A Longitudinal Study of Tobacco Use Transitions in Southeast Asia

The Lancet Regional Health – Southeast Asia is an open access journal under the Lancet franchise, established in June 2022 and published by Elsevier. It is part of the Lancet Global Health Initiative to promote equal access to quality healthcare services worldwide, and is devoted to advancing clinical practice and improving health policies in Southeast Asia. Through publishing high-quality evidence-based medical papers, the journal aims to enhance the health outcomes of the region and its countries, ultimately leading to better health for the populations of Southeast Asia.

The publication features high-quality original research aimed at improving or inspiring clinical practices and healthcare policies in Southeast Asia. Additionally, it includes related reviews, commentary, and communications. Topics covered include, but are not limited to, infectious and non-communicable diseases, child and adolescent health, maternal and reproductive health, mental health, universal health coverage, and healthcare systems.

On April 12, 2023, a journal published a paper titled "A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: implications for tobacco control in the Southeast Asia region". The study investigated the correlation between smoking and smokeless tobacco use in Bangladesh, and the potential implications for effective tobacco control in Southeast Asia.

Image Source: The Lancet Regional Health (Southeast Asia) paper, dated April 12, 2023, titled "Longitudinal study on the transition between smoking and smokeless tobacco use in the ITC Bangladesh survey: Implications for tobacco control in Southeast Asia".

The main contents of the paper are as follows:

First, the research team:

This study was jointly conducted by experts including Daniel Tzu-Hsuan Chen, Nigar Nargis, Geoffrey T. Fong, Syed Mahfuzul Huq, Anne C. K. Quah, and Filippos T. Filippidis. They come from various institutions.

Public Health Policy Evaluation Department at Imperial College London School of Public Health in the United Kingdom.

The Public Health Policy Evaluation Unit, located within the School of Public Health at Imperial College London in the United Kingdom.

The Nuffield Department of Primary Care Health Sciences at the University of Oxford in the United Kingdom.

The Nuffield Department of Primary Care Health Sciences, which is located in the United Kingdom at the University of Oxford, focuses on research in the field of primary care health sciences.

The American Cancer Society, based in Washington D.C., United States.

The American Cancer Society is located in Washington, DC, United States of America.

The Department of Psychology at the University of Waterloo, located in the city of Waterloo, Ontario, Canada.

The Psychology Department of the University of Waterloo is located in Waterloo, Ontario, Canada.

The University of Waterloo's School of Public Health Sciences in the city of Waterloo, Ontario, Canada.

The School of Public Health Sciences at the University of Waterloo in Waterloo, Ontario, Canada.

Ontario Cancer Research Institute, Toronto, Ontario, Canada.

The Ontario Institute for Cancer Research is located in Toronto, Ontario, Canada.

The World Health Organization Country Office in Dhaka, Bangladesh.

The World Health Organization's country office in Dhaka, Bangladesh.

This research project is an observational study that uses the ITC Bangladesh dataset and has no funding. The ITC Bangladesh survey was funded by the US National Cancer Institute (P01 CA138389), the International Development Research Centre (IDRC grant 104831-003), and the Canadian Institutes of Health Research (MOP-79551, MOP-115016).

Background Overview:

Smoking poses a major threat to public health in Southeast Asian countries, causing the deaths of 1.6 million people in the region in 2020 alone. The World Health Organization reports that the Southeast Asia region accounts for more than 22% of global smokers and over 80% of smokeless tobacco (SLT) users. Tobacco is consumed in various forms in the region, including smoked products like cigarettes and bidis (a cheaper form of hand-rolled tobacco), as well as widely used SLT. Limited awareness of the negative health impacts may be linked to cultural customs and misconceptions about its effects on health.

Tobacco users in Southeast Asia may switch or simultaneously use both smoked and smokeless tobacco (SLT), making effective tobacco control challenging. A study tracked usage transitions among users of different products (cigarettes, bidi, and SLT) in Bangladesh, one of the largest tobacco consuming countries in the region, and examined factors related to transition and cessation.

3. Research Method:

This article analyzes four waves of the International Tobacco Control (ITC) Bangladesh survey from 2009 to 2015, which included a sample of 3,245 tobacco users. A generalized estimating equation (GEE) model was used to explore the socioeconomic correlates of transitioning from using exclusively cigarettes, beedi, or smokeless tobacco to using other tobacco products or quitting over time.

4. Important discovery:

This study conducted statistical analysis and data collection on various factors including age, gender, urban or rural residency, and level of education of the subjects. Based on this analysis, the following results were obtained:

Among exclusive cigarette users, most remain unchanged (68.1%). However, rural smokers are more likely than urban smokers to transition to using beedi cigarettes (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.29); using smokeless tobacco (OR = 2.68, 95% CI = 1.79-4.02); and quitting smoking (OR = 1.57, 95% CI = 1.06-2.33). In exclusive beedi cigarette users, the transition pattern is even more unstable. In the entire wave, less than half (43.3%) of dedicated beedi users maintained their share. Compared to low socioeconomic status (SES) smokers, those with higher SES are more likely to quit smoking (OR = 4.16, 95% CI = 1.08-13.12). Exclusive users of smokeless tobacco either continue to use it or quit smoking with a rare transition to other products (≤2%).

However, men are more likely to switch to other tobacco products. Younger individuals (OR = 2.94, 95% CI = 1.23-6.90 compared to older individuals), those with higher education levels (OR = 1.55, 95% CI = 1.77-3.12 compared to those with lower education levels), and non-smokers in urban areas (OR = 0.52, 95% CI = 0.30-0.86 for rural and urban users) are more likely to quit smoking.

Conclusion:

In this study, the researchers have identified specific product trajectories and attributes that are associated with the complex transition patterns over time among different types of tobacco product users in Bangladesh, a country with high rates of tobacco and smokeless tobacco use in Southeast Asia. These transition patterns are not random: some product consumers are more likely to transition than others, for example, cigarette users are more likely to transition to smokeless tobacco than bidi users, while smokeless tobacco users are unlikely to transition at all.

The changing patterns revealed across these three product markets demonstrate the interdependence of each. The observed patterns of use and transition for a variety of tobacco products in Bangladesh suggest that users have the ability to choose from a range of options to maintain their addiction to nicotine rather than quit smoking. While this study does not evaluate attitudes towards harm and social status, or how tobacco control policies impact such behavior, it provides a starting point for deeper analysis of the dynamics between these tobacco products in Bangladesh. Future research can explore these additional elements and include more locally relevant products such as e-cigarettes, heated tobacco, and other emerging nicotine products. Understanding the transitions and trajectories of tobacco users can lead to more targeted and effective tobacco control strategies, to limit tobacco use in Southeast Asia.

References:

Title: "Longitudinal Study on the Transition between Smoking and Smokeless Tobacco Use in Bangladesh: Its Impact on Tobacco Control in Southeast Asia" by ITC. The study examines the relationship between smoking and smokeless tobacco use in Bangladesh and its impact on tobacco control in Southeast Asia. The research focuses on the transition from smoking to smokeless tobacco use among individuals and the associated health risks. The study was conducted by the International Tobacco Control Policy Evaluation Project (ITC) in collaboration with local partners in Bangladesh and other Southeast Asian countries. The findings provide insights into the challenges faced by tobacco control policies in the region and offer recommendations for future tobacco control efforts.

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