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Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 699--704

Tobacco use among rural Nepalese women: Cross-sectional community based study

RB Khatri1, SR Mishra2, V Khanal3,  
1 Plan Nepal, Nepal
2 Public Health Foundation, Nepal
3 Curtin University, Australia

Correspondence Address:
S R Mishra
Nepal Public Health Foundation


INTRODUCTION: Tobacco use is responsible for a considerable number of morbidity and mortality in the world. Annually 14,000 deaths are attributed to tobacco use in Nepal. Despite having social acceptability of tobacco in Nepalese society, little has been known about tobacco use among rural women. The aim of this study was to report the prevalence of and examine the factors associated with tobacco consumption among women of reproductive age in a rural community of Dailekh district of Nepal. MATERIALS AND METHODS: It was descriptive, cross-sectional study carried out among women of reproductive age in the rural community of Dailekh district. A random sampling was used to obtain 110 women aged 15-49 years. RESULTS: More than two in five were tobacco user and among them 4 in 5 used smoked form of tobacco. This study showed early initiation of tobacco using habit (mean: 14.96 year) where 92% of participants initiated <19 years. Influencing factors for initiation of tobacco use was peer's pressure (95.8%), and respondents reported that they used tobacco to reduce stress (37.5%). CONCLUSION: Tobacco using pattern was high in reproductive age group women. Knowledge and perceptions on tobacco use were poor. Hence, an effective and appropriate community based awareness programs are required to discourage the use of tobacco.

How to cite this article:
Khatri R B, Mishra S R, Khanal V. Tobacco use among rural Nepalese women: Cross-sectional community based study.Indian J Cancer 2015;52:699-704

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Khatri R B, Mishra S R, Khanal V. Tobacco use among rural Nepalese women: Cross-sectional community based study. Indian J Cancer [serial online] 2015 [cited 2021 Oct 18 ];52:699-704
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Tobacco use is responsible for considerable number of morbidity and mortality in the world. It is one of the most important modifiable risk factor of most non-communicable diseases.[1] Globally, nearly 5 million persons die every year from tobacco related illness, with disproportionately higher mortality occurring in developing countries.[2] The global burden of deaths attributable to tobacco use each year is estimated to double from 5 million in 2005 to 10 million in 2020.[3],[4] Tobacco uses predict to be one of the major causes of death and disability adjusted life years in the 21st century. There is one death in every seven seconds. If the currents trends continue, there will be one death in every three seconds by 2030.[4]

It is estimated that one-third of the world's adults population, of whom 200 million female, are smokers. Approximately, 22% of women in developed countries and 9% of women in developing countries smoke, but because most women live in developing countries, there are numerically more women smokers in developing countries.[5]

Use of tobacco occurs in two forms; smoking tobacco and non-smoking tobacco. Use of non-smoking tobacco products is increasing in Nepal.[6],[7],[8],[9] Tobacco use and other high risk behavior are emerging as significant problems in Nepalese society as 14,000 annual deaths attributable to tobacco.[10] Tobacco use by women results in adverse effects on the individual, family as well as maternal and child health (fetal health).[3],[11],[12],[13],[14] Smoking is responsible for over 90% of all cases of lung cancer, 75% of chronic bronchitis and emphysema cases and nearly 25% of cases of ischemic heart disease. Chewing tobacco causes a significant proportion of oral cancer.[4]

Chronic non-communicable diseases represent 42% of all the deaths in Nepal.[15] This high rate may be attributed to current high tobacco use among men and women.[16] According to a study on tobacco economics of Nepal, the prevalence of tobacco use is higher in rural areas (45.8%) than in urban areas (34.4%). Among the three ecological regions, the prevalence of tobacco use is the highest in the high hills (68.2%), among illiterate persons (55.2%) and very high in illiterate boys (77.4%). In Nepal, 71.7% of women smoked in high hills while only 14.2% of women did so in Katmandu, the urban area.[6] A survey conducted in Dharan municipality of Eastern part of Nepal among women showed that 12.9% were cigarette smokers and 14.1% were smokeless tobacco users. Among smokers, 7.2% of those at the reproductive age (15-49 years) compared to 37.7% of those aged 50 years and above were smokers.[9]

Though there has been some studies based on nationally representative National Demographic Health Survey 2006[7] and other studies among women, students in other part of the country.[8],[9],[17],[18] But recent estimates of tobacco use among rural reproductive age female population is lacking. This study was conducted to determine the prevalence of and factors associated with tobacco use among reproductive age female population in a rural village of Nepal.

 Materials and Methods

A cross-sectional study was conducted in Bada Bhairab Village Development Committee of the Dailekh district during July 2011. Bada Bhairab is one of the 55 Village Development Committees (VDCs) in Dailekh district of Nepal. Total sample size of 110 was calculated based on reported prevalence of females smoking at 71.6% in the mountain region of Nepal.[11] A study from Eastern Terai reported a prevalence of 12.9% and 14.1% respectively for cigarette smoking and smokeless tobacco use among women.[9] Participants were selected using random sampling based on probability proportionate to population from each wards of the VDC. STAT Calculator of EPI Info 7[19] developed by Center for Disease Control and Prevention, Atlanta was used, considering at 10% allowable error for sample size estimation. Data was collected by using the structured questionnaire used in the previous study.[18] Considering the sensitivity of the issue, other member of the family was requested not to be present during the interview session. For this, a sample frame was prepared from the households list in Village Development Committee Office. From each family one women of reproductive age (15-49) was interviewed. This study obtained the ethical approval from the Ethical Review Board of Department of Community Medicine and Public Health, Maharajgunj Medical Campus, Tribhuvan University, Nepal.

Outcome variables of this study were prevalence and knowledge of smoking habits. The prevalence of the smoking was expressed in percentage. Regular users were those who used tobacco daily, occasional users were those used tobacco in the last 1-week and ever users those who used tobacco at any time of her age. Five attitude statements were asked in addition to what influenced them to start smoking, continue smoking:

Parents' tobacco using habit harms children Once starting tobacco use, it is difficult to stop Smoke harms the people sitting the nearby the smokers hazards of passive smoking The price of tobacco should be increased Marketing of tobacco by children should be banned.

Pre-tested questionnaire having socio demographic features of respondents, tobacco-using habits, factors influencing initiation of tobacco use and causes of tobacco use, knowledge and perceptions about tobacco use, tobacco use in family and among friends were asked. Here the tobacco product implies smoked and smokeless form of tobacco. Smoked form of tobacco includes smoked cigarettes and smoked other tobacco products such as Bidis, Hukka, Sisa and Pipes.[20] Smokeless tobacco encompasses a wide-range of tobacco products used orally or nasally.[21] Among these are chewing tobaccos, dry snuff, moist snuff, betel quid, guthka, zarda, tambaku and newer dissolvable tobacco products may be applicable to Nepalese contest.


Two-thirds (67.3%) of the respondents were Chhetri and 32.7% were Dalit. According to the Ethnic classification of Nepal, Chhetri belongs to the upper caste group and Dalit are the lower caste groups. Nearly half (49.1%) of the respondents were involved in agriculture followed 50.9% of housewives. Most of the respondents were illiterate (78.2%) while one in ten had secondary (12.7%) education. Majority of respondents were married (87.3%) and more than half (54.5%) were from nuclear families. Regarding the age group of respondents, less than a quarter of them were in below 19 years of age followed by 58.2% of respondents in 20-35 years of age [Table 1].{Table 1}

The prevalence of tobacco consumption was 43.6%. Smoked type of tobacco was mostly used (95.8%) [Table 2]. Mean age of the start of tobacco use was 15 years. Respondents reported that they started using tobacco as early as at age of 8 years and approximately 87% of the tobacco user started using tobacco at less than 19 years of age. Most of the respondents reported peer's pressure (95.8%) followed by the desire to experiment (4.2%) to be the influencing factors for initiation of tobacco use. Respondents reported that they use to relieve tension and stress of work (37.5% each) followed by enjoy (25%) [Table 2].{Table 2}

Higher percentage of tobacco non-user (72.7%) has heard about hazards of tobacco use during pregnancy than tobacco user. Respondents were asked total five statement regarding attitude towards of tobacco use. On an average, more than 65% of respondents agreed on each of five statements [Table 3]. They were asked to respond on the statement. Whether they agree, disagree and cannot say. On the statement about tobacco using habit effects children, more than half (54.17%) agreed comparison to 87.10% among non-user. Tobacco users (62.50%) has low perception of possible harmful risk of their tobacco using habits than non-users (90.32%). More than nine in 10 (90.32%) respondents among non-users agreed that passive smoking is harmful than users (83.33%). Six in 10 (60.50%) of tobacco users agreed that after starting tobacco use it is difficult to quit and 84.87% of non-users did so. More than two-thirds among users agreed that the price of tobacco should be increased compared to 58.33% among non-users. Slightly more than seven in ten users agreed (72.92%) that marketing of tobacco by children should be banned than non-users agreed (88.71%) table not shown.{Table 3}

Slightly higher percentage of Dalit women (44.4%) was using tobacco %) than Chhetri women (43.2%). High percentage of respondents working in the agriculture sector used tobacco (55.6%) followed by household works (32.1%). More married women were tobacco users (47.9%) compared to unmarried women. Similarly, illiterate women (51.2%) were using tobacco more than women having primary education (20%). More than a half of respondents in more than 35 years age group were tobacco user. Lowest tobacco use was reported among the women in less than 19 years age group (12.5%). Fifty percent of respondents who were living in the nuclear family were tobacco user followed by Joint/extended family (36%) [Table 4].{Table 4}

Multiple logistic regressions showed that age, occupation and knowledge on ill-effect of smoking on children remained statistically significant after controlling for education status of the participants. Higher age (>35 years) participants were less likely (odds ratio [OR] 0.136; 95% confidence interval [CI] [0.025-0.743]) to be smokers than their <19 years counter parts. The participants who were from agriculture occupation were less likely (OR 0.378; 95% CI [0.149-0.957]) to be smokers than those who were housewives. Surprisingly, the participants who disagree that smoking have ill effects on children if parents smoke were less likely (OR 0.195; 95% CI [0.073-0.519]) to be smokers than those who knew the ill-effects of parent's smoking [Table 4].


The aim of this study was to determine the prevalence and type of tobacco use among women of reproductive age in Rural community of Dailekh district and identify the factor that influence tobacco use.

More than two in five were tobacco user and they mostly used smoked form of tobacco. This study showed that the majority of the participant started smoking in their younger age (<20 years) (mean age of start: 14.96 year). One study from Nepal found median age of tobacco use among college students to be low (median age of start: 16 years).[17] Tobacco using habit started at an early age due to peer influence and curiosity. Besides that, smoking habit of family members as such husband may have increased likelihood of smoking in women. This increases risk to her own health, when she is exposed to second hand smoke. This also has an effect to the fetus if she is pregnant. Three major reasons were evident as reported to initiate tobacco use: Peer pressure, belief that tobacco reduces stress and having a family member or friends who use tobacco. Alarmingly, about two-third of respondents had no knowledge about the hazards of tobacco use during pregnancy.

This study showed a high prevalence of tobacco use (46.9%) among women of 20-35 years of age. This is higher than finding previous study from Dharan of Nepal where 27% of reproductive age women used tobacco,[9] and still higher (19.6%) than nationally representative survey reported prevalence in 2006.[7] Mid-Western Development region of Nepal where the study district lies has one of the largest smoking prevalence in Nepal.[22],[23] Contrary to the previous study where 8% of respondents started to use tobacco before the age of 19 years, a higher proportion of respondents in this study had started tobacco use before 19 years.[8] There are a number of factors that can be attributable to such as higher status of tobacco use. Firstly, the study location is one of the least developed areas of Nepal. It has limited access to information such as television and print media. In such situation, it is highly likely that tobacco prevention efforts may not have reached to women. The women literacy is only 53% and over all socio-economic status of population is low.[24] Other studies report that there is high tobacco use among the people of low literacy, low socio-economic status and among disadvantaged castes.[5],[25] In rural communities of Nepal, including the Dailekh district, tobacco is still socially accepted and offered to guest in many occasions. While there has not been any researches about cultural practice of tobacco use in Nepal, literatures from India describes it to be culturally accepted in some communities in Maharashtra.[26] The strict enforcement of tobacco Control and Regulatory Act 2010 is necessary to ban smoking in public places. Encouraging smoke-free homes by awaking people about the health consequences of tobacco use and secondhand smoke is necessary to reduce such a high smoking prevalence.[8]

High percentage of women in agriculture (55.6%), ever married women (47.9%), and women who are illiterate (51.2%) had tobacco using habits. There was no caste based difference in tobacco using habit among Dalit and Chhetri women.

Tobacco non-user agreed comparatively more on statements about respondents' attitude toward tobacco use than among tobacco user. A marginal difference was seen among tobacco user and non-user on the statement effects of passive smoking. Passive smoking has many adverse effect on maternal and child health.[27],[28],[29],[30] This poor attitude may have been contributed by low level of literacy of the respondents as the majority of tobacco user were illiterate.[6] The educational curricula in Nepal do not target messages to aware people about hazards of tobacco use. Amidst of aggressive branding of tobacco products in non-electronic media, there is no such the awareness activities by Department of Health Services, Ministry of Health and Population (MoHP).[7],[31] This is largely because of lack of implementation Tobacco Product (control and regulatory) Act 2010 and inadequate enforcement framework convention for tobacco control in Nepal.[32] Use of tobacco by women within the family has adverse effect on herself, family members, her children and also the fetus if she is pregnant. The adverse birth outcome of smoking during pregnancy and childhood illnesses are reported in many studies.[3],[12],[13],[33]

Multiple logistic regressions showed that age, occupation and knowledge on ill-effect of smoking on children remained statistically significant after controlling for education status of the participants. Women at higher age (>35 years) participants were less likely to be smokers than their <19 counter parts. This may be attributed to the fact that smoking starts in early adolescent and peak at around adulthood. Smoking habits falls slowly afterward owing to increased sensitization of health consciousness and perceived risk of diseases and morbidities.[7]

The participants who were from agriculture were less likely to be smokers than those who were housewives. Nepal being largely a rural country, women work hours in agriculture than in household work. They have hardly any free time in a day. This is because these women who worked in agriculture have to work in household work as well. Hence, comparatively housewives have less work to carry out and much free time to enjoy than the agriculture workers. Being in the home means better access to tobacco products. In addition to this, loneliness in home and stress of household works may contribute rural women to use tobacco products more in home.[34]

Surprisingly, the participants who disagree that smoking have ill-effects on children if parents smoke were less likely to be smokers than those who knew the ill-effects of parent's smoking. Partly, this may be due to the high number of illiterate nonsmokers. This research has a higher percentage of smokers in adult (20-35 years) group. Smokers are often subjected to anti-smoking message than non-smokers. By this age, smokers might have perceived risk of tobacco smoking and started thinking of leaving this habit.[35] The tobacco control programs should target non-smokers who have risk of tobacco using habits. The non-smokers can also be powerful change agents in society to say “no to tobacco.”

Awareness program should focus girls from teenage. Early age of tobacco use should be viewed as a public health problem. This not only increases the risk of cancers but also poses a risk to motherhood. This includes risk of acute respiratory infections, asthma, conjunctivitis and eczema in children, fetal growth restriction and other poor obstetric outcomes in pregnant women.[13],[36],[37],[38],[39] As there is no any non-communicable disease control program in Nepal. MoHP do not specifically target reduction of non-communicable diseases and its risk factors in Nepal.[31] Tobacco product (control and regulatory) Act 2010 has prohibited the sell or distribution of tobacco products to pregnant women and children below 18 years of age.[40] By this act, smoking and tobacco consumption in public places is prohibited. However, the level of implementation of this act is still questionable. But in the context of rural village, many women have little access to such tobacco prevention messages and less access to participate urban focused, media based tobacco control program. Therefore, rural focused community based organization led drama, street programs during local festivals and fests are necessary to reach the majority of rural women in the Dailekh and similar settings of Nepal.

Tobacco prevention program should give emphasis on reducing the use of tobacco during pregnancy, in the family and public places. Community based educational programs focusing on hazard during pregnancy should be channeled through behavioral change communication activities utilizing the occasions such as women groups and other gatherings, visits at health institutions, primary health outreach clinic. A further step to increase awareness is banning tobacco use, based on the local level initiatives, in the public places such as health facilities, schools, temples and markets. Mobilization of mothers groups and local youth clubs may impact positively on such efforts. Furthermore, awareness programs for family members, husbands would helpful to discontinue tobacco use and to be create a supportive environment within a family to leave tobacco using habit.

This study is one of the few studies among tobacco use among Nepalese women particularly from the rural areas. A number of limitations need to be taken care of while interpreting the result from this study. Small sample size, small study area and cross sectional nature of study limits generalizability to the entire country. Nevertheless, the current finding does suggest some important areas that tobacco prevention effort should consider in future.


A high percentage of women were tobacco user. Most of them initiated tobacco use at early adolescent age. Mostly disadvantaged, illiterate, housewives and women working in agriculture were using tobacco. Peer's pressure was strong influencing factor for the initiation of tobacco use. This study suggests for further implementation of tobacco prevention programs among Nepalese women of reproductive age.


The authors would like to express appreciation of time and information provided by the respondents. We are also thankful to Dr. Bandana Pardhan for her valuable guidance during the research period.


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