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Journal of Smoking Cessation
Barriers to cigarette smoking cessation in pakistan: evidence from qualitative analysis.
Background . With over 25 million tobacco users, Pakistan has one of the largest smoking populations in the world. Tobacco addiction comes with grave health consequences, especially for the poor and marginalized. Objective . This study explores barriers to smoking cessation in marginalized communities of Islamabad and the possibility of their use of Harm Reduction Products (HRPs), primarily e-cigarettes. Methodology . The study has used primary data of 48 respondents from marginalized communities. Several domains have been employed to evaluate the barriers to smoking cessation in these communities. Using qualitative technique, data was organized and categorized into objective themes. Conclusion . The experience of combustible smoking usually occurs in the 10-20 years’ age bracket. Regular smokers in marginalized areas of Islamabad smoke 20 cigarettes or a pack per day. Their choice of cigarette brand is largely driven by affordability. Most smokers have made at least one attempt to quit smoking. Peer pressure and friendship are major barriers to smoking cessation. Lack of knowledge seems to be the major reason for not seeking medical assistance for quitting smoking. Knowledge about HRPs, especially e-cigarettes, can best be described as vague. Higher prices of the alternatives to combustible smoking are a major hurdle preventing their use for smoking cessation.
1. Introduction
Globally, tobacco is a major cause of more than 8 million deaths per year and a key risk factor for the development of multiple diseases, including lung, liver, oral, and throat cancers, Chronic Obstructive Pulmonary Disease (COPD), heart disease, and stroke [ 1 ]. A large proportion of these deaths—approximately 7 million—is a result of direct tobacco use while 1.2 million from exposure to secondhand smoke (SHS). The majority of smokers worldwide belong to low- and middle-income countries with different socioeconomic characteristics [ 2 , 3 ]. Cigarette smoking increases the burden of disease and the probability of death. Historically, cigarette consumption has declined in various regions. Despite the reduced number of smokers in many countries, population growth continues to trigger an increase in cigarette consumption in China (0.71 trillion), Africa (0.03 trillion), the Eastern Mediterranean Region (0.09 trillion), and South East Asia (0.23 trillion). All these areas have distinct socioeconomic characteristics [ 4 ].
Pakistan, India, and Bangladesh are the most vulnerable countries, with a high proportion of consumers of tobacco and cigarettes [ 5 ]. Pakistan and Bangladesh are among those countries where a significant number of adults aged 15-65 years and older use tobacco [ 6 ]. Pakistan currently has an estimated more than 25 million tobacco users, and several types of tobacco products are available, including cigarettes, water pipes (“shisha”), stove, “gutka,” and “niswar” [ 7 ]. In Pakistan, smoking is a major cause of cardiovascular disease, lung cancer, emphysema, and chronic bronchitis [ 8 ].
Tobacco prevalence increases with age and decreases between the ages of 65 years and older in Pakistan. Smoking prevalence is highest in men aged 45 to 64 years. According to the Pakistan Demographic and Health Survey (PDHS), 23% men and 5% women used some form of tobacco in 2017-18, including cigarettes, “hookah,” “shisha,” “paan,” “gutka,” and “niswar.” The PDHS reports that 22% of men and 3% of women in fact smoke cigarettes. Pakistan has taken a number of initiatives within the framework of the WHO guidelines on tobacco control, including an increase in prices and taxation, enforcement of warning laws, bans on public smoking and advertising, and prohibition of sale of cigarettes in educational institutions. A price analysis of 20-stick packages of premium and cheapest cigarette brands in dollars in 2016 showed prices in Sri Lanka higher than in Pakistan, Bangladesh, and India. It is clear higher prices contribute to lower prevalence. Prevalence of cigarette smoking in Sri Lanka is less than in India, Pakistan and Bangladesh [ 9 ].
Various cigarette brands are available in Pakistan; they include Marlboro, Benson and Hedges, Dunhill, Gold Leaf, Capstan, Gold Flake, Embassy, Morven Gold, Diplomat, K2, Red and White, Gold Street Premium, and Kisan. According to previous study results, a typical 10% rise in the cost of 20-stick cigarette packets will reduce 4% of the adult cigarette demand [ 10 ]. A number of taxes were levied on cigarettes and tobacco products [ 11 ]. However, smoking cessation appears to be the weakest link in the fight against the tobacco epidemic in Pakistan. The success rate of smoking cessation is less than 3% [ 12 ]. Based on previous studies, most smokers in Pakistan want to quit smoking knowing that combustible smoking is cancer-causing and even acknowledge that SHS is harmful to the health of those around them and their families. However, even if they are aware of the dangers, they are unable to stop smoking [ 13 , 14 ].
This qualitative study is the first one of its kind to highlight barriers to smoking cessation in marginalized, low-income communities. It assesses adult smokers’ knowledge and understanding of the health hazards of smoking, as well as the critical question of why attempts to quit smoking remain unsuccessful. In particular, it examines the dichotomy between easy and cheap access to combustible tobacco and the lack of cessation services for marginalized communities. Therefore, a full understanding of the barriers to smoking cessation in marginalized communities will help to develop effective, indigenous, and accessible interventions.
This is perhaps the first study which has uniquely focused on the smokers in marginalized communities of Pakistan’s capital vis-à-vis their smoking habits and quit attempts. All interviews were recorded in order to have a detailed picture of the respondent’s smoking pattern and the quit attempts. Most of the interviews took place at the workplaces of the respondents. Another important focus was on the knowledge about cessation services through the perspective of socially and economically backward smokers. It highlighted the fact that the most ignored smokers in the marginalized communities have the most access to the unregistered, illicit, and the cheapest cigarette brands in Islamabad. Section 2 of the study addresses material and methods. The findings of the empirical analysis are discussed in Section 3 , while Section 4 focuses on discussion, and Section 5 reports policy implications and conclusion.
2. Material and Methods
2.1. data and instruments.
The study has used primary data of eight areas out of 28 self-identified marginalized communities from Islamabad Capital Territory (ICT) of Pakistan (Figure 1 ).
Key Informant Interviews (KIIs) have been used for primary data collection. A semistructured questionnaire, prepared in English and translated into the local language (Urdu), was used for conducting KIIs. To verify the coherence and reliability of the questionnaire, it was retranslated from Urdu to English. To translate the KIIs questionnaire into Urdu, a specialized team of translators was formed. Two translators, who had no communication with each other, independently translated the questionnaire. A third senior translator reconciled the two versions to verify the final document was understandable and accurately conveyed the questions’ substance. To ensure that the field teams accumulate and manage high-quality data, a two-day training session was conducted, with one day allocated for field practice session. The questionnaire was based on local and international literature on tobacco and smoking cessation. The study used Pencil and Paper Interview (PAPI) and Digital Voice Recording (DVR) for primary data collection, which is a simple and precise data collection technique with high-quality results and high precision. Furthermore, DVR was turned into transcripts based on study themes. This procedure was overseen closely by the survey project manager and senior research analyst, who ensured the substance of the questions was clearly and correctly conveyed in the translated scripts. This was done to verify that the translation properly conveyed the respondents’ views.
2.2. Sampling
A two-step sampling for the selection of respondents employed a self-constructed frame. Qualitative research requires a smaller sample for measuring and exploring goals and scope, compared to quantitative research. Qualitative samples must be large enough to obtain enough data to adequately describe the research objectives. In other words, qualitative research is achieving optimal saturation. With respect to qualitative data, [ 17 ] suggested 30 to 50 interviews, while [ 18 ] suggested only 20 to 30. This study was conducted with 48 KIIs, which is enough to achieve saturation.
2.3. Selection Procedure
During the first step of determining the Primary Sampling Units (PSUs), 14 urban and rural charges (A charge is a census defined geographical area used in the 2017 population census in Pakistan. Each charge has several circles with each circle comprising several census blocks (enumeration areas): http://www.statistics.gov.pk/assets/publications/Pakistan%20Paopulation%20and%20Housing%20Census-2017%20National%20Report.pdf ) in the Islamabad district were divided into 28 self-identified marginalized areas (Figure 1 ), followed by a random collection of eight marginalized areas. In the second step, a Quick Count listing of at least 40-50 potential individuals (who had firsthand knowledge about barriers to smoking cessation and use of HRPs) in the target population was used in each selected PSU. The criterion for the respondent selection was as follows: (1) 18 years and above (2) Adult smoker residing in the marginalized community area
Furthermore, based on each selected PSU and the list of potential individuals, the required number of diverse individuals was selected using simple random sampling (Table 1 ).
2.4. Methodological Framework
The study used several domains to evaluate barriers to smoking cessation in the marginalized communities of Islamabad. These included, in particular, the demographic and socioeconomic background of the smoker, smoking and quitting behavior, factors that may convince a smoker to quit smoking, the possible use of HRPs to quit smoking, and assessment of individual perceptions regarding smoking cessation policy. Figure 2 depicts the conceptual framework, which used qualitative techniques to analyze obstacles to smoking cessation in Pakistan. This study included three primary themes linked to smoking consumption and quitting behavior, as well as the usage of HRPs to quit smoking. Furthermore, these overarching themes have been subdivided into subthemes. The study evaluated four domains that might impact smoking cessation as policy predictors: (1) Individual-level control of combustible smoking, for example, use of cigarettes, health-related risk, social and family life constrictions, and well-being (2) Community and indoor workplace level control of smoking, for example, prohibited smoking at workplace (3) Smoking control regulation and guidelines (4) The possibility of using HRPs to quit smoking
Internal validity, dependability, objectivity, and external validity are common concepts used by quantitative researchers. This study has adopted several steps that evaluated Lincoln and Guba’s fundamental Four-Dimension Criteria (FDC) to generalizability, internal validity, dependability, and objectivity. The trustworthiness relates to how qualitative research ensures credibility, reliability, conformability, and transferability [ 30 ]. The following steps have helped to assess the investigator’s confidence in the reality of findings based on the research design, informants, and context: (1) Credibility: to establish confidence that the results are true, credible, and believable, this study employed simple random sampling to select potential respondents. Further, to ensure field teams are capable of accumulating and managing high-quality data, a two-day training session was held. Additionally, one day was allocated for field practice for enumeration and data collection. This study also used Digital Voice Recording (DVR) for primary data collection, which is a simple and precise data collection technique with high-quality results and precision (2) Dependability: to ensure the findings are repeatable if the inquiry occurred within the same cohort of participants, coders, and context, this study used detailed drafts of the study protocol, including semistructured questionnaire based on the previous literature, translation into local language, training of supervisor and enumerators, and data analysis plan. Additionally, a detailed track record of the data collection process and stepwise data coding was employed to convert information into themes (3) Conformability: to extend the confidence that the results would be confirmed or corroborated by other researchers, this study employed line-coding for open-ended questions and key concepts—statements moved to subcategories and broken down into conceptual components and indicators to make sense of data. Moreover, relation and causal links have been built between categories using STATA software (4) Transferability: to extend the degree to which the results can be generalized or transferred to other contexts or settings, the study used simple random sampling, instead of purpose sampling. Simple random sampling produced self-weighted proportion or prevalence of research indicators. Quantified operational and theoretical data saturation in discussion section with literature verification
2.5. Data Analysis
In qualitative research, data analysis is a systematic process of examining and organizing qualitative information in the form of interview transcripts, observation notes, or other nontextual resources. Evaluating qualitative data entails coding or classifying the data. Essentially, it is to make sense of massive data by decreasing the volume of raw information, detecting relevant patterns, deriving meaning from data, and lastly creating a logical chain of evidence [ 29 , 31 ]. The study has used stepwise process of analysis to evaluate qualitative information. (1) Data collection and transcribed to text: qualitative information has been turned into transcripts based on study objectives. This procedure was overseen closely by the survey project manager and senior research analyst, who ensured the real meaning of questions was clearly and correctly conveyed in the translated scripts. This was done to verify the translation properly conveyed the respondents’ views. Create themes: qualitative transcribed text data divided into study themes (2) Developed categories: prepared data categories in accordance with themes and subthemes (3) Data coding and synthesis: used line-coding for open-ended questions and key concepts. Moved to subcategories, statements were broken down into conceptual components and indicators to make sense of data. Moreover, relation and causal links have been built between categories
2.6. Ethical Consideration
The study was approved by the ARI internal Ethics and Technical Committee to ensure research quality and ethics. A verbal consent of the participants was obtained before starting the interview. Furthermore, confidentiality, anonymity, and honesty follow from this premise.
3.1. Respondent Characteristics
The findings show that of the 48 respondents, 15% were between 18 and 24 years of age, 54% were aged between 25 and 44 years, and 31% were 45 to 64 years old. Education levels were classified into six groups—bachelors or master’s, intermediate (Fsc/FA/A levels), matriculation (10 th grade), middle (8 th grade), primary, and illiterate. The majority (69.%) of the respondents had schooling up to matriculation (10th year), with only 8% going beyond the 10 th year (intermediate, bachelors, and masters). At least 15% of the respondents were illiterate. Furthermore, 46% were employed, 48% were self-employed, and 6% were unemployed. Employment status shows combustible smoking is much more common among self-employed workers than the employed and the unemployed. However, the proportional difference between salaried smokers and self-employed smokers was small but statistically significant between self-employed smokers and unemployed smokers.
The personal income of combustible cigarette smokers was classified into four groups—less than and equal to 10k, 11k-20k, 21k-30k, and more than 30k. To this effect, 8% combustible cigarette smokers earned an average monthly income of less than Rs. 10,000 ($67), 44% earned Rs. 11,000-20,000 ($73-133), 33% earned Rs. 21,000-30,000 ($140-200), and 15% earned a monthly income of more than Rs. 30,000. These income estimates indicate the majority of combustible cigarette smokers have an average personal income of between Rs. 11,000 and 20,000 (see Table 2 ).
3.2. Smoking Consumption Behavior
In marginalized communities of Islamabad, men have a higher chance of smoking their first cigarette before the age of 18 years. Most respondents reported their first experience with combustible cigarettes between the age of 10 and 15 years. One respondent reported having initiated smoking when he was “in grade 2 or 3.” As he would play with an older friend who used to smoke, “ we would smoke a bit. Afterwards, I would steal one or two sticks from my father’s cigarette pack. So you can say that I started proper smoking when I was in fifth grade .”
3.2.1. Reasons to Initiate Smoking
The primary reason for initiating smoking (age range 10-20 years) is the company of and friendship with smokers within and outside the household, and at the workplace. An environment where smoking is accepted as normal social behavior by seniors and friends entices young people to start smoking as teenagers. It is considered part of everyday life, with no social stigmatization attached. Those with friends or family who smoke are more likely to initiate smoking than those without.
When in their teens, the curiosity of trying out smoking just for the fun of it is a major reason for becoming a smoker—60% of smokers attributed their smoking initiation to friends and fun. This indicates the company of friends who are smokers is a strong pull for initiating smoking. The respondents recalled that when they saw their friends smoking, they also started smoking. The use of a tobacco product in the household as a normal social practice leads to initiation of smoking. A respondent recalled, “ When I was a child, my grandmother used to smoke ‘hukka’ (water pipe). It was my responsibility after coming from school to fill the water pipe with tobacco. While performing that duty, I would also have one or two puffs of the water pipe. Of course, afterwards I also started smoking cigarettes. ”
In the workplace, the presence of smokers is an important reason for smoking initiation. The combination of economic pressure and smoking company is too strong to withstand. One respondent argued that when he started looking for work after the death of his father, “ most of the people I met were smokers. ” He also began to smoke as a normal social behavior. In marginalized communities, smoking is seen as providing relief from stress caused by a limited economic situation.
One respondent said since he was poor and depressed, he took to smoking to relieve stress. “ Now it is a habit, which is very difficult to give up. ” In the marginalized communities of Islamabad, a regular smoker consumes 20 cigarettes or a pack per day, which is more cigarettes per day than the national level.
3.2.2. Smoking Density
In this study, we asked respondents when and why they smoke more than usual. Overall, more than two-thirds of respondents reported smoking more cigarettes than usual. Tension is the main reason for smokers to consume more cigarettes than their average consumption. Mostly when worried, smokers invariably smoke more. While for others, as smoking becomes a habit, it becomes an essential part of daily life. They may smoke more in the morning and after lunch. Some said their cigarette consumption increases during winters. Others reported when in the company of friends who are also smokers, they consume more cigarettes than usual. Similarly, some smokers when busy in a task may smoke more than their usual quota of cigarettes.
3.2.3. Choice of Cigarette Brand
For smokers in marginalized communities, the choice of cigarette brand is largely driven by affordability. A little more than half of the respondents (54.2%) opted for Capstan, mainly because it is cheap. A pack of Capstan costs less than half a dollar in Pakistan. The possibility of changing brands, depending on the income of the respondent in the marginalized communities, is frequent. One of the respondents currently using Capstan said he would look for local cheaper alternatives. These include locally made unregistered and tax-evading cigarette brands such as Kisan.
3.3. Smoking Cessation Behavior
The study found that most smokers (75%) made at least one attempt to quit smoking, but these attempts were made without any medical assistance. Even though the respondents made several attempts, they were unable to stop smoking. While quitting smoking is urgently needed, attempts to quit smoking are not successful. This was pointed out by one respondent who tried to stop smoking every two months before reoffending.
3.3.1. Barriers to Smoking Cessation
Barriers to smoking cessation were derived from self-reported reasons and causes for smoking behaviors among respondents. Most smokers reported having made attempts to quit but failed. While they recognize smoking as a health hazard, they continue to do so based on their individual beliefs, priorities, and lack of knowledge and medical assistance. Most attempts to quit smoking in Pakistan are made without help.
3.3.2. Lack of Self-Efficacy
Self-efficacy is conceptualized as self-control or belief in our ability to overcome given challenges and successfully complete tasks. Since respondents have been unable to quit smoking despite several attempts, they try to justify the failure with two diametrically opposed attitudes—helplessness in giving up smoking and the expression of confidence in their strong will to quit as and when they wanted. One of the study participants said he did not have the will power to quit while another was confident that he would be able to quit whenever he so decided. Others said the habit of smoking is too strong to quit.
3.4. Physiological Barriers to Cessation
At the individual level, physiological factors such as tension, stress, and headache are common among smokers. One participant said worries turn him towards smoking. Another identified numerous reasons for not quitting smoking; these included tension, stress, headache, and poverty. However, a participant saw companionship in smoking, saying, “ When one is alone, what should one do but smoke . Cigarette is your companion in loneliness. ”
According to literature, prolonged smoking leads to stress, tension, and headache. Conversely, smokers find tobacco as a source of relief from these symptoms. In the long run, it becomes a habit and causes stress, anxiety, and tension.
3.4.1. Peer Pressure
Peer pressure is a major barrier to smoking cessation. It is important to highlight that the environment in which smoking is accepted as normal social behavior works both ways—as an attractive and accepted invitation to initiating smoking and as a strong barrier to cessation. Friends, family members, school and college fellows, and colleagues play a significant role in influencing decisions made by an individual. The participants’ inability to resist peer pressure—the company of smoker friends—remains a strong barrier to quitting smoking. One of the participants narrated the difficulty in saying “no” to smoker friends.
“If you have friends who are smokers, it is very, very difficult to give up smoking. When you are with them, you are bound to smoke.”
Mostly, respondents reported close friends and the surrounding environment as a barrier.
“It has happened more than often that just when I am in one of those quit smoking periods, I meet a smoker friend, and before I know, I start smoking again.”
Some respondents understood that smoking brings no relief from tension and worries but pointed out that cessation is a difficult task in an environment in which smoking is an accepted behavior.
“People think smoking brings some kind of relief, such as you forget your worries. I do not think that is the case. Peer pressure is a major hurdle in smoking cessation. Your surroundings are most critical to your attempt to quit. When you are among smokers, you will inevitably start smoking sooner or later. Even a non-smoker will start smoking.”
3.4.2. Craving
Some of the respondents said craving for the habit of smoking is a barrier. They said the habit of holding something in their hand, especially when they are alone, is too strong to resist. Even the real-life experiences of how combustible smoking results in serious health problems fail to convince them to quit.
“One of my cousins in Lahore fell ill because of smoking. He was admitted to a hospital for heart disease. I saw his condition, got scared, and decided to quit smoking. For a brief period, I thought I too could fall ill because of smoking. But I could not quit smoking because of its craving. You know your hands need something to hold and smoke. Your hands grow used to holding a cigarette.”
3.5. HRPs and Marginalized Communities
In Pakistan, e-cigarettes are legally imported and sold. In this sample study, the current knowledge about HRPs, especially e-cigarettes, can best be described as vague in Islamabad’s marginalized communities. Only one-third of the respondents knew about HRPs. It is important to highlight that e-cigarettes are the only HRP they know about. None of the respondents, it seems, used HRPs with the intent of smoking cessation. Those who used e-cigarettes did so more out of curiosity than anything else. There was no evidence of any respondent opting for a longer use of e-cigarettes with the intent of harm reduction or smoking cessation. Friends are the main source of knowledge about HRPs. This also shows members of marginalized communities may come to know about HRPs but they seem uninterested in buying, largely because of high prices.
An e-cigarette device in Pakistan costs Rs. 3,000-18,000 ($20-120). The expenditure on e-liquids makes e-cigarettes costlier. Most of the respondents smoked local cigarette brands which cost less than Rs. 2,100 ($14) a month. The respondents who said they have used an e-cigarette took it from their friends. Only one respondent said he bought an e-cigarette. Additionally, the respondents (56%) who have used an e-cigarette have no idea about their prices. This is mainly because they took e-cigarette from their friends. It is evident that higher prices of alternatives to combustible smoking are a major hurdle to their use for smoking cessation or as a harm reduction product. One of the respondents shared his experience of using nicotine gum as a smoking cessation tool. However, he found the nicotine gum expensive. A pack of nicotine gum costing Rs. 800 ($5.3) was too expensive for the respondent. However, he continued to smoke combustible cigarettes alongside using nicotine gum. Though there is vagueness about HRPs, most of the respondents expressed readiness to use e-cigarettes with the intent of smoking cessation or harm reduction. However, they want the prices of HRPs to be heavily subsidized.
4. Discussions
In marginalized communities, it is highly likely that smoking initiation will begin before the age of 18 years. This can be due to the presence of older smokers at home (fathers, uncles, brothers, etc.), no parental guidance or monitoring, lack of knowledge about the legal age to start smoking, and poor enforcement of tobacco legislation. Less educated or illiterate populations have high smoking prevalence, as less educated smokers find it more difficult to quit smoking [ 19 ]. Recent research shows that lower level of education and poverty or social deprivation are also associated with higher rates of smoking [ 20 ]. Moreover, peer pressure is also a major obstacle to smoking cessation in marginalized communities. Critically, the environment in which smoking is an accepted social behavior works as an attractive and accepted invitation to initiating smoking and as a strong barrier to giving it up. The question arises as to why smoking cessation or quitting is not effective in Pakistan. Pakistan’s lack of quit-smoking services, alternative nicotine delivery systems (ANDs), and policy-based research on the barriers to combustible smokers are key fences [ 15 , 16 ].
The main reason for starting smoking is the company and friendship of smokers within and outside the household, and at the workplace. The environment in which smoking is a normal social behavior leads to young people initiating smoking. The curiosity of trying out smoking just for the fun of it is a major reason for a teen becoming a smoker. In this study, most of the smokers have made at least one attempt to quit smoking. However, these attempts have been made without any medical help. Most of the quitting attempts in Pakistan are made without assistance. Exposure to secondhand smoke is a serious health concern in Pakistan. More than half of the nonsmoking adults (56%) and one-third (34%) of youth (13-15 years) are exposed to SHS in public places [ 21 ].
The study participants were not aware about the presence of smoking cessation clinics in Islamabad or elsewhere in Pakistan. Some of them, for the first time in their lives, have come to know about a smoking cessation clinic. Literature points to a strong relationship between health risk and cigarette consumption. In many studies, the lowest cigarette consumption bench was set at 1-9 or 1-15 cigarettes per day, investigating communicable, heart, and lung-related diseases [ 22 , 23 ]. However, heavy smoking can lead to schizophrenia [ 24 ]. Since marginalized communities in Pakistan lack access to health facilities, their deficient knowledge about smoking cessation clinics is understandable. Further, lack of knowledge about the health hazards of smoking seems to be the major reason for not seeking medical assistance for quitting smoking. Respondents in marginalized communities did not consider smoking a health issue and therefore did not feel the need to consult a doctor in this regard.
As none of the respondents has been able to quit smoking despite making numerous attempts, they try to justify the failure in two diametrically opposed attitudes—helplessness in giving up smoking and the expression of confidence in their strong will to quit as and when they want. For most of the KIIs, an increase in the prices of cigarette packs would force them to look for cheaper alternatives. The availability of cheaper and illicit cigarette brands is a major issue in Pakistan. As cigarette prices in Pakistan are the cheapest in the world [ 7 ], the cheaper options for smokers in the marginalized communities are multiple. Though none of the respondents has succeeded in quitting smoking, most seek help in this regard. They want smoking cessation clinics at health facilities. For the understanding of smoking cessation behavior, most studies have used daily smoking amount of nicotine or number of cigarettes for assessing quit attempts, quit success, and use of cessation assistance [ 25 ]. The annual success rate of quitting smoking in Pakistan is only 2.6% [ 13 ]. Though every year around 25% of smokers make an attempt to quit smoking in Pakistan, 97.4% fail to quit [ 14 ]. Numerous experimental studies observed main reasons behind multiple efforts along with high failure rate are lack of clinical and health care delivery systems, effective treatments, practical counseling, and social support [ 25 ].
Current knowledge about HRPs, especially e-cigarettes, in the marginalized communities of Islamabad can best be described as vague. None of the respondents has used HRPs with the intent of smoking cessation. Those who used e-cigarettes did so more out of curiosity than anything else. According to the proponents, e-cigarettes are 95% less harmful than conventional or combustible tobacco [ 26 , 27 ] and it is useful for quitting smoking [ 28 ].
There was no evidence of any respondent opting for prolonged use of e-cigarettes with the intent of harm reduction or cessation. Friends are the main source of knowledge about HRPs. Respondents who used an e-cigarette took it from their friends. Members of the marginalized communities may know about HRPs, but they seem uninterested in buying them, largely because of high prices [ 32 ]. An e-cigarette device in Pakistan costs Rs. 3,000-18,000 ($20-120). The expenditure on e-liquids makes e-cigarettes costlier. Most of the respondents are smoking local cigarette brands which cost less than Rs. 2,100 ($14) a month.
5. Conclusion and Recommendations
This study explores barriers to smoking cessation in marginalized communities in Islamabad and the possibility of using HRPs. In the marginalized communities, the first combustible smoking experience usually occurs between 10 and 18 years’ age bracket. The main reason for initiating smoking is the company and friendship of smokers within and outside the household, and at the workplace. Smokers in these communities are consuming more cigarettes per day than the national level. On average, a regular smoker in marginalized areas in Islamabad smokes 20 cigarettes or a pack per day. Respondents reported stress as the main reason for consuming cigarettes more than their average consumption. Their choice of cigarette brand is largely driven by affordability. They would opt for the least expensive legally sold brand in Pakistan. A little more than half of the respondents opted for Capstan, mainly because it is cheap. In this sample study, most of the smokers have made at least one attempt to quit smoking. However, these attempts have been made without any medical help. Peer pressure is a major barrier to smoking cessation. Lack of knowledge seems to be the major reason for not seeking medical assistance for quitting smoking. Knowledge about HRPs, especially e-cigarettes, can best be described as vague. Friends are the main source of knowledge about HRPs. Higher prices of alternatives to combustible smoking are a major hurdle to their use for smoking cessation. Smoking cessation mechanisms are missing from tobacco control efforts in Pakistan, especially for marginalized communities. Evidently, smokers in marginalized communities need help in quitting smoking. There is a need to establish smoking cessation clinics in hospitals and create buy-in about them through mass awareness. The main barriers to quitting smoking are lack of medical and clinical assistance, peer pressure, and low perceived risks of smoking. There is a need to provide medical and clinical assistance for quitting smoking. This assistance should be backed with public advocacy on the negative effects of combustible smoking. Easy availability of cheap smoking options is a major barrier to smoking cessation. Lack of tobacco-control law enforcement, especially in marginalized areas, is the other demand side barrier. Tobacco law enforcement on smoking at public and private places should be ensured. Lack of knowledge about alternatives (HRPs) to combustible smoking and their higher prices in Pakistan is a barrier to their adoption. There is a need to create an understanding about HRPs, backed by sensible regulation.
6. Limitations and Further Research
The study has been limited by several constraints. It used a qualitative design instead of using prevalence significance. Therefore, the sample population is not fully represented at the national level. Interviewing women in Pakistan is difficult due to cultural constraints, especially among tobacco users. Women do smoke in Pakistan but avoid smoking in the public, and additionally, they would avoid discussing their smoking habit. There, we were unable to find an adult female smoker. There is a need for national and provincial level research to assess barriers to smoking cessation in marginalized communities in Pakistan and the possibility of using HRPs.
Data Availability
The data can be obtained from the corresponding author upon request.
The contents, selection, and presentation of facts, as well as any opinions expressed herein, are the sole responsibility of the authors and under no circumstances shall be regarded as reflecting the positions of the Foundation for a Smoke-Free World, Inc.
Conflicts of Interest
The corresponding author on the behalf of all authors declares that there is no competing interest among authors for this study.
Authors’ Contributions
Abdul Hameed performed the conceptualization, methodology, data management, investigation, formal analysis, visualization, writing of the original draft, and writing, reviewing, and editing the manuscript. Daud Malik performed the investigation, visualization, and writing, reviewing, and editing of the manuscript.
Acknowledgments
This study was funded by a grant from the Foundation for a Smoke-Free World, a US nonprofit 501(c)(3) private foundation with a mission to end smoking in this generation. The foundation accepts charitable gifts from PMI Global Services Inc. (PMI); under the Foundation’s Bylaws and Pledge Agreement with PMI, the foundation is independent from PMI and the tobacco industry.
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Prevalence and determinants of second-hand tobacco smoking in Pakistan
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Aqeela Zahra, 1 Sehar-un-Nisa Hassan, 2 Aasma Batool 3 , Naveed Iqbal, 4 Fahmida Khatoon5 and Mohamed Atteya 6
Background : Exposure to second-hand tobacco smoke is a public health problem in countries with high prevalence of active smoking such as Pakistan. However, few studies have assessed the prevalence and risk factors for exposure to second-hand tobacco smoke.
Aims : To estimate the prevalence and factors associated with exposure to second-hand tobacco smoke in Pakistan.
Methods : This study used data from the 2017–2018 Pakistan Demographic and Health Survey to calculate the prevalence and determinants of second-hand tobacco smoke exposure. Sociodemographic characteristics, family size and exposure to media by the respondents were the independent variables. The chi-square test and logistic regression analyses were used to evaluate the relationship between exposure to second-hand tobacco smoke and the independent variables.hy9
Results : The survey included 61 940 adults, of which 30 027 (48.5%) were males and 31 913 (51.5%) females. The overall prevalence of exposure to second-hand tobacco smoke was 34.3%: 35.6% among males and 33.2% among females. Higher education level and rural residence were significantly positively associated with exposure to second-hand tobacco smoke among both sexes. Having a radio was inversely associated with exposure while having a television was positively associated with exposure among both sexes. Large family size was inversely associated with exposure. Currently and previously married females had significantly greater risk of exposure than never-married females.
Conclusion : Tailored health interventions and policies are needed that target populations at high-risk of exposure to second-hand tobacco smoke. Strict smoking bans in public places should be implemented to limit exposure to second-hand tobacco smoke in Pakistan.
Keywords: second-hand smoking, tobacco smoke pollution, prevalence, risk factors, Pakistan.
Citation: Zahra A; Hassan S; Iqbal N; Khatoon F; Batool A; Atteya R. Prevalence and determinants of second-hand tobacco smoking in Pakistan. East Mediterr Health J. 2022;28(11):805–812. https://doi.org/10.26719/emhj.22.086 Received: 06/12/21; accepted: 11/08/22
Copyright © Authors 2022; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction
Tobacco smoke is one of the leading causes of death worldwide. It affects the health of the smokers and it is a threat to the lives of people inhaling second-hand smoke (1). According to the Global Burden of Disease Study 2013, second-hand tobacco smoke causes 600 000 deaths a year worldwide (2). Second-hand smoke exposure is associated with a risk of several diseases including cancer, diabetes, stroke and asthma (3–5). In children, second-hand tobacco smoke causes sudden infant death syndrome and other respiratory diseases, and is associated with preterm deliveries and lower weight of newborn babies in pregnant women (6).
The prevalence of exposure to second-hand tobacco smoke is considerably higher in low- and middle-income countries such as Pakistan (7). Tobacco is used in many different forms in Pakistan including as hookah and shisha. According to the 2014 Global Adult Tobacco Survey, the prevalence of active smoking in Pakistan was 19.1% while exposure to second-hand tobacco smoke was 69.1% and 48.3% at the workplace and home, respectively (8). In the Pakistan Demographic and Health Survey for 2012–2013, 39.1% of people were exposed to indoor tobacco smoke every day (8). Tobacco consumption including second-hand smoking is the fourth leading cause of death and disability in Pakistan (9). Second-hand tobacco smoke exposure caused 33 524 deaths in Pakistan in 2017, which was 2.37% of the total deaths (9).
As second-hand tobacco smoke exposure is a major public health threat in Pakistan, calculating the precise prevalence and identifying high-risk population groups can support evidence-based policies on banning smoking. However, adequate research in this field is lacking in Pakistan. Previously, most of the studies in Pakistan focused on the prevalence and determinants of active smoking (8,10). The few studies on second-hand tobacco smoke mostly focused on knowledge and attitude of people towards active and passive smoking (11,12). Some studies analysed the relationship between second-hand tobacco smoke and specific diseases such as respiratory diseases and pregnancy outcomes (13,14), and a few calculated the prevalence of exposure to second-hand tobacco smoke in a specific region or age group (12,15). We found only one study that calculated second-hand tobacco smoke prevalence at the national level in Pakistan (16). However, this study did not consider all the factors that can affect the prevalence of exposure to second-hand tobacco smoke. Most of these previous studies are outdated and are not based on the latest information on second-hand tobacco smoke exposure in Pakistan.
Therefore, this study aimed to calculate the prevalence of second-hand tobacco smoke exposure in Pakistani adults, disaggregated by sex, using the latest data from the 2017–2018 Pakistan Demographic and Health Survey. We analyzed the association between socioeconomic characteristics, family type and media-related factors and the prevalence of exposure to second-hand tobacco smoke. The results of this study will be useful for policymakers’ interventions focusing on high-risk groups.
Data source
This study used secondary data from the 2017–2018 Pakistan Demographic and Health Survey (17), a nationally representative household survey which provides the most recent and reliable data on a wide range of indicators, including maternal health, women’s empowerment, domestic violence and HIV and AIDS. The data are freely accessible. This survey included four provinces of Pakistan: Punjab, Sindh, Khyber Pakhtunkhwa and Balochistan, as well as Azad Jammu and Kashmir and the former Federally Administered Tribal Areas, which were not included in the previous surveys.
The Pakistan Demographic and Health Survey included 16 240 households selected by two-stage, stratified, random sampling. In the first stage, all the regions were separated into urban and rural populations and divided further into small areas called enumeration blocks. In the second stage, households were selected from each block using random sampling design (17). For this study, we included males and females aged 15 years and older, both smokers and non-smokers.
The outcome variable was exposure to second-hand tobacco smoke. Respondents were asked how frequently household members smoked inside the house with four response categories: never, daily, weekly and monthly. We recoded the responses into no or yes.
The independent variables were sociodemographic characteristics of the respondents, family and media-related factors. Sociodemographic variables included: age group (15–35, 36–59, ≥ 60 years); level of education (no education, primary or secondary level, higher education); wealth index measured in quartiles (poor, middle, rich); place of residence (urban, rural); and region of residence (Punjab, Sindh, Balochistan, Khyber Pakhtunkhwa, other). Others included Gilgit Baltistan, Azad Jammu Kashmir, Federally Administered Tribal Areas and Islamabad Capital Territory. Family-related factors included family size (2, 3–5, > 5 members) and marital status (never married, currently married, previously/ever married). Media-associated variables were having a radio, a television, the internet; responses for all three categories were coded no or yes.
Statistical analysis
SPSS version 20 was used to analyse the data. To account for complex sampling design, weighted data were used to produce nationally representative results. Descriptive statistics were calculated and the chi-square test was used to assess the association between exposure to second-hand tobacco smoke and the independent variables. Binary logistic regression analysis was used to calculate the adjusted effects of the different variables on the prevalence of exposure to second-hand tobacco smoke. Results were presented separately for males and females.
Ethical considerations
No ethical approval was needed for this study because we used secondary data from the Pakistan Demographic and Health Survey. These data are publicly available (17). Consent was not needed from subjects because we used already collected anonymized data from a national survey.
The total sample size was 61 940; 30 027 (48.5%) males and 31 913 (51.5%) females. Respondents were aged 15–85 years. Of the total sample, 34.3% (21 271/61 940) were exposed to second-hand tobacco smoke. Of males, 35.6% (10 686/30 027) were exposed to second-hand tobacco smoke compared with 33.2% (10 585/31 913) of females. Table 1 shows prevalence of exposure to second-hand tobacco smoke in males and females by independent variables. In the younger population, the prevalence of exposure to second-hand tobacco smoke was higher in females while exposure in the older age group was greater in males (P < 0.001). Greater proportions of males with primary, secondary or higher education level were exposed to second-hand tobacco smoke than females of the same education level (P < 0.001). The prevalence of exposure to second-hand tobacco smoke was higher in males than females in urban areas. A greater proportion of males living in a two-member family reported exposure to second-hand tobacco smoke than females, as did never-married males.
Logistic regression analysis showed that higher education versus no education, living in rural rather than urban areas, and being in the high or middle wealth index versus low wealth index were positively and significantly associated with second-hand tobacco smoke exposure in both males and females ( Table 1 ). Compared with Punjab, both males and females in Sindh and other areas had a significantly greater odds of second-hand tobacco smoke exposure, while males and females in Khyber Pakhtunkhwa and Balochistan had significantly lower odds. In both males and females, having a radio was significantly negatively associated with second-hand tobacco smoke exposure while having a television was positively associated. In males, having internet connections was significantly positively associated with second-hand tobacco smoke exposure. The odds of exposure to second-hand tobacco smoke were significantly lower in large families than two-member families for both males and females. Previously married males had significantly lower odds of exposure to second-hand tobacco smoke than never married males. However, both currently and previously married females had significantly greater odds of exposure to second-hand tobacco smoke than never married females. Table 2
Our analysis showed a high rate of exposure to second-hand tobacco smoke in Pakistan (34.3%), which is comparable with previous studies from other Asian countries (18,19). A study in Bangladesh found that 43% of non-smoking adults were exposed to second-hand tobacco smoke at home (20). In our study men had higher rates of exposure to second-hand tobacco smoke than women (35.6% versus 33.2%) which is consistent with other studies (21,22). Greater exposure of men in other environments such as public places and workplaces may explain the higher exposure of men to second-hand tobacco smoke in traditional societies. We could not examine second-hand tobacco smoke exposure by place of exposure (at home or in other places) and sex as the data did not provide this information.
In our study, exposure to second-hand tobacco smoke differed by age group, region, socioeconomic status and education level, which concurs with previous studies (23,24). Rural and wealthier respondents in Pakistan were at increased risk for second-hand tobacco smoke exposure. This pattern is consistent with a study in tobacco-cultivating rural areas of China (21). In our study, respondents in Sindh, which is the largest province of Pakistan by area and second largest province by population, had the highest odds of second-hand tobacco smoke exposure. These findings underscore the need to devise appropriate policies and programmes at the provincial level to reduce second-hand tobacco smoke exposure in this region. Focus should be on creating tobacco-smoke-free environments with implementation of smoke-free laws in all public places, such as education institutes, health care facilities, workplaces, shopping malls, train and bus stations, and places of entertainment.
Regarding education, respondents with primary and higher education were 1.2 times more likely to report second-hand tobacco smoke exposure than those with no education. A higher proportion of male respondents with higher education levels were exposed to second-hand tobacco smoke than females with similar educational backgrounds. This differs from other studies that showed that a higher level of education was negatively associated with smoking behaviour (25), and that educated people had better risk perceptions of many environmental health risks and protective factors against them (26). However, this association and explanation is less likely to be true in developing countries where people, despite higher levels of education, are at increased odds of exposure to hazardous work environments. Such disparities have also been observed in developing countries where educated Black and Hispanic people were at increased risk of second-hand tobacco smoke exposure than White educated people (27). Thus, higher education, despite being a significant determinant of health behaviour, does not guard all people against exposure to second-hand tobacco smoke. Social influences and cultural factors contribute to the health behaviour of the general population. Tobacco use is associated with masculinity in some patriarchal societies (28). These findings emphasize the need to recognize the complex interaction of these factors in developing countries which can help policy-makers devise effective anti-smoking interventions focused on people of higher education status.
People who reported access to the internet and television at home were significantly more likely to report second-hand tobacco smoke exposure. This association may be connected with fancy advertisements and scenes in movies showing heroes as smokers. Although, these advertisements and scenes carry written health warnings, visual effects are more effectual and memorable. Television and media campaigns focus more on the health effects of active smoking rather than on health risks of second-hand tobacco smoke. Therefore, policymakers should seek to raise awareness on the dangers of second-hand tobacco smoke through television and the internet and ban content that promotes smoking and tobacco products. Educational campaigns should develop messages that target both males and females bearing in mind the specific contexts that increase their vulnerability. For instance, second-hand tobacco smoke exposure of males is more likely to be in their work environment, whereas females are more likely to be exposed to second-hand tobacco smoke in their home settings. In this study 33.2% of the women reported second-hand tobacco smoke exposure, which is alarmingly high. Addressing the hazards of second-hand tobacco smoke exposure at the grass-roots level by creating smoke-free homes has been recommended (29).
Women who were currently married or ever married were 1.3 times more at risk of second-hand tobacco smoke exposure than unmarried women. In Middle Eastern and Asian societies, the rates of tobacco smoking are relatively low among women because social norms usually disapprove of women smoking (30,31). However, these women are often at increased risk of second-hand tobacco smoke exposure because of the tobacco use of their husbands, fathers or brothers (32). Women are not empowered enough to stop their male relatives from smoking; thus spreading information to whole families, especially men, about the effects of second-hand tobacco smoke exposure on health could be helpful. Indeed, even educated people perceive second-hand tobacco smoke as non-hazardous, therefore, it is important to create more awareness about the health-related effects of second-hand tobacco smoke across all education groups.
In our study, the risk of exposure to second-hand tobacco smoke was greater among respondents of higher socioeconomic status, which contradicts previous studies that demonstrated an inverse relationship between income and second-hand tobacco smoke exposure (33) or no relationship (21). The reasons for this difference in findings are unclear but it suggests that people of all socioeconomic levels are at risk of exposure to second-hand tobacco smoke and interventions should focus both on rich and poor communities. We found that people living in tribal regions such as Federally Administered Tribal Areas, Gilgit Baltistan, and Azad Jammu Kashmir were at a higher risk of exposure to second-hand tobacco smoke than those in Punjab. The positive relationship between better wealth status and second-hand tobacco smoke exposure could be due to confounding variables such as region of residence.
Our study has some limitations. First, the analysis is based on secondary data obtained from a demographic health survey in Pakistan which measured exposure to second-hand tobacco smoke through self-reporting. Second, the survey did not provide information on frequency of second-hand tobacco smoke exposure and the environments in which respondents were exposed. Lastly, we did not analyse the prevalence of second-hand tobacco smoke exposure among non-smokers. Despite these limitations, our findings indicate the need for all-inclusive interventions to prevent second-hand tobacco smoke exposure for all populations and directions for future research to obtain comprehensive data about the predictors of second-hand smoke exposure and its effect on health in Pakistan.
In conclusion, the prevalence of second-hand smoke exposure is quite high in Pakistan and needs the attention of the public health authorities.
Funding : None.
Competing interests : None declared.
Prévalence et déterminants du tabagisme passif causé par la cigarette au Pakistan
Contexte : L'exposition à la fumée secondaire de cigarette est un problème de santé publique dans les pays où la prévalence du tabagisme actif est élevée tels que le Pakistan. Cependant, peu d'études ont évalué la prévalence du tabagisme passif et les facteurs de risque y afférents.
Objectifs : Estimer la prévalence de l'exposition à la fumée secondaire de cigarette ainsi que les facteurs associés à celle-ci au Pakistan.
Méthodes : La présente étude a utilisé les données de l'enquête démographique et sanitaire 2017-2018 du Pakistan pour calculer la prévalence et les déterminants de l'exposition passive à la fumée de cigarette. Les caractéristiques sociodémographiques, la taille de la famille et l'exposition des répondants aux médias constituaient des variables indépendantes. Le test du chi carré et les analyses de régression logistique ont été utilisés pour évaluer la relation entre l'exposition passive à la fumée de cigarette et les variables indépendantes.
Résultats : L'enquête portait sur 61 940 adultes, dont 30 027 (48,5 %) étaient des hommes et 31 913 (51,5 %) des femmes. La prévalence globale du tabagisme passif était de 34,3 % : 35,6 % chez les hommes et 33,2 % chez les femmes. Un niveau d'éducation plus élevé et la résidence en milieu rural étaient associés de manière significativement positive à l'exposition à la fumée secondaire chez les deux sexes. Le fait de posséder une radio était inversement associé au tabagisme passif, tandis que le fait de posséder une télévision était positivement associé à ce type d'exposition chez les deux sexes. La grande taille de la famille était inversement associée au tabagisme passif. Les femmes mariées au moment de l'étude et précédemment présentaient un risque d'exposition passive à la fumée de cigarette considérablement plus élevé que les femmes jamais mariées.
Conclusion : Des interventions et des politiques sanitaires adaptées sont nécessaires pour cibler les populations à haut risque d'exposition à la fumée secondaire de cigarette. Des interdictions strictes de fumer dans les lieux publics devraient être mises en œuvre pour limiter l’exposition au tabagisme passif au Pakistan.
معدل انتشار تدخين السجائر غير المباشر ومحدّداته في باكستان
عقيلة زهرة، سحرالنسا حسن،أسماء باتول، نافيد إقبال، فهميدا خاتون، محمد عطية
الخلفية : يمثل التعرُّض لدخان السجائر غير المباشر مشكلة من مشكلات الصحة العامة في البلدان التي يرتفع فيها معدل انتشار التدخين النشط، مثل باكستان. إلا أنه لا يُوجَد سوى عدد قليل من الدراسات التي قيَّمت مدى انتشار التعرُّض للدخان غير المباشر، وعوامل الخطر المرتبطة بهذا التعرض.
الأهداف : هدفت هذه الدراسة الى تقدير معدّل انتشار التعرض لدخان السجائر غير المباشر والعوامل المرتبطة بذلك التعرض في باكستان.
طرق البحث : استخدمت هذه الدراسة بيانات من المسح السكانيي والصحي لباكستان لعام -2018-2017، لحساب معدل انتشار التعرض لدخان السجائر غير المباشر ومحدِّدات ذلك التعرض. وقد بحثت الدراسة متغيرات مستقلة، هي: السمات الاجتماعية والسكانية، وعدد أفراد الأسرة، ومدى تعرض من أجابوا عن الاستبيان لوسائل الإعلام. واستُخدم اختبار مربع كاي وتحليلات الانحدار اللوجستي لتقييم العلاقة بين التعرض لدخان السجائر غير المباشر والمتغيرات المستقلة.
النتائج : شملت الدراسة 61940 بالغًا، منهم 30027 (48.5%) من الذكور و 31913 (51.5%) من الإناث. وبلغ المعدل العام لانتشار التعرُّض للدخان غير المباشر 34.3%: 35.6% بين الذكور و 33.2% بين الإناث. وقد ارتبط ارتفاع مستوى التعليم والعيش في الريف ارتباطًا إيجابيًّا كبيرًا بالتعرض لدخان السجائر غير المباشر بين الجنسين. وفيما يتعلق بوسائل الإعلام، ارتبط امتلاك مذياع ارتباطًا عكسيًّا بالتعرض، في حين ارتبط امتلاك التلفزيون ارتباطًا إيجابيًّا بالتعرض بين الجنسين. وقد ارتبط كِبَر عدد أفراد الأسرة ارتباطًا عكسيًّا بالتعرض. وقد زادت احتمالات التعرض بين الإناث المتزوجات حاليًّا واللاتي كن متزوجات من قبلُ زيادةً كبيرة عن الإناث اللاتي لم يسبق لهن الزواج.
الاستنتاجات : هناك حاجة إلى وضع تدخلات وسياسات صحية مُصممة كي تلائم فئات السكان ممَّن يزيد خطر تعرُّضهم لدخان السجائر غير المباشر، وتكون موجهة إليهم. وينبغي تطبيق حظر صارم للتدخين في الأماكن العامة في باكستان، للحد من التعرض لدخان السجائر غير المباشر.
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Prevalence and Predictors of Smoking In Pakistan: Results of the National Health Survey of Pakistan
2005, European Journal of …
It is estimated that in the year 2000 alone, nearly half of the 4.83 million premature deaths attributable to smoking in the world occurred in developing countries, mainly among men aged 30-69 years . According to the World Health Organization, if appropriate preventive measures are not taken, the number of these deaths will increase to 10 million per year by 2030, with 70% of them taking place in the developing world .
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Background: Use of smokeless tobacco (SLT) is significantly associated with poor oral health and cancers. The objectives of this study were to estimate the proportion of use and the knowledge about SLT in relation to oral cancer and its differentials by socio-demographic and patient’s diagnostic categories. This study also aimed to assess the SLT user’s attitude and practices for its use.Methods: In a cross-sectional study, 502 adult patients (≥15 years) were randomly interviewed in family practice clinics in Karachi, Pakistan. SLT use was considered as usage of any of the following: betel quid (paan) with tobacco, betel nuts with tobacco (gutkha), and snuff (naswar).Results: Overall, 52.4% subjects had used SLT at least in one form. More males were using SLT than females (P = 0.03). Similarly, higher proportion of patients with gastro-intestinal diseases were using SLT compared with other diagnostic categories (P = 0.004). Knowledge about the oral carcinogenic effect of SLT was higher among men and those who had schooling of >10 years (P < 0.001). This knowledge was also higher in patients with non-communicable and infectious diseases. Among SLT users, 31.3% tried to quit this habit but failed. The majority of users started using SLT before the age of 15 years; 40.2% and 30.8% started after being inspired by media advertisements and friends/peer pressure, respectively.Conclusions: In this study, over half of the patients were using SLT in various forms and had poor knowledge about its hazards. We suggest that there is a need for socially and culturally acceptable educational and behavioral interventions for control of SLT usage.
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The burden of coronary heart disease (CHD) is increasing at a greater rate in South Asia than in any other region globally, but there is little direct evidence about its determinants. The Pakistan Risk of Myocardial Infarction Study (PROMIS) is an epidemiological resource to enable reliable study of genetic, lifestyle and other determinants of CHD in South Asia. By March 2009, PROMIS had recruited over 5,000 cases of first-ever confirmed acute myocardial infarction (MI) and over 5,000 matched controls aged 30–80 years. For each participant, information has been recorded on demographic factors, lifestyle, medical and family history, anthropometry, and a 12-lead electrocardiogram. A range of biological samples has been collected and stored, including DNA, plasma, serum and whole blood. During its next stage, the study aims to expand recruitment to achieve a total of about 20,000 cases and about 20,000 controls, and, in subsets of participants, to enrich the resource by collection of monocytes, establishment of lymphoblastoid cell lines, and by resurveying participants. Measurements in progress include profiling of candidate biochemical factors, assay of 45,000 variants in 2,100 candidate genes, and a genomewide association scan of over 650,000 genetic markers. We have established a large epidemiological resource for CHD in South Asia. In parallel with its further expansion and enrichment, the PROMIS resource will be systematically harvested to help identify and evaluate genetic and other determinants of MI in South Asia. Findings from this study should advance scientific understanding and inform regionally appropriate disease prevention and control strategies.
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Burden of Tobacco in Pakistan: Findings From Global Adult Tobacco Survey 2014
Affiliations.
- 1 Pakistan Health Research Council, Head Office, Islamabad, Pakistan.
- 2 Pakistan Bureau of Statistics, Islamabad, Pakistan.
- 3 World Health Organization, Country Office, Islamabad, Pakistan.
- 4 World Health Organization, Geneva, Switzerland.
- PMID: 29059338
- DOI: 10.1093/ntr/ntx179
- Burden of Tobacco in Pakistan: Findings From Global Adult Tobacco Survey 2014. Saqib MAN, Rafique I, Qureshi H, Munir MA, Bashir R, Arif BW, Bhatti K, Ahmed SAK, Bhatti L. Saqib MAN, et al. Nicotine Tob Res. 2019 Jan 1;21(1):136. doi: 10.1093/ntr/ntx282. Nicotine Tob Res. 2019. PMID: 29452373 No abstract available.
Introduction: The Global Adult Tobacco Survey (GATS) is the global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators.
Methods: Using a multistage stratified cluster design, 9856 households were sampled, and one individual was randomly selected from each household. Standard GATS questionnaire was used to collect information on tobacco use, cessation, second-hand smoke, knowledge, attitudes, and perceptions. Data were analyzed per standard GATS protocol.
Results: Of 9856 individuals, 7831 individuals completed the interview. The response rate was 81%. Overall, 19.1% adults were currently using tobacco products and among them, 12.4% smoked tobacco, and 7.7% smokeless tobacco. Exposure to second-hand smoke was seen in 86% in a restaurant while it was 76% on public transportation. A total of 24.7% smokers made a quit attempt in the past 12 months. Anticigarette smoking information was observed by 37.7% adults, while 29.7% current smokers thought about quitting after reading health warning labels on cigarette packages. Most (85%) adults favored no smoking in public places, and 74.8% favored increasing taxes on tobacco products. Current cigarette smokers spent Pakistani Rupees 767.3 per month (7.78 USD) on manufactured cigarettes and consumed 4500 cigarette sticks (225 packs) annually.
Conclusions: Besides 19.1% tobacco users, the majority (86%) were exposed to second-hand smoke at public places indicating that ban on tobacco use in public places is not being followed. A quarter of current smokers wants to quit smoking who may be provided assistance to reduce tobacco burden.
Implications: This study provides national-level data about tobacco use and its burden and also indicates weak implantation of tobacco control laws. There is need to devise a strategy for proper implementation of these laws to reduce the tobacco burden in the country.
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- Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S; GATS Collaborative Group. Giovino GA, et al. Lancet. 2012 Aug 18;380(9842):668-79. doi: 10.1016/S0140-6736(12)61085-X. Lancet. 2012. PMID: 22901888 Review.
- Prevalence of tobacco consumption and the associated factors among the adults in an urban slum: Findings from the WHO STEPwise survey. Razzaq S, Nagi MLF, Athar U, Kazmi T, Alslamah T, Naz S, Abalkhail A. Razzaq S, et al. Tob Induc Dis. 2022 Oct 31;90:91. doi: 10.18332/tid/154636. eCollection 2022. Tob Induc Dis. 2022. PMID: 36381179 Free PMC article.
- A gender-specific assessment of tobacco use risk factors: evidence from the latest Pakistan demographic and health survey. Zubair F, Husnain MIU, Zhao T, Ahmad H, Khanam R. Zubair F, et al. BMC Public Health. 2022 Jun 6;22(1):1133. doi: 10.1186/s12889-022-13574-2. BMC Public Health. 2022. PMID: 35668426 Free PMC article.
- Rasagiline Pharmacokinetics in CYP1A2 Variant Healthy Smokers & Non-smokers in Different Doses. Bilal R, Ahmad NS, Zaffar S, Mazhar MU, Siddiqui WA, Tariq S. Bilal R, et al. Pak J Med Sci. 2022 Mar-Apr;38(3Part-I):589-594. doi: 10.12669/pjms.38.3.4940. Pak J Med Sci. 2022. PMID: 35480532 Free PMC article.
- Evaluation of C-reactive protein and hematological parameters in smokeless tobacco users: A comparative cross-sectional study. Memon SM, Kumar N, Rahman AAU, Syed BM. Memon SM, et al. Pak J Med Sci. 2021 Jul-Aug;37(4):983-987. doi: 10.12669/pjms.37.4.3841. Pak J Med Sci. 2021. PMID: 34290770 Free PMC article.
- Industry manipulation of pictorial health warning labels in Pakistan. Crespi E, Iacobelli M, Welding K, Saraf S, Clegg Smith K, Cohen JE. Crespi E, et al. Tob Control. 2022 Sep;31(5):687-688. doi: 10.1136/tobaccocontrol-2020-056433. Epub 2021 Apr 16. Tob Control. 2022. PMID: 33863834 Free PMC article. No abstract available.
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The daily smoking rate in Pakistan is 15.9%, with 32.4% of Pakistani males and 5.7% of Pakistani women being regular users of tobacco.. 3 Tobacco-related diseases cost the country over Rs.2.5...
Pakistan Global Youth Tobacco Survey (PGYTS) (2017) estimated that over 25% of teenagers still use tobacco products such as hookah and shisha and Latif et al (2017 p 240) estimates that cigarette...
In the Pakistan Demographic and Health Survey for 2012-2013, 39.1% of people were exposed to indoor tobacco smoke every day (8). Tobacco consumption including second-hand smoking is the fourth leading cause of death and disability in Pakistan (9). Second-hand tobacco smoke exposure caused 33 524 deaths in Pakistan in 2017,
There have been significant bidirectional changes in smoking patterns since COVID-19 in Pakistan. While many people stopped, reduced, or tried quitting smoking, some increased smoking, and some relapsed after quitting. Implications We observed significant and complex changes in people's smoking patterns, which are likely to be
Passive smoking was a major contributor of tobacco exposure. Prevalence of 'Shisha' use was 33%. Smoking continues to be a major Public Health issue in Pakistan. The prevalence in healthcare professionals and adolescents is alarming. Adequate measures need to be taken to ensure its control. KEY WORDS: Smoking, Tobacco, Adolescents, Pakistan ...
Smoking prevalence is highest in men aged 45 to 64 years. According to the Pakistan Demographic and Health Survey (PDHS), 23% men and 5% women used some form of tobacco in 2017-18, including cigarettes, "hookah," "shisha," "paan," "gutka," and "niswar.". The PDHS reports that 22% of men and 3% of women in fact smoke cigarettes.
A quarter of current smokers wants to quit smoking who may be provided assistance to reduce tobacco burden and weak implantation of tobacco control laws are indicated. Introduction The Global Adult Tobacco Survey (GATS) is the global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. Methods Using a multistage stratified cluster design, 9856 ...
• Pakistan exports tobacco leaf, although most tobacco grown in the country is used locally. • Pakistan imposes a variety of taxes on tobacco products, with a multi-tier tax on cigarettes. • Pakistan's government received 115.33 billion Pakistani rupees (PKR) (1.09 billion US dollars [USD]) from tobacco taxes in 2015-2016.
OBJECTIVE To determine the factors contributing to the initiation and propagation of smoking in visitors to a major tertiary health center in Karachi, Pakistan. METHODS Seven major contributing factors to the initiation and propagation of smoking were presented to consenting study participants (n=170) in a questionnaire.
Prevalence and Pattern of Smoking in Pakistan Pages with reference to book, From 64 To 66 Syed Ejaz Alam (PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi. Abstract Objective: To determine the prevalence and pattern of smoking amongst Pakistanis. Sampling Design: A two stage stratified sample design was adopted for the survey, Primary Sampling Units (PSU's) and
An overview of smoking practices in Pakistan Smoking remains a major player in morbidity and mortality worldwide. It is a matter of immense public health importance as single leading cause of preventable deaths. The aim of this study was to assess smoking practices that prevail across Pakistan & Attitude of people towards this issue. We co …
estimates total economic costs from all smoking-attributable diseases and deaths in Pakistan in 2019. The survey results show that smoking prevalence in Pakistan is 8.8 percent. Prevalence is highest in Balochistan (14.43 percent) and in the age category of 65 and older (15.90 percent), though the 35-64 age group is not far behind (15.07 ...
According to WHO 2011 report 32.4% males and 5.7% females are current tobacco smokers in Pakistan . ... Research has shown that smoke free policy is only effective if all indoor public places are completely smoke free. ... and practice of university students regarding waterpipe smoking in Pakistan. Int J Tuberc Lung Dis 2008;12:1077-84. 3 ...
Original Scientific Paper Prevalence and predictors of smoking in Pakistan: results of the National Health Survey of Pakistan Khabir Ahmada,b, Fahim Jafaryc, Imtiaz Jehana, Juanita Hatchera, Abdul Qayum Khand, Nish Chaturvedie and Tazeen H. Jafara,f,g aClinical Epidemiology Unit, Department of Community Health Sciences, bSection of Ophthalmology, ...
understudies to begin smoking was from guardians, kin and companions. 80% of the smokers are happy to surrender smoking and they attemptedordinarily. The examination demonstrated that little exertion was made by the College Staff to enable understudies to quitand avoid smoking. Most understudies began smoking in the high auxiliary schools.
Survey Report: Consumption Behaviour of Cigarette Smokers in Pakistan Download PDF The main objective of this research is to study the consumption patterns of cigarette smokers. The survey provides information on the price and non-price drivers of cigarette consumption behaviour and explores the impact of price changes on consumption.
According to the 2014 Global Adult Tobacco Survey, the prevalence of active smoking in Pakistan was 19.1% while exposure to second-hand tobacco smoke was 69.1% and 48.3% at the workplace and home, respectively (8). In the Pakistan Demographic and Health Survey for 2012-2013, 39.1% of people were exposed to indoor tobacco smoke every day (8).
1.2% reduction in smoking prevalence among adults 1.23% reduction in smoking intensity among adults 71,900 lives saved ... Salim, Wasim and M. Asif Iqbal, The impact of tobacco use on household consumption in Pakistan. Research Report. Social Policy and Development Centre. 2020. 5. According to the monthly bulletins of the Pakistan Bureau of ...
Received 13 July 2004 Accepted 22 December 2004 Objective We analysed data collected during a nationwide cross-sectional household survey to estimate the prevalence of and identify factors associated with smoking in Pakistan. Design Population-based, cross-sectional survey [National Health Survey of Pakistan (NHSP) 1990-1994].
The smoking-attributable expenditure was calculated by the WHO tool kit. Results: In 2018, the economic burden attributed to smoking related illnesses was Rs 192 billion (USD 1.3 billion). Smoking-attributable expenditure on cardiovascular disease was Rs 123 billion (USD 0.9 billion) which was 69% of the total economic cost of tobacco attributed
The response rate was 81%. Overall, 19.1% adults were currently using tobacco products and among them, 12.4% smoked tobacco, and 7.7% smokeless tobacco. Exposure to second-hand smoke was seen in 86% in a restaurant while it was 76% on public transportation. A total of 24.7% smokers made a quit attempt in the past 12 months.