT products were family tradition, to get relief from toothache, to enhance the taste during betel chewing, to get relief from anxiety, and to obtain a good taste or to enhance taste in general. However, SLT users were less likely to believe that Bangladeshi adults use SLT products because of addiction or lack of awareness about its harmful effects.
Perceived harmful effects of SLT use
Almost all (97%) participants considered that SLT products were harmful to health. There was no difference in response between SLT users and non–SLT users (Table 1). Many participants considered that SLT use caused heart disease (40%), cancer (39%), tuberculosis (20%), lung disease (14%), and hypertension (10%). However, compared to non–SLT users, SLT users were less likely to believe that tuberculosis, lung disease, breathlessness, and cough were associated with SLT use. SLT users were more likely than non–SLT users to believe that diseases associated with SLT use included gastric problems, visual impairment, and dizziness. The harmful effects of SLT use, apart from the fact that it caused diseases, were waste of money, causing harm to the environment (users spitting chewed betel leaf and/or SLT products), and causing social embarrassment, family conflicts, and conflicts with religious beliefs. However, SLT users were less likely to believe that SLT use is harmful for the environment compared to non–SLT users (Table 1).
Perceived benefits of SLT use
The majority (77%) of participants believed that there were no benefits of using SLT products. However, SLT users were less likely to believe that compared to non-SLT users. The users believed that SLT use helped them in the following ways (Table 1): relieved toothache (11%), enhanced taste perceptions (6%), helped in digestion (3%), made the teeth harder (3%), and relieved anxiety (1%).
Factors influencing initiation of SLT use
A quarter (25%) of the SLT users mentioned that they started using SLT products primarily because of the influence of parents or siblings. They were attracted by the flavor of SLT products as well as the chewing habits of family members and initially tried those SLT products out of curiosity. Later on, they believed that they became habituated to those products. Another 17% of SLT users were influenced by relatives or neighbors; 16% were influenced by grandparents, parents-in-law, and teachers; and 14% started using those products to get relief from toothache. The other factors those led to initiation of SLT use are mentioned in Table 4. It is interesting to note that 5% of SLT users started using SLT products following smoking cessation because they believed that SLT helped decrease smoking addiction. Because the use of SLT is a Bangladeshi cultural tradition and it is served to guests in cultural celebrations, 3% of SLT users started using SLT at such occasions. Sometimes older family members such as mothers and mothers-in-law advised the female respondents (2%) to use SLT products with betel leaf to get relief from pregnancy symptoms such as anorexia, nausea, and vomiting. A few female participants (<1%) reported getting the advice from their mothers-in-law: “using betel and SLT would make a wife more attractive to the husband.”
Experience of SLT Users.
Abbreviations: SLT, smokeless tobacco; BDT, Bangladeshi Taka.
Factors influencing quitting of SLT
Among the 704 SLT users, 56 (8%) had successfully quit SLT use after using it for at least 2 years. The SLT quitters mentioned two main reasons for quitting: advice from doctors (36%) and development of certain health problems (39%). Health problems included abdominal pain, dizziness, loss of teeth, and throat problems. Other reasons given by the quitters were self-motivation and advice from family members. On the other hand, many more SLT users (33%) reported unsuccessful attempts to quit SLT products. They cited two main incentives for their quitting attempts: self-motivation (30%) and advice from doctors (23%). The other factors those motivated them to attempt quitting are mentioned in Table 4.
Costs of SLT products
Costs of SLT use depended on the products used by participants. Gul, which is used alone usually, was relatively cheaper than other SLT products. On the other hand, jarda and sada-pata are usually used together with betel leaves; hence, the total costs for these products are greater compared with that of gul. The minimum weekly expense for SLT use in this study was only 1.00 Bangladeshi Taka (~0.01 US dollar) for those who used gul alone 2 to 3 times a day. On the other hand, the maximum weekly expense for SLT use was 1050.00 Bangladeshi Taka (~US$15) for those who used jarda alone more than 4 times a day (Table 4). The average weekly income of Bangladeshi people is about US$46, and uneducated people earn US$21 or lower per week on an average. 24 Thus, the cost of SLT use represents 0.05% to 33% of an average weekly income in this study.
Comparing Perceptions of SLT Use Between CHD-Positive Individuals and CHD-Negative Individuals
There was no difference between CHD-positive and CHD-negative individuals regarding the reasons for using of SLT products by Bangladeshi adults, perceived harmful effects, and perceived benefits of SLT use (analyses not shown). The only difference was that CHD-positive SLT users were more likely (compared to CHD-negative SLT users; P < .05) to start using SLT products because of influence from peers and attempted to quit because of religious awareness (analyses not shown).
Discussion
Addiction and lifestyle habits were cited as the main reasons for continued use of SLT products, and this is consistent with the effects of nicotine in SLT products. 10 A study reported that African traditional healers, who were regular users of SLT products, stated that almost all of them strongly believed that those products were addictive in nature. 25 A study from Pakistan revealed similar opinions about the addictive nature of the SLT products.12,22
We conducted a case-control study to determine whether SLT use and CHD were significantly associated. This case-control study did not find a significant association between CHD and SLT use when all forms of SLT were combined. Although the results of this study have been reported elsewhere, it is useful to note that when gul use was examined individually, there was a significant association between gul use and CHD. 23 Almost all participants in this study believed that use of SLT products was harmful to health, which is consistent with the results of the recent Global Adult Tobacco Survey (GATS) in Bangladesh. 2 GATS reported that 93% of adults perceived that SLT products could cause serious illness. 2 The participants of this study perceived that SLT use was associated with heart disease, cancer, tuberculosis, lung disease, and hypertension. There was a difference between SLT users and non–SLT users in terms of perceptions about association between SLT use and these diseases, including CHD. This disease-specific perception difference could be a result of differences in the level of awareness because SLT users were less educated and mostly of lower socioeconomic status compared with non–SLT users in this study. An earlier study from Bangladesh also suggests that use of SLT decreases with increase in education. 16 GATS also reported that Bangladeshi people believed that SLT products could cause oral cancer, heart attack, and stroke. 2 Heart disease and lung disease were also perceived as SLT-related diseases by Pakistani SLT users. 12 Oral cancer was perceived to be a SLT-related disease by highly educated professionals interviewed in the United States. This group perceived SLT use to be a higher risk in this regard than smoking cigarettes. 26 These findings are in contrast to the findings of a study in South Africa, where the majority of the respondents considered SLT use to be harmless. 25 Health education campaigns in Bangladesh should start with the assumption that many people are already aware that SLT is harmful. People need to be informed about the exact nature of the detrimental effects of SLT use, along with the seriousness and severity of SLT-related diseases.
Although the majority of study participants did not mention any benefit of using SLT products, relieving toothache was one common benefit mentioned by some SLT users. Dental health is often neglected in Bangladesh and in other developing countries in general. 27 Lack of awareness regarding oral health, financial constraints, and scarcity of dental services result in high rates of dental diseases. It is common for Bangladeshi adults, specifically in rural areas, to rely on traditional remedies and herbal treatments. Studies from India and South Africa also have found that SLT products were used to obtain relief from toothache.11,25
In this study, the principal factor for initiating SLT use was influence of family members. Gupta and Ray reported that the perceived medicinal benefits of SLT use in some cases led to “advice for initiating tobacco use from adults to non–SLT users and even children.” 11 Generally, advice from older family members is respected within the sociocultural context of Bangladesh. This may explain why SLT initiation occurred on recommendation by other family members in this study. This finding also reflects the cultural acceptability of betel leaf and/or SLT use in Bangladesh, as in other areas of the subcontinent. In contrast, smoking is not socially acceptable, and smokers tend not to smoke in front of elders in Bangladesh.
In this study, advice from doctors was the common factor reported for successful quitting as well as for making a quitting attempt among SLT users. A previous study from Bangladesh 18 identified three major factors for permanent quitting of tobacco use: self-restraint, support from family members or friends, and advice from doctors. Self-motivation (ie, ideas about self-control) was also identified as another factor in quitting attempts in this study. Similar findings have been reported from other studies.12,28 These are important findings because they point to the need for defining health education campaigns, which should not only target the individuals but also involve family members. The campaigns need to consider that betel leaf use is regarded as a cultural phenomenon by many Bangladeshis but not the use of SLT products. Providing specific messages regarding the harmful effects of SLT use in the tobacco campaigns would more likely sensitize SLT users as well as family members to change their habit of using SLT products.
Weekly expenditure for SLT use varied according to the types of SLT products used in this study. One study from Bangladesh 18 reported that average tobacco-related (both smoking and SLT) expenditure for an adult was 50 to 75 Bangladeshi Taka (~0.71-1.07 US dollars) per week. Although expenses for SLT products are presumably lower than those associated with cigarette smoking, it has been estimated that Bangladeshi tobacco users spend approximately 4.5% of their total monthly household expenditure on tobacco, which is a significant burden for people of lower socioeconomic status. 13 Although increasing taxation on cigarettes is associated with decreased prevalence of smoking and people from lower socioeconomic groups are more responsive to price, 29 there is no policy for regulating the price of SLT products in Bangladesh. Along with the sociocultural acceptability of SLT use, low prices of SLT products could be one of the important factors for the increased prevalence of SLT use in Bangladesh.
Strengths of this study include exploring perceptions of SLT use among the Bangladeshi population involving a large sample of nonsmoking adults. Some of the issues explored in this study included the fact that whilst most participants were aware of the harmful effects of SLT use in general, specific disease-related awareness was not strong among the SLT users. Awareness-raising campaigns should focus on SLT-related diseases those are consistently associated with the use of SLT products, such as oral diseases and cancers. Smokers have many functional, strong, positive beliefs about smoking which prevent them from quitting smoking, 22 but SLT users in this study did not have similar strong, positive beliefs for SLT use. We could use this opportunity to create awareness among Bangladeshi adults focusing on the adverse effects of SLT use, which would outweigh the benefits of using SLT products. Family members had an important role to play to help in quitting SLT use, which indicates the need to involve family members in tobacco control activities. Advice from doctors was another important influencing factor for quitting SLT use. Hence it is important to involve physicians in tobacco control activities, because physicians are influential and may be able to help convince the general public to quit tobacco use. 30 Mass media campaigns should highlight the adverse effects of SLT use along with smoking-related harm. In terms of limitations, the data were collected from urban areas of Bangladesh; perceptions may differ among rural populations because of variations in education levels and exposure to media.
Conclusions
This is the first study from Bangladesh reporting comprehensive perception data of SLT use among nonsmoking adults. Findings of this study could be considered for formulating future tobacco control policies in Bangladesh. Awareness campaigns should highlight the adverse effects of SLT use that outweigh the perceived benefits and should focus on specific SLT-related diseases. The campaigns should also alert people regarding the influence of families and friends in introducing SLT products to their kin.
Footnotes
Acknowledgements
We would like to remember with sincere gratitude the late Professor Konrad Jamrozik from the University of Adelaide, Australia, for his contribution in developing the concept of this research area. We would like to thank the Director of the National Institute of Cardiovascular Diseases (NICVD) and the Chairman of the National Heart Foundation Hospital and Research Institute (NHFH&RI) for providing their official support in collecting data from the hospital patients. Also, we are very grateful to the physicians and nurses of NICVD and NHFH&RI for their cooperation in collecting data—specifically, Dr Monwarul Islam, Registrar of NICVD, and Dr Ziauddin Ahmad from Bangladesh. We appreciate the support received from the fellow colleagues of IEDCR (Institute of Epidemiology, Disease Control and Research), Bangladesh, during training and selection of data collectors for this study. Special thanks to Mrs Habibun Nahar Lotus, Ms Shafia Zerin, Ms Afroza Begum Nilu, Mr Sheikh Mohd Shafiqul Bari, and Ms Bilkis Sultana for their sincere and conscientious efforts in collecting data for this study. Above all, we would like to express our sincere gratitude to each of the study participants from both hospitals and communities within Dhaka City Corporation, Bangladesh, for giving us their valuable time and participating in this 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: Funding for this study was provided by the Discipline of Public Health, University of Adelaide. Additionally, human resource and in-kind support for the research was also provided by the Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh, and the National Heart Foundation Hospital & Research Institute (NHFH&RI), Dhaka, Bangladesh.