Citation

Shimul S., Ghulam Hussain A.K.M., Nargis, N. (2023). Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh. Tobacco Control, doi: 10.1136/tc-2022-057679.

Abstract

Objectives: The overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature.

Methods: Using cohort data of nearly 6000 individuals from the International Tobacco Control Bangladesh survey, this study estimated the own-price and cross-price elasticity and income elasticity of cigarette demand by price tiers in Bangladesh. The elasticity was estimated in three stages of consumer decisions: whether to smoke, which brand to smoke and finally, how many cigarettes to smoke per day. The decision to smoke cigarettes and the choice of cigarette brands were modelled using instrumental variable probability regression. The cigarette consumption per day was modelled using seemingly unrelated regression.

Results: The price elasticity of cigarette smoking prevalence with respect to the price of low-price cigarettes is −0.0487. The total elasticity for low-price cigarette consumption with respect to its own price is −0.1678. The own-price elasticity of smoking intensity of high-priced brands is −0.2512. The cross-price elasticity of low-price cigarette consumption with respect to high-price brand prices is 0.2643. The income elasticity of smoking prevalence overall is 0.0564. The income elasticity of daily consumption of low-price cigarettes is −0.1934 and for high-price cigarettes, it is 1.4044. The total income elasticity is 1.4608 for high-price cigarettes.

Conclusion: A cigarette tax policy that raises the prices of both low-price and high-price brands—but increases prices in the low-price tier at a faster rate than in the high-price tier and increases prices of all brands at a pace faster than income growth—can effectively reduce cigarette consumption in Bangladesh.

Citation

Naznin, E., George, J., Driezen, P., Palazzi, K., Faulkner, J., Wynne, O., Nargis, N., Fong, G.T., Bonevski, B. (2023). Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys. Drug and Alcohol Review, 42(7), 1838-1849. doi: 10.1111/dar.13735.

Abstract

Introduction: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts.

Methods: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group.

Results: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015.

Discussion and Conclusions: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Citation

Chen, D.T.H., Nargis, N., Fong, G.T., Huq, S., Quah, A.C.K., Millet, C., Filippidis, F.T. (2023). A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: Implications for tobacco control in the Southeast Asia region. The Lancet Regional Health - Southeast Asia, 14, 100185. doi: 10.1016/j.lansea.2023.100185.

Abstract

Background: In Southeast Asia, tobacco use is a major public health threat. Tobacco users in this region may switch between or concurrently use smoked tobacco and smokeless tobacco (SLT), which makes effective tobacco control challenging. This study tracks transitions of use among different product users (cigarettes, bidis, and SLT) in Bangladesh, one of the largest consumers of tobacco in the region, and examines factors related to transitions and cessation.

Methods: Four waves (2009–2015) of the International Tobacco Control (ITC) Bangladesh Survey with a cohort sample of 3245 tobacco users were analysed. Generalized Estimating Equations (GEE) models were used to explore the socioeconomic correlates of transitions from the exclusive use of cigarettes, bidis, or SLT to the use of other tobacco products or quitting over time.

Findings: Among exclusive cigarette users, most remained as exclusive cigarette users (68.1%). However, rural smokers were more likely than urban smokers to transition to bidi use (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45–6.29); to SLT use (OR = 2.68, 95% CI = 1.79–4.02) and to quit tobacco (OR = 1.57, 95% CI = 1.06–2.33). Among exclusive bidi users, transitional patterns were more volatile. Fewer than half (43.3%) of the exclusive bidi users maintained their status throughout the waves. Those with higher socio-economic status (SES) were more likely to quit (OR = 4.16, 95% CI = 1.08–13.12) compared to low SES smokers. Exclusive SLT users either continued using SLT or quit with minimal transitions to other products (≤2%). Nevertheless, males were more likely to switch to other tobacco products; younger (OR = 2.94, 95% CI = 1.23–6.90 vs. older), more educated (OR = 1.55, 95% CI = 1.77–3.12 vs. less educated), and urban SLT users (OR = 0.52, 95% CI = 0.30–0.86 for rural vs. urban users) were more likely to quit.

Interpretation: Complex transitional patterns were found among different types of tobacco product users over time in Bangladesh. These findings can inform more comprehensive and multi-faceted approaches to tackle diversified tobacco use in Bangladesh and neighbouring countries in the Southeast Asia region with similar tobacco user profiles of smoked tobacco and SLT products.

Citation

Chen, D.T.H., Nargis, N., Fong, G.T., Huq, S., Quah, A.C.K., Filippidis, F.T. (2023). Perceptions and reasons for quitting and transitioning between smoking and smokeless tobacco products: Findings from four waves of the ITC Bangladesh Survey. Tobacco Induced Diseases, 21(February), 25. doi:10.18332/tid/159137.

Abstract

Introduction: 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 reasoning 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.

Abstract

Introduction: Smokeless tobacco (ST) is the predominant form of tobacco used in Bangladesh and is associated with adverse health outcomes. Bangladesh ratified the World Health Organization's Framework Convention on Tobacco Control (FCTC) in 2004. There are concerns that FCTC legislation and implementation of ST control policy is insufficient in Bangladesh. The aim of this study was to investigate the achievements and challenges of ST policy in Bangladesh and its alignment with the FCTC.

Methods: We conducted semi-structured key informant interviews with 20 stakeholders from government and non-government offices and international funding agencies, including tobacco control advocates, policy makers and non-governmental organisation workers. We used NVivo software to create key themes and the framework method for thematic analysis.

Results: Our findings revealed a lack of national policy in terms of disclosure of harmful contents, illicit trade and standardised packaging of ST. Legislation remains ineffective in relation to graphical health warnings and tax measures. Challenges to ST control identified included inadequate law enforcement; paucity of research, surveillance, and evidence generation; and supply chain control. We identified lack of congruence of ST policies with FCTC due to slow progress in implementation of FCTC measures, lack of a country-specific policy and industry interference. To comply with FCTC, participants recommended strong leadership and political commitment, co-ordination between public and private sectors and proper use of tobacco control resources.

Discussion and conclusions: Bangladesh has adopted several important FCTC

Abstract

Objective: To estimate the pooled prevalence of smokeless tobacco consumption (STC) by gender and location in Bangladesh, India and Myanmar and to identify periodic changes in STC prevalence using data extracted from published studies.

Methods: We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. We undertook a meta-analysis to estimate pooled prevalence and confidence intervals within these countries. To compare periodic changes in STC prevalence, we grouped studies into five-year periods (2000-2004, 2005-2009, 2010-2014 and 2015-2019).

Results: The pooled estimates of STC prevalence were 25% (95% CI: 22-28%), 22% (95% CI: 15-28%) and 21% (95% CI: 14-28%) for Bangladesh, India and Myanmar, respectively. In pooled estimates across these countries, we found higher STC prevalence for men (30%; 95% CI: 24-35%) than women (16%; 95% CI: 10-23%) and for rural dwellings (24%; 95% CI: 18-31%) than urban dwellings (17%; 95% CI: 10-24%). We found significant decrease in STC in Bangladesh and India in the period 2010-2014 and 2015-2019, respectively. In Myanmar, STC prevalence increased significantly and substantially in 2010-2014, to levels higher than in Bangladesh and India.

Conclusions: The prevalence of STC in Bangladesh, India and Myanmar is highest in rural areas and among men. Public health prevention strategies are needed to maintain decrease in STC in Bangladesh and India, and to reverse the increased use in Myanmar.

Citation

Nargis, N., Hussain, A.K.M.G., Goodchild, M., Quah, A.C.K., Fong, G.T. (2020). Tobacco Industry Pricing Undermines Tobacco Tax Policy: A Tale from Bangladesh. Preventive medicine, 132, 105991. doi: 10.1016/j.ypmed.2020.105991.

Abstract

The effectiveness of tax increase in reducing tobacco use depends on the extent to which the industry passes on the tax to consumers. Evidence suggests that tobacco industry may absorb or raise the price more than the tax increase depending on the price segment of tobacco products. In this paper, we examined the industry's pricing strategy by price segment of the cigarette market in Bangladesh by observing the deviation between the market retail prices (MRP) of cigarettes faced by consumers and government recommended retail prices (RRP) used as tax base in a four-tiered ad valorem tax structure. The RRPs by brands were collected from government sources. The MRPs by brands were collected by the International Tobacco Control Bangladesh Wave 3 Survey 2011-12 and Wave 4 Survey 2014-15. Applying linear regression to the deviation of MRP from RRP by price tiers, we found MRPs were higher than RRPs for higher-price brands allowing extra profit margin from the high end while lowering the relative price of and expanding demand for cheaper brands. Bangladesh cigarette industry adopted a differential pricing strategy that undermined the intended effect of tax policy change in reducing cigarette consumption and improving public health. This pricing strategy was supported by the tiered excise tax structure which should be replaced with a uniform specific excise system. In the face of growing cigarette affordability, it is crucial that the specific tax be increased routinely by an amount that induces cigarette price increases large enough to make cigarettes less affordable over time.

Citation

Nargis, N., Yong, H.H., Driezen, P., Mbulo, L., Zhao, L., Fong, G.T., Thompson, M.E., Borland, R., Palipudi, K.M., Giovino, G.A., Thrasher, J.F., Siahpush, M. (2019). Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys. PLOS One, 14(9), e0220223.

Abstract

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.

Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.

Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).

Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Citation

Nargis, N., Stoklosa, M., Drope, J., Fong, G.T., Quah, A.C.K., Driezen, P., Chaloupka, F.J., Shang, C. (2019). Trend in the affordability of tobacco products in Bangladesh: Findings from the International Tobacco Control Bangladesh Survey. Tobacco Control, 28(Suppl1), S20-S30.

Abstract

Background: The price of tobacco products in relation to the income of tobacco users—affordability—is recognised as a key determinant of tobacco use behaviour. The effectiveness of a price increase as a deterrent to tobacco use depends on how much price increases in relation to the income of the potential users. The aim of this paper is to examine the distribution of and trends in the affordability of tobacco products in Bangladesh.

Method: Using four waves of International Tobacco Control Survey data on Bangladesh, this study measures affordability of tobacco products at the individual level as the ratio of self-reported price and self-reported income. The trends in affordability by brand categories of cigarettes and of bidi and smokeless tobacco are estimated using multivariate linear regression analysis.

Results: Despite significant increase in price, the affordability of cigarettes increased between 2009 and 2014–2015 due to income growth outpacing price increase. The increase was disproportionately larger for more expensive brands. The affordability of bidis increased over this period as well. The affordability of smokeless tobacco products remained unchanged between 2011–2012 and 2014–2015.

Conclusion: The tax increases that were implemented during 2009–2015 were not enough to increase tobacco product prices sufficiently to outweigh the effect of income growth, and to reduce tobacco consumption. The findings from this research inform policymakers that in countries experiencing rapid economic growth, significant tax increases are needed to counteract the effect of income growth, in order for the tax increases to be effective in reducing tobacco use.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

Nargis, N., Hussain, A.K.M.G., GoodChild, M., Quah, A.C.K., Fong, G.T. (2019). A decade of cigarette taxation in Bangladesh: lessons learnt for tobacco control policy and practice. Bulletin of the World Health Organization, 97(3), 221-229.

Abstract

Bangladesh has achieved a high share of tax in the price of cigarettes (greater than the 75% benchmark), but has not achieved the expected health benefits from reduction in cigarette consumption. In this paper we explore why cigarette taxation has not succeeded in reducing cigarette smoking in Bangladesh. Using government records over 2006–2017, we link trends in tax-paid cigarette sales to cigarette excise tax structure and changes in cigarette taxes and prices. We analysed data on smoking prevalence from Bangladesh Global Adult Tobacco Surveys to study consumption of different tobacco products in 2009 and 2017. Drawing on annual reports from tobacco manufacturers and other literature, we examine demand- and supply-side factors in the cigarette market. In addition to a growing affordability of cigarettes, three factors appear to have undermined the effectiveness of tax and price increases in reducing cigarette consumption in Bangladesh. First, the multitiered excise tax structure widened the price differential between brands and incentivized downward substitution by smokers from higher-price to lower-price cigarettes. Second, income growth and shifting preferences of smokers for better quality products encouraged upward substitution from hand-rolled local cigarettes (bidi) to machine-made low-price cigarettes. Third, the tobacco industry’s market expansion and differential pricing strategy changed the relative price to keep low-price cigarettes inexpensive. A high tax share alone may prove inadequate as a barometer of effective tobacco taxation in lower-middle income countries, particularly where the tobacco tax structure is complex, tobacco products prices are relatively low, and the affordability of tobacco products is increasing.

Citation

Huq, I., Nargis, N., Lkhagvasuren, D., Hussain, A.K.M.G., Fong, G.T. (2019). The impact of income and taxation in a price-tiered cigarette market: Findings from the ITC Bangladesh Surveys. Tobacco Control, 28(Suppl 1), S37-S44.

Abstract

Background: Taxing tobacco is among the most effective measures of tobacco control. However, in a tiered market structure where multiple tiers of taxes coexist, the anticipated impact of tobacco taxes on consumption is complex. This paper investigates changing smoking behaviour in lieu of changing prices and changing income. The objective of the paper is to evaluate the effectiveness of change in prices (through taxes) and change in income in a price-tiered cigarette market.

Method: A panel dataset from the International Tobacco Control Bangladesh surveys is used for analysis. For preliminary analysis transition matrices are developed. Next, probit and multinomial logit regression models are used to identify the effects of changes in prices and changes in income along with other control variables.

Findings: Transition matrices show significant movement of smokers across price tiers from one wave to another. Regression results show that higher income raises the probability to up-trade and decreases the probability to down-trade. Results also show that higher prices raises the probability to up-trade and reduces the probability to down-trade. Although not significant, there exists a negative relationship between the probability to down-trade and the probability to intend to quit.

Conclusion: It is evident from the results that a price-tiered market provides smokers more opportunities to accommodate their smoking behaviour when faced with price and income change. Therefore, tiered structure of the tax system should be replaced with uniform taxes. Moreover, overall cigarette taxes need to be raised to an extent so that it off-sets any positive effects of income growth.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Mutti-Packer, S., Reid, J.L., Thrasher, J.F., Romer, D., Fong, G.T., Gupta, P.C., Pednekar, M.S., Nargis, N., Hammond, D. (2017). The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis. Addictive Behaviours, 73, 22-29.

Abstract

Objective: There is strong evidence showing that pictorial health warnings are more effective than text-only warnings. However, much of this evidence comes from high-income countries and is limited to cigarette packaging. Moreover, few studies have identified mechanisms that might explain the impact of warnings.

Methods: The current study examined the potential mediating role of negative affect and the moderating influence of message credibility in perceived effectiveness of smokeless tobacco warnings in two low- and middle-income countries (LMICs). Field interviews were conducted in India and Bangladesh, with adult (19 + years) smokeless tobacco users (n = 1053), and youth (16–18 years) users (n = 304) and non-users (n = 687). Respondents were randomly assigned to view warnings in one of four conditions: (1) Text-only, (2) pictorial with symbolic imagery, (3) pictorial with graphic images of health effects, or (4) pictorial with personalized graphic images plus a personal testimonial.

Results: The findings provide support for the mediating influence of negative affect in perceived effectiveness, for adult and youth smokeless tobacco users who viewed pictorial warnings (vs. text-only), and graphic health warnings (vs. personal testimonials). Among adults, message credibility moderated the indirect effect; the association was stronger when credibility was high and weaker when it was low. Among youth users and non-users, message credibility did not moderate the indirect effect.

Conclusions: Consistent with research from high-income countries, these findings highlight the importance of selecting imagery that will elicit negative emotional reactions and be perceived as credible. Differential effects among adults and youth highlight the importance of pre-testing images.

Citation

Driezen, P., Abdullah, A.S., Quah, A.C.K., Nargis, N., Fong, G.T. (2016). Determinants of intentions to quit smoking among adult smokers in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Wave 2 Survey. Global Health Research and Policy, 1, 11-22.

Abstract

Background: With about 22 million adult smokers, Bangladesh needs strong measures that would promote smoking cessation. Using data from Wave 2 of the International Tobacco Control (ITC) Survey, this study examined the factors associated with intention to quit smoking among Bangladeshi smokers.

Methods: Data from Wave 2 of the International Tobacco Control (ITC) Survey in Bangladesh, a face to face survey of adult smokers, were analysed. In the ITC survey, households were sampled using a stratified multistage design and interviewed using a structured questionnaire.

Results: Of the respondents (N = 2982), most were male (96 %), married (80 %), and Muslim (83 %); 33 % were illiterate and 54 % were aged below 40. Almost two-thirds were from areas outside Dhaka, 78 % smoked cigarettes exclusively; and 36 % had an intention to quit smoking in the future. This study identified several predictors, comparable to other international studies, of intention to quit smoking: area of residence, number of cigarettes smoked daily, previous quit attempt, visiting a doctor in the past, having child aged 5 or below at home, perceived benefit from quitting, being worried about own health, knowledge of SHS, not enjoying smoking and workplace smoking policy.

Conclusions: These findings suggest that the prevalence of intention to quit smoking is lower among Bangladeshi smokers than those among smokers in developed countries. However, the factors relating to quit intentions among Bangladeshi smokers are comparable to those found in Western countries. Population based tobacco control programs and policies should consider these predictors in the design of interventions to increase quitting among smokers in Bangladesh.

Citation

Driezen, P., Abdullah, A.S., Nargis, N.N., Hussain, G.A.K.M., Fong, G.T., Thompson, M.E., Quah, A.C.K., Xu, S. (2016). Awareness of tobacco-related health harms among vulnerable populations in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. International Journal of Environmental Research and Public Health, 13(9), 848-863.

Abstract

This study assessed the knowledge of the harmful effects of tobacco use among vulnerable populations in Bangladesh and whether vulnerability was associated with the presence of complete home smoking bans. Data came from Wave 3 (2011–2012) of the International Tobacco Control (ITC) Bangladesh Survey, a nationally-representative survey of 3131 tobacco users and 2147 non-users. Sociodemographic measures of disadvantage were used as proxy measures of vulnerability, including sex, residential location, education and income. Outcome measures were awareness of the harmful effects of (a) cigarette smoking and (b) smokeless tobacco use and (c) whether respondents had complete smoking bans in their homes. Logistic regression was used to examine whether the adjusted prevalence of each outcome differed by socio-demographic proxies of vulnerability. Smaller percentages of women, the illiterate, urban slum residents and low-income Bangladeshis were aware of the health harms of tobacco. These vulnerable groups generally had lower odds of awareness compared to the least disadvantaged groups. Incomplete knowledge of tobacco’s harms may prevent vulnerable groups from taking steps to protect their health. Development goals, such as increasing literacy rates and empowering women, can complement the goals of WHO’s Framework Convention on Tobacco Control.

Citation

Nargis, N., Thompson, M.E., Fong, G.T., Driezen, P., Hussain, A.K., Ruthbah, U.H., Quah, A.C., Abdullah, A.S. (2015). Prevalence and patterns of tobacco use in Bangladesh from 2009 to 2012: Evidence from International Tobacco Control Study. PLOS One, 10(11), e0141135.

Abstract

Background: Smoking and passive smoking are collectively the biggest preventable cause of death in Bangladesh, with major public health burden of morbidity, disability, mortality and community costs. The available studies of tobacco use in Bangladesh, however, do not necessarily employ nationally representative samples needed to monitor the problem at a national scale. This paper examines the prevalence and patterns of tobacco use among adults in Bangladesh and the changes over time using large nationally representative comparable surveys.

Methods: Using data from two enumerations of the International Tobacco Control (ITC) Bangladesh Project conducted in 2009 and 2012, prevalence estimates are obtained for all tobacco products by socioeconomic determinants and sample types of over 90,000 individuals drawn from over 30,000 households. Household level sample weights are used to obtain nationally representative prevalence estimates and standard errors. Statistical tests of difference in the estimates between two time periods are based on a logistic regression model that accounts for the complex sampling design. Using a multinomial logit model, the time trend in tobacco use status is identified to capture the effects of macro level determinants including changes in tobacco control policies.

Results: Between 2009 and 2012, overall tobacco use went down from 42.4% to 36.3%. The decline is more pronounced with respect to smokeless tobacco use than smoking. The prevalence of exclusive cigarette smoking went up from 7.2% to 10.6%; exclusive bidi smoking remained stable at around 2%; while smoking both cigarette and bidi went down from 4.6% to 1.8%; exclusive smokeless tobacco use went down from 20.2% to 16.9%; and both smokeless tobacco use and smoking went down from 8.4% to 5.1%. In general, the prevalence of tobacco use is higher among men, increases from younger to older age groups, and is higher among poorer people. Smoking prevalence is the highest among the slum population, followed by the tribal population, the national population and the border area population, suggesting greater burden of tobacco use among the disadvantaged groups.

Conclusions: The overall decline in tobacco use can be viewed as a structural shift in the tobacco market in Bangladesh from low value products such as bidi and smokeless tobacco to high value cigarettes, which is expected with the growth in income and purchasing power of the general population. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37%. The world average of daily smoking among men is 31.1%. The Tobacco Control Act 2005 and the Amendment have yet to make a significant impact in curbing tobacco usage in Bangladesh. The findings in this paper further suggest that the tobacco control policies in Bangladesh need to include targeted interventions to restrain the use of particular types of tobacco products among specific demographic and socio-economic groups of the population, such as smoked tobacco among men, smokeless tobacco among women, and both smoked and smokeless tobacco among those living in rural areas, those in low socio-economic status and those belonging to the tribal and the slum population.

Citation

Abdullah, A.S., Driezen, P., Quah, A.C.K., Nargis, N., Fong, G.T. (2015). Predictors of smoking cessation behavior among Bangladeshi adults: Findings from ITC Bangladesh Survey. Tobacco Induced Diseases, 13(1), 23.

Abstract

Background: Research findings on the predictors of smoking cessation behavior identified in Western countries may not be generalizable to smokers in the Southeast Asian countries (i.e., Bangladesh). This study examined the factors associated with smoking cessation behavior (quit attempts and smoking cessation) among a representative sample of Bangladeshi adults.

Methods: Data from Wave 1 (2009) and Wave 2 (2010) of the International Tobacco Control (ITC) Survey in Bangladesh, a face-to-face survey of adult smokers, were analysed. Households were sampled using a stratified multistage design and interviewed using a structured questionnaire. Respondents included in the study are 1,861 adult daily smokers (cigarette only or dual use of cigarette and bidi) in the Wave 1 survey who completed the Wave 2 follow up.

Results: Of the smokers (N = 1,861), 98 % were male, 18 % illiterate, 78 % married and 42 % were aged 40 or above; 89 % were cigarette smokers and 11 % were dual users (cigarette & bidi). Overall, 21.8 % of the baseline smokers made quit attempts (that is, making at least one quit attempt that lasted for at least 24 hours) during the 11- to 12-month interval between Waves 1 and 2 with only 4.1 % quitting successfully (that is, smokers who had stopped smoking for at least 6 months at the time of the Wave 2 survey). Significant predictors of attempts to quit included: residing areas outside Dhaka (OR = 3.41), being aged 40 or older (OR = 1.53), having a monthly income of above BDT10,000 (US$126) versus below BDT 5,000 (US$63) (OR = 1.57), intending to quit sometime in the future (OR = 1.73). Respondents not working indoors/outside the home were less likely to have made a quit attempt than those with no workplace restrictions on smoking (OR = 0.62). Predictors of successful smoking cessation included: being aged 40 or older (OR = 3.11), perceiving self-rated health as good or excellent (OR = 2.40), and an increased level of self-efficacy (OR = 1.75). Smokers who made a quit attempt not so recently (6 months ago or earlier) were less likely to quit than those who made a more recent (in last 6 months) quit attempt (OR = 0.23).

Conclusion: Among Bangladeshi smokers, different factors were associated with quit attempt or successful cessation. Population based smoking cessation programs should take these factors into consideration in the design of smoking cessation interventions. At the same time, measures are necessary to encourage more smokers to make quit attempts.

Citation

Abdullah, A.S., Driezen, P., Sansone, G.C., Nargis, N., Hussain, A.K.M.G., Quah, A.C.K., Fong, G.T. (2014). Correlates of exposure to secondhand smoke (SHS) at home among non-smoking adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. BioMed Central Pulmonary Medicine, 14, 117-127.

Abstract

Background: Exposure to secondhand smoke (SHS) is a serious global public health problem. Understanding the correlates of SHS exposure could guide the development of evidence based SHS exposure reduction interventions. The purpose of this study is to describe the pattern of and factors associated with SHS exposure among non-smoking adults in Bangladesh.

Methods: Data come from adult non-smokers who participated in the second wave (2010) of the International Tobacco Control Policy (ITC) Evaluation Bangladesh Survey conducted in all six administrative divisions of Bangladesh. A structured questionnaire gathered information on participants' demographic characteristics, pattern of SHS exposure, SHS knowledge, and attitudes towards tobacco control. Exposure to SHS at home was defined as non-smokers who lived with at least one smoker in their household and who reported having no home smoking ban. The data were analyzed using chi-square tests and logistic regression procedures.

Results: The SHS exposure rate at home among the participants (N = 2813) was 43%. Several sociodemographic and attitudinal factors were associated with SHS exposure. Logistic regression analyses identified eight predictors of SHS exposure: being female (OR = 2.35), being aged 15-24 (OR = 2.17), being recruited from Dhaka slums (OR = 5.19) or non-tribal/non-border areas outside Dhaka (OR = 2.19) or tribal/border area (OR = 4.36), having lower education (1-8 years: OR = 2.45; illiterate: OR = 3.00, having higher monthly household income (5000 to <10,000 Taka: OR = 2.34; 10,000 Taka or more: OR = 2.28), having a father who smoked in the past or currently smokes (OR = 2.09), having lower concern about the harms of tobacco on children (unconcerned OR = 3.99; moderate concern OR = 2.26), and not knowing the fact that SHS causes lung cancer in non-smokers (OR = 2.04).

Conclusions: Almost half of non-smoking Bangladeshi adults are exposed to SHS at home. The findings suggest the need for comprehensive tobacco control measures that would improve public understanding about health hazards of SHS exposure at home and encourage educational initiatives to promote smoke-free homes. Interventions should deliver targeted messages to reach those in the low socioeconomic status group.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Abdullah, A.S., Driezen, P., Ruthbah, U.H., Nargis, N., Quah, A.C.K., Fong, G.T. (2014). Patterns and predictors of smokeless tobacco use among adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. PLOS One, 9(7), 101934.

Abstract

Background: Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.

Methods: The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.

Results: Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18– 3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73–9.21) or nontribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94–6.03), being illiterate (OR = 3.37; 95% CI: 1.99–5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38– 10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53–4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51–5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36–3.62).

Conclusion: The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.

Citation

Nargis, N., Hussain, A.K.M.G., Fong, G.T. (2014). Smokeless tobacco product prices and taxation in Bangladesh: Findings from the ITC Survey. Indian Journal of Cancer, 51(Suppl 1), S33-38.

Abstract

Smokeless tobacco use occupies a significant portion of overall tobacco consumption in Bangladesh. Yet very little is known about the effectiveness of tax and price policy in controlling the use of smokeless tobacco use in the country.

Methods: The paper examines the price distribution of various smoked (cigarette, bidi) and smokeless tobacco products (zarda, gul) using the univariate Epanechnikov kernel density function. It estimates the own and cross price elasticity of demand for the most widely used smokeless tobacco product zarda using two-step regression analysis. The analysis is based on data from the ITC Bangladesh Wave 3 Survey which is a nationally representative cohort survey of tobacco users and nonusers conducted in in Bangladesh during 2011-12. Results: The price elasticity of lower price brands of zarda is estimated at −0.64 and of higher priced brands at −0.39, and the cross price elasticity of zarda with respect to cigarette price at 0.35. The tax increase on smokeless tobacco needs to be greater than the tax increase on smoked tobacco to bridge the wide price differential between the two types of products that currently encourages downward substitution from smoked to smokeless tobacco and discourages quitting behavior.

Conclusions: This paper argues that increasing tax on smokeless tobacco simultaneously with the tax increase on smoked tobacco can have significant negative impact on the prevalence of smokeless tobacco use in Bangladesh. Finally, a specific excise system replacing the existing ad valorem excise tax can substantially contribute to the revenue collection performance from smokeless tobacco products.

Citation

Nargis, N., Ashiquzzaman, S.M., Huq, I., Fong, G.T., Hussain, A.K.M.G., Ruthbah, U.H. (2014). The price sensitivity of cigarette consumption in Bangladesh: Evidence from the International Tobacco Control (ITC) Bangladesh Wave 1 (2009) and Wave 2 (2010) Surveys. Tobacco Control, 23(Suppl 1), i39-i47.

Abstract

Background: In Bangladesh, the average excise tax on cigarettes accounted for just 38% of the average retail price of cigarettes in 2009, and 45% in 2010. Both these rates are well below the WHO recommended share of 70% of the retail price at a minimum. There is thus ample room for raising taxes on cigarettes in Bangladesh. The objective of the present work was therefore to estimate the price elasticity of demand for cigarettes and the effect of tax increases on the consumption of cigarettes and on tax revenue in Bangladesh.

Methods: Based on data from Wave 1 (2009) and Wave 2 (2010) of the International Tobacco Control Bangladesh Survey, we estimated the overall impact of a price change on cigarette demand using a twopart model. The total price elasticity of cigarettes was measured by the sum of the elasticity of smoking prevalence and the elasticity of average daily consumption conditional on smoking participation. The price elasticity estimates were used in a simulation model to predict changes in cigarette consumption and tax revenue from tax and price increases.

Results: The total price elasticity of demand for cigarettes was estimated at −0.49. The elasticity of smoking prevalence accounted for 59% of the total price elasticity. The price elasticity of cigarette consumption is higher for people belonging to lower socioeconomic status. Increases in taxes would result in a significant reduction in cigarette consumption while increasing tax revenue.

Conclusions: Raising cigarette prices through increased taxation could lead to a win-win-win situation in Bangladesh: it would reduce cigarette consumption, increase tobacco tax revenue and potentially decrease socioeconomic inequities.

Citation

Abdullah, A.S., Hitchman, S.C., Driezen, P., Nargis, N., Quah, A.C.K., Fong, G.T. (2011). Socioeconomic differences in exposure to tobacco smoke pollution (TSP) in Bangladeshi households with children: Findings from the International Tobacco Control (ITC) Bangladesh Survey. International Journal of Environmental Research and Public Health, 8(3), 842-860.

Abstract

This study assessed the pattern of exposure to tobacco smoke pollution (TSP; also known as, secondhand smoke) in Bangladeshi households with children and examined the variations in household smoking restrictions and perception of risk for children‘s exposure to TSP by socioeconomic status. We interviewed 1,947 respondents from Bangladeshi households with children from the first wave (2009) of the International Tobacco Control (ITC) Bangladesh Survey. 43.5% of the complete smoking restrictions at home and 39.7% were very or extremely concerned about TSP risk to children‘s health. Participants with lower level of education were significantly less likely to be concerned about the risk of TSP exposure to children‘s health and less likely to adopt complete smoking restrictions at home. Logistic regression revealed that the predictors of concern for TSP exposure risk were educational attainment of 1 to 8 years (OR = 1.94) or 9 years or more (OR = 4.07) and being a smoker (OR = 0.24). The predictors of having complete household smoking restrictions were: urban residence (OR = 1.64), attaining education of 9 years or more (OR = 1.94), being a smoker (OR = 0.40) and being concerned about TSP exposure risk to children (OR = 3.25). The findings show that a high proportion of adults with children at home smoke tobacco at home and their perceptions of risk about TSP exposure to children‘s health were low. These behaviours were more prevalent among rural smokers who were illiterate. There is a need for targeted intervention, customized for low educated public, on TSP risk to children‘s health and tobacco control policy with specific focus on smoke-free home.