Tracey Koehlmoos: The hidden burden of women smokers in Bangladesh

Tracey KoelhmoosChange is afoot in Bangladesh in terms of smoking and may represent a missed opportunity to prevent women from smoking.

According to the WHO report on the Global Tobacco Epidemic, 2008, nearly two-thirds of the world’s smokers live in 10 countries including Bangladesh. Tobacco use is common among men across all sectors. 60% of men smoke and 20% of men consume smokeless tobacco. In Bangladesh smoking is more prevalent among those men in the poorest groups (70%) compared to those in the wealthiest (46.4%) and among those with no education (73%) versus those who have completed secondary or higher (38.6%) (NIPORT 2009). 

There are more than 1.2 million cases of tobacco-attributable illness in Bangladesh each year and around 9% of all deaths in a year (57,000 deaths) in the country are the result of tobacco use (WHO 2008). In addition, exposure to secondhand smoking kills tens of thousands of non-smokers every year in Bangladesh (WHO SEARO 2007).

Traditionally, rates of smoking among women are low (2.0% urban and 3.6% rural) but increase slightly with age.  Unfortunately the Bangladesh demographic and health survey 2007 only included men as respondents for tobacco usage survey items.

Anecdotal evidence points to potentially hidden rates of smoking among college women and the urban elite. Smoking is seen to be so inappropriate for women, that perhaps as evidenced by questions about age of marriage, female respondents might lie to interviewers to be within the cultural norm or avoid the taboo. However, if major surveillance instruments used in the country do not ask women if they smoke, then it will remain impossible to know the real burden of this risk factor.

An alarming new study by led by Bhuiya and his team revealed a trend in smoking in Chakaria, Bangladesh—a rural area in the South-East of the country. Chakaria might be considered the tobacco road of Bangladesh because of the importance that tobacco plays as a cash crop. Both men and women work in the tobacco growing industry. The data for the study were from two surveys conducted in 1994 and 2008 in Chakaria. 

Overall, the results seem promising, showing that smoking levels among the population declined from 40% in 1994 to 23% in 2008. However, the rates among illiterate women in Chakaria held steady at 27% and demonstrate the clear need for targeted action for the long term health benefit of this group. (Hanifi et al. 2010) Health programmes that serve this population, be they public, NGO, or private, should work to incorporate anti-tobacco messages into family planning services, general health services, and especially into pre-natal care.

Bangladesh is a signer of the Framework Convention on Tobacco Control and should strongly implement the national policies, even far away from the capital. Rather than brushing this taboo issue under the rug, women should be asked if they smoke as a norm in surveys of national importance, and perhaps different means of capturing female cigarette consumption are necessary in order to get a real figure. Further, action should be taken to reach the poor and the illiterate, especially if they are working in the tobacco growing industry. 

National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International (2009). Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and training, Mitra and Associates, and macro International.

World Health Organization, Regional Office for South-East Asia [WHO SEARO] (2007) Impact of tobacco-related illnesses in Bangladesh. Zaman MM, Nargis N, Perucic A, Rahman K (editors) India: World Health Organization Regional Office for South-East Asia.

World Health Organization. (2008) WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package. Geneva: World Health Organization.

Hanifi S, Mahood S, Bhuiya A (2010) Smoking has declined but not for all: Findings from a study in a rural area of Bangladesh. Asia Pacific Journal of Public Health. Available on line at:

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University.