Predictors of smoking cessation behavior among Bangladeshi adults: findings from ITC Bangladesh survey

Tobacco use is the leading cause of preventable death and disease worldwide and is estimated to kill more than 5 million people each year [1]. Public health strategies to combat tobacco-induced illnesses have aimed at reducing uptake and promoting smoking cessation. Given the limitations of population-based programs to reduce smoking initiation among the public [2], the need to provide cessation support to those who continue to smoke is substantial. Therefore, identification of factors that could facilitate cessation is important in the design of evidence-based smoking cessation interventions.

With a population of 150 million, Bangladesh is one of the top ten countries in the world having a high smoking prevalence, where over 22 million adults smoke [3]. The overall smoking (cigarettes, bidis, and hookah) prevalence has increased in Bangladesh from 20.9 % in 2004 to 22.0 % in 2010 [4]. Studies also identified a 9-percentage point increase of smoking-attributable deaths among Bangladeshi adults; from 16 % in 2004 [5] to 25 % in 2010 [6]. This high rate of tobacco-attributable mortality underscores the rapidly growing health and economic burden of tobacco use in Bangladesh. To address this growing epidemic of tobacco-induced deaths, there is an urgent need to reduce tobacco use in Bangladesh which will require curtailing initiation of tobacco use and promotion of smoking cessation.

Previous research [7‐10] has identified factors associated with smoking cessation, including low nicotine dependence, male gender, higher educational attainment, being married, being older, consuming fewer cigarettes per day, and not having other smokers in the household. However, little is known about the factors that are associated with smoking cessation among the Bangladeshi population. The identification of Bangladesh-specific factors is needed to assess the need for and nature of smoking cessation services that would be appropriate for Bangladesh and other developing countries with similar socioeconomic characteristics.

The aim of this study is to examine the factors associated with smoking cessation behavior (that is, quit attempts and smoking cessation) among a nationally representative sample of Bangladeshi adults.

Of 1,861 daily smokers present in both Waves 1 and 2 (Table 1), the majority (85 %) were recruited from non-tribal areas outside Dhaka. The vast majority of smokers were male (98 %), married (78 %), Muslim (87 %), smoked cigarettes exclusively (89 %), and had monthly household incomes of more than 5,000 BDT (1US$ = 79 BDT) (74.7 %). Almost three quarters of selected smokers came from homes having two or more smokers. Overall, 4 % of adult smokers quit smoking for at least six months in 2010 while another 22 % tried to quit but were not successful.

Bivariate associations between demographic variables and Wave 2 quit status (quit attempts and successful quitting) showed that older age and area of residence were associated with quit status. Specifically, older (aged 40 or above) smokers were significantly more likely to try to quit (25.2 %) or quit successfully (6.4 %) than younger (aged 15–39) smokers (20.5 % and 2.7 %, respectively) (χ² = 15.10; p < 0.001). Subjects recruited from outside of Dhaka were significantly more likely to try to quit (22.9 %) or quit successfully (4.4 %) than Dhaka (13.7 % and 1.3 %, respectively) (χ² = 8.86; p = 0.012). (Data not shown)

Tables 2 and 3 examine bivariate associations between Wave 2 quit status (quit attempts and successful quitting) and behavioural, belief, environmental and motivational factors. Many of these factors were not significantly associated with quit status. However, quit recency, perceived addiction, quit intentions and workplace smoking restrictions were significantly associated with quit status (Table 2). In addition, cigarette consumption (mean numbers smoked daily) and attitudes toward smoking differed by quit status (Table 3). A greater percentage of smokers who made previous attempts to quit had tried again by wave 2 compared to smokers who never tried to quit. Specifically, almost 30 % of smokers who ever tried to quit in Wave 1 reported making additional attempts to quit in Wave 2. Another 6.1 % of smokers who, in Wave 1, tried to quit within the last six months managed to quit successfully by Wave 2 (Table 2). A larger percentage of smokers who planned to quit sometime in the future in Wave 1 reported making additional attempts to quit by wave 2, compared to smokers who never tried to quit in Wave 1 (29.3 % vs 17.5 %, respectively). Smokers having more definite plans to quit in Wave 1 were more likely to have quit successfully by Wave 2: 7.7 % of smokers who planned to quit within the next six months quit successfully by Wave 2 compared to less than 4 % of smokers who had no plans or non-definite plans to quit in Wave 1 (Table 2). Other factors significantly related to quit status included daily cigarette consumption and holding favorable attitudes toward smoking (Table 3).

To better understand the predictors of (a) attempts to quit smoking and (b) successful smoking cessation among Bangladeshi smokers, weighted multi-variable logistic regression was used to model the independent predictors of each outcome controlling for socio-demographic covariates. As shown in Table 4, significant predictors of attempts to quit included: residing outside of Dhaka (OR = 3.41), being aged 40 or older (OR = 1.53), having a monthly income of above BDT 10,000 versus below BDT 5,000 (OR = 1.57), having an intention to quit sometime in the future versus having no plans to quit (OR = 1.73). Respondents not working indoors/outside the home were less likely to have made a quit attempt than those with no workplace restrictions on smoking (OR = 0.62). As shown in Table 5, predictors of successful smoking cessation included: being aged 40 or older (OR = 3.11), perceiving self-rated health as good or excellent (OR = 2.40), and an increased level of self-efficacy (OR = 1.75), where a one point increase in smoker’s self-efficacy increased the odds of successful cessation by 80 %. Smokers who made a quit attempt not so recently (6 months ago or earlier) were less likely to quit than those who made a more recent (in last 6 months) quit attempt (OR = 0.23).

This is the first nationally representative survey to study predictors of smoking cessation behavior among Bangladeshi adults. Our findings suggest that several factors are associated with quitting attempts and successful quitting among adult smokers from Bangladesh. The proportion of Bangladeshis who successfully quit smoking (4.3 %) was almost identical to the natural quit rate among other populations, such as Chinese adult smokers (4.4 %) [15]. However, one-fifth of adult smokers made quit attempts in this study though they were not successful, underscoring the need for organized smoking cessation programs. Previous research has shown that making attempts to quit is a strong predictor of successful quitting [16].

Consistent with findings from previous research [17, 18], in this study, older (aged 40 or above) smokers were more likely to make quit attempts or quit successfully. This may be due to the fact that older smokers experienced more health problems and visited more healthcare professionals and received repeated advise to quit smoking, which encouraged them to make quit attempts or quit successfully [19, 20]. In a Hong Kong study, older smokers wanted to set an example by quitting smoking for the future young generation [21]. The findings that smokers from areas outside the capital city of Dhaka had made more quit attempts than smokers who were residing inside the city underscore the fact that the limited tobacco use prevention and cessation campaigns in the city are not reaching the target population to encourage them to try to quit. The high quit intention among residents living outside Dhaka may also suggest the low level of income among these residents that limits their ability to buy cigarettes and, hence, they may make greater efforts to quit.

In this study, higher income smokers (monthly income above BDT 10,000) made more successful quit attempts compared to those with a monthly income of less than BDT 5,000. This suggests the need to target low income smokers with cessation interventions. In a study by Haas et al. [22], a proactive smoking cessation outreach program was effective in reaching low income smokers with smoking cessation services.

Although in previous studies home [23] or workplace [24] smoking restrictions had a significant effect on quitting attempts or quitting, the effect of these variables was not significant in the current study. In this study, respondents not working indoors/outside the home were less likely to have made a quit attempt than those with no workplace restrictions on smoking. This difference in our findings may have been due to the wide acceptance of smoking in Bangladeshi families and the dominating nature of smokers in the family who are mostly male. This phenomenon underscores the lack of enforcement of smoking restrictions in the home or workplace which might allow smokers to continue to smoke without affecting their quitting intentions. In a cross-sectional study of a large national sample of U.S. residents, Farkas et al. found that living in smoke-free households and working in smokefree workplaces had significant impacts on cessation [24].

The finding that recent quitting efforts (tried to quit less than six months ago) were associated with increased quitting success compared to making an attempt six months ago or earlier, is of note. These findings are most likely due to differences in smokers’ readiness to quit, while recent quitters try again and smokers without a recent quit attempt may simply not be ready to quit currently and thus not try to quit. This suggests the need to encourage smokers to make frequent quit attempts that should also reinforce their confidence to quitting, regardless of perceived likelihood of success on that quit attempt. In a study by Borland et al. [14] study, motivational factors predicted quit attempts but not maintenance of smoking cessation.

Consistent with the findings from other studies [25], perceiving one’s health as good or excellent was positively associated with quit success. This is due to the fact that those who are in good perceived health status practice more healthy behaviors and possess greater perceived benefits of quitting smoking. This group of people is more aware of the health risks of smoking and has high perceived vulnerability [26], which might mediate their quitting success. This underscores the need to incorporate risk perception as a construct within the population-based smoking cessation intervention programs.

The study has several limitations. First, our analysis was limited to daily smokers only, therefore, the findings may not be applicable to non-daily smokers. However, according to Wave 1 data, 96.1 % of cigarette smokers/dual users smoke cigarettes daily and 94.4 % of dual users smoke bidis daily, thus our results are representative for the vast majority of smokers in Bangladesh. Second, we limited successful quitters to those who quit for more than 6 months at the time of data collection, but some people will relapse [27], and thus our analysis probably included some people who did not quit permanently. Third, we were not able to examine the impact of using pharmacological therapy (i.e. nicotine replacement therapy or medications), if any, because the information was unavailable in the data set. Studies have reported that the use of such therapy predict quitting [28]. However, given the fact that these products were not registered and unavailable in Bangladesh at the time of the study, the probability of using these products by the respondents was very low. Fourth, because of the self-reported nature of smoking status, smoking could be underreported due to the respondents’ wish to give a socially desirable response [29, 30]. However, there is evidence that self-reports and biochemical measurements of serum cotinine concentration provide similar estimates of smoking prevalence in the United States [31]. Fifth, most of the earlier literature reported nicotine dependence as a predictor for smoking cessation [19, 20, 32]. However, we were unable to include nicotine dependence as a predictor of quitting attempts or smoking cessation due to the way data was collected in Wave 1. We did try to compensate for this by using CPD (total number of cigarettes smoked per day) and perceived addiction as predictors, although they were dropped from the model. It might be the case that a single measure such as nicotine dependence would have been better in this case. Finally, data were collected by trained interviewers who followed written interviewer guidelines. Any difference between their understanding and explanation of the questions asked could result in bias in information collected. However, such bias was minimized by the periodical observation of interviews by the senior research team members and investigator’s bi-weekly meetings with the interviewers.

In conclusion, the present study identified several predictors of quitting attempts and successful quitting amongst adult Bangladeshi smokers. The promoters of smoking cessation services should consider these factors when designing comprehensive tobacco control initiatives and in service planning. This could be done by identifying smokers who are not making any quitting attempt or were more likely to be unsuccessful in their quitting attempt, and then promoting targeted interventions for these groups of smokers. Our results call for an integrated intervention approach to promote smoking cessation at the population level which should target both social environmental and individual level factors. Efforts to intervene in quitting behavior (i.e. attempt to quit and smoking cessation) will have limited effectiveness unless they take into account the social environmental context in which such behavior takes place.