Tobacco Induced Diseases
Research Paper
Perceptions and reasons for quitting and transitioning
between smoking and smokeless tobacco products: Findings
from four waves of the ITC Bangladesh survey
Daniel T. H. Chen1,2, Nigar Nargis3, Geoffrey T. Fong4,5,6, Syed Mahfuzul Huq7, Anne C. K. Quah4, Filippos T. Filippidis1
ABSTRACT
Transitions between different tobacco products are frequent among
tobacco users in Bangladesh; however, the reasons leading to such transitions
and why they quit are not well researched. The aim of the study is to examine
perceptions and reasons reported by tobacco users in Bangladesh to transition to
other products or quit.
METHODS Data from four waves (2009–2015) of the International Tobacco Control
(ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons
for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to
either start using other products or quit were analyzed with sampling weights.
The percentages of responses across waves were used to calculate the pooled
proportion data using a meta-analysis approach.
RESULTS Common reasonsig for respondents switching to other tobacco products
were influence of friends/family (73.8–86.0%), and curiosity (44.4–71.3%). The
perceived calming effect of smoking cigarettes and bidis (43.2–56.9%), and the
impression that bidis were less harmful (52.3%) and taste better (71.2%) were
major reasons for exclusive SLT users to switch products. Health concerns (16.5–
62.7%) and disapproval from friends/family (29.8–56.4%) were generally the
main reasons for quitting. For smoked tobacco users, doctor’s advice (41.6%),
package warning labels (32.3%), and price (32.4%) seemed to be the major
driving factors to quit.
CONCLUSIONS Results highlight that the reasons for switching between tobacco
products and quitting include social factors (e.g. friends/family) and (mis)
perceptions regarding the products. Tobacco control policy could emphasize
cessation support, increased price and education campaigns as key policies to
reduce overall tobacco use in Bangladesh. Data from four waves (2009–2015) of
the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated
data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130),
and SLT users (n=308) to either start using other products or quit were analyzed
with sampling weights. The percentages of responses across waves were used to
calculate the pooled proportion data using a meta-analysis approach.
INTRODUCTION
Tob. Induc. Dis. 2023;21(February):25
https://doi.org/10.18332/tid/159137
AFFILIATION
1 Public Health Policy
Evaluation Unit, School
of Public Health, Imperial
College London, London,
United Kingdom
2 Primary Care Epidemiology,
Nuffield Department of
Primary Care Health Sciences,
University of Oxford, Oxford,
United Kingdom
3 American Cancer Society,
Atlanta, United States
4 Department of Psychology,
University of Waterloo,
Waterloo, Canada
5 School of Public Health
Sciences, University of
Waterloo, Waterloo, Canada
6 Ontario Institute for Cancer
Research, Toronto, Canada
7 Country Office of World
Health Organization, Dhaka,
Bangladesh
CORRESPONDENCE TO
Daniel T.H. Chen. Public
Health Policy Evaluation
Unit, School of Public Health,
Imperial College London,
Room 319, Reynolds Building,
St. Dunstan’s Road, London
W6 8RP, United Kingdom.
E-mail: t.chen17@imperial.
ac.uk
ORCID ID: https://orcid.
org/0000-0001-9849-4966
KEYWORDS
smoking, smokeless tobacco,
dual use, poly tobacco use,
tobacco control
Received: 1 November 2022
Revised: 9 January 2023
Accepted: 12 January 2023
INTRODUCTION
Tobacco use, whether smoking or smokeless, is widely regarded as the leading
cause of preventable morbidity and premature mortality worldwide, particularly
Published by European Publishing. © 2023 Chen D.T.H. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International
License. (https://creativecommons.org/licenses/by/4.0/)
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Tobacco Induced Diseases
Research Paper
in low- and middle-income countries (LMICs)1,2. The
World Health Organization (WHO) estimated that in
2022 the South-East Asia Region accounted for more
than 22% of global smokers aged ≥15 years and was
home to 90% of the world’s smokeless tobacco (SLT)
users3. In South-East Asia, tobacco is consumed in
diverse forms, including smoked tobacco (ST), such
as cigarettes, bidis (a cheaper hand-rolled substitute
for cigarettes) and SLT, which covers a variety of
tobacco containing products that are used orally or
nasally without combustion3,4.
Although the proportion of tobacco users has
declined in most South-East Asian countries in
recent decades1, the growing tobacco market and the
variety of products used within this region have led
to concurrent use of multiple tobacco products and
transitions of use between products4-7. A large number
of tobacco users in South-East Asian countries
were persistent users and unwilling to quit despite
awareness of smoking hazards 8. This is especially
prominent in Bangladesh, one of the highest tobaccoconsuming countries in the region, where there were
37.8 million (35.3%) adults consuming tobacco
products (mainly cigarettes, bidis, and SLT)9 in 2017.
SLT is the most commonly used form of tobacco
in Bangladesh, accounting for a substantial portion of
overall tobacco use in the nation3. Available products
include betel quid with tobacco, zarda, gul, sada
pata, and khoinee, the majority of which are also
available in neighboring India and Myanmar10. As
with ST, SLT is found to be associated with adverse
health effects such as the development of cancer,
cardiovascular disease, hypertension, and adverse
pregnancy outcomes11,12. However, almost one in ten
(9.3%) tobacco users in Bangladesh is a dual user of
both ST and SLT, and one in eleven (8.8%) is a polyuser of two or more tobacco products6. Furthermore,
regardless of the country’s high health and economic
burden from tobacco use, quit ratios have remained
low, even though the population of former smokers
has increased in most South-East Asian countries in
recent years13,14.
Most studies, to date, have explored factors
associated with different tobacco use patterns and
quitting of smoked and smokeless tobacco7,13,15. Shared
traits of these users in the South-East Asian context
were that they were older, of lower education level, in
poverty, and higher intentions to quit13,15. However,
no studies have focused on users’ perceptions and
reasons for changes in their tobacco use behavior.
Within the context of Bangladesh, which represents a
substantial proportion of the region’s tobacco market,
it is essential to understand both person/product-level
factors (i.e. product knowledge, appeal, and perceived
harm, etc.) and contextual factors (i.e. policy
restrictions, affordability and product availability, etc.)
that influence the behavioral changes of these users for
tobacco product substitution/initiation and nicotine
seeking16. This will improve our understanding of the
factors that help to reduce overall use and lead to
quitting, and will inform policies on tobacco control
to maximize their impact. Such information can also
inform tobacco control policies in neighboring SouthEast Asian countries with similar tobacco use profiles.
In light of this, this study aimed to explore factors
of product transitions, reasons and perceptions about
quitting, using cohort data from adult smokers in
Bangladesh.
METHODS
Data and sample
Data come from all four waves of The International
Tobacco Control (ITC) Survey in Bangladesh. The ITC
Bangladesh Survey uses a nationally representative
probability sample of adult tobacco users and nonusers aged ≥15 years, recruited using a multistage
cluster sampling design since the first wave in 2009.
Participants were re-contacted in 2010, 2011–2012
and 2014–2015, to complete follow-up questionnaires.
The retention rates were fairly high, between 87.1%
and 94.0%. Details on survey interview procedures,
questionnaires, sampling, weighting, and information
on accessing the data are available on the ITC website
(https://itcproject.org/countries/bangladesh/) and
the technical reports17-20.
To explore respondent-level changes in tobacco
product use and reasons related to the transitions of
use among Bangladeshi adults throughout the surveys,
we used a balanced sample of respondents present in
all four waves yielding a total of 958 respondents that
were followed up since the first wave on perceptions
and reasons for tobacco use transition to other smoked
or smokeless products or to quitting. All tobacco userelated questions and data were retrieved from the
tobacco users’ survey, except for data on SLT use
in Waves 1 and 2, which were partially recorded
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Tobacco Induced Diseases
Research Paper
to the questions include the influence of friends/family;
people on media (cigarettes and bidis); curiosity; to
occupy time; the calming effects (cigarettes and bidis);
sign of sophistication (cigarettes); the packaging (bidis
and SLT); to reduce stress (SLT); to help quit tobacco
(SLT); the taste (bidis and SLT); and considered to be
less harmful (bidis and SLT). Respondents were asked
to respond ‘yes’, ‘no’, and ‘don’t know’ to the series of
questions in the relevant waves. Reasons for quitting
in the following waves were assessed by a number
of questions asking cigarette (Waves 2 to 3) and bidi
(Waves 2 to 4) smokers, or SLT (Waves 3 to 4) users,
whether any of the following reasons led them to
think about quitting: concerns for health; concerns for
others; fewer places to smoke; workplace restrictions
(SLT); set an example for children; doctor’s advice;
price; warning labels; friends/family disapprove; and
society disapproves (SLT). The responses to these
questions were ‘yes’, ‘no’, and ‘don’t know’.
It is worth noting that some questions were asked
only in certain waves. Therefore, data were analyzed
only among the waves for which data were available.
Supplementary file Table 1 shows a list of all the full
questions asked above in relation to perceptions and
reasons for transitions/quitting in the ITC Bangladesh
Survey.
and derived from the non-users’ surveys due to
questionnaire design.
Measures
Sociodemographic characteristics
Sociodemographic characteristics examined were
sex, age group (15–17, 18–24, 25–39, 40–54, and
≥55 years), residence (urban, rural), marital status
(married, single or living alone), and education level
(illiterate, 1–8 years or ≥9 years), and the CASHPOR
housing index as a proxy of socioeconomic status
(SES) (low, intermediate, high). The CASHPOR
index of housing conditions was originally constructed
by the ITC researchers and used as the basis for
stratification of the population by socioeconomic
status21.
Current tobacco use
In the current study, respondents were considered
as current tobacco users if they reported current use
of cigarettes, bidis or smokeless (SLT) products on a
daily, weekly, or less than weekly basis (e.g. monthly),
in the surveys. For users of smoking products, the
question was: ‘Do you currently smoke cigarettes/
bidis?’. Those who answered ‘yes’ (Wave 1) or ‘daily/
weekly/less than weekly’ (Waves 2, 3, and 4) were
categorized as current users. For the identification
of SLT users, the relevant question asked in Waves
1 and 2 was: ‘In the past 6 months, have you used
any smokeless products?’ (yes/no); and a response to
the statement ‘I generally use SLT at least weekly.’
(yes/no). Those who responded ‘yes’ to both, were
classified as current SLT users. In Waves 3 and 4,
the question was asked: ‘Do you currently use SLT?’,
with response options ‘daily’, ‘weekly’, or ‘less than
weekly’ indicating current use. However, those who
responded ‘no’ to all of the above, were classified as
non-users or quitters.
Statistical analysis
Descriptive data of the sample characteristics are
shown as weighted percentages and 95% confidence
intervals (CI).
The responses to questions around reasons for
transitions between products and quitting were
analyzed using repeated data from Waves 2 to 4,
with Wave 1 as the base wave, of the ITC Bangladesh
Survey. To obtain the pooled percentage of response
across all waves, the Stata command metaprop was
used to perform meta-analyses of the proportion
data22. This command offers proper techniques for
pooling percentage data using the random-effects
model and permits computation of accurate binomial
and score test-based confidence intervals when the
estimated proportion of the sub-group is between 0
and 122. All analyses were weighted using the ITC
sampling weights respective to the waves analyzed.
Weighted estimates are presented to ensure that
results are representative of the Bangladeshi
population of tobacco users.
Perceptions and reasons for quitting and transitions
A set of questions around perceptions and reasons
why exclusive cigarette, bidis, and SLT users in
Wave 1 transitioned to other tobacco products (either
exclusively or as dual/poly users of other products)
in subsequent waves, were assessed. Current tobacco
users were asked a series of questions about why they
started smoking cigarettes (Waves 2 to 4), bidis (Waves
2 to 4), or using SLT (Waves 3 to 4). Potential answers
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Tobacco Induced Diseases
Research Paper
Table 1. Sample characteristics of exclusive tobacco users at Wave 1, who transitioned to other products or to quitting at Waves 2–4 of the International Tobacco
Control (ITC) survey Bangladesh, 2009–2015 (N=958)
Characteristics
Exclusive cigarette smokers at Wave 1* (Males only)
Transition to
bidis
(N=110)
Transition to
SLT
(N=190)
Transition to
quitting
(N=220)
Exclusive bidi smokers at Wave 1* (Males only)
Transition to
cigarettes
(N=61)
Transition to
SLT
(N=47)
Transition to
quitting
(N=22)
Exclusive SLT users at Wave 1*
Transition to
cigarettes
(N=23)
Transition to
quitting
(N=263)
Transition to
bidis
(N=22)
Gender
Male
74.6 (65.8–81.5)
31.5 (18.3–49.1)
27.6 (22.6–33.3)
Female
25.4 (18.5–34.2)
68.5 (60.9–91.7)
73.4 (66.7–77.4)
Age (years)
15–24
16.6 (10.7–24.7)
11.7 (7.8–17.1)
20.7 (15.9–26.6)
3.7 (1.5–12.4)
2.5 (1.0–5.6)
5.2 (3.6–14.3)
7.9 (3.9–17.0)
2.1 (0.5–9.3)
10.8 (7.5–15.1)
25–39
28.6 (20.9–37.7)
48.7 (41.7–55.8)
43.2 (36.9–49.8)
21.7 (13.1–33.7)
10.3 (3.2–15.5)
6.0 (3.3–15.6)
17.5 (14.0–36.8)
3.1 (3.5–8.9)
33.9 (28.4–39.8)
40–54
30.4 (22.5–39.5)
19.5 (14.4–25.7)
18.1 (13.5–23.7)
41.8 (30.2–54.3)
49.4 (43.5–55.4)
15.8 (5.2–26.6)
64.3 (56.8–74.9)
6.8 (3.1–13.6)
33.3 (27.9–39.2)
≥55
24.5 (17.4–33.4)
20.2 (15.0–26.5)
18.0 (13.4–23.6)
32.9 (22.4–45.4)
37.8 (33.5–44.6)
73.1 (61.9–87.4)
10.3 (5.3–17.8)
88.0 (71.1–90.2)
22.0 (17.1–27.4)
Urban
18.3 (12.1–26.7)
19.2 (14.2–25.4)
27.4 (21.9–33.6)
7.4 (2.7–17.2)
9.1 (2.4–14.0)
9.3 (1.4–13.2)
21.2 (16.0–30.3)
4.7 (2.7–12.5)
24.5 (19.7–30.1)
Rural
81.7 (73.3–87.9)
80.8 (74.6–85.8)
72.7 (66.4–78.1)
92.6 (82.8–97.3)
90.9 (86.0–97.6)
90.8 (90.8–98.6)
78.8 (59.7–84.0)
95.3 (88.3–99.3)
75.5 (69.9–80.3)
Low
26.6 (19.2–35.6)
31.9 (25.6–38.8)
25.3 (20.0–31.4)
47.1 (35.1–59.4)
44.4 (29.1–50.8)
29.4 (24.4–40.5)
32.9 (23.2–50.8)
5.2 (3.5–18.9)
29.5 (24.3–35.3)
Medium
35.5 (27.2–44.9)
38.7 (32.1–45.8)
34.1 (28.1–40.5)
37.2 (26.1–49.8)
41.3 (36.5–50.9)
35.8 (29.2–46.6)
1.2 (3.6–9.6)
74.6 (65.2–84.8)
32.6 (27.2–38.5)
High
37.8 (29.3–47.2)
29.4 (23.4–36.3)
40.7 (34.4–47.3)
15.7 (8.5–27.1)
14.3 (5.7–20.2)
34.8 (28.4–45.7)
66.0 (48.2–76.0)
20.2 (12.7–30.9)
37.9 (32.3–43.9)
Illiterate
22.1 (15.3–30.8)
20.2 (15.1–26.5)
18.8 (14.2–24.5)
57.7 (45.2–69.3)
49.0 (33.2–55.0)
43.0 (34.9–53.2)
26.0 (18.9–34.7)
68.6 (54.6–74.4)
41.7 (35.9–47.7)
1–8
60.7 (51.3–69.4)
61.0 (53.9–67.7)
45.7 (39.3–52.3)
33.6 (23.0–46.2)
49.6 (33.8–55.6)
51.0 (41.6–60.2)
50.5 (25.7–65.0)
21.1 (15.6–35.4)
49.3 (43.4–55.3)
≥9
17.2 (11.1–25.4)
18.8 (13.8–25.0)
35.5 (29.4–42.0)
8.7 (3.5–18.8)
1.4 (0.5–10.0)
6.0 (2.2–15.3)
23.6 (7.4–32.5)
10.3 (23.5–33.5)
9.0 (6.1–13.1)
Married
82.3 (74.0–88.4)
81.8 (75.6–86.6)
78.56 (72.6–83.5)
95.5 (86.3–99.2)
97.4 (83.7–99.1)
94.81 (85.69–99.52)
73.60 (64.88–90.87)
72.52 (60.87–84.61)
81.37 (80.92–94.50)
Single/live alone
17.7 (11.6–26.0)
18.2 (13.4–24.4)
21.5 (16.5–27.4)
4.5 (0.9–13.7)
2.6 (1.1–6.3)
5.19 (2.61–14.31)
26.40 (19.13–35.12)
27.48 (15.39–39.13)
18.63 (14.31–23.89)
Residence
Housing index
Education level (years)
Marital status
*Weighted % with 95% CI. Blank: no data. N=520 for exclusive cigarette smokers. N=130 for exclusive bidi smokers. N=308 for exclusive SLT smokers. Male respondents only for exclusive cigarette and bidi smokers. SLT: smokeless tobacco.
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Tobacco Induced Diseases
Research Paper
In the current study, only male adults were included
for analyses for exclusive cigarette and exclusive bidi
smokers, considering the inadequate size of the female
smoker sample (the prevalence of cigarette and bidi
smoking among female adults was less than 2% in all
waves of the survey).
among those who were illiterate or received less
education (1–8 years) for most exclusive users
(≥76.4%). Additionally, most exclusive SLT users who
transitioned to smoking cigarettes were male (74.6%),
while those who transitioned to bidi use or to quitting,
were mainly female (68.5% and 73.4%, respectively).
RESULTS
Sample characteristics of respondents who
transitioned
The analytical sample consisted of 958 exclusive users
(520 male exclusive cigarette smokers, 130 male
exclusive bidi smokers, and 308 male and female
exclusive SLT users) recruited at Wave 1 and who
had transitioned to using other tobacco products
(either exclusively or as dual or poly users with other
products) or quit at Waves 2 to 4. The breakdown
of the numbers of respondents who transitioned in
subsequent waves is presented in Supplementary file
Table 2.
As presented in Table 1, most exclusive users who
transitioned to using other tobacco products were of
younger age (≤54 years), living in rural areas, and
married. However, an exceptionally large proportion
(73.1%) of exclusive bidi smokers who quit were of
older age (≥55 years). Within this cohort sample,
34.8–40.7% of respondents who quit were from
better housing conditions (higher SES). Percentages
of transitions to using other products were higher
Perceptions and reasons for quitting and
transition
Figures 1 to 4 present the pooled proportions of
perceptions and reasons for exclusive cigarette,
bidis, and SLT users in Waves 2 to 4, to start using
other products or to quit. Estimates with 95% CIs are
presented in Supplementary file Table 3. As shown
in Figure 1, the top three reasons for exclusive SLT
users to start smoking cigarettes were the influence
of friends/family (73.8%), curiosity (71.3%), and to
calm stress (56.9%). The reasons for exclusive bidi
smokers to start smoking cigarettes were generally the
same, the proportions were 77.3%, 56.4%, and 44.7%,
respectively, for the above reasons.
In Figure 2, the most common two reasons for
exclusive bidi and exclusive cigarette smokers to
start using SLT were friends/family (86.0% and
80.0%, respectively) and curiosity (46.8% and
45.4%, respectively). A larger proportion of exclusive
cigarette smokers started SLT because of the better
taste (37.9%), and because they thought that it
helps quit tobacco use (31.9%); 36.6% exclusive
Figure 1. Perceptions and reasons for exclusive bidis and smokeless tobacco (SLT) users to start using
cigarettes from Wave 2 (2009) to Wave 4 (2014) of the ITC-Bangladesh survey (pooled %)
N=23 for exclusive SLT. N=61 for exclusive bidis.
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Figure 2. Perceptions and reasons for exclusive cigarettes and bidis users to start using smokeless tobacco
(SLT) from Wave 3 (2011) to Wave 4 (2014) of the ITC-Bangladesh survey (pooled %)
Data available only for Wave 3 and Wave 4. N=25 for exclusive bidis. N=73 for exclusive cigarettes.
Figure 3. Perceptions and reasons for exclusive smokeless tobacco (SLT) and cigarette users to start using bidis
from Wave 2 (2009) to Wave 4 (2014) of the ITC-Bangladesh survey (pooled %)
N=100 for exclusive cigarettes. N=22 for exclusive SLT.
bidi smokers started SLT because they thought it is
less harmful, and 30.8% smokers considered that it
reduces stress. Only around 6% of exclusive cigarette/
bidi smokers started SLT because of the packaging
warning characteristics, which is ranked in last place
among all reasons.
In Figure 3, the top four reasons for exclusive
SLT users to start smoking bidis were friends/family
(82.9%), curiosity (71.5%), the impression that bidis
taste better (71.2%), and thinking that bidis are less
harmful (52.3%). Regarding exclusive cigarette users,
the major reasons to start smoking bidis were friends/
family (80.2%), curiosity (44.4%), calming of stress
(43.2%), to occupy time (30.1%), and the impression
that bidis taste better (26.7%).
Figure 4 describes the top reasons for exclusive
users to quit. For exclusive cigarette smokers, the
majority quit because of their concerns for health
(62.7%), disapproval from friends/family (56.4%),
followed by doctor’s advice and concerns for others
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Figure 4. Perceptions and reasons for exclusive cigarettes, bidis, and smokeless tobacco (SLT) to quit from
Wave 2 (2009) to Wave 4 (2014) of the ITC-Bangladesh survey (pooled %)
Wave 2 and Wave 3 data are only available for exclusive cigarette users. Wave 3 and Wave 4 data are only available
for exclusive SLT users. N=263 for exclusive SLT. N=22 for exclusive bidis. N=140 for exclusive cigarettes. # Asked as
society disapproves for exclusive SLT users. * Asked as work place restrictions for exclusive SLT users. § Pooled responses
for concerns of poor health, future health, and information about health.
(41.6% and 41.4%, respectively). The lowest ranked
reason for exclusive cigarette smokers to quit was
smoking bans (8.7%) in public places. As for exclusive
bidi smokers, the leading reported reasons were price
and health concerns (32.4% and 33.0%, respectively),
followed by disapproval of friends/family, concern
for others (25.2% and 24.6%, respectively), and
doctor’s advice to quit (23.2%). Only around 5% of
exclusive bidi smokers quit because of the warning
labels and smoking bans. For exclusive SLT users,
the majority quit because of their friends/family
(29.8%), and concerns about health (16.5%). About
10% quit because of the price and to set an example
for their children. Only 1.5% of exclusive SLT users
quit because of the doctor’s advice, which was the
least reported reason.
Promotion & Sponsorship (TAPS) in entertainment
media, and health education programs for awareness
of the harmful effects, have an essential influence on
the reported reasons for consumers to switch to, couse or discontinue using different tobacco products.
Friends/family were the most common social factor
for respondents switching to other tobacco products.
This is in line with established evidence emphasizing
that smoking behaviors are heavily impacted by peers
and others close to the respondents’ social contacts,
such as friends/family23. Such influence was found to
be more relevant in developing countries and Asian
15
cultures, where smoking is a social activity to develop
social networks and a tool for networking24. However,
social factors also act as a double-edged sword;
tobacco users are prone to switching products due
to peer influence and are also more inclined to quit
because of their disapproval23. Our study results show
that health concerns and disapproval from friends/
family were also reported as important reasons for
quitting. This may indicate that consumer education
and anti-tobacco campaigns may be an effective policy
to aid tobacco users to quit. A recent study identified
education and raising public awareness around antitobacco advocacies in Bangladesh, would stand as
DISCUSSION
Transitions between tobacco products are frequent
among tobacco users in Bangladesh. Social factors
were major reasons for quitting and transitioning.
Curiosity and misperceptions of tobacco products
were also drivers for users to switch between
products. Furthermore, tobacco control measures
such as price/tax, ban on Tobacco Advertisement
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The status of tobacco control policies appears
to be an important factor in influencing smoking
behaviors and tobacco use. There is clear evidence
that smoking restrictions in workplaces and public
places contribute to smoking cessation and reduce
tobacco use prevalence1. Large pictorial warnings
with strong messages are also proven to effectively
persuade smokers to quit smoking and increase
compliance with smoke-free laws31,32. However, amid
all responses, smoking restrictions and packaging
warning labels were generally not a frequently cited
reason for smokers to quit (particularly exclusive bidi
smokers).
Bangladesh has implemented various policies and
initiatives since the implementation of the Tobacco
Control Act in 2005. A series of policy amendments
have then been brought forward since the first ITC
Bangladesh Survey in 2009, including amendments
to the Act in 2013 (after Wave 3) and framing new
guidelines in 2015 (before Wave 4), to supersede
the original 2005 Act and bring the nation closer to
compliance with the WHO Framework Convention
on Tobacco Control (FCTC). It was not until 2013
that the list of smoke-free public areas was largely
expanded and the requirement imposed that all
tobacco products have warning labels that cover at
least 50% of the total display space on the packaging33.
Therefore, implementations of smoke-free laws and
regulations on warning labels may have been less
effective at the time when the surveys were conducted
and should be continuously reinforced to further
reduce tobacco consumption. However, up until now,
restrictions on tobacco use in the transport area and
public places, covers mainly smoked tobacco but not
SLT11,33.
Generally, in many LMICs, smoke-free policies are
often poorly implemented or enforced34. Social norms
in most homes in LMICs still permit smoking indoors.
Therefore, continuous reinforcements on expanding
smoke-free policies to cover all public places and
warning labels on alternative products, including
bidis and SLT, should be enacted to curb the growing
prevalence of use and to increase people’s awareness
of the harms of tobacco in Bangladesh.
Regarding price, it was considered a driving factor
for bidi smokers to quit but was not a frequently
cited reason for cigarette and SLT users. Despite the
increase in taxes and prices of tobacco products at the
a key opportunity against the culturally engrained
acceptance of tobacco and SLT use 25. Therefore,
educational campaigns should focus on the social
aspect of smoking behaviors.
Factors related with perceptions of harm, curiosity,
and mistaken belief of the calming effect or stressreducing properties of tobacco products, were the
major reasons for their transition between smoking
and smokeless products. This might be driven by
advertising strategies that promote the misleading
impression that SLT or bidis are more appealing
(taste better) than manufactured cigarettes 26 .
Previous studies also pointed out that curiosity about
tobacco products was highly associated with product
initiation27. Receptivity to tobacco industry advertising
and promotions may explain the high proportions of
respondents susceptible to smoking due to curiosity28.
This is an exceptionally a prominent reason why SLT
users in Bangladesh start using smoked products. As
noted in previous studies, this proportion increased
with additional exposure to tobacco marketing
throughout adolescence29. Educational campaigns
and TAPS bans of bidis and smoking products,
should be deemed critical policies and strengthened
to discourage people from consuming tobacco
products to reduce overall tobacco use prevalence in
Bangladesh30.
Furthermore, results indicate that doctor’s
advice accounted for a significant share of why bidi
and cigarette smokers quit. Doctors’ and health
professionals’ advice may be an effective strategy
to combat misinformation/misconception and may
have an impact on smoking behaviors, since many
smokers identify health concerns as a primary
reason for quitting. However, this was not the case
with SLT users. Our results show that only 1.5% of
SLT users received doctors’ advice to quit. Despite
the high disease burden associated with SLT use in
Bangladesh, access to doctors’ advice and cessation
services are not yet widely available for SLT users in
routine healthcare in Bangladesh11,25. To combat the
high prevalence of SLT use and the frequent transition
between smoking and smokeless products, authorities
should place a greater emphasis on integrating SLT
cessation services on treating nicotine dependence25
and provide support for high-risk populations (e.g.
rural female SLT users or older male SLT users
transitioning to cigarette use).
Tob. Induc. Dis. 2023;21(February):25
https://doi.org/10.18332/tid/159137
8
Tobacco Induced Diseases
Research Paper
time of the surveys from 2009 to 2015 in Bangladesh35,
cigarettes became more affordable as a result of the
rising economy and income growth4. Cheaper brands
and products are becoming increasingly popular,
which may explain why price was not reflected in the
respondents’ reasons for quitting. Taxation and price
increases have been shown to be powerful motivators
for reducing tobacco use and encouraging quitting1.
Particularly in LMICs, such as Bangladesh, where
taxation on tobacco products, especially on SLT,
remains low35, increasing taxes and prices of all types
of tobacco products is essential to ensure that the
affordability of tobacco products continues to decline.
To our knowledge, this is the first cohort study
exploring perceptions and reasons for transitions
between smoked and smokeless tobacco products
and quitting among adult smokers in Bangladesh.
The current study examined a range of factors that
were considered important by the respondents at
the time of the study. However, the landscape of
tobacco control policies in Bangladesh is changing.
The perceptions and reasons do not necessarily reflect
the actual effectiveness of various policies. Regardless,
these findings can be informative of future tobacco
control policies and could be incorporated into the
revision of current regulations in the country to
strengthen existing policies that appeal to the users’
concerns and motivations to quit. Furthermore, the
factors influencing decisions about transitions and
quitting may be shared among neighboring LMICs
with similar tobacco use landscapes.
self-reported and defined as 30-day abstinence; we
cannot verify that respondents remained abstinent
from smoking.
CONCLUSIONS
Influence of friends/family, curiosity, and misleading
beliefs regarding tobacco products play important
roles in the initiation and switching between products
in Bangladesh. On the other hand, health concerns,
friends/family disapproval, doctors’ advice, and
package warning labels were seen to be effective
reasons in encouraging cessation, especially for
smoking products. Although Bangladesh has made
notable progress in adopting various tobacco control
policies during the past decades, the implementation
of policies could be strengthened towards full
compliance with FCTC. Understanding initiation to
and transition between products could inform such
policies, for example in terms of taxation levels across
products, to reduce tobacco use in the country.
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CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for
disclosure of potential conflicts of interest. The authors declare that
they have no competing interests, financial or otherwise, related to the
current work. G.T. Fong and A.C.K. Quah report that since the initial
planning of the work The ITC Bangladesh Surveys were supported by
grants from the US National Cancer Institute (P01 CA138389), the
International Development Research Centre (IDRC Grant 104831-003),
and Canadian Institutes for Health Research (MOP-79551, MOP115016), and that they were supported by the Canadian Institutes for
Health Research (FDN-148477). Furthermore, G.T. Fong reports that
in the past 36 months he received a Senior Investigator Award from
Ontario Institute for Cancer Research (IA-004).
FUNDING
The ITC Bangladesh Surveys were supported by grants from the
US National Cancer Institute (P01 CA138389), the International
Development Research Centre (IDRC Grant 104831-003), and Canadian
Institutes for Health Research (MOP-79551, MOP-115016). GTF and
ACKQ were supported by the Canadian Institutes for Health Research
(FDN-148477). Additional support to GTF was provided by a Senior
Investigator Grant from the Ontario Institute for Cancer Research. The
authors alone are responsible for the views expressed in this article and
they do not necessarily represent the views, decisions or policies of the
institutions with which they are affiliated. The funding agencies did not
have any role in study design; collection, analysis, and interpretation
of data; writing the report; nor the decision to submit the report for
publication. No WHO funds are involved in developing this manuscript.
ETHICAL APPROVAL AND INFORMED CONSENT
The survey protocols and all materials, including the survey
questionnaires, were cleared for ethics by the Office of Research Ethics,
University of Waterloo, Canada (REB#15019 and REB#19862/30312);
Bangladesh Medical Research Council, Bangladesh (IRB BMRC/
ERC/2013-2016/1729 and IRB BMRC/ERC/2007-2010/1372).
DATA AVAILABILITY
In each country participating in the International Tobacco Control
Policy Evaluation (ITC) Project, the data are jointly owned by the lead
researcher(s) in that country and the ITC Project at the University
of Waterloo. Data from the ITC Project are available to approved
researchers, 2 years after the date of issuance of cleaned data sets by
the ITC Data Management Centre. Researchers interested in using ITC
data are required to apply for approval by submitting an International
Tobacco Control Data Repository (ITCDR) request application and
subsequently to sign an ITCDR Data Usage Agreement. The criteria for
data usage approval and the contents of the Data Usage Agreement are
described online (http://www.itcproject.org). The authors of this article
obtained the data following this application process. They did not have
any special access privileges. Others would be able to access the data in
the same manner.
AUTHORS’ CONTRIBUTIONS
DTHC and FTF conceived of the study idea and study methodology.
DTHC designed and conducted the analyses. DTHC wrote the first draft,
and FTF contributed to the development of the final version of the
manuscript. All authors contributed to reviewing and editing of the
manuscript, provided comments and accepted the final version. All the
authors were involved in the interpretation of data and revision of the
manuscript for critical intellectual input.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
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