Changes in prevalence, and factors associated with tobacco use among Bangladeshi school students: evidence from two nationally representative surveys

Tobacco is the only legal drug that kills too many of its users when explicitly used as instructed by its manufacturers [1]. World Health Organization (WHO) estimated eight million deaths annually, and many of these deaths occurred prematurely across the world because of tobacco use [2]. Additionally, second-hand smoking is responsible for 1.2 million deaths per year [2]. Tobacco-related mortality obstructs the social and economic advancement of a country. Untimely death from tobacco decreases the living standards of a family, raises the healthcare cost and hampers the financial condition [2]. As nearly only 20% of the world’s 1.1 billion smokers living in high-income countries [2], Southeast Asia is a high-risk region and experiences 1.2 million tobacco- attributable deaths per annum [3].

Adolescents (age group 10–19 years) make up the majority of the population in South East Asian countries, and they are particularly vulnerable to tobacco use [4, 5]. As Bangladesh is one of the top ten countries with China, India, Indonesia, Russia, the USA, Japan, Brazil, Germany, and Turkey, where the world’s two-thirds of smokers live [6], adolescent tobacco use is also a growing problem for Bangladesh [7, 8]. According to the Global Burden of Disease Study, in 2019, tobacco kills about 157,862 people, which is about 19% of total deaths [9], and there are 1.2 million tobacco-related diseases each year in Bangladesh [10]. A ten-year prospective study of twenty thousand adult participants in Bangladesh has revealed that smoking was responsible for 25% of men’s death and 7.6% of women’s death [11]. It is a clear indication that Bangladesh has a large number of tobacco-related deaths and illnesses that warrants national attention to this enormous problem.

Trends in smoking among adolescents have been increasing across the world [5]. Globally, 21% of school students smoked tobacco [12]. According to the 2013 Global Youth Tobacco Survey (GYTS), 3% of 7-9th grade students were tobacco users, and 2% were cigarette smokers in Bangladesh [13]. However, Bangladesh’s situation was not the worst compared to other South Asian countries. For example, in India, Nepal, Maldives, and Pakistan, the prevalence of smoking among secondary school students was calculated to be at 4.4, 6.9, 4.3, and 3.3%, respectively [12].

In developing countries, over 50% of teenagers who begin smoking at a young age become habitual users [14]. Moreover, research showed that most smokers start smoking before they reach adulthood [15, 16]. Adolescents, in fact, are more likely to develop a nicotine addiction [17], and the majority of adolescents who use tobacco on a daily basis continue to use it later in life. For example, although only 5% of adolescent smokers believe they are still smoking after five years, 75% still smoke after eight years [18]. The probability of contracting tobacco-related diseases is proportional to the time tobacco is used [15]. Some studies in Bangladesh found that smoking is a probable cause of hypertension, coronary artery disease, and acute myocardial infarction in young people [19‐21]. One out of three young people who start smoking will eventually face an adverse outcome because of tobacco-related diseases [22]. Therefore, adolescence is the most critical phase for tobacco use initiation, and adolescent smokers are at higher risk for the adverse effect of tobacco use later in life.

The reasons for such prevalent usages, particularly among boys, are thought to reflect tobacco companies’ strategic marketing approach and ineffective execution of tobacco control policies making tobacco products more accessible and affordable to youth. Besides, parental smoking, the best friend’s smoking behaviour, peer pressure, and achieving a poor grade at school influence tobacco use among adolescents [23‐27]. Previous studies have also reported a higher prevalence of smoking among adolescents if their favourite film star smokes [28] and if they have sufficient pocket money. Furthermore, tobacco contents in movies are portrayed as societal support for tobacco consumption [29]. There is a paucity of information for adolescent smoking in Bangladesh [16].

In Bangladesh, there are well-established tobacco prevention laws and initiatives, such as currently, there is a national tobacco control legislation named “The Smoking and Tobacco Products Usage (Control) Rule, 2015”, signed by the President of the People’s Republic of Bangladesh on 12 March 2015. It has rectified the Smoking and Tobacco Products Usage (Control) Act, 2005 to correct certain clauses [30]. These initiatives have ensured that tobacco merchandise is priced and taxed appropriately, that smoking is prohibited in public places, that the selling of tobacco products to and by minors is prohibited, that tobacco products are packaged and labelled properly, and prohibiting tobacco advertisements and promotions. These initiatives are combined with increasing awareness through education, training, communication, and research and partnership building to control tobacco use [7].

Despite the initiatives to regulate tobacco use in Bangladesh, adolescent tobacco use’s prevalence rate is still unsatisfactory [31]. While a lot of studies have been conducted on developed countries to look at adolescent tobacco use and its factors, those studies’ results are not sufficient for developing countries, particularly Bangladesh. Because of a lack of national-level information, we do not have sufficient knowledge of the effect of the antitobacco laws on the adolescents smoking trends in Bangladesh.

Considering the long-term adverse health effects of adolescents tobacco use and its long-term effect on the country’s economic growth, we analysed two available datasets from the Global Youth Tobacco Survey (GYTS) during 2007 and 2013, intending to identify the factors associated with adolescents tobacco use in Bangladesh and to examine changes in these factors between the GYTS 2007 and 2013 surveys and to explore the policy relevance.

Among 3113 selected students in 2007, 49.53% (n = 1542) students were male whereas, in 2013, there were 41.08% (n = 1333) male students and most of the students were from 9th grade and above (2007: 55.57%; vs 2013: 38.52%). More students in 2007 (79.57%) favoured banning smoking in public places than in 2013 (62.68%). Moreover, in 2013, the number of students who were exposed to tobacco smoke was increased from 48.02 to 68.84%.

Our study is the first comprehensive evaluations of changes in patterns of tobacco use over time among adolescent students in Bangladesh using large, nationally representative comparable surveys. The surveys were cross-sectional and adolescent school students’ samples were independent. We found that the prevalence rate of tobacco use among Bangladeshi students decreased by more than 1 % point, consistent with the findings of other studies [8, 31, 32]. A declined in tobacco use prevalence between 2007 and 2013 does not necessarily mean a decrease in the number of adolescent tobacco users, given the population growth and changing age composition. However, in 2007, ‘10–19 years’ age group represented 22.5% (32.1 million) of the entire population (142.7 million) of Bangladesh [38, 39] resulted in about 2.7 million estimated tobacco users in that age group. On the other hand, in 2013, 21% (32.08 million) of the entire population (152.8 million) [39, 40] fell in that age group having an estimated 2.2 million tobacco users. We observed similar patterns regarding smoking and smokeless tobacco users. Therefore, it is a clear indication of a decline in the number of adolescent tobacco users. The decrease in prevalence may reflect the effect of the tobacco control policy in Bangladesh [7, 8]. However, the decreasing rate is not adequate to control the problem.

Looking at the characteristics of the users, the percentage of male tobacco users was higher than that of female users in this study, and the difference between the male-female ratio slightly increased between the two surveys (male 10.4% & female 5.2% vs male 9.2% & female 2.8%). As male predominance in the smoking prevalence is not unexpected as it was found in most countries [8, 13]. However, contrary to the previous findings, this study showed that the girls’ user rate is now decreasing [8]. Possible reasons could be the social acceptability and attitudes about smoking vary between males and females, and society frowns upon females’ smoking in male-dominated countries [41‐43]. According to the 2007 Bangladesh GYTS survey, 26% believe boys, while only 10% believe girls who smoke have more friends. In addition, 45% of them find boys, and 11% find girls who smoke are more appealing [44]. Female tobacco user, while currently low, may increase and will also require monitoring. Bangladesh has lagged behind other South Asian countries in terms of teaching teenagers about the risks of tobacco use [13]. For school-aged children, the advantages of early education programs have been well established. These initiatives should reflect on the harmful effects of tobacco use.

In line with the previous studies [8, 31], age was not significantly associated with overall tobacco use and smokeless tobacco use in 2007, but in 2013, there was a significant difference in tobacco use for students regarding age. When comparing students aged above 14 years to those younger than 14 years, older students were almost four times more likely to be tobacco users. It indicated that tobacco use is more common among older school students. Thus, prevention and cessation programs need to be initiated for these groups.

The prevalence of overall tobacco use was significantly higher among the adolescents receiving a higher amount of pocket money in 2007 aligns with results from other studies [8, 31]. This could indicate that having spare money is responsible for easier access to tobacco products, and therefore, initiate tobacco using [10]. Besides, similar to previous findings [5], we found a relationship between smoking and overall tobacco use and the lower price of a pack of cigarettes in 2013. Therefore, raising the price of tobacco products would be useful in reducing tobacco use among adolescents. While other factors influence the price of tobacco products, the rise in the excise tax has generally resulted in an equal or more dramatic rise in the price of tobacco products. Therefore, it makes tobacco products less desirable and affordable to adolescents with minimal financial ability and less option for spending available money [45]. For example, a uniform excise tax on average could reduce 27% smoking prevalence among adolescents [5]. In Bangladesh, there were significant rises in prices. However, because of increased pocket money, adolescents can still afford tobacco products [46]. Increasing awareness among guardians about pocket money through different campaigns would be helpful in this regard.

Students in this study were exposed to tobacco smoke everywhere. This smoking-friendly atmosphere exposes them to health risks and encourages them to start consuming tobacco. Consistent with other studies in the literature [8, 33, 34, 47], we also observed significantly higher odds ratios of tobacco use among adolescents exposed to tobacco smoke compared to their counterparts. Exposure to smoking significantly increases the tobacco use risk three to seven times, indicating that the scope and enforcement of smoke-free policies were not enough. Furthermore, consistent with Khan et al.’s findings [31], a significant association was found between smoking and overall tobacco use and students’ negative attitudes towards banning smoking in public places in 2013. To overcome this problem, the Bangladesh government banned smoking in public places through the 2015 Smoking and Tobacco Products Usage (Control) Rule [48]. However, these laws are yet to be strictly enforced. Weak or non-existent enforcement of such legislation results in prevalent tobacco usage in public places. Smoking bans in public places were found to have a major preventive impact on the prevalence of smoking [49]. Therefore, more vigorous implementation of laws and policies and smoking bans in public places is essential. Furthermore, in model I (Additional file 1), we observed that being offered free tobacco products from the vendors was positively associated with overall tobacco use. However, the scenario changed completely in 2013. Maybe this is because, though the current law in Bangladesh prohibits direct tobacco advertisement, the tobacco industries use sneaky ways to advertise their products [31] and maybe trying to create new consumers by offering free products to the non-users rather than existing users. Therefore, it is necessary to intensify the tobacco control acts in Bangladesh. It will be useful to create a National Health Research Institute for assessing the effect of tobacco marketing campaigns. This program will pave the foundations for a greater understanding of tobacco advertisement, promotion, and distribution, as well as their effects on adolescents [50]. Other initiatives, such as age limits in purchasing tobacco products, awareness campaigns about the adverse effects of tobacco use, using dramas and movies to portray unfavourable outcomes, could also play a vital role along with law enforcement.

In Bangladesh, there was a decline in tobacco use among school-going adolescents, especially among female students. It appeared that established tobacco control laws and policies, i.e., anti-smoking campaigns, age restriction policies, were working. However, the prevalence of tobacco use is still high. Controlling adolescent tobacco use may be more effective if a combination of government-social-and home-based anti-smoking strategies and interventions are used.