Tobacco Knowledge, Attitude and Practices among Adults attending Outpatient Department of Public Hospitals in Bangladesh Palash Chandra Banik Senior Lecturer Department of Noncommunicable Diseases Bangladesh University of Health Sciences (BUHS) January 19, 2016

Background Tobacco smoking is a major cause of preventable morbidities and mortality Tobacco use results in the deaths of nearly 6 million people per year If current trends continue, by 2030 tobacco will kill more than 8 million people per year Tobacco smoking rates have decreased in many developed countries in the last 20 years, they remain high in developing nations

Background... (cont’d) Hospitals are no smoking zones in Bangladesh but sometimes this law is broken by the peoples Adults attending a hospital outpatient department can be directly or indirectly affected by tobacco related harms The knowledge, attitudes and practices among the adults attending a hospital has not yet been assessed

Objectives General objective To assess the tobacco knowledge, attitude and practices among adults attending Outpatient Department (OPD) of public hospitals in Bangladesh Specific Objectives To identify the practice regarding tobacco use among the study subjects To assess the knowledge of tobacco consumption among the study subjects To assess the attitude towards tobacco use among the study subjects To find out the relationship between the knowledge and practice with selected socio-demographic variables

Methodology Study design: A cross-sectional study Study areas: Outpatient departments of 07 government hospitals: Sher-e-Bangla Medical College Hospital, Barisal Chittagong Medical College Hospital, Chittagong Dhaka Medical College Hospital, Dhaka Khulna Medical College Hospital, Khulna Rajshahi Medical College Hospital, Rajshahi Rangpur Medical College Hospital, Rangpur Sylhet MAG Osmani Medical College Hospital, Sylhet Study period: March to November 2015 Study population: Adults aged 15 to 65 years

Methodology… (cont’d) Sample Size: By using the software Power Analysis and Sample Size System (PASS), a total of 1140 sample was calculated Sampling technique: Hospitals were selected by purposive sampling Samples (patients and their relatives) were selected through convenient sampling technique Data Collection tools and technique: Semi-structured pretested questionnaire Face-to-face interview was conducted for data collection

Methodology… (cont’d) Data analysis: Univariate analysis: number, percentage, mean, median, standard deviation Bivariate analysis: Chi-square test Multivariate analysis: Binary logistic regression has also been done as multivariate analysis Ethical consideration: Informed consent was taken before interview session Ethical clearance was obtained from Ethical Review Committee (ERC) of Bangladesh University of Health Sciences (BUHS)

Results

Socio-demographic characteristics Table 1: Socio-demographic characteristics of the study subjects (n=1200) Variables Number (n) Percentage (%) Sex Male 682 59.8 Female 458 40.2 Age (years) 15-24 328 28.8 25-44 574 50.4 45-64 230 20.2 65 and above 8 0.7 Mean ±SD 33.0 ±12.1 Education Illiterate 146 12.8 Less than primary 122 10.7 Primary complete 331 29.0 SSC completed 195 17.1 HSC completed 217 19.0 Graduation and above 129 11.3

Socio-demographic characteristics ...(cont’d) Table 1: Socio-demographic characteristics of the study subjects… (cont’d) Variables Number (n) Percentage (%) Occupational status Employed 198 17.4 Unemployed 61 5.4 Business 138 12.1 Farmer 78 6.8 Laborer 76 6.7 Students 212 18.6 Homemaker 343 30.1 Others 34 3.0 Area of residence Urban 535 46.9 Semi urban 75 6.6 Rural 530 46.5 Monthly Income (BDT) Median 15000

Use of tobacco consumption Table 2: Prevalence of tobacco consumption (n=1140) Tobacco use Number (n) Percentage (%) Current users 400 35.1 Former users 75 6.6 Never users 665 58.3

Use of tobacco consumption...(cont’d) Figure 1: Types of tobacco product used by the tobacco users

Figure 2: Type of smoking tobacco (n=228) Use of smoking tobacco Figure 2: Type of smoking tobacco (n=228)

Use of smoking tobacco (cont’d) Figure 3: Frequency of cigarette/ bidi smoke (n=228)

Use of smoking tobacco (cont’d) Table 3: Number of sticks, age of initiation, money spent for smoking (n=228) Variables Number (n) Percentage (%) Number of sticks/per day <10 175 76.8 10-20 21 9.2 >20 32 14.0 Mean ±SD 9.3±8.5 Age of first initiation (years) <20 160 70.2 68 29.8 19.5±4.5 Money spent/day (TK.) <100 180 79.2 100-200 13.7 200-300 13 5.8 >300 3 1.3 70±79.8

Use of smoking tobacco (cont’d) Table 5: Reason(s) of smoking among the respondents Reasons of smoking Percent (%) of Cases Helps me to feel stress free 43.9 Keep me away from family problem 7.4 Keep me away from personal problem 18.0 It is easily accessible to me 4.2 Peer pressure 36.0 Other 40.7 Base 190.0 Multiple responses

Use of smokeless tobacco Figure 4: Type of smokeless tobacco used by the users (n=172)

Figure 5: Frequency of SLT consumption Use of smokeless tobacco (cont’d) Figure 5: Frequency of SLT consumption

Use of smokeless tobacco (cont’d) Table 6: Age of initiation, money spends by the respondents for SLT Variables Number (n) Percentage (%) Age of first tried SLT (years) <26 129 61.4 >26 81 38.6 Mean ±SD 26.0±9.7 Money spend /day for SLT <100 182 86.7 100-200 17 8.1 200-300 8 3.8 >300 3 1.4 56.1±77.5

Knowledge about tobacco related health hazard Figure 6: Respondent’s knowledge of tobacco related health hazard

Knowledge of tobacco related health hazard (cont’d) Table 7: Knowledge on types of health hazard caused by tobacco consumption Types of health hazard Percent (%) of Cases Respiratory problems 85.8 Heart Disease 26.9 Stroke 17.4 Cancer 79.2 Causes harm to fetus 2.8 Others* 31.9 Base 1106 Multiple responses

Knowledge of tobacco related health hazard (cont’d) Table 8: Others knowledge about tobacco consumption Variables Number Percent (%) Tobacco cause addiction (n=1140) No 128 11.2 Yes 1012 88.8 Which one is more addictive (n=1012) Smoking tobacco 482 47.6 Smokeless tobacco 149 14.7 Both 286 28.3 Don’t know 95 9.4 Which one is more injurious to health? Smoking 500 43.9 172 15.1 398 34.9 70 6.1 Danger of smoking increases with dose 45 3.9 1095 96.1

Attitude towards tobacco use (cont’d) Table 9: General Attitude towards tobacco use (n=1140) Statements Disagree (%) Neutral (%) Agree (%) Smokers have more friends than non-smokers 12.8 5.2 82.0 Tobacco consumption is less harmful than illegal drug use 33.0 17.5 49.6 Smoking is a waste of money 0.9 0.7 98.4 Smoking helps to feel stress free 51.6 12.5 35.9 Smokers seems to be smarter 78.3 8.3 13.3 Smoking helps to be creative or think diversely 68.7 16.5 13.8 Sales of cigarettes should be outlawed 91.6 2.0 6.4

Sociodemographic variables Use of tobacco products Results... (cont’d) Table 11: Relationship between tobacco consumption with Socio-demographic variables Sociodemographic variables Use of tobacco products Chi square (χ2) p-value No n(%) Yes n(%) Sex Male 386 (56.6) 296 (43.4) 51.5 0.001* Female 354 (77.3) 104 (22.7) Age group 15-24 years 265 (80.8) 63 (19.2) 71.2 25-44 years 362 (63.1) 212 (36.9) 45-64 years 110 (47.8) 120 (52.2) 65+ years 3 (37.5) 5 (62.5) Education level Illiterate 66 (45.2) 80(54.8) 28.551 Literate 674 (67.8) 320 (32.2) p<0.05 is considered as a level of significance, *=significant

Sociodemographic variables Knowledge on tobacco related health hazard Results... (cont’d) Table 11: Relationship between knowledge on health hazard with Socio demographic variables Sociodemographic variables Knowledge on tobacco related health hazard Chi square (χ2) p-value No n(%) Yes n(%) Age group a 15-24 years 3 (0.9) 325 (99.1) 16.695 0.001* 25-44 years 17 (3.0) 577 (97.0) 45-64 years 12 (5.2) 218 (94.8) 65+ years 2 (25.0) 5 (75.0) Education level Illiterate 13 (8.9) 133 (91.1) 20.29 Literate 21 (2.1) 973(97.9) Occupational status Unemployed 5 (8.2) 56 (91.8) 6.056 0.014* Employed 29 (2.7) 1050 (97.3) a Fisher’s Exact test p<0.05 is considered as a level of significance, *=significant

Results... (cont’d) Table 12: Binary logistic model applied for uses of tobacco with socio demographic variables Variables B p-value OR 95% CI for OR Lower Upper Sex Male Ref. Female -1.250 0.001* 0.286 0.213 0.385 Age group 15-24 years 25-44 years 0.688 1.990 1.392 2.846 45-64 years 1.044 2.840 1.839 4.386 Educational level Illiterate SSC completed -1.084 0.338 0.203 0.563 HSC completed -1.538 0.215 0.124 0.371 Graduation and Above -1.524 0.218 0.123 Monthly Income (BDT) 0.000 0.003* 1.000 Constant -0.188 0.483 0.828 p<0.05 is considered as a level of significance, *=significant

Conclusions Almost all the respondents had very good knowledge on health hazards related to tobacco consumption irrespective of gender but they were not that much motivated which is reflected in their practices Mixed types of attitudes has been followed about tobacco consumption among the respondents

Recommendations Awareness program should be launched in all government and private hospitals and hospitals should be tobacco free This types of study should be conducted on different groups of population to know the actual situation which might be helpful to any intervention

Policy implications This study findings can be used by the policy makers for effectiveness of the anti-smoking policies for adults, like higher excise taxes and VATs on cigarettes, and import restrictions.

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