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| REVIEW ARTICLE |
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| Year : 2012 | Volume
: 49
| Issue : 4 | Page : 342-346 |
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Prevalence of smokeless tobacco use among adults in WHO South-East Asia
DN Sinha1, PC Gupta2, CS Ray2, PK Singh1
1 World Health Organization, Regional Office for South-East Asia, New Delhi, India
2 Healis Sekhsaria Institute of Public Health, Mumbai, Maharashtra, India
| Date of Web Publication | 26-Feb-2013 |
Correspondence Address:
D N Sinha
World Health Organization, Regional Office for South-East Asia, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-509X.107726
Smokeless tobacco (SLT) use is an understudied problem in South-East Asia. Information on SLT use among the adult population was collected from various available sources. SLT use prevalence varies among countries in the region. The prevalence of SLT use is known for all countries at national level in the region with the exception of Bhutan and DPR Korea. For Bhutan, data pertains to Thimphu only. There is no available data on SLT use for DPR Korea. Using all available data from Bhutan, India, Myanmar, Nepal, and Sri Lanka, SLT use was found to be higher among males as compared to females; however, in Bangladesh, Indonesia, and Thailand, SLT use was higher among females as compared to males. Among males, prevalence of SLT use varied from 51.4% in Myanmar to 1.1% in Thailand. Among females, the prevalence of SLT use varied from 27.9% in Bangladesh to 1.9% in Timor-Leste. The prevalence also varies in different parts of countries. For instance, the prevalence of current use of SLT in India ranges from 48.7% in Bihar to 4.5% in Himachal Pradesh. In Thailand, prevalence of current use of tobacco use varies from 0.8% in Bangkok to over 4% in the northern (4.1%) and northeastern (4.7%) region. Among all SLT products, betel quid was the most commonly used product in most countries including Bangladesh (24.3%) and Thailand (1.8%). However, Khaini (11.6%) chewing was practiced most commonly in India. Nearly 5% of the adult population used tobacco as dentifrice in Bangladesh and India. SLT is more commonly used in rural areas and among disadvantaged groups. Questions from standard "Tobacco Questions for Surveys (TQS)" need to be integrated in routine health system surveys in respective countries to obtain standardized tobacco use data at regular intervals that will help in providing trends of SLT use in countries.
Keywords: Adults, chewing, tobacco as dentifrice
How to cite this article:
Sinha D N, Gupta P C, Ray C S, Singh P K. Prevalence of smokeless tobacco use among adults in WHO South-East Asia. Indian J Cancer 2012;49:342-6 |
| » Introduction | |  |
WHO South-East Asia region is home to 90% of global smokeless tobacco (SLT) users as over 250 million of such users live in the region. Myriad forms of SLT products are used in different parts of the Region. This paper presents prevalence of SLT use among adults at national and sub-national levels from available sources.
Data source and extent of information
National level comparable data on the prevalence of SLT use among adults and its different dimensions are available for the age group 15 years through the Global Adult Tobacco Survey (GATS) for Bangladesh (2009), [1] India (2009-10), [2] Indonesia (2011), [3] and Thailand (2011) [4] . The STEPS NCD risk Factor Survey (STEPS) has data on the prevalence of SLT use among adults aged 15-64 years at the national level for Nepal [5] and Myanmar [6] and for Thimphu in Bhutan. [7] Data on SLT use prevalence from Maldives and Timor-Leste are obtained from secondary analysis of Demographic Health Surveys (DHS) data. [8],[9],[10]
Prevalence of smokeless tobacco (SLT) use among adults at the national level and genderwise variation
Based on the available information, prevalence of SLT use in the region varies from 1.1% in Thailand to 51.4% in Myanmar among males, while it ranges from 1.9% in Timor-Leste to 27.9% in Bangladesh among females. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Indonesia, Maldives, Thailand, and Timor-Leste shows a low level of SLT use in the region [Figure 1]. | Figure 1: Prevalence of smokeless tobacco use among adults (current users) in the South-East Asia region
Click here to view |
The prevalence is generally higher among men than women. In Bhutan, India, Maldives, Myanmar, Nepal, and Sri Lanka, SLT use is higher among males as compared to females, whereas in Bangladesh, Indonesia, and Thailand, SLT use is higher among females than in males [Figure 1].
Socio-demographic associations
Prevalence of SLT use increases with age. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] SLT use is higher in groups with less education and lower socio-economic groups in Bangladesh and Thailand [Table 1]. This is noticed in Nepal [11] and India [12] as well. | Table 1: Current use of smokeless tobacco and smokeless tobacco products in adults aged 15 years and above in Bangladesh, India and Thailand, by socio-demographic characteristics, 2009-2011[1,2,4]
Click here to view |
SLT use is more commonly practiced in rural areas in many countries of the region [Figure 2] and [Table 1]. [1],[2],[3],[4],[6] | Figure 2: Current users of any smokeless products, by selected member states in South-East Asia region
Click here to view |
Prevalence of SLT use among adults at sub-national level
There is a wide variation in SLT use prevalence at sub-national level in most of the countries in the region. In India such variation is very wide. The India Global Adult Tobacco Survey (2009-10) showed that nationally, over a quarter of Indians aged 15 and above use SLT products (26%), but prevalence ranges from about 5% in Himachal Pradesh and Goa to nearly 50% in Bihar, Jharkhand, and Chhattisgarh. [2] The proportion of men using SLT was the highest in Bihar (62.2%) and lowest in Goa and Pudducherry (6%). Women in the northeastern states of Mizoram (49%) and Tripura (43.5%) used SLT products the most, while there was almost a negligible use of SLT among women in Punjab (0.6%) and Himachal Pradesh (0.2%) [Figure 3]. [2]
In Sri Lanka, Indonesia, and Nepal, SLT use prevalence among adults in some sub-national populations is quite different from national estimates. In 2010, a sub-national study conducted in six provinces of Indonesia showed that the prevalence of betel quid use was 10.4% among males and 31.7% among females. [13] In Nepal, SLT use prevalence varied from nearly 10% in the mid-western region to nearly 20% in the eastern region. [11] In Thailand, prevalence of current use of SLT varied from 0.8% in Bangkok region to 4.7% in the northeastern region (GATS 2011). [4] | Figure 3: Percentage of adults aged 15 and above in India who are current users of any smokeless products, by their state
Click here to view |
Prevalence of specific SLT product use
In Bangladesh, among all SLT products, the prevalence of the use of betel quid with tobacco was the highest (24.3%), followed by gul (oral snuff) (5.3%), sadapatta (1.8%) khoinee (1.5%), and others (1.4%) [1] [Table 1]. In India, [2] khaini was used by 11.6%, gutka or similar mixtures (areca nut, lime, and tobacco) by 8.2%, betel quid with tobacco by 6.2%, powdered tobacco products such as oral snuff by 4.7% and all other SLT products by 4.4% [Table 1]. In Thailand, betel quid with tobacco was used by (1.8%) followed by snuff by mouth (1.3%), chewing tobacco (0.2%), and snuff by nose (0.2%) [Table 1]. [4]
Khaini, chewing was more common among men residing in the Terai region of Nepal as reported in the DHS of 2006. [14]
In Nepal and Sri Lanka, betel quid with tobacco is a common form of SLT use. [13]
In Indonesia, SLT use is practiced most as betel quid chewing, and is most common among women, while fire-cured snuff is used only by some elderly. Tobacco, chewed with betel quid is called sirih (a mixture of betel, areca nut, lime, and some flavorings). Betel quid chewing in Indonesia is mostly practiced in rural areas and among older people. [15],[16] The Myanmar STEPS survey of 2009 showed that among SLT users (both men and women) use of oral snuff, nasal snuff, chewing tobacco, and betel quid was about equally distributed. [6]
Prevalence of SLT products by states in India and regions in Thailand
Chewing of betel quid with tobacco across states of India varies widely, the lowest being in Himachal Pradesh (0.6%) and the highest in Tripura (33%). The prevalence was reported <1% in Haryana, Uttrakhand, Chandigarh, and Himachal Pradesh and over 25% in Manipur, Mizoram, Nagaland, and Tripura. The prevalence of khaini use ranged from <2% in the southern states of Tamil Nadu, Puducherry, and Goa to >25% in the northern states of Bihar and Nagaland/Manipur/Mizoram. [2] The prevalence of gutka chewing varied from <1% in Tamil Nadu, Puducherry, and Goa to 20% in Bihar, Madhya Pradesh, and Arunachal Pradesh. Oral tobacco use was less prevalent (5%) as compared to other SLT products, except that in Odisha, Jharkhand, Maharashtra, and Chattishgarh, the prevalence was higher than the national average. In addition, there is a wide assortment of other smokeless products consumed locally. About 4% of Indians use other types of SLT products. While Punjab, Chandigarh, and Haryana present very low prevalence of use, Arunachal Pradesh, and Bihar display rates >20%. [2]
The prevalence of betel quid chewing, and snuff taking in Thailand varied from 0.2% in Bangkok to 3.5% in the northern region and from 0.4% in Bangkok and the central region to 2.4% in northeastern region, respectively (GATS 2011). [4]
Dual/mixed tobacco use
When someone is a smoker and also uses SLT, this person's use of tobacco is called dual or mixed use. Dual users may have a harder time quitting tobacco than people who only smoke or only chew. Among all male tobacco users in Bangladesh, India and Myanmar, dual tobacco use was 22.4%, 19.4%, and 31%, respectively; while while the proportions were much smaller in Indonesia (0.1%) and Thailand (1%). Among females, dual use was practiced by a very small proportion of tobacco users in Bangladesh (2.6%), Thailand (3.3%), Indonesia (3.7%), and India (5.3%), but it was high in Myanmar (13%) [Figure 4]. | Figure 4: Percentage distribution of current tobacco users by type of tobacco use and gender among adults aged 15 years and above in Bangladesh, India, Indonesia, Myanmar, and Thailand
Click here to view |
Women tobacco users in Bangladesh, India, Myanmar, and Thailand were more likely to use SLT than to smoke. However, in Indonesia, women were more likely to smoke than to use SLT. Men tobacco users in Bangladesh, Indonesia, and Thailand were more likely to smoke [Figure 4].
Trends in adult prevalence
Precise data for computing trends of SLT use in countries are not available. It can, however, be observed that a substantial decrease in the use of SLT products has occurred in Thailand and Indonesia during the second half of the 20 th century, although, during the same period, cigarette smoking increased significantly. The trend in the decrease of SLT use in Thailand continues, as revealed by GATS 2009 and 2011 data. An increase in prevalence of SLT has been seen in three successive WHO Sentinel Tobacco Surveys in Myanmar. [17]
Challenges
There are limitations and gaps in information. DHS involving the use of household informants are much easier to administer than those based on individual self-reporting, the prevalence is underestimated especially for younger age groups. DHS only collects information on chewing tobacco and snuffing in the age groups of 15-49/15-54 years. DHS does not collect data on the type and amount of tobacco consumed, which remains one of the weaknesses of this survey. The prevalence of SLT use has not been reported so far in published DHS reports. [8],[9],[14],[18],[19],[20],[21] Information through secondary data analysis on prevalence of chewing among adults aged 15-49 years is available only for India (2006) [12] and Nepal (2006). [11] Special analyses had to be undertaken to extract this information from DHS data series. STEPS include different age groups. It needs to align with the 15+ age group to better address the tobacco epidemic in adolescents and adults.
| » Conclusions | | |
SLT is used in all countries of the South-East region (except DPR Korea) and is high in Bangladesh, India, Myanmar, Nepal, and Sri Lanka. High prevalence of chewing SLT products in Member States of the Region, especially among disadvantaged groups calls for urgent intervention targeting the poor sections of the population.
The public policy implications of SLT use in the region are two-fold. Research on tobacco use needs to be considerably systematized with the use of more consistent definitions of tobacco consumption and study methodologies. More rigorous comparable prevalence studies using standard "Tobacco Questions for Surveys (TQS)" [22] over time are needed to establish the trends in prevalence and evaluate the effect of different public policies pursued to control tobacco use. Secondly, future studies should investigate the prevalence rates of different tobacco products (both smoking and chewing tobacco) separately, as the economic and health effects of different products vary considerably.
| » References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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