title: Current tobacco use and its associated factors among adults in a country with comprehensive ban on tobacco: findings from the nationally representative STEPS survey, Bhutan, 2014.
abstract: Despite a comprehensive ban on cultivation, manufacture, distribution, and sale of tobacco products since 2004, two nationwide surveys conducted in 2012 and 2013 reported high tobacco use in Bhutan. National Health Survey 2012 reported that 4 % of the population aged 15-75 years used smoked tobacco and about 48 % used smokeless tobacco. Similarly, Global Youth Tobacco Survey (GYTS) of Bhutan reported tobacco use prevalence of 30.3 % in 2013. However, factors associated with this high tobacco use were not systematically studied. Hence, we assessed the prevalence of tobacco use and its associated sociodemographic, behavioral, and environmental factors.
  
  
  
  This cross-sectional analytical study used secondary data collected in a nationally representative Non-communicable Disease Risk Factors Surveillance STEPS Survey 2014 conducted among Bhutanese adults (18-69 years). The survey included a total of 2820 adults; selected using multistage stratified cluster sampling. Weighted analysis was done to calculate the prevalence of tobacco use. Unadjusted and adjusted prevalence ratios were calculated using log binomial regression.
  
  
  
  The prevalence of current overall tobacco use was 24.8 % (95 % CI: 21.4-28.3) and that of smoked, smokeless, and dual forms (smoked and smokeless forms) were 7.4 % (95 % CI: 5.8-9.0), 19.7 % (95 % CI: 16.5-22.9), and 2.3 % (95 % CI: 1.8-2.9), respectively. Significantly higher prevalence of tobacco use in all forms was found among males, younger age groups, and alcohol users. The prevalence of smoked form was higher in urban areas compared to rural areas (11 % vs 6 %; aPR 1.8, 95 % CI: 1.5-2.0). Among individuals who reported having a non-communicable disease, the prevalence of smoked tobacco use was significantly lower than those who did not have disease (3.5 % vs. 8.3 %; aPR 0.5, 95 % CI: 0.3-0.9). Exposure to health warnings was protective for current tobacco use and smokeless tobacco use, while exposure to tobacco warnings through the media was helpful among smokers and overall tobacco users.
  
  
  
  Despite a comprehensive ban on tobacco, tobacco use was high in Bhutan, especially the smokeless form. Males, younger age groups, and alcohol users should be targeted with behavioral interventions along the stricter implementation of tobacco control measures.
authors: Ministry of Health, Thimphu, Bhutan.
authors: Mongal Singh
authors: MS
authors: Gurung
authors: Ministry of Health, Thimphu, Bhutan.
authors: Dorji
authors: D
authors: Pelzom
authors: Ministry of Health, Thimphu, Bhutan.
authors: Tandin
authors: T
authors: Dorji
authors: Ministry of Health, Thimphu, Bhutan.
authors: Wangchuk
authors: W
authors: Drukpa
authors: Ministry of Health, Thimphu, Bhutan.
authors: Chador
authors: C
authors: Wangdi
authors: Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
authors: Palanivel
authors: P
authors: Chinnakali
authors: Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors: Sonu
authors: S
authors: Goel
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000428:Alcohol Drinking; D001631:Bhutan / Q000453:epidemiology; D005260:Female; D006291:Health Policy / Q000331:legislation & jurisprudence*; D006293:Health Promotion; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012424:Rural Population; D012737:Sex Factors; D012907:Smoking / Q000453:epidemiology; D064424:Tobacco Use / Q000453:epidemiology* / Q000331:legislation & jurisprudence; D014029:Tobacco Use Disorder; D014030:Tobacco, Smokeless / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D014505:Urban Population; D055815:Young Adult
keywords: Bhutan; Prevalence; STEPS; Smokeless tobacco; Smoking; Tobacco