Objective: Prevalence of tobacco consumption is increasing including both smoked and smokeless tobacco. The objective of this paper is to highlight the prevalence of smokeless tobacco use, its demographic trends as well as socioeconomic determinants based on Global Adult Tobacco Survey 2014 (GATS) -Pakistan.
Methods: Secondary analysis of GATS data was done which was a nationally representative survey, conducted among non-institutionalized males and females aged 15 years and above. The survey included a total of 9,856 households which were selected using multistage stratified cluster sampling technique.
Results: Secondary analysis of GATS data revealed that 8.6% of the Pakistani population was current users of smokeless tobacco; among them, 8.0% were daily users and 0.6% were less than daily users. Prevalence of SLT use was higher in males (13.7%) compared to females (3.9%) (p = 0.000). Mean age of male users was 39.96±14.43 years and of females was 47.71±16.21 (p=0.000). Males (3.959 95% CI = 3.291-4.764) and respondents with primary or less education (2.216 95%CI = 1.841-2.668) were at higher odds of SLT use prevalence. Among daily users, Naswar was the preferred (71.8%) SLT product in males, compared to females (p = 0.000). Whereas, in females, use of Paan with tobacco (26.4%) (P = 0.000) and Naas (20.9%) (P = 0.000) was more common compared to males. Among SLT users, 71.1% participants used to spend 1-100 Rs (0.0095-0.95USD) per week on purchase of SLT products. However 28.9% were spending more than one dollar on the purchase of SLT products including 19.1% who were spending Rs 101-200 (0.96-1.9USD) followed by 7.2% spending Rs 201-300 (1.91-2.85 USD) and 2.6% spending Rs. >300 (>2.85 USD).
Conclusion: Males and less educated individuals should be targeted with behavioral interventions for control of SLT use. Males started SLT use at an earlier age compared to females which can result in premature morbidity and mortality in males. SLT products are cheaper compared to cigarettes, therefore, taxes need to be levied on SLT products.
Keywords: Smokeless tobacco use, insight, GATS, Pakistan, 2014. (JPMA 68: S-7 (Suppl. 2); 2018)
Approximately 6 million people die every year due to the use of both smoked and smokeless tobacco while smokeless tobacco (SLT) use causes about 12% adult deaths globally.1,2 It was predicted that deaths due to SLT consumption might increase to 10 million/annum by the year 20203 and around a billion deaths in this century.4 The consumption of SLT is a primary reason of preventable death worldwide.5,6 According to statistics of World Health Organization (WHO), almost 90% of SLT users reside within South East Asia and use of SLT in South East Asia had acquired the form of an epidemic.7-10 Almost one-third of tobacco used in this region is consumed in the form of smokeless tobacco.11,12 A reason behind this much high prevalence may be that use of SLT is considered socially acceptable, unlike smoking and alcohol use. The Paan is a commonly used form of SLT in Pakistan and is frequently served at public occasions as a cultural dish, in this region.13,14 Another reason for extensive use can be easy availability and low prices, as South Asia is a noteworthy maker and a net exporter of tobacco.15-18 Use of SLT is common in Pakistan and is generally used by sniffing and chewing i.e. Nass/Naswar and betel nut respectively.19,20 National Health Survey of Pakistan has reported that 15% male respondents and 10% females were users of SLT; Gutka, Naswar, and Paan were the most common forms being used.16,17 A study conducted in different medical colleges of Pakistan has reported that 6.4% medical students were lifetime consumers of SLT.17 Similarly, Global Youth Tobacco Survey (GYTS) 2013 has reported that overall 7.3% of youth aged 13-15 years, were using smokeless tobacco (Naswar, Paan, Gutka etc).18 SLT products are widely available and consumed in the country despite the fact that these products pose serious health hazards for the users.20 It is a point of great concern that Pakistani public mainly perceives that chewing of tobacco is not harmful and it is socially acceptable to use SLT. The Global Adult Tobacco Survey (GATS) is an international standard for analytically observing tobacco use among adults and tracking main indicators of tobacco control. GATS is a nationally representative household survey of adults aged 15 years or older using a standard core questionnaire, sample design, and data collection and management procedures that were reviewed and approved by international experts. GATS is intended to enhance the capacity of countries to design, implement, and evaluate tobacco control interventions. GATS Pakistan was undertaken using a nationally representative household sample to collect information on tobacco use in adults. The target population for this survey included all males and females in Pakistan aged 15 years and above. The present study was planned to describe the burden of smokeless tobacco use, demographic trends and socioeconomic determinants based on GATS-Pakistan survey data.
This paper is based on the secondary analysis of data of the Global Adult Tobacco Survey Pakistan 2014 (GATS-2014). GATS was a cross-sectional national level survey in which a three stage geographically clustered sampling technique was used to produce representative data of the country. A total of 9,856 households were selected using multistage stratified cluster sampling technique. From the selected household, 7831 individuals (both male and females aged 15 years and above) completed the interview. The survey data was released for the general researchers by Center for Disease Control (CDC) (Data set is available at CDC Website (https://www.cdc.gov) and no prior permission is required for data use). Detailed survey methodology is reported in the GATS-Pakistan report 2014.20
Urdu words being used in the article are defined as following; Naswar: a mixture of sun-dried/partially cured, tobacco, ash, oil, flavoring agents, coloring agents, lime, water and guar gum, consumed by chewing, Naas: moist, powdered mixture of tobacco, ash, coloring agents consumed by sniffing. Paan with tobacco: a preparation combining betel leaf with areca nut, tobacco and slaked lime, Gutka: a preparation of crushed areca nut, tobacco, catechu, paraffin wax, slaked lime and sweet or savory flavorings. Mainpuri: a preparation of betel nut, camphor, tobacco, cinnamon, clove, slaked lime. For current study the GATS question "Do you currently use smokeless tobacco?" was used. Current users were daily plus less than daily users combined. The present study had taken following questions in consideration. What is the mean age of SLT users\\\' gender wise? What are the trends of SLT use in narrow (5 years) age groups? Association of demographic factors like age, gender education and residence with SLT use. (Age is a continuous variable therefore categories of age group were created to see the association of SLT use with age groups, other variables were already categorical variables). Type of preferred SLT product among male and female daily users. Expenditures incurred by daily users on SLT products. For current study Odds ratios were calculated and for that actual percentages of variables were required therefore actual percentages were calculated from original data set of GATS survey). Therefore, the finding might have some difference from the results of the GATS report as well as the main article where weighted percentages had been reported.
Data was analyzed using IBM-SPSS Statistics 20 Software. For quantitative variables like age, mean ± SD was calculated. For comparison of mean age of urban/rural and male/female SLT daily users, t-test was applied and p-value < 0.05 was considered as significant. For determining the association of SLT use with socio-demographic variables like gender, education level, residence and age, univariate analysis and Chi square test was performed. For preferred SLT product use among genders, z-score and p-value were calculated by using an online statistical software.21 Chi square test was applied for determining an association between expenditure on SLT products and different socio-demographic characteristics. P-value <0.05 was considered significant.
The GATS survey included 7,831 individuals [3,782 (48.3%) males] and [4,049 (51.7%) females] having a mean age of 35.6±15.2 years. The mean age of male respondents was 36.36±15.7 years and of female respondents was 35.06±14.7 years. Among respondents, 3797 (48.49%) were urban and 4034 (51.51%) were rural residents. Overall 8.6% of the Pakistani population was current users of smokeless tobacco, among them 8.0% were daily users and 0.6% were occasional users. Prevalence of SLT use was higher in males (13.7%) compared to females (3.9%). Among daily users of SLT, mean age of urban users was 42.17±14.58 and of rural users was 41.50±15.67 (p=0.580) whereas, mean age of male users was 39.96±14.43 and of females was 47.71±16.21 (p=0.000). Among urban daily users of SLT, mean age of males was 40.02±13.50 and of females was 48.75±15.85 (p=0.000) whereas, in rural daily users mean age of males was 39.92±15.08 and of females was 46.87±16.54 (p=0.000). Prevalence of SLT use varied among different age groups, it was more in the age range 25 to 44 years and maximum (13.1%) prevalence was observed in the age group 25-29 years (Figure-1).
The trend of smokeless tobacco use according to age was also different among genders. In males, highest (14.7%) prevalence of smokeless tobacco use was observed in the age group 30-34 years followed (13.9%) by age group 25-29 years and it declined with increasing age (Figure-2). Whereas, among females, three peaks of SLT prevalence were observed at age groups 25-29 (10.3%), 40-44 (16.0%) and 55-59 (16.7%) years (Figure-2).
Univariate analysis of demographic factors revealed that males (OR=3.959, 95% CI = 3.291-4.764) and respondents with primary or less education (OR=2.216, 95% CI = 1.841-2.668) were at higher odds of SLT use prevalence while urban residence (OR= 0.786, 95%CI = 0.670-0.922) and age group 15-35 years (OR= 0.466, 95% CI = 0.396-0.547) had protective effect against SLT use (Table-1).
Among daily users, the use of Naswar was highest (64.9%) followed by Paan with tobacco (15.1%) and Gutka (12.4%). Use of Naswar was more common (71.8%) in males compared to (42.6%) females (p=0.000). Whereas, use of Naas (20.9%) and Paan with tobacco (26.4%) was more common in females compared to (2.3%) (11.6%) males (P= 0.000) (P = 0.000). A significant difference was not found regarding the use of Gutka, Mainpuri and other SLT products among genders (Table-2).
Among SLT users, 71.1% participants used to spend 1-100 Rs (0.0095-0.95USD) per week on purchase of SLT products and 19.1% used Rs 101-200 (0.96-1.9USD). Expenditure on SLT products was found to be associated with gender, age and education level (Table 3-4).
The secondary analysis of GATS showed that 8.6% of the Pakistani population was current SLT users. Prevalence of SLT use was higher in males (13.7%) and male users started SLT use at an earlier age compared to females. Males and respondents with primary or less education were at higher odds of SLT use prevalence. Among different smokeless tobacco products, use of Naswar was the highest (64.9%). Naswar was the preferred (71.8%) SLT product in males whereas, in females, use of Naas (20.9%) and Paan with tobacco (26.4%) was more common. Weekly expenditure on purchase of SLT products by the majority of the SLT users was less than 1 USD. The SLT use prevalence in adults i.e. 8.6% is almost similar as seen in the Global Youth Tobacco Survey (GYTS) 2013 i.e. 7.3% (youth aged 13-15)18 but is much less than the prevalence reported by small scale studies i.e. 42.25%22 and 80%.23 However, in comparison with other South Asian countries, prevalence of SLT use in Pakistan was lower than India (36.7%), Nepal (34.8%) Bangladesh (21.3%), Maldives (8.48%) and higher than Indonesia (0.46%).24 Socio-demographic factors have a strong link with the prevalence of SLT use. In the present study, SLT consumption was more prevalent (13.7%) in males. In a small scale local study, 43.4% males were SLT users compared to 15.5% females.25 In GATS India26 SLT use among males was 33% and among females, it was 18% whereas, in GATS Bangladesh,27 the prevalence of SLT use was higher among females (27.9%) compared to males (26.4%). In a review study of nine South Asian countries, the prevalence of SLT use among males was higher in rural areas compared to urban areas.24 The reason for high prevalence of SLT use mainly among males may be due to the fact that in many low and middle-income countries, tobacco use is generally more common in males compared to high-income countries where it is the same in males and females. In the present study, SLT use was more common (10.8%) in less educated individuals compared to educated. This is consistent with the study which reported that in all 9 countries, among both genders, the prevalence of SLT use was usually highest among the least educated group and the lowest among the highly educated group.24 Although the reason for higher SLT prevalence in uneducated individuals is not well established, it can be postulated that relatively poor and less educated population have more exposure to conditions predisposing them to tobacco use, have a lesser awareness of the hazards of tobacco use and have higher risk taking behavior.28 These findings suggest that the disproportionately high burden of tobacco use in disadvantaged groups will necessitate use of different strategies for tobacco control in different socioeconomic and cultural groups because effectiveness, as well as access to various programs across these groups, is likely to be variable.28 In the present study, among different smokeless tobacco products, the use of Naswar followed by Paan with tobacco was highest among both genders. In a study conducted in Karachi, Gutka, Naswar, Chalia and Paan users were 45.45%, 37.56%, 12.83% and 6.95% respectively.19 In another study conducted in fisherman of Karachi,23 use of Gutka was 80%. In that study, Paan (fresh betel leaf), Gutka and betel nut were more popular among subjects who migrated from Hazara and North Punjab, while Naswar was preferred SLT among Pathans from the Khyber Pakhtunkhwa Province. In other South Asian countries use of different SLT products has been reported compared to the present study. In a GATS based Indian study, among males use of khaini was highest (18%) followed by gutka (13.1%) and betel quid with tobacco (7.25%) while in females, use of oral tobacco (snuff, mishri, gul, gudakhu) was highest (6.3%) followed by betel quid with tobacco (4.9%) and khaini (4.7%).29 In GATS Bangladesh,27 the prevalence of use of betel quid with tobacco was 24.3% followed by gul (5.3%), sadapata (1.8%), khoinee (1.5%) and others (1.4%). These variations in preferred SLT product for use may be due to diverse socio-cultural behavior in different ethnicities and countries. In the present study, 71.1% participants used to spend 1-100 Rs (0.0095-0.95 USD) per week on the purchase of SLT products and 19.1% used Rs 101-200 (0.96-1.9 USD). In GATS India, the average expenditure on smokeless tobacco products during the last purchase was 6.0 INR (0.09 USD).26 In GATS Pakistan,20,30 average weekly expenditure on manufactured cigarettes per week was 179 Rs (1.7 USD) which is almost double as compared to expenditure on SLT. This may be due to the fact SLT products are available at a very low price and prices of cigarettes got elevated due to an increase in taxes on cigarettes.
Strengths and limitations
This paper provides findings of secondary analysis of nationally representative GATS data on SLT use; therefore the results can be generalized and may be helpful for policy making for control of SLT use. However, there is a potential limitation i.e. effect of confounding variables on SLT use has not been evaluated.
Male gender and primary or less education were predictors of SLT use. Males and less educated individuals should be targeted with behavioral interventions for control of smokeless tobacco use. Further, male users started SLT use at an earlier age compared to females this also needs attention as it can result in premature morbidity and mortality in males. In Pakistan currently, no public policy exists regarding SLT use and SLT products are cheaper compared to cigarettes. Taxes need to be levied on SLT products in Pakistan like cigarettes in order to control SLT use.
1. Hossain MS, Kypri K, Rahman B, Arslan I, Akter S, Milton AH. Prevalence and Correlates of Smokeless Tobacco Consumption among Married Women in Rural Bangladesh. PLOS ONE 2014: 9; e84470.
2. Ezzati M, Lopez AD. Regional, disease specific patterns of smoking attributable mortality in 2000.Tob Control 2004; 13: 388-395.
3. World Bank. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: World Bank 1999.
4. Report on the Global Tobacco Epidemic 2008. [Home page of WHO] [Online] 2008 last updated [cited 2017August 1st] Available from URL: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf.
5. Bartal M. Health effects of tobacco use and exposure. Monaldi Arch Chest Dis 2001; 56 545-554.
6. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. The Lancet 2012; 380: 668-679.
7. 90% of smokeless tobacco users live in South-East Asia. [Home page of WHO] [Online] 2013 September 11th last updated [Cited 2017 August 10th]. Available from URL: http://www.searo.who.int/mediacentre/releases/2013/pr1563/en/.
8. Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003; 8: 419-31.
9. Thakur JS, Garg R, Narain JP, Menabde N. Tobacco use: a major risk factor for non-communicable diseases in South-East Asia region. Indian J PublicHealth 2011; 55: 155-60.
10. Sinha DN, Gupta PC, Rav C, Singh PK. Prevalence of smokeless tobacco use among adults in WHO South East Asia. Indian J Cancer 2012; 49: 342-6.
11. SEARO. WHO: report on oral tobacco use and its implications in South East Asia. New Delhi: SEARO; 2004.
12. Palipudi K, Rizwan SA, Sinha DN, Andes LJ, Amarchand R, Krishnan A, et al. Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: findings from the Global Adult Tobacco Survey. Indian J Cancer. 2014; 51: S24-32.
13. Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Medicine 2015; 13:194. DOI 10.1186/s12916-015-0424-2.
14. Ali NS, Khawaja AK (2011) Betel nut (Areca catechu) usage and its effects on health. In. Preedy V, Watson R, Patel V, editors. Nuts and Seeds in Health and disease Prevention. New York: Elsevier Inc, 197-203.
15. Pakistan Medical Research Council. National Health Survey of Pakistan 1990-94. Islamabad, Pakistan: Pakistan Medical Research Council, Network Publication Service, 1998.
16. Sufia S, Khan AA, Ijaz S. Patterns of tobacco use in Pakistan. Pak Oral Dental J 2003; 23:45-50.
17. Sardar Z Imam, Haq Nawaz, Yasir J Sepah, Aqueel H Pabaney, MahwishIlyas and ShehzadGhaffar.Use of smokeless tobacco among groups of Pakistani medical students-a cross sectional study. BMC Public Health 2007; 7: 231.
18. Global Youth Tobacco Survey fact sheets and country reports. [Home page of WHO] [Online] 2016 last updated [cited 2017August 22nd]. Available from: URL: http://www.emro.who.int/tobacco/ gtss-youth-survey/gyts-fact sheets-reports.html.
19. Rubab Z, Mughal AM, Baig S, Lucky MH, KhanMA.Relationship of Human Papilloma Virus with Trismus in Chewable Tobacco Users.Pakistan Journal of Medicine and Dentistry 2013; 2): 3-11.
20. Global Adult Tobacco Survey, Pakistan 2014; Pakistan Health Research Council.
21. Z score calculator for two population proportions. [Home page of Social Science Statistics ] [Online] 2017 last updated [Cited 2017 July 25th]. Available from URL: http://www.socscistatistics.com/tests/ztest/Default2.aspx. /
22. Iqbal N, Irfan M, Ashraf N, Awan S, Khan JA. Prevalence of tobacco use among women: a cross sectional survey from asquatter settlement of Karachi, Pakistan. BMC Res Notes 2015; 8:469. DOI 10.1186/s13104-015-1455-7.
23. Patoli1 S, Jabeen N, Masood RT, Butt AI. Socioeconomic Status and Smokeless Tobacco Consumption in fishermen Community of a Coastal Area of Karachi.ASH & KMDC 2015; 20: 34.
24. Sreeramareddy CT, Pradhan PMS, Mir IA, SinS.Smoking and smokeless tobacco use in nine south and Southeast Asian countries: prevalence estimates and social determinants from demographic and Health Surveys. Population Health Metrics 2014; 12:22.
25. Iqbal MP, Yakub M. Smokeless Tobacco Use: A Risk Factor for Hyperhomocysteinemia in a Pakistani Population. PLoS One 2013; 8(12): e83826.
26. Global Adult Tobacco Survey 2009-10. Ministry of Health and Family Welfare, Government of India, New Delhi, 2010.
27. Global Adult Tobacco Survey. Bangladesh 2009. World Health Organization, Country Office for Bangladesh., 2009.
28. Sansone GC, Raute LJ, Fong GT, et al (2012). Knowledge of health effects and intentions to quit among smokers in India: findings from the Tobacco Control Policy (TCP) India pilot survey. Int J Environ Res Public Health, 2012; 9: 564-78.
29. Bhawna G. Burden of Smoked and Smokeless Tobacco Consumption in India - Results from the Global adult Tobacco Survey India (GATS-India)- 2009-2010. Asian Pacific J Cancer Prev 2014;14: 3323-3329.
30. Saqib MAN, Rafique I, Qureshi H, Munir MA, Bashir R, Arif BW et al. Burden of Tobacco in Pakistan-Findings from Global Adult Tobacco Survey 2014. Nicotine & Tobacco Research. 2017. Page 1-6.