Nicotine & Tobacco Research, 2016, 750756

doi:10.1093/ntr/ntv286
Original investigation
Advance Access publication January 4, 2016

Original investigation

Prevalence and Sociodemographic

Determinants of Any Tobacco Use and Dual Use
in Six Countries of the WHO South-East Asia
Region: Findings From the Demographic and
Health Surveys
Dhirendra N.Sinha PhD1, Rizwan A.Suliankatchi MD2, RitvikAmarchand
PhD3, AnandKrishnan PhD3
1
Tobacco Free Initiative Unit, World Health Organization, Regional Office for South-East Asia, New Delhi, India;
2
Department of Community Medicine, Velammal Medical College Hospital and Research Institute, Madurai, India;
3
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India

Corresponding Author: Dhirendra N.Sinha, PhD, Tobacco Free Initiative Unit, World Health Organization, Regional Office for
South-East Asia, I.P. Estate, New Delhi 110002, India. Telephone: 91-11-23309501; Fax: 91-11-23705714; E-mail: sinhad@who.int

Abstract
Background: Tobacco control is an important strategy to reduce the disease burden caused by sev-
eral noncommunicable diseases. An in-depth understanding of the sociodemographic variations
in tobacco use is an important step in achieving effective tobacco control.
Aims: We aimed to estimate the age-standardized prevalence of any tobacco use and dual tobacco
use and determine their association with sociodemographic variables in six countries (Bangladesh,
Indonesia, India, Maldives, Nepal, and Timor Leste) of the WHO South-East Asia Region.
Methods: The main outcome variables any tobacco use and current dual use were created
from the latest available Demographic and Health Surveys data for each country. The prevalence
estimates were weighted using sample weights and age standardized using the WHO standard
population. Associations between the sociodemographic variables and tobacco use were calcu-
lated by performing multivariable logistic regression analysis. Analyses were performed in Stata
12 using svyset and svy commands.
Results: The highest prevalence of any tobacco use among men was in Indonesia (76.4%) and
among women in Nepal (15.7%). Also, Nepal had the highest prevalence of dual tobacco use in
both men (17.9%) and women (1.5%). With regard to sociodemographic determinants, despite the
inter-country variations, any and dual tobacco use were significantly associated with age, higher
education, greater wealth, rural residence, and ever-married marital status. The poor and unedu-
cated had a higher odds ratio for these practices.
Conclusion: Prevalence of dual tobacco use and its underlying socioeconomic disparities should
be taken into account for the planning of tobacco control activities in the region.
Implications: The dual tobacco use phenomenon is being increasingly recognized as a distinct
entity in the fight against tobacco addiction. When compared with single product users, dual users
have a greater risk of developing tobacco related diseases and are less likely to quit their habits.
However, this phenomenon has not been studied adequately in the South-East Asia region. In
this context, this study has provided a detailed and comprehensive view of dual tobacco use and

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Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
its sociodemographic determinants in six countries of the region. This study recommends that
tobacco control interventions should be targeted specifically at the disadvantaged sections of the
society, such as the poor and the uneducated, who are more likely to engage in dual as well as
any tobacco use. This study could prove as an important reference and tool for policy making in
the South-East Asia region.
Introduction
Control of tobacco use has been considered one of the priority tar-
gets for reducing disease burden caused by a number of disease cat-
egories such as cardiovascular diseases, peripheral vascular diseases,
chronic respiratory diseases, and cancers.1 As a result of effective
tobacco control policies, usage has been declining in the Western
countries in the recent decades.2 However, the developing countries
which bear the major brunt of tobacco related illnesses have not been
very successful in achieving larger magnitudes of reductions2,3 prob-
ably because the traditional tobacco control policies do not always
necessarily target the interventions towards the vulnerable sections
of the society defined by race, gender, income, and residence.4
Understanding the sociodemographic variations in tobacco use
is an important step in achieving effective tobacco control. Several
studies have previously endeavored to examine the socioeco-
nomic determinants of tobacco use.510 Although such studies have
included the various forms of tobacco use, they have not examined
dual tobacco use in great detail. Dual use is commonly defined as
the use of a smokeless tobacco (SLT) product along with tobacco
smoking.11 Reasons for the emergence of the dual use phenomenon
vary between developed and developing countries and therefore a
regional analysis of dual use assumes importance.
Tobacco research has seen a gradual realization of the impor-
tance of other forms of tobacco usage such as SLT products and
dual or concomitant tobacco use.12,13 Dual users need to be given a
higher priority for control because they are more prone to develop
tobacco related diseases and are less likely to quit than single prod-
uct users.14,15 Therefore, the aim of the present study was to estimate
age-standardized prevalence of dual use and any tobacco use and
to determine their association with selected sociodemographic vari-
ables in six countries of the WHO South-East Asia region, using the
latest Demographic and Health Surveys (DHS) data.
Materials and Methods
Data Sources
We used the datasets of six countries (Bangladesh, Indonesia,
India, Maldives, Nepal, and Timor Leste) of the WHO South-
East Asia region from the DHS program. These surveys were con-
ducted between 2006 and 2012 in the study countries by Macro
International Inc and country-level research organizations and were
funded by the USAID. The methodological details of DHS have been
described elsewhere.16 Briefly, they used a multistage stratified ran-
dom sampling with Population Proportional to Size (PPS) technique.
The sample was meant to be nationally representative. Although in
most countries all the eligible persons in the reproductive age group
(15 to 49years) were sampled, in few countries, only the currently
married persons were selected.
Data Collection
Trained interviewers collected data from the members of the
selected households by a face-to-face interview. The interviewers
751
used a pretested standard questionnaire, translated in appropriate
local languages. Strict quality control measures were employed to
maintain the data quality. The methods were fairly uniform in all
study countries. The periods of data collection were as follows: 2007
in Bangladesh, 2012 in Indonesia, 20052006 in India, 2009 in
Maldives, 2011 in Nepal and 20092010 in Timor Leste.
Tobacco and Sociodemographic Variables
The DHS used a set of four standard questions on tobacco use in all
the countries and some country specific options on certain tobacco
products. All the questions were framed with relevance to current
users of tobacco only and the reference time period was not defined.
For the purpose of this study, we analyzed two tobacco use vari-
ables. The current dual use variable included those individuals
who reported the use of at least one tobacco smoking product and at
least one SLT product concurrently. The current any tobacco use
variable included those individuals who reported the use of at least
one tobacco product (smoking or SLT) at present. All these variables
were created separately for both genders. Aset of six variables col-
lected in the DHS was used to explain the sociodemographic vari-
ations in tobacco use. These included age, residential area, marital
status, education, religion and wealth index. To maintain uniformity
across the surveys analysis was restricted to 1549years of age.
Statistical Methods
The prevalence of dual and any tobacco use was reported along with
95% confidence intervals (CI). All the proportions were weighted
using sample weight provided by the DHS to account for complex
sample design and age-standardized using the WHO 20002025
standard population proportions to provide comparable estimates
across countries.17 Associations between sociodemographic vari-
ables and tobacco use were calculated by performing multivariable
logistic regression to provide adjusted odds ratios (OR) for the vari-
able under consideration, while adjusting for all the other variables
in the model. All analyses were performed in Stata (Stata Statistical
Software: Release 12. College Station, TX: StataCorp LP.) using the
svyset and svy commands to account for the complex multistage
stratified sampling design of the DHS.
Ethics Statement
Ethical clearance was not sought since the present study involved only a
secondary analysis of publicly available survey data. However, the origi-
nal DHS obtained clearance from the Institutional Review Boards of all
the participating agencies and the participants were informed about the
option of voluntary participation and the confidentiality of information.
Results
Prevalence of Current Any Tobacco Use and DualUse
It has to be noted that all proportions were age standardized (to
enable cross-country comparisons) and therefore, they do not repre-
sent the actual prevalence.
752
Among men, the highest prevalence of any tobacco use was
seen in Indonesia (76.4%), followed by Timor Leste (73.2%),
Bangladesh (66.9%), India (58.1%), Nepal (55.6%), and the lowest
was in Maldives (51.2%). Among women, the highest prevalence
of any tobacco use was seen in Nepal (15.7%), followed by India
(11.8%), Maldives (8.4%), Timor Leste (5.4%), and the lowest was
in Indonesia (2.7%). Among men, the highest prevalence of dual
use was observed in Nepal (17.9%), followed by India (13.4%),
Bangladesh (9.5%), Timor Leste (2.6%), Maldives (1.5%), and the
lowest prevalence in Indonesia (0.2%). Among women, dual use was
low in all the countries with the highest prevalence in Nepal (1.5%)
and the lowest in Indonesia (0.1%; Table1, Figure1).
Association With Sociodemographic Determinants
Among men, any tobacco use was significantly associated with age,
only in India, Nepal and Timor Leste. In India, the OR increased with
increasing age whereas an inverted U shaped relationship was noted
in Nepal (peak in 3539years) and Timor Leste (peak in 2529years).
Among women also, any tobacco use was significantly associated with
age and the magnitude increased with increasing age in all the countries.
Among men, current dual use was significantly associated with age, only
in India, Nepal, and Timor Leste. In Timor Leste, there was an inverted
U shaped relationship with age, with the peak OR in the 3035years
age group. Among women, the OR for dual use significantly increased
with age only in India and Nepal. Rural areas had a lower OR for
any tobacco use as compared to urban areas among men in India and
among women in Indonesia, Maldives and Timor Leste. Similarly, rural
areas had a lower OR for dual use when compared with urban areas
among men in India and among women in Timor Leste. In comparison
to never-married persons, ever-married persons were found to have a
higher OR for any tobacco use among men in India and Maldives and
among women in all the countries. Similarly, ever-married persons were
found to have a higher OR for dual use among men in India and Nepal
and among women in Indonesia. The OR for any tobacco use decreased
with increasing educational status in both the genders in all the coun-
tries (except among men in Timor Leste). In Timor Leste, men who were
educated up to primary and secondary school reported the highest OR
for any tobacco use as compared to men with no or higher education.
Similarly, dual use also had an inverse relationship with educational
status in both the genders in all the countries. Asignificant inverse rela-
tionship between any tobacco use and wealth index was noted among
men in Bangladesh, Indonesia, and Nepal and among women in all
the countries. Similarly, a clear inverse relation between dual use and
wealth index was noted among men in Indonesia and among women in
Indonesia and Maldives (Table1).
Discussion
Large inter-country variations were observed in the prevalence of dual
tobacco use and any tobacco use. The problem of dual use was very
prominent among the men of Bangladesh, India and Nepal. Men of
other countries and women of all the study countries reported only a
low level of dual use. It was interesting to note that the three countries
(Bangladesh, India, and Nepal) that had a significant burden of dual
use, also had a prominent SLT use burden (data not shown). Agen-
eral pattern suggested that the dual use prevalence mirrors the preva-
lence of SLT use and it is also generally low in countries dominated by
exclusive smoking. This pattern might be related to the availability and
acceptability of smokeless products in the specific country. However,
such assumptions need to be verified by further longitudinal studies.
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
A number of studies have been previously carried out using com-
parable DHS datasets.6,10,18,19 However, in comparison to the cur-
rent study, the studies cited did not take certain important issues
into accountnot analyzing dual use prevalence, not examining the
sociodemographic determinants of dual use, and not performing the
age-standardization in some cases. Another study carried out using
Indian DHS reported only the time trends in the sociodemographic
determinants of dual use.19
Studies on dual tobacco use carried out using other datasets (such
as the Global Adult Tobacco Survey) have been published for some
of the study countries. The previous investigation of dual use in three
of the present study countries (Bangladesh, Indonesia and India) by
the authors of the present study, using the Global Adult Tobacco
Survey data,20 showed that the sociodemographic determinants were
similar to the current study, thereby adding credibility to the find-
ings. Other authors who analyzed the Global Adult Tobacco Survey
data have also corroborated this finding for India.21,22 However, there
was one contradiction with regard to the association with rural resi-
dence. The present study suggested that rural areas were less likely
to report dual use while the above reports suggested otherwise. The
reasons for this were not immediately clear and might be related
to differences in sample acquisition. A study conducted using the
WHO-Stepwise method among Bangladeshi men also arrived at con-
clusions similar to the Indian studies, with regard to the dual tobacco
use prevalence and its determinants.23 Other nations in the region
also appeared to follow the general sociodemographic distribution
for dual use.24 The dual use phenomenon has also been explored
in the developed countries such as the United States, Norway, and
Sweden.2527 In a study carried out among US men using nationally
representative survey data, it was seen that dual use was uncommon
on the whole, but it was more common in young adults than in older
adults, especially in males.26 The study carried out in Norwegian
men found a relatively small overall prevalence of dual use but a
relatively greater prevalence in younger adults.27
With respect to the sociodemographic determinants of tobacco use,
in general, the results of the present study were consistent with several
studies. The relationship between age and tobacco use was similar to
that reported by various other surveys.7,9,28 The gradient of increas-
ing ORs from never married to currently married to formerly married
persons has been previously stressed for tobacco smoking.12,29 The pro-
tective effects of higher education and greater wealth observed in our
study for any tobacco use were also similar to the studies carried out in
other regions of the world.7,9,28,30 Among the several reasons offered for
this lopsided socioeconomic distribution, marketing strategies that tar-
get people in the lower rungs of society have been widely blamed.31,32
Implications of the Findings
It is well known that dual tobacco users form a special risk group for
two main reasons. Firstly, the risk of oral, pharyngeal and esophageal
cancers and coronary heart disease was found to be higher with dual
use.14,15,33 Secondly, quit rate or intention to quit was lower and nico-
tine addiction rates were higher among dual users.25,3436 Hence, one
must consider them as separate entities and their sociodemographic
profiles must be scrutinized more meticulously. The dual use phe-
nomenon is quite complex and is influenced by a number of factors
depending on the market forces and vulnerability of the consumers.
Many authors acknowledge the fact that further research is required
to have a greater understanding of the dual use phenomenon in both
developed and developing nations.21,26,27 The drivers and determi-
nants of dual use are likely to be different for the developed and
Table1. Age-Standardized Weighted Prevalence and Sociodemographic Determinants of Current Any Tobacco Use and Current Dual Use by Gender and Country
Bangladesh Indonesia India Maldives Nepal Timor Leste

Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use

Men
Prevalence, 66.9 (62.4, 71.1) 9.56 (7.52, 12.0) 76.4 (74.3, 78.4) 0.19 (0.11, 0.31) 58.1 (57.4, 58.8) 13.4 (12.9, 13.9) 51.2 (43.2, 59.2) 1.51 (0.97, 2.32) 55.6 (53.4, 57.8) 17.9 (16.0, 20.1) 73.2 (71.4, 74.8) 2.64 (2.00, 3.48)
% (95% CI)
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Age group
1519 1 1 1 1 1 1 1 1 1 1
2024 1.61 (0.50, 5.19) 1.61 (0.17, 15.1) 0.45 (0.14, 1.43) 1 2.79 (2.57, 3.03) 3.57 (3.07, 4.15) 0.98 (0.14, 6.72) 3.02 (2.22, 4.10) 5.23 (2.93, 9.33) 5.69 (4.29, 7.56) 8.12 (3.60, 18.2)
2529 1.26 (0.41, 3.85) 1.79 (0.21, 14.8) 0.41 (0.13, 1.26) 5.78 (0.64, 52.1) 3.50 (3.18, 3.85) 4.38 (3.67, 5.23) 1.05 (0.16, 6.98) 1 4.71 (3.25, 6.82) 8.99 (4.73, 17.0) 11.9 (8.28, 17.3) 20.1 (6.36, 63.6)
3034 1.67 (0.52, 5.32) 2.02 (0.23, 17.3) 0.38 (0.12, 1.15) 2.68 (0.30, 23.5) 3.69 (3.31, 4.11) 4.30 (3.55, 5.21) 1.15 (0.17, 7.73) 0.43 (0.06, 2.76) 4.20 (2.79, 6.32) 7.44 (3.82, 14.4) 9.16 (6.07, 13.8) 24.4 (5.48, 108)
3539 1.68 (0.55, 5.11) 2.30 (0.27, 19.1) 0.37 (0.12, 1.12) 3.9 (0.44, 34.5) 3.87 (3.46, 4.33) 4.33 (3.56, 5.27) 0.91 (0.13, 6.27) 1.63 (0.31, 8.57) 5.26 (3.58, 7.72) 10.0 (4.89, 20.6) 5.65 (3.82, 8.34) 11.9 (3.20, 44.6)
4044 2.18 (0.69, 6.79) 3.62 (0.42, 30.5) 0.29 (0.09, 0.91) 1.50 (0.15, 14.3) 4.06 (3.61, 4.57) 4.03 (3.28, 4.95) 0.89 (0.13, 6.15) 1.02 (0.19, 5.29) 4.75 (3.09, 7.32) 10.6 (4.86, 23.5) 5.93 (3.74, 9.41) 10.6 (2.59, 43.4)
4549 3.45 (1.08, 10.9) 6.61 (0.76, 57.4) 0.30 (0.09, 0.93) 7.70 (0.80, 74.0) 3.98 (3.54, 4.48) 3.58 (2.90, 4.42) 1.03 (0.14, 7.13) 0.98 (0.15, 6.26) 4.35 (2.67, 7.08) 8.09 (3.54, 18.5) 5.32 (3.46, 8.16) 12.7 (2.74, 58.7)
Residence
Urban 1 1 1 1 1 1 1 1 1 1 1 1
Rural 0.90 (0.69, 1.17) 0.80 (0.51, 1.24) 0.97 (0.82, 1.15) 0.70 (0.23, 2.12) 0.83 (0.78, 0.90) 0.79 (0.70, 0.89) 1.02 (0.51, 2.03) 0.40 (0.07, 2.23) 1.03 (0.81, 1.32) 1.14 (0.79, 1.63) 1.13 (0.88, 1.44) 0.95 (0.46, 1.96)
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5

Marital status
Never married 1 1 1 1 1 1
Currently married 1 1 1.49 (1.38, 1.60) 1.49 (1.32, 1.69) 1 1.78 (1.39, 2.27) 1.71 (1.08, 2.72) 1.12 (0.84, 1.50) 0.73 (0.26, 2.03)
Formerly married 0.70 (0.21, 2.33) 0.16 (0.02, 1.23) 2.59 (1.99, 3.37) 3.10 (2.17, 4.42) 1.78 (0.91, 3.48) 4.95 (1.74, 14.0) 4.60 (1.26, 16.7) 1.12 (0.49, 2.58) 0.68 (0.13, 3.56)
Education
No education 1 1 1 1 1 1 1 1 1 1 1 1
Primary 0.70 (0.54, 0.91) 0.66 (0.43, 1.02) 1.68 (1.00, 2.81) 0.48 (0.08, 2.65) 0.92 (0.83, 1.01) 0.93 (0.82, 1.06) 0.76 (0.51, 1.15) 0.51 (0.18, 1.47) 0.74 (0.53, 1.03) 0.56 (0.36, 0.85) 0.91 (0.72, 1.14) 0.66 (0.35, 1.23)
Secondary 0.44 (0.32, 0.59) 0.27 (0.15, 0.46) 1.37 (0.81, 2.31) 0.16 (0.02, 0.96) 0.60 (0.55, 0.65) 0.60 (0.53, 0.67) 0.60 (0.36, 0.99) 0.16 (0.03, 0.69) 0.37 (0.27, 0.52) 0.29 (0.18, 0.46) 0.56 (0.44, 0.72) 0.30 (0.16, 0.57)
Higher 0.28 (0.20, 0.39) 0.15 (0.07, 0.31) 0.66 (0.38, 1.16) 0.33 (0.30, 0.37) 0.27 (0.22, 0.33) 0.32 (0.15, 0.69) 0.68 (0.08, 5.64) 0.21 (0.14, 0.30) 0.06 (0.03, 0.12) 0.31 (0.19, 0.48) 0.21 (0.05, 0.81)
Religion
Islam 1 1 1 1 1 1
Hinduism 0.97 (0.70, 1.34) 0.77 (0.45, 1.30) 0.89 (0.81, 0.98) 1.05 (0.90, 1.24) 0.85 (0.52, 1.38) 0.75 (0.33, 1.70)
Christianity 2.12 (0.62, 7.21) 2.98 (1.93, 4.61) 0.69 (0.58, 0.83) 0.90 (0.67, 1.21) 0.22 (0.10, 0.51) 0.23 (0.07, 0.77)
Others 0.41 (0.35, 0.49) 0.42 (0.32, 0.57) 0.64 (0.36, 1.15) 0.28 (0.11, 0.74)
Wealth index
Poorest 1 1 1 1 1 1 1 1 1 1 1 1
Poorer 0.76 (0.53, 1.08) 0.81 (0.48, 1.37) 0.89 (0.71, 1.12) 0.02 (0.00, 0.14) 0.86 (0.77, 0.95) 0.77 (0.67, 0.89) 0.91 (0.59, 1.39) 0.37 (0.11, 1.16) 0.85 (0.62, 1.17) 1.12 (0.74, 1.69) 0.91 (0.69, 1.20) 1.23 (0.57, 2.66)
Middle 0.70 (0.51, 0.96) 0.81 (0.50, 1.33) 0.78 (0.61, 0.99) 0.07 (0.02, 0.20) 0.62 (0.56, 0.69) 0.47 (0.41, 0.55) 0.76 (0.52, 1.13) 0.38 (0.11, 1.29) 0.98 (0.66, 1.45) 1.25 (0.73, 2.14) 0.88 (0.66, 1.17) 0.58 (0.27, 1.20)
Richer 0.60 (0.43, 0.84) 0.46 (0.27, 0.80) 0.55 (0.42, 0.71) 0.02 (0.00, 0.13) 0.46 (0.41, 0.52) 0.32 (0.27, 0.38) 0.66 (0.41, 1.09) 0.10 (0.02, 0.41) 0.70 (0.48, 1.03) 0.72 (0.43, 1.23) 0.83 (0.64, 1.09) 0.68 (0.31, 1.47)
Richest 0.44 (0.30, 0.64) 0.31 (0.17, 0.57) 0.44 (0.33, 0.58) 0.12 (0.02, 0.53) 0.31 (0.27, 0.35) 0.21 (0.17, 0.25) 1.11 (0.51, 2.41) 0.12 (0.01, 1.39) 0.67 (0.45, 0.99) 0.57 (0.32, 1.00) 0.67 (0.49, 0.91) 0.39 (0.16, 0.93)
Women
Prevalence, 2.65 (2.39, 2.93) 0.09 (0.05, 0.15) 11.8 (11.3, 12.3) 0.41 (0.35, 0.48) 8.42 (7.50, 9.44) 0.03 (0.01, 0.10) 15.7 (14.2, 17.3) 1.45 (1.09, 1.94) 5.45 (4.92, 6.03) 0.83 (0.66, 1.03)
% (95% CI)
Age group
1519 1 1 1 1 1 1 1 1
2024 1.53 (0.91, 2.58) 0.90 (0.14, 5.86) 1.50 (1.30, 1.72) 1.33 (0.58, 3.03) 1.11 (0.28, 4.40) 1.65 (0.99, 2.74) 1 4.07 (2.05, 8.06) 2.01 (0.62, 6.44)
2529 1.96 (1.15, 3.35) 1.56 (0.25, 9.66) 2.30 (1.98, 2.66) 1.93 (0.88, 4.24) 0.91 (0.22, 3.75) 4.49 (2.64, 7.66) 25.0 (4.46, 140) 4.86 (2.43, 9.70) 2.60 (0.78, 8.62)
3034 2.16 (1.24, 3.78) 0.59 (0.09, 3.58) 3.24 (2.78, 3.77) 2.68 (1.21, 5.90) 2.30 (0.57, 9.32) 6.18 (3.59, 10.6) 62.4 (8.36, 466) 6.94 (3.46, 13.9) 1.89 (0.57, 6.24)
3539 2.74 (1.55, 4.83) 1.05 (0.14, 7.46) 4.34 (3.73, 5.06) 5.39 (2.43, 11.9) 3.15 (0.78, 12.7) 9.63 (5.67, 16.3) 90.7 (13.0, 633) 12.1 (6.03, 24.3) 3.68 (1.06, 12.7)
4044 2.99 (1.62, 5.52) 0.56 (0.09, 3.48) 4.92 (4.21, 5.74) 4.98 (2.24, 11.0) 4.71 (1.16, 19.0) 15.9 (9.02, 28.1) 205. (28.6, 1476) 15.9 (8.08, 31.4) 4.24 (1.14, 15.7)
4549 4.02 (2.09, 7.70) 1.11 (0.14, 8.51) 5.87 (5.00, 6.88) 6.14 (2.77, 13.5) 6.59 (1.62, 26.7) 17.6 (10.2, 30.5) 161. (22.4, 1161) 18.4 (9.18, 37.1) 5.26 (1.50, 18.3)
Residence
Urban 1 1 1 1 1 1 1 1 1
Rural 0.74 (0.60, 0.91) 0.72 (0.30, 1.72) 0.88 (0.78, 0.99) 1.20 (0.81, 1.79) 0.52 (0.29, 0.91) 0.93 (0.69, 1.24) 0.56 (0.26, 1.19) 0.57 (0.42, 0.76) 0.53 (0.29, 0.95)
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Table1. Continued
754

Bangladesh Indonesia India Maldives Nepal Timor Leste

Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use Any Tobacco Use Dual Use

Marital status
Never married 1 1 1 1 1 1 1 1
Currently married 1.19 (0.79, 1.81) 6.10 (1.02, 36.2) 1.29 (1.12, 1.49) 2.03 (0.82, 5.01) 1 3.32 (2.15, 5.12) 0.47 (0.10, 2.17) 1.27 (0.89, 1.82) 1.94 (0.74, 5.05)
Formerly married 2.24 (1.43, 3.52) 13.5 (1.48, 123) 1.59 (1.35, 1.88) 2.88 (1.06, 7.81) 1.74 (1.19, 2.55) 4.16 (2.45, 7.06) 0.61 (0.10, 3.78) 1.66 (1.00, 2.75) 1.82 (0.55, 6.02)
Education
No education 1 1 1 1 1 1 1 1 1
Primary 0.40 (0.28, 0.57) 0.18 (0.04, 0.70) 0.92 (0.85, 1.00) 0.70 (0.49, 1.00) 0.62 (0.45, 0.84) 0.92 (0.76, 1.13) 0.46 (0.22, 0.94) 0.78 (0.62, 0.97) 0.53 (0.30, 0.93)
Secondary 0.50 (0.33, 0.75) 0.16 (0.03, 0.90) 0.53 (0.48, 0.59) 0.31 (0.19, 0.50) 0.16 (0.10, 0.27) 0.35 (0.25, 0.48) 0.17 (0.05, 0.56) 0.41 (0.30, 0.55) 0.33 (0.16, 0.65)
Higher 0.37 (0.22, 0.63) 0.02 (0.00, 0.37) 0.20 (0.16, 0.26) 0.29 (0.06, 1.23) 0.38 (0.06, 2.15) 0.07 (0.02, 0.19) 0.22 (0.08, 0.60)
Religion
Islam 1 1 1 1
Hinduism 0.93 (0.82, 1.05) 0.72 (0.43, 1.21) 2.02 (1.16, 3.53) 17.6 (2.06, 151)
Christianity 1.38 (1.10, 1.74) 1.85 (1.06, 3.24) 1.50 (0.62, 3.58) 19.0 (1.50, 241)
Others 0.89 (0.70, 1.14) 0.96 (0.39, 2.37) 3.76 (2.08, 6.77) 47.3 (5.39, 415)
Wealth index
Poorest 1 1 1 1 1 1 1 1 1
Poorer 0.54 (0.42, 0.70) 0.32 (0.09, 1.10) 0.64 (0.59, 0.71) 0.48 (0.32, 0.70) 0.79 (0.61, 1.03) 0.44 (0.35, 0.55) 0.53 (0.35, 0.80) 0.87 (0.66, 1.14) 0.92 (0.52, 1.64)
Middle 0.40 (0.31, 0.52) 0.41 (0.16, 1.00) 0.44 (0.39, 0.49) 0.22 (0.15, 0.33) 0.52 (0.39, 0.68) 0.29 (0.22, 0.38) 0.24 (0.13, 0.45) 0.75 (0.57, 0.98) 0.93 (0.53, 1.61)
Richer 0.44 (0.33, 0.59) 0.00 (0.00, 0.04) 0.30 (0.26, 0.33) 0.13 (0.07, 0.21) 0.36 (0.24, 0.54) 0.22 (0.16, 0.30) 0.17 (0.08, 0.35) 0.67 (0.50, 0.88) 0.64 (0.31, 1.33)
Richest 0.31 (0.22, 0.44) 0.28 (0.05, 1.40) 0.17 (0.14, 0.20) 0.07 (0.04, 0.13) 0.32 (0.15, 0.68) 0.12 (0.08, 0.18) 0.03 (0.00, 0.16) 0.64 (0.43, 0.95) 0.81 (0.37, 1.76)

CI=confidence interval; OR=odds ratio. Age group was coded into 5-year age groups from 15 to 49years. Residence was classified into urban and rural. Marital status included never married or in union, currently
married or in union and formerly married or in union (widowed, divorced and separated). Educational status included categories such as no education, primary, secondary and higher. Religion was categorized
into Islam, Hinduism, Christianity, and Others. The Others category constituted a heterogeneous group of religions that were different in different countries. The wealth index variable was categorized into five
quintiles, the lowest being the poorest and the highest being the richest.
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
Figure1. Prevalence of current exclusive tobacco smoking, current exclusive smokeless tobacco (SLT) use and current dual use by country and gender.
developing nations and therefore, require specific enquiries to avoid
oversimplified generalizations. Longitudinal studies are required to
track the exclusive use behaviors and understand the circumstances
for the adoption of a second product or multiple products. The
tobacco control policies of a country should take into account the
factors driving the adoption of a second tobacco product and place
a greater stress on providing cessation interventions for such users.
Strengths and Limitations
The dual use phenomenon has been examined in great detail for
a number of countries in the South-East Asia region. Anumber of
sociodemographic factors were analyzed together and analyses were
conducted separately, for both the genders. The age standardization
of the prevalence estimates enabled a better and valid comparison
between the countries. Other strengths of the study arise from the
strengths of the DHS itself, that is, a large nationally representative
sample with robust methodology, uniform definitions of independ-
ent and outcome variables and rigorous quality control.
A number of limitations arise when using DHS for tobacco
related data analysis and they have been discussed elsewhere.10 There
are also a few other limitations. Firstly, the surveys were conducted
in different years in the various countries between 2005 and 2012
but the short duration of 7years may not have influenced the results
significantly. Secondly, although the DHS were implemented using
the standard methodology in different countries, minor variations
at the country level due to variations in interview techniques and
local language translation might have occurred. Thirdly and finally,
cross-country comparison was limited by inter-country differences in
eligibility criteria with regard to marital status. These points have to
be kept in context while interpreting the results.
Conclusions and Recommendations
This study has highlighted the need for an in-depth exploration
of the dual use phenomenon, which needs to be increasingly
755
recognized as a distinct tobacco use indicator, especially in countries
of the South-East Asia region where this phenomenon is prevalent.
Future surveys and reports on tobacco use should report preva-
lence by exclusive categories and dual use. Future DHS should also
take into consideration the limitations discussed above and make
the necessary modifications in the questionnaires, in order to make
them more useful and versatile for tobacco surveillance. The lop-
sided sociodemographic pattern of tobacco use has underscored
the need to focus interventions specifically on the disadvantaged
sections of the society, such as the poor and the uneducated, similar
to smoking and SLT use. Since countries have several differences in
the issues related to tobacco use, varied and localized interventions
are needed for achieving effective tobacco control in the respective
regions.
Funding
None declared.
Declaration of Interests
None declared.
Acknowledgments
DNS and RAS conceived the study. RAS performed the data retrieval and sta-
tistical analysis. DNS, RA, AK critically modified the analysis. RAS wrote the
first draft. DNS, AK, and RA provided critical comments to the discussion. All
authors read and approved the final manuscript.
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