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Applied nutritional investigation

Parental tobacco use is associated with increased risk of childmalnutrition in Bangladesh

Cora M. Best, M.H.S.a,c, Kai Sun, Ph.D.a,b, Saskia de Pee, Ph.D.c,Martin W. Bloem, M.D.a,c, Gudrun Stallkamp, M.Sc.d, and Richard D. Semba, M.D., M.P.H.a,b,*

a Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USAb Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA

c World Food Program, Rome, Italyd Concern Worldwide, Dublin, Ireland

Abstract Objectives: We investigated the relation between parental tobacco use and malnutrition in children

5 y of age and compared expenditures on foods in households with and without tobacco use.

Methods: Tobacco use, child anthropometry, and other factors were examined in a stratified,

multistage cluster sample of 77 678 households from the Bangladesh Nutrition Surveillance Project

(20052006). Main outcome measurements were stunting, underweight, and wasting, and severe

stunting, severe underweight, and severe wasting. Secondary outcomes included the proportion of

household expenditures spent on food.

Results: The prevalence of parental tobacco use was 69.9%. Using the new World Health

Organization child growth standards, prevalences of stunting, underweight, and wasting were

46.0%, 37.6%, and 12.3%, respectively. After adjusting for potential confounders, parental tobacco

use was associated with an increased risk of stunting (odds ratio [OR] 1.17, 95% confidence interval

[CI] 1.121.21,P 0.0001), underweight (OR 1.17, 95% CI 1.121.22, P 0.0001), and wasting

(OR 1.10, 95% CI 1.031.17, P 0.004), and severe stunting (OR 1.16, 95% CI 1.101.23, P

0.0001), severe underweight (OR 1.21, 95% CI 1.131.30, P 0.0001), and severe wasting (OR

1.14, 95% CI 0.981.32, P 0.09). Households with tobacco use spent proportionately less percapita on food items and other necessities.

Conclusions: In Bangladesh parental tobacco use may exacerbate child malnutrition and divert

household funds away from food and other necessities. Further studies with a stronger analytic

approach are needed. These results suggest that tobacco control should be part of public health

strategies aimed at decreasing child malnutrition in developing countries. 2007 Elsevier Inc. All

rights reserved.

Keywords: Bangladesh; Malnutrition; Poverty; Smoking; Tobacco

Introduction

Cigarette smoking causes 5 million deaths worldwide

annually, and it is estimated that the annual death toll from

smoking will climb to 10 million deaths by 2030, with 7

million deaths in developing countries [1,2]. Cigarette

smoke damages the lower respiratory tract, increases oxi-

dative stress, and increases the risk of bronchitis, chronic

obstructive lung disease, cancer, and death[1].As tobacco

control legislation in developed countries has exerted pres-

sure on tobacco companies, these companies have gradually

shifted their market from high-income to low-income coun-

tries, where many people are poorly informed about the

health risks of tobacco use and antismoking policy is rela-

tively weak[2].Although much research has been focused

on the relation between smoking and adverse outcomes such

as cancer, respiratory disease, and cardiovascular disease,

the problem of smoking and its relation to malnutrition and

poverty has not been well characterized [2]. Tobacco use

may have adverse consequences for nutrition, health, and

This work was supported in part by a Lew R. Wasserman Merit Award

for Research to Prevent Blindness to Dr. Semba and by the Eye Foundation

of America.

* Corresponding author. Tel: 410-955-3572; fax: 410-955-0629.

E-mail address: [email protected] (R. D. Semba).

Nutrition 23 (2007) 731738

www.elsevier.com/locate/nut

0899-9007/07/$ see front matter 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.nut.2007.06.014

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household budgets, especially among families living in pov-

erty in developing countries.

The amount of money spent on tobacco is especially

problematic in low-income countries [3,4]. Bangladesh is

one of the poorest countries in the world. Nearly half of the

population lives below the poverty line and consumes

2122 cal/d[2]. One investigation suggested that tobaccoexpenditures exacerbate the effects of poverty and divert

household income away from food, clothing, housing,

health, and education [3]. It is estimated that the average

male cigarette smoker in Bangladesh spends more than

twice as much on cigarettes than the per capita expenditure

on clothing, housing, health, and education combined [3].

As in many countries, prevalence of tobacco use is highest

in the poorest of households, the same households that are

most likely to have malnourished children[2].Efroymson et

al. [3] estimated that if a portion of the money spent on

tobacco by poor households in Bangladesh could be redi-

rected toward food purchases, this would provide enoughcalories to prevent nearly 130 000 deaths from malnutrition

each year in children 5 y of age.

Previous estimates of the current prevalences of tobacco

use in Bangladesh are 48.3% in adult men and 20.9% in

adult women. The highest estimate is in men 35 49 y of age

at 73%[3,5].Since the 1980s, Bangladesh has had a grow-

ing negative trade balance in tobacco and tobacco products,

yet between 1993 and 1996 annual per-capita cigarette con-

sumption increased 33% [2]. Although it is difficult to

estimate the health costs associated with tobacco use in

Bangladesh, the Bangladesh Cancer Society estimates that

half of the annual cancer mortality of 75 000 people is dueto tobacco[2].

Although smoking appears to exacerbate poverty in de-

veloping countries, it is not well known whether smoking

contributes to malnutrition among children. We hypothe-

sized that among families in Bangladesh, 1) children are at

higher risk for malnutrition in households where a parent

uses tobacco and 2) household income spent on tobacco is

associated with lower expenditures on food. To examine

these hypotheses, we characterized tobacco use and child

malnutrition among families in Bangladesh.

Materials and methods

The study consisted of 77 678 households that partici-

pated in the Nutritional Surveillance Project (NSP) of Ban-

gladesh in 20052006. The NSP has been conducted by

Helen Keller International (HKI) and the Institute of Public

Health Nutrition of the Government of Bangladesh since

1989[6].The surveillance design is guided by the concep-

tual framework of the United Nations Childrens Fund on

the causes of malnutrition[7]and collects data on indicators

of health, nutrition, socioeconomic status, food production

and consumption, and health services [8].The NSP used astratified multistage cluster sample of households in rural

areas and cities of the six major divisions of the Bangladesh:

Barisal, Chittagong, Dhaka, Khulni, Rajshahi, and Sylhet

[6].Data were collected on a structured coded questionnaire

by two-person field teams from partner non-governmental

organizations trained by the HKI. The questionnaire was

used to record data on children 059 mo of age, including

anthropometry, date of birth, and sex. The mother of thechild or other adult member of the household was asked to

provide information on the households composition, paren-

tal education, and household expenditures, along with other

socioeconomic, environmental, sanitation, and health indi-

cators.

The field teams measured and recorded the weight of

each child 059 mo of age to a precision of 0.1 kg and

length/height to a precision of 0.1 cm. Birth dates were

estimated using a calendar of local and national events and

converted to the Gregorian calendar.Zscores of height for

age (stunting), weight for age (underweight), and weight for

height (wasting) were calculated using the new WorldHealth Organization (WHO) child growth standards [9].

The new WHO child growth standards have not yet been

widely applied, and for comparison purposes conventional

Zscores were also calculated using EpiInfo software (Cen-

ters for Disease Control and Prevention, Atlanta, GA,

USA), which uses the reference population of the U.S.

National Center for Health Statistics (NCHS). Children with

Zscores 2 SD for weight for height, weight for age, or

height for age were considered wasted, underweight, or

stunted, respectively, and Zscores 3 SD for weight for

height, weight for age, or height for age were considered

severely wasted, severely underweight, or severely stunted[10].

In 20052006, the NSP included questions on paternal

and maternal tobacco use and weekly expenditures on to-

bacco products. In each household, data were gathered re-

garding expenditures the previous week on rice, wheat, dal,

eggs, fish, fruits, vegetables, milk, meat, poultry, sweet

biscuits, cooking oil, sugar, snacks, spices, and other foods.

Because few homes purchased significant amounts of staple

foods (rice and wheat), the amount of rice produced and/or

received from relatives, friends, and aid programs was re-

ported in kilograms and assigned a monetary value deter-

mined by the daily market price of rice at the time of thesurvey. This monetary value was included when calculating

the total monthly household expenditure per capita. The

previous monthly expenditure on housing, education, med-

ical care, agricultural inputs, livestock purchases, electric-

ity, fuel, loan payment, taxes, and other household items

was also recorded. Expenditure and price variables were

collected using the Bangladeshi taka.

The study protocol complied with the principles enunci-

ated in the Helsinki Declaration[11].The field teams were

instructed to explain the purpose of the NSP and data

collection to each childs mother or caretaker and, if

present, the father and/or household head; data collectionproceeded only after written informed consent was ob-

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tained. Participation was voluntary and all subjects were

free to withdraw at any stage of the interview. The NSP was

approved by the ethical review committee of the Bang-

ladesh Medical Research Council. The plan for secondary

data analysis was approved by the institutional review boardof the Johns Hopkins University School of Medicine.

In analyses where child malnutrition was the outcome

and there was more than one child in the household, the

youngest child in the household was used as the index of

child malnutrition for that particular household (i.e., house-

holds were not counted more than once). The status ofparental tobacco use was determined by whether the mother

Table 1

Characteristics of children and households where a parent uses tobacco or does not use tobacco among poor families in Bangladesh (n 77 678)

Characteristics n Tobacco use n No tobacco use P

Maternal age (y)

22 15 308 27.8 9316 39.2 0.0001

2326 14 325 26.0 7030 29.6

2730 10 844 19.7 4043 17.031 14 612 26.5 3379 14.2

Maternal education (y)

0 24 856 45.4 5723 24.2 0.0001

13 3550 6.5 1235 5.2

46 14 589 26.6 7030 29.7

79 9255 16.9 6645 28.1

10 2513 4.6 3038 12.8

Paternal education (y)

0 25 404 47.6 6259 27.7 0.0001

13 2893 5.4 953 4.2

46 11 629 21.8 5485 24.3

79 8328 15.6 4878 21.6

10 5121 9.6 4983 22.1

Child age (mo)05 4941 9.8 2248 10.4 0.0001

611 5613 11.2 2596 12.0

1223 12 004 23.8 5422 25.0

2435 11 185 22.2 4748 21.9

3647 9487 18.8 3876 17.8

4859 7060 14.0 2800 12.9

Child malnutrition, conventional NCHS standard

Height-for-ageZscore 2 21 388 39.3 7734 32.8 0.0001

Height-for-ageZscore 3 6244 11.4 2011 8.5 0.0001

Weight-for-ageZscore 2 25 343 46.0 9430 39.7 0.0001

Weight-for-ageZscore 3 5797 10.5 1869 7.9 0.0001

Weight-for-heightZscore 2 6418 11.8 2466 10.5 0.0001


Child malnutrition, new WHO child growth standard*

Height-for-ageZscore 2 26 418 48.1 9800 41.3 0.0001Height-for-ageZscore 3 9250 16.8 3097 13.0 0.0001

Weight-for-ageZscore 2 21 783 39.5 7901 33.3 0.0001

Weight-for-ageZscore 3 5961 10.8 1909 8.0 0.0001



No. of individuals eating from same cooking pot

24 21 900 39.7 10 253 43.1 0.0001

4 33 195 60.3 13 516 56.9

Geographic location

Rural 47 903 86.9 21 155 89.0 0.0001

Urban 7192 13.1 2614 11.0

Monthly household expenditure per capita (taka) 56 246 772 22 432 886 0.0001

Monthly household expenditure per capita (taka) in quintiles

Quintile 1 9890 17.9 3754 15.8 0.0001Quintile 2 11 166 20.3 4045 17.0

Quintile 3 11 291 20.5 4449 18.7

Quintile 4 11 528 20.9 5086 21.4

Quintile 5 11 220 20.4 6435 27.1

Monthly household food expenditure per capita (taka) 56 246 358 22 432 405 0.0001

NCHS, U.S. National Center for Health Statistics; WHO, World Health Organization

* Stunting, underweight, and wasting defined as a Zscore 2 SD for height for age, weight for age, and weight for height, respectively [9].

733C. M. Best et al. / Nutrition 23 (2007) 731738

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or the father in the household currently used tobacco (cig-

arette, bidi, hukah, or chewing tobacco). Child age was

categorized as 011, 1223, 2435, 3547, and 4859 mo.

Maternal and paternal education levels were categorized as

0, 13 y (first half of primary), 4 6 y (second half of

primary), 79 y (junior high), and 10 y (at least highschool).

Univariate and multivariate logistic regression models

were used to examine the relation between parental tobacco

use and the risk of stunting, underweight, and wasting. The

multivariate regression models included risk factors se-

lected on the basis of their known association with child

malnutrition in developing countries. Because information

on household income was not available, quintiles of total

monthly household expenditures per capita were included in

all multivariate models to serve as a proxy for socioeco-

nomic status. HKIs assigned sampling design weights were

used to adjust for population size, and all results areweighted. The analyses were conducted using SAS Survey

(SAS Institute, Cary, NC, USA) [12]. P 0.05 was con-

sidered statistically significant.

Results

The analysis included 77 678 households that were sur-veyed between January 1, 2005 and January 31, 2006. The

overall prevalence of parental tobacco use was 69.9%. The

prevalences of paternal and maternal tobacco uses were

68.2% and 20.1%, respectively. Of all the households, the

father and mother used tobacco in 17.6%, only the father

used tobacco in 50.8%, only the mother used tobacco in

2.5%, and neither parent used tobacco in 29.1%.

The characteristics of households in which the father

and/or mother used tobacco were compared with house-

holds in which neither parent used tobacco (Table 1). In

households with tobacco use, the levels of paternal and

maternal education were lower and maternal age was older.When using the new WHO child growth standards and the

conventional NCHS reference population, prevalences of

stunting, underweight, and wasting, and severe stunting and

severe underweight were significantly higher in households

with tobacco use compared with no tobacco use. The prev-

alence of severe wasting was significantly higher in house-

holds with tobacco use compared with no tobacco use using

the new WHO standards but not with the NCHS reference

population. There was a larger proportion of more than four

people eating from the same cooking pot in households with

parental tobacco use. The mean total monthly household

expenditure per capita and mean monthly household expen-diture on food were lower in households with tobacco use

than in households with no tobacco use. The relation be-

tween stunting, underweight, wasting, and severe stunting,

severe underweight, and severe wasting and parental to-

bacco use was consistent and significant in each quintile of

total monthly per capita household expenditure (Table 2).

In households where neither parent used tobacco, the

average proportion of household expenditures devoted to

food purchases was 58.0%. In households where at least one

parent used tobacco, this proportion was 56.6%. In a sub-

sample of 51 655 households where specific data on expen-

ditures on types of food were collected, families with notobacco use also devoted a greater proportion of the total

monthly household expenditure to animal foods, plant

foods, education, and medical care (Fig. 1). In contrast,

households with tobacco use spent a greater proportion of

money on clothing, housing, and other household items. In

households with no parental tobacco use, the median ex-

penditure was greater for animal food products (fish, eggs,

meat, poultry, and milk) and plant products (vegetables,

fruits, anddal), education and health care, and other house-

hold resources such as clothing, housing, electricity, fuel,

agricultural inputs, etc. As socioeconomic status increased,

the proportion of the total household expenditure devoted totobacco decreased. This proportion was 6.0% in the poorest

Table 2

Proportion of children 5 y of age with malnutrition in households by

parental tobacco use, stratified by quintile of monthly household

expenditure using new World Health Organization child growth standard

Tobacco

use (%)

No tobacco

use (%)

P

Quintile 1Stunting 53.8 48.2 0.0001

Severe stunting 20.6 18.0 0.004

Underweight 45.8 41.6 0.0001

Severe underweight 14.5 11.4 0.0001

Wasting 16.1 13.4 0.0009

Severe wasting 2.9 2.5 0.22

Quintile 2

Stunting 51.4 45.0 0.0001


Underweight 42.5 36.5 0.0001


Wasting 13.6 12.7 0.24


Quintile 3Stunting 49.3 44.9 0.0001


Underweight 40.6 35.9 0.0001


Wasting 13.2 11.2 0.005


Quintile 4

Stunting 46.2 40.0 0.0001


Underweight 37.4 31.7 0.0001


Wasting 11.7 10.0 0.01


Quintile 5

Stunting 40.2 33.4 0.0001Severe stunting 12.4 9.4 0.0001

Underweight 32.1 25.7 0.0001


Wasting 9.9 9.3 0.28



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quintile (quintile 1) and decreased linearly to 1.8% in thewealthiest quintile (quintile 5).

In the following results, the new WHO child growth

standards were applied. The prevalence of stunting was

46.0%. In a univariate model (model 1) and a multivariate

model (model 2) adjusting for child age, child gender,

maternal age, maternal education level, total monthly

household expenditure per capita, and other factors, parental

tobacco use was associated with an increased risk of stunt-

ing (odds ratio [OR] 1.17, 95% confidence interval [CI]

1.121.21, P 0.0001;Table 3). The prevalence of under-

weight was 37.6%. In a univariate model (model 1) and a

multivariate model (model 2) adjusting for child age, childgender, maternal age, maternal education level, total

monthly household expenditure per capita, and other fac-

tors, parental tobacco use was associated with an increased

risk of a child being underweight (OR 1.17, 95% CI 1.12

1.22, P 0.0001). The prevalence of wasting was 12.3%.

In a univariate model (model 1), and a multivariate model

(model 2) adjusting for child age, child gender, maternal

age, maternal education level, total monthly household ex-

penditure per capita, and other factors, parental tobacco use

was associated with an increased risk of wasting (OR 1.10,

95% CI 1.031.17, P 0.004).

Using the conventional NCHS reference population, theprevalences of stunting, underweight, and wasting were

37.4%, 44.1%, and 11.4%, respectively. When multivariatemodels were analyzed, adjusting for the same variables as in

Table 3, paternal tobacco use was associated with an in-

creased risk of stunting (OR 1.17, 95% CI 1.121.23, P

0.0001), underweight (OR 1.15, 95% CI 1.111.20, P

0.0001), and wasting (OR 1.08, 95% CI 1.011.15, P

0.029).

Using the new WHO child growth standards, the preva-

lence of severe stunting was 15.7%. In a univariate model

(model 1) and a multivariate model (model 2) adjusting for

child age, child gender, maternal age, maternal education

level, total monthly household expenditure per capita, and

other factors, parental tobacco use was associated with anincreased risk of severe stunting (OR 1.16, 95% CI 1.10

1.23, P 0.0001; Table 4). The prevalence of severe

underweight was 10.0%. In a univariate model (model 1)

and a multivariate model (model 2) adjusting for child age,

child gender, maternal age, maternal education level, total

monthly household expenditure per capita, and other fac-

tors, parental tobacco use was associated with an increased

risk of a child being severely underweight (OR 1.21, 95%

CI 1.131.30,P 0.0001). The prevalence of severe wast-

ing was 2.0%. In a univariate model (model 1), parental

tobacco use was associated with an increased risk of severe

wasting (OR 1.26, 95% CI 1.101.44, P 0.001). In themultivariate model (model 2) adjusting for the same factors

Fig. 1. Median monthly household expenditures per capita ( taka) in Bangladeshi households with and without parental tobacco use.


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as the previous multivariate models above, parental tobaccouse was marginally associated with severe wasting (OR

1.14, 95% CI 0.981.32, P 0.09).

Using the conventional NCHS reference population, the

prevalences of severe stunting, severe underweight, and

severe wasting were 10.5%, 9.7%, and 0.6%, respectively.

When multivariate models were run, adjusting for the same

variables as inTable 4,paternal tobacco use was associated

with an increased risk of severe stunting (OR 1.18, 95% CI

1.101.26, P 0.0001), severe underweight (OR 1.21,

95% CI 1.121.29, P 0.0001), and severe wasting (OR

1.02, 95% CI 0.791.31, P 0.89).

We also examined alternative multivariate logistic re-gression models where weekly per-capita household expen-

diture on tobacco instead of paternal tobacco use was eval-

uated as a risk factor. Expenditures on tobacco were divided

into the highest half of expenditures on tobacco and lowest

half of expenditures on tobacco versus no expenditures on

tobacco (reference category). In multivariate models, ad-

justing for child age, child gender, maternal age, maternal

education level, total monthly household expenditure per

capita, and other factors, the highest half of tobacco expen-

ditures (OR 1.18, 95% CI 1.131.24, P 0.0001) and lower

half of tobacco expenditures (OR 1.18, 95% CI 1.121.23,

P 0.0001) were associated with stunting. In multivariatemodels, adjusting for child age, child gender, maternal age,

maternal education level, total monthly household expendi-ture per capita, and other factors, the highest half of tobacco

expenditures (OR 1.21, 95% CI 1.131.29, P 0.0001) and

lower half of tobacco expenditures (OR 1.14, 95% CI 1.07

1.22, P 0.0001) were associated with severe stunting. In

similar multivariate logistic regression models, tobacco ex-

penditures were also significantly associated with under-

weight, severe underweight, and wasting but not with severe

wasting (data not shown).

Discussion

This analysis reveals that in households in Bangladesh,

parental tobacco use is associated with an increased risk of

stunting, underweight, wasting, and severe malnutrition

(stunting and underweight) in children 059 mo of age.

Similar research on poor urban households in Indonesia also

detected an association between paternal smoking and an

increased risk of child malnutrition[13].This study found

that paternal smoking in poor urban areas of Indonesia,

where the prevalence of smoking in adult males is 73.8%,

was associated with an increased risk of stunting and severe

wasting in children. In the present study, current parental

tobacco use increased the risk of child malnutrition, anddata were not available on long-term tobacco use and du-

Table 3

Logistic regression models for parental tobacco use and risk of moderate child malnutrition in households in Bangladesh

Characteristics Stunting Underweight Wasting

OR 95% CI P OR 95% CI P OR 95% CI P

Model 1

Parental tobacco use 1.32 1.271.37

0.0001 1.31 1.261.36

0.0001 1.18 1.121.25

0.0001Model 2

Parental tobacco use 1.17 1.121.21 0.0001 1.17 1.121.22 0.0001 1.10 1.031.17 0.004

Male gender 1.09 1.051.13 0.0001 1.00 0.971.04 0.94 1.21 1.141.27 0.0001

Child age (mo)

05 0.40 0.370.43 0.0001 0.43 0.390.46 0.0001 0.75 0.660.85 0.0001

611 0.45 0.420.48 0.0001 0.53 0.490.57 0.0001 1.04 0.941.17 0.41

1223 1.18 1.111.26 0.0001 0.90 0.850.96 0.0008 1.54 1.401.69 0.0001

2435 1.29 1.221.38 0.0001 1.04 0.981.11 0.22 1.17 1.061.29 0.0013

3647 1.23 1.161.31 0.0001 0.98 0.911.04 0.44 0.98 0.881.08 0.66

4959 1.00 1.00 1.00

Maternal age (y) 0.93 0.980.99 0.0001 0.99 0.980.99 0.0001 1.00 0.991.00 0.33

Maternal education level (y)

0 2.67 2.462.91 0.0001 2.36 2.162.58 0.0001 1.65 1.451.89 0.0001

13 2.58 2.322.87 0.0001 2.22 1.992.47 0.0001 1.60 1.361.88 0.0001

46 2.08 1.912.26 0.0001 1.87 1.712.05 0.0001 1.44 1.261.65 0.000179 1.53 1.401.67 0.0001 1.40 1.281.54 0.0001 1.18 1.031.36 0.02

10 1.00 1.00 1.00

4 individuals eating from same cooking pot 1.02 0.981.07 0.27 0.98 0.941.02 0.37 0.96 0.901.02 0.14

Total monthly household expenditures per capita (taka)

Quintile 1 1.58 1.491.68 0.0001 1.64 1.541.74 0.0001 1.49 1.371.63 0.0001

Quintile 2 1.41 1.331.49 0.0001 1.41 1.331.50 0.0001 1.27 1.161.38 0.0001

Quintile 3 1.36 1.291.44 0.0001 1.35 1.271.43 0.0001 1.23 1.141.34 0.0001

Quintile 4 1.20 1.131.27 0.0001 1.20 1.131.27 0.0001 1.09 1.011.20 0.044

Quintile 5 1.00 1.00 1.00

Urban location 0.86 0.820.89 0.0001 0.88 0.830.92 0.0001 0.90 0.840.97 0.005

CI, confidence interval; OR, odds ratio


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ration of exposure. Studies have shown that cigarettes andother forms of tobacco are addicting and that patterns of

tobacco use are regular and compulsive [14].

The new WHO child growth standards were applied in

this study, and it is notable that the prevalence of stunting,

severe stunting, wasting, and severe wasting were higher

when compared with the prevalence when the conventional

NCHS reference population was used. The new WHO child

growth standards are considered to be more accurate in

defining child malnutrition and are now being more widely

applied in epidemiologic studies.

The large proportion of household finances devoted to

food expenditures indicates that poverty is widespread inthis sample. In all socioeconomic status quintiles food ex-

penditures account for 50% of total expenditures on av-

erage. Poorer households spent proportionally more money

on tobacco products than wealthier households, suggesting

tobacco addiction imposes the greatest strain on the house-

hold budgets of the poorest sector of society. These are the

same households in which children are most likely to have

malnutrition. Households with no tobacco use were able to

devote a larger proportion of money to purchase micronu-

trient-rich animal and plant foods such as eggs, fish, meat,

milk, green leafy vegetables, and fruits. Thus, efforts to

decrease tobacco use, which would lead to a decrease inexpenditures on tobacco and medical care due to tobacco

use in the household, could increase disposable income andcontribute to poverty reduction and nutritional interven-

tions.

Tobacco control legislation in Bangladesh had been

weak until the recent passing of the Tobacco Control Act in

2005. This legislation bans all forms of direct and indirect

advertising for tobacco products, excluding point-of-pur-

chase advertising [15]. The sale of tobacco products in

vending machines has been outlawed, and pack warnings

now must convey more specific health messages and cover

30% of the package. The Tobacco Control Act also bans

all forms of sponsorship to promote tobacco and smoking in

public and government facilities. Tobacco activists in Ban-gladesh are concerned that the portion of the legislation that

allows for the creation of smoking areas within smoke-free

public places lacks clarity and that, without greater descrip-

tion, smoke-free public places will not be sufficiently free of

tobacco smoke[15].British American Tobacco remains one

of the nations most profitable industries, but the govern-

ment has agreed to develop programs to discourage the

entrance of new tobacco companies into the country. Cur-

rently, there is no research available that reviews the com-

pliance and success of this legislation. But this act signifies

a major success for tobacco control in Bangladesh and for

the Framework Convention on Tobacco Control to which itis signatory.

Table 4

Logistic regression models for parental tobacco use and risk of severe child malnutrition in households in Bangladesh

Characteristics Severe stunting Severe underweight Severe wasting

OR 95% CI P OR 95% CI P OR 95% CI P

Model 1

Parental tobacco use 1.35 1.281.42

0.0001 1.39 1.301.48

0.0001 1.26 1.101.44

0.0001Model 2

Parental tobacco use 1.16 1.101.23 0.0001 1.21 1.131.30 0.0001 1.14 0.981.32 0.09

Male gender 1.16 1.111.22 0.0001 1.05 0.991.12 0.08 1.50 1.321.71 0.0001

Child age (mo)

05 0.62 0.550.70 0.0001 0.84 0.730.97 0.016 3.18 2.354.30 0.0001

611 0.62 0.550.70 0.0001 0.96 0.851.10 0.58 2.65 1.963.59 0.0001

1223 1.64 1.501.78 0.0001 1.54 1.391.71 0.0001 3.04 2.314.00 0.0001

2435 1.62 1.491.77 0.0001 1.56 1.401.73 0.0001 1.95 1.462.59 0.0001

3647 1.43 1.311.56 0.0001 1.24 1.111.38 0.0002 1.31 0.961.78 0.09

4959 1.00 1.00 1.00

Maternal age (y) 0.99 0.980.99 0.0001 0.99 0.990.99 0.01 1.00 0.991.01 0.79

Maternal education level (y)

0 3.05 2.643.52 0.0001 2.97 2.483.55 0.0001 1.66 1.212.26 0.0015

13 2.54 2.163.00 0.0001 2.64 2.153.24 0.0001 1.07 0.721.59 0.76

46 2.24 1.942.59 0.0001 2.28 1.902.84 0.0001 1.27 0.931.74 0.1479 1.46 1.261.70 0.0001 1.54 1.271.86 0.0001 0.97 0.701.35 0.86

10 1.00 1.00 1.00

4 individuals eating from same cooking pot 1.07 1.011.12 0.022 1.07 1.011.14 0.039 0.98 0.851.13 0.77

Total monthly household expenditure per capita (taka)

Quintile 1 1.61 1.491.75 0.0001 1.80 1.631.99 0.0001 1.49 1.331.83 0.0001

Quintile 2 1.41 1.301.53 0.0001 1.46 1.321.61 0.0001 1.16 0.941.42 0.17

Quintile 3 1.34 1.241.46 0.0001 1.44 1.301.59 0.0001 1.19 0.971.46 0.09

Quintile 4 1.16 1.071.26 0.0004 1.23 1.111.37 0.0001 1.03 0.831.27 0.82

Quintile 5 1.00 1.00 1.00

Urban location 0.99 0.931.05 0.70 0.96 0.891.04 0.32 0.92 0.781.09 0.33

CI, confidence interval; OR, odds ratio


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8/8

The high prevalence of adult tobacco use in Bangladesh

indicates that the nations public health efforts in tobacco

control must be of sustained intensity. A decrease in tobacco

consumption in Bangladesh could improve immediate

health outcomes, such as the incidence of cancer, cardio-

vascular, and respiratory diseases, and intermediate health

outcomes that are mediated by poverty, such as child mal-nutrition. Compliance with the recent Tobacco Control Act

is essential for a reduction in the negative health outcomes

caused by tobacco addiction and exposure to tobacco

smoke.

Conclusions

Parental use of tobacco increases the risk of child mal-

nutrition among households in Bangladesh and diverts

money from necessities such as animal and plant foods,

education, and health care. Tobacco control should be con-

sidered as part of integrated public health strategies aimed at

decreasing child malnutrition in developing countries.

Acknowledgments

The authors acknowledge the contribution of the survey

participants and the entire NSP team.

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