KINGDOM OF BHUTAN

WAVE 1 TECHNICAL REPORT

2012

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The International Tobacco Control Policy Evaluation Project (the ITC Project) is a

multi-country prospective cohort study designed to measure the psychosocial

and behavioural impact of key policies of the WHO Framework Convention on

Tobacco Control (FCTC).

ITC Bhutan Survey Team

Bhutan Team

Sonam Phuntsho La Trobe University, Australia and Ministry of Health, Bhutan

Ugyen Norbu Ministry of Health, Bhutan

ITC International Team

Geoffrey T. Fong, Mary E. Thompson, Pete Driezen, Grace Li, Mary McNally (Project Manager), Anne C.K.

Quah University of Waterloo

Ron Borland, Hua-Hie Yong, Lin Li The Cancer Council Victoria

Funding

The ITC Bhutan Project has received funding support from:

International Development Research Centre (IDRC) Research for international Tobacco Control (RITC)

Ontario Institute for Cancer Research (OICR)

Canadian Institutes of Health Research (CIHR) Knowledge Transfer and Utilization Grant (#104765)

Canadian Cancer Society Research Institute Prevention Scientist Award

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Contents

1. Introduction .............................................................................................................................................. 5

1.1 Background ......................................................................................................................................... 5

1.2 Survey Design ...................................................................................................................................... 6

1.3 The Research Team ............................................................................................................................. 6

1.4 Maps of Bhutan ................................................................................................................................... 6

2. Sampling Design ........................................................................................................................................ 8

2.1 Target Population................................................................................................................................ 8

2.2 Sampling Design .................................................................................................................................. 8

2.3 Sample Size ......................................................................................................................................... 8

3. Survey Development and Content ............................................................................................................ 9

3.1 Survey Development ........................................................................................................................... 9

3.2 Survey Content .................................................................................................................................... 9

4. Protocols and Quality Control ................................................................................................................. 11

4.1 ITC Bhutan Survey Protocol .............................................................................................................. 11

4.2 Respondents ..................................................................................................................................... 11

4.3 Components of the ITC Bhutan Survey Fieldwork ............................................................................ 11

4.4 Remuneration and Conclusion .......................................................................................................... 13

4.5 Monitoring & Quality Assurance ....................................................................................................... 13

5. Disposition Codes and Cooperation Rate ............................................................................................... 14

5.1 Outcome codes: Household .............................................................................................................. 14

5.2 Outcome codes: Individual ............................................................................................................... 14

5.3 Respondent ID ................................................................................................................................... 14

5.4 Cooperation Rate .............................................................................................................................. 15

6. Weights Construction ............................................................................................................................. 16

6.1 Wave 1 Sampling Plan ....................................................................................................................... 16

6.2 Weights Construction Overview ....................................................................................................... 17

6.3 Computation of Enumerated Household Weights (EHWT) .............................................................. 17

6.4 Prevalence Estimation ...................................................................................................................... 19

6.5 Computation of Individual Weights .................................................................................................. 19

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6.6 Rescaling ........................................................................................................................................... 21

6.7 Screener Weights .............................................................................................................................. 21

Appendix A: Sample of Bhutan Household Enumeration Form.................................................................. 22

Appendix B: Sample of Bhutan Wave 1 Screener Survey ........................................................................... 25

Appendix C: Sample of Bhutan Wave 1 Mixed User Survey ...................................................................... 27

Appendix D: Sample of Consent Form ........................................................................................................ 28

7. References .............................................................................................................................................. 29

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1. Introduction

1.1 Background

The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever

international cohort study of tobacco use. The ITC Project is a collaborative effort with international

health organizations and policymakers in over 20 countries so far. The International Tobacco Control

Policy Evaluation Project in Bhutan (the ITC Bhutan Project) was created in 2009 to evaluate rigorously

the psychosocial and behavioural effects of Bhutanese tobacco control legislation. Wave 1 of the ITC

Bhutan Survey was conducted from September to November 2009, which is 5 years after Bhutan

became the only nation in the world with a comprehensive ban on all tobacco sales.

1.1.1 Objectives of the ITC Bhutan Survey

The general objective of the ITC Bhutan Survey is to evaluate the ban on the sale of tobacco products

and other tobacco control policies in order to support the Bhutan Governments activities in tobacco

control.

Eight specific objectives are:

a) To estimate the prevalence of tobacco use among the adult population in Bhutan.

b) To estimate the level of support for the ban on the sale of tobacco products and for

other tobacco control measures, and to assess public perceptions on the effectiveness

of enforcement and how it may vary by geographical area, by other demographic

variables, and by tobacco use.

c) To assess the effect of the ban on the sale of tobacco products in Bhutan on tobacco use,

on quitting, and on psychosocial predictors of quitting (e.g., intentions to quit, thinking

about quitting, forgoing a cigarette).

d) To establish baseline data for measuring the impact of forthcoming measures to curb

smuggling and for increasing enforcement of the ban.

e) To estimate the availability of tobacco products via legal and illegal means, and relate

this to reported/observed/perceived purchasing of cigarettes, the price paid, and the

sources.

f) To determine regional differences, if any, in tobacco use, smuggling of tobacco products,

exposure to second-hand smoke, and other measures relevant to tobacco use.

g) To estimate the impact of the sales ban on tobacco consumption, on attitudes and

beliefs of tobacco users about tobacco-related habits and consequences, and on public

health outcomes, and examine variation across socio-demographic and economic

groups and regions.

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1.2 Survey Design

The ITC Bhutan Survey was designed as a prospective longitudinal cohort study designed to evaluate

national level impact of tobacco control policies, which implies that participants selected in the present

will be followed in the future. The longitudinal cohort design allows the evaluation studies arising from

the survey data to address research questions of greater precision and complexity because the same

individuals are tracked over time.

1.3 The Research Team

The ITC Bhutan Project is conducted by team members from Bhutan Ministry of Health, in collaboration

with the ITC Bhutan Project team, centered at the University of Waterloo, in Canada. This team

comprises three Principal Investigators, Mr. Sonam Phuntsho, La Trobe University, Australia & Ministry

of Hearth, Bhutan; Geoffrey T. Fong, University of Waterloo; and Ron Borland, The Cancer Council

Victoria.

The ITC Bhutan Project was funded by the International Development Research Centre (IDRC)

Research for International Tobacco Control (RITC), the Ontario Institute for Cancer Research (OICR), the

Canadian Institutes of Health Research (CIHR) Knowledge Transfer and Utilization Grant (#104765) and

the Canadian Cancer Society Research Institute Prevention Scientist Award.

1.4 Maps of Bhutan

Figure 1. Map of Bhutan 1

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Figure 2. Administrative map of Bhutan 2

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2. Sampling Design

2.1 Target Population

Eligible respondents included four categories of respondents: smoked tobacco users, smokeless tobacco

users, mixed tobacco users, never-monthly-users of tobacco and ex-users of tobacco who are

permanent residents and aged 18 and above in each household. Smoked tobacco users are adults (aged

18 years) who used smoked tobacco products including manufactured and hand-rolled cigarettes, bidis,

cigars & pipes at least once a month. Smokeless tobacco users are adults (aged 18 years) who used

smokeless tobacco products including khaini, zarda and snuff at least once a month. Mixed tobacco

users are adults (aged 18 years) who were both smoked tobacco users and smokeless tobacco users.

Ex-users/Never-monthly-users are adults (aged 18 years) who were neither smoked tobacco users nor

smokeless tobacco users.

2.2 Sampling Design

A total of 1604 households were enumerated successfully in four districts Bumthang, Chukha,

Thimphu, and Trashigang. All adults in each household who were thought by the original informant to

be current tobacco or ever monthly tobacco users, and a randomly selected one of those who were

thought by the original informant to be never-monthly tobacco users, were interviewed. A cohort of

1806 respondents was sampled: 59 smoked tobacco users, 181 smokeless tobacco users, 11 mixed

tobacco users (smoked and smokeless) and 1555 non-users of tobacco from 1521 households.

A multi-stage sampling frame was designed to ensure probability sampling selection of households

within strata defined by 4 (Thimphu, Chukha, Bumthang and Trashigang) of the 20 geographic districts in

Bhutan. The districts were chosen purposively for regional representation. The sample of households

was allocated to districts approximately in proportion to the square root of the population size, so as to

allow for some regional comparisons, while maintaining efficiency over the whole study population.

The households were recruited via a multistage sampling. In the first stage of sampling, each of the four

districts was stratified into an urban area and a rural area. In the rural stratum of each district, 3 or 4

gewogs were selected. For the urban areas of Bumthang and Trashingang, 2 gewogs were selected in

each district using probability proportional to size in the urban stratum. For the urban area of Chukha,

Phuntsholing was selected along with 2 other gewogs with probability proportional to size. The urban

part of Thimphu consists of just one gewog, the city of Thimphu. That city was divided into blocks, of

which 10 were selected with probability proportional to size. From each selected gewog, except for

Thimphu, normally 3 Enumeration Areas (EAs) (blocks or chiwogs) were chosen with probability

proportional to size. A list of randomized households in each EA was created by the field supervisor,

based on information received from the Head of the gewog of the area.

2.3 Sample Size

The ITC Bhutan Country cohort consists of 1806 respondents. Of these respondents, 59 were smoked

tobacco users, 181 were smokeless tobacco users, 11 were both smoked and smokeless tobacco users,

and 1555 were non-users.

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3. Survey Development and Content

3.1 Survey Development

The ITC Bhutan Survey was developed by the project team with members form the Ministry of Health,

Bhutan; University of Waterloo, Ontario, Canada; The Cancer Council Victoria, Australia; and La Trobe

University, Australia. The survey methods and a large proportion of the survey questions were adapted

form standardized protocols and surveys used in ITC surveys conducted in (at the time) 19 other

countries.

In the ITC Bhutan Survey, each participant first completed a screener survey, then was categorized into:

a) smoked tobacco user (those who used smoked tobacco, including manufactured and hand-rolled

cigarettes, bidis, cigars, and/or pipes, at least monthly); b) smoked tobacco user (those who used

smokeless tobacco products, including khaini, zarda and snuff, at least monthly) ; c) mixed tobacco user

(those who used both smoked and smokeless tobacco); d) non-user of tobacco ( those who had never

used tobacco monthly or those who were ex-users, i.e., those who had used tobacco in the past but who

had quit).

3.2 Survey Content

The ITC Bhutan Wave 1 Surveys including the Screener Survey, Smoked Tobacco User Survey, Smokeless

Tobacco User Survey, Mixed User Survey, and Ex-user/Non-user Survey are available at

www.itcproject.org.

3.2.1 Screener Survey

The Screener Survey was asked of all respondents, and included questions about the sales ban in Bhutan

and questions about smoking history.

3.2.2 Tobacco User Survey

The Tobacco User Survey includes:

1) Smoked tobacco user survey, which focuses on respondents who smoke tobacco products.

2) Smokeless tobacco user survey, which focuses on respondents who use smokeless tobacco products.

3) Mixed user survey, which focuses on respondents who use both smoke and smokeless tobacco

products.

Respondents who were smokers were asked the following types of survey questions:

1) Tobacco Use Behaviour and Cessation. Tobacco use history and frequency, as well as current

smoking behaviour and dependence, tobacco purchasing and quitting behaviours;

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2) Knowledge and Basic Beliefs About Smoking. Knowledge of the health effects of smoking and

important beliefs relevant to smoking and quitting, perceived risk and perceived severity of tobacco-

related diseases;

3) Tobacco Control Policies. Awareness of, impact of, and beliefs relevant for each of the FCTC demand

reduction policy domains (warning labels, taxation/price, sale-bans)

4) Other Important Psychosocial Predictors of smoking behaviour and potential moderator variables

(e.g., normative beliefs, self-efficacy, intentions to quit);

5) Individual Difference Variables Relevant to Smoking (e.g., depression, stress, time perspective);

6) Marijuana and Alcohol Use;

7) Demographics (e.g., age, marital status, income, education, occupation).

3.2.3 Ex-user/ Non-user Survey

The Ex-user/Non-user survey focuses on respondents who do not currently use tobacco. Respondents

who were Ex-users/Non-users responded to similar questions, with the exception of the tobacco-use-

relevant and cessation-relevant questions.

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4. Protocols and Quality Control

4.1 ITC Bhutan Survey Protocol

The protocols and scripts used in the ITC Bhutan Survey were similar to those used in other ITC face-to

face surveys. At the time of recruitment, the key informant or head of household was given a survey

requesting a list of the people living in the household and basic information including each persons

gender, date of birth, and tobacco use status.

4.2 Respondents

The sample consisted of 1806 respondents, of which 59 were smoked tobacco users, 181 were

smokeless tobacco users, 11 were both smoked and smokeless tobacco users, and 1555 were

non-users.

The eligible respondents for the cohort surveys were those who lived within the selected

households selected from 4 geographic districts in Bhutan.

The respondents were users and non-users of tobacco aged 18 years. The first part of the

cohort surveys contained the questions that were used to determine whether the individual met

the criteria for inclusion.

4.3 Components of the ITC Bhutan Survey Fieldwork

The ITC Bhutan Survey protocol consisted of seven main steps:

Random selection of households based on the sampling plan

Household enumeration ( including tobacco use status, socio-economic and demographic

information)

Selection of respondents within the household to complete the survey

For each respondent, selection of the correct survey questionnaire (this depended on the

tobacco use status of respondents collected from the enumeration: tobacco users, ex-users or

never monthly users and confirmed in the screener).

Documentation of verbal consent

Completion of the survey questionnaire

Expression of thanks to the respondent

4.3.1 Household Enumeration (including demographic information)

20 trained interviewers were assigned to an Enumeration Area (EA) from one of the four

districts that were being surveyed in Bhutan. Within each EA, households were chosen through

a random process.

If a member of the household agreed to participate in the enumeration of his/her household,

then information on all adults (aged 18 years or older) in the home was collected, including their

tobacco use status. 1604 households were enumerated from the 4 districts across Bhutan.

Only Bhutanese citizens were eligible for the interview.

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If the key informant refused to participate in enumeration, the interviewer would request the

following two pieces of information:

1) How many people aged 18 years and above live in the household? and

2) How many of them use tobacco regularly?

A maximum of 4 attempts in all urban areas and a minimum of 2 visits in rural areas were made

to enumerate each household.

Interviewers kept careful records of which households were visited, the outcome of each visit,

and whether or not a listing or an interview was obtained.

4.3.2 Survey Participant Selection and Consent

Respondents were selected based on their smoking status, were administered the screener, and

accordingly completed the appropriate survey.

Within each enumerated household, all adults who had ever been tobacco users were selected.

One adult from each household who had never used tobacco on a monthly basis was selected

randomly by a roll of a die. If the selected respondent had an individual outcome code that

required substitution, the die was rolled again to choose another respondent. If no eligible

person existed, then this spot would remain unfilled for the household.

A substitution from the same household was allowed only if a selected respondent from the

Never-monthly smoker category had outcome language barrier or health/mentally

incapable.

A verbal consent was obtained from each participant and each eligible, consenting participant

was interviewed independently, using a standardized consent form (either the user or non-user

version) that had been reviewed and cleared by ethics committees at the University of Waterloo

and Bhutan Ministry of Health. An interviewer was required to complete the Confirmation of

Verbal Consent Form to verify that consent had been given and that the information letter was

given to the respondent to keep.

4.3.3 ITC Bhutan Survey Interview

Interview method and procedure

Cohort respondents were qualified by their responses to the screener surveys.

The method of the interview was face to face, with interviewers using pen-and-paper surveys to

collect the interviewees responses.

The majority of survey items offered multiple-choice response options.

There were several open-ended questions with options that indicated other-specify, to which

the interviewer was required to record the participants response verbatim.

All survey interviews were conducted with strict confidentiality.

Proxy interviews were not to be conducted under any circumstances.

Length of interviews

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The length of interviews was 35-40 minutes for the Smoked Tobacco User or Smokeless Tobacco User

Survey, 45 minutes for the Mixed User Survey and 25-30 minutes for Ex-user/Non-user Survey.

Languages of survey questionnaire

When possible, the survey was conducted in English. The interviewer would conduct surveys in

Dzongkha or other dialects as needed.

4.4 Remuneration and Conclusion

Conclusion of the survey interview

At the end of each survey interview, the interviewer thanked that participant for his/her participation.

The interviewer then checked to ensure that the name of the participant, the date and time when the

consent was given , as well the signature of the interviewer were included on the consent form and

made sure the information letter was given to the respondent to keep.

Remuneration

There was no financial remuneration given.

4.5 Monitoring & Quality Assurance

Ugyen Norbu, the Project Investigator, was on site and responsible for monitoring and quality assurance.

4.6 Data Processing

Cleaning of the data was carried out to resolve issues of duplicated uniqids, and uniqids that could not

be linked from individual and screener data to households. The changes are given in the document:

Uniqid Issues and Solutions in ITC Bhutan Survey Wave 1, along with released Bhutan datasets available

at the ITC website www.itcproject.org.

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5. Disposition Codes and Cooperation Rate

5.1 Outcome codes: Household

The list of Household Outcome Codes on the Enumeration Form represents FINAL dispositions, that

were assigned either when the household was enumerated or after the maximum number of attempts

was made to enumerate each household.

1. Could not find

2. Vacant

3. Not a household (e.g. Business)

4. Treat to safety

5. No contact weather condition

6. No answer maximum attempts

7. No answer - survey period ends

8. Household refusal

9. Language barrier

10. No one capable of answering

11. Enumeration prevented for other reasons

12. Enumerated

5.2 Outcome codes: Individual

Individual outcome codes were to be assigned to everyone enumerated and selected for the survey on

the household enumeration form.

1. Missed (after maximum attempts)

2. Language barrier

3. Health/Mentally incapable

4. Proxy refusal

5. Refusal

6. Incomplete (start, breakoff)

7. Complete

5.3 Respondent ID

Each participant was assigned a 13-digit number, which was a combination of the 2-digit Dzongkhag

Number, 1-digit Urban/Rural Number, 2-digit Gewog Number, 2-digit EA Number, 4-digit Household

Number and 2-digit individual ID Number. This number was recorded to ensure that each participant

had a unique identification number, which could be referred to for recontact and also to indicate the

location of the respondent within the Dzongkhags of Bhutan.

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5.4 Cooperation Rate

Total completed individual interviews 1806

Total individuals selected and capable of responding 2031

Individual cooperation rate 88.92%

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6. Weights Construction

6.1 Wave 1 Sampling Plan

The research team was to conduct a survey of 1604 households, interviewing all adults in each

household who were thought by the original informant to be current tobacco or ever monthly tobacco

users, and a randomly selected one of those who are thought by the original informant to be never-

monthly tobacco users.

The households were recruited via a multistage sampling design in 4 of the 20 districts of the country.

The table of the 4 chosen districts and their populations is shown next. They were chosen purposively

for regional representation. The sample of households was allocated to districts approximately in

proportion to the square root of the population size, so as to allow for some regional comparisons, while

maintaining efficiency over the whole study population.

PHCB, 2005 and EC

District Population Household sample size

Bumthang 16,116 200

Chukha 74,387 500

Thimphu 98,676 500

Trashigang 51,134 400

Bhutan overall 634,982 1600

In the first stage, each of the 4 districts was stratified into an urban part and a rural part. Except in the

urban parts of Thimphu and Chukha, a selection of 2 gewog (towns) was made using probability

proportional to size in each urban stratum, and a selection of 3 gewog was made similarly in each rural

stratum. In the urban part of Chukha, Phuentsholing was selected, along with 2 other gewog with

probability proportional to size. The urban part of Thimphu consists of just one gewog, the city of

Thimphu.

From each selected gewog a selection of chiwog (blocks or villages) was made with probability

proportional to size, as detailed below and on the accompanying spreadsheet. The size measure at each

stage was the estimated number of households in the area unit. A certain number of households

(specified in the spreadsheet) were selected by systematic sampling with random start within each

selected chiwog. Within a district, the number of households in each urban/rural stratum was

approximately proportional to stratum size. The expected household weights were calculated, to check

that the final weights would be fairly uniform within each district.

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6.2 Weights Construction Overview

There were two stages in weights construction. In the first stage, each enumerated household was

given a household weight, interpretable as the number of households in the district represented by the

household. In the second stage, each interviewed individual was given a weight, interpretable as the

number of individuals in the district represented by the individual. The household and individual

weights are consistent in the sense that they yield the same estimates of tobacco use prevalence by

gender.

Since several gewogs were removed from consideration at the outset, the district represented is

actually the district minus the removed gewogs.

6.3 Computation of Enumerated Household Weights (EHWT)

The formula used normally for the weight of a household was the product of 3 factors:

ecw

cw

cwch

gew

gewg

str

h

N

Nn

N

Nn

N~

where Nstr is the census number of households in the stratum (district crossed with urban/rural), ng is

the number of gewog selected with probability proportional to size from the stratum, Ngew is the census

number of households in the households gewog, nch is the number of chiwog selected with probability

proportional to size from the households gewog, Ncw is the census number of households in the

households chiwog, cw is the counted number of households (dwellings) in the households chiwog,

and hecw is the number of households selected systematically and enumerated from the households

chiwog. In the preliminary calculations at the design stage, it was assumed that cw = Ncw.

Bumthang rural: Here the anticipated sampling plan was implemented. That is, 3 gewogs (Chhokhor,

Chumey and Tang) were selected with probability proportional to size, and within each, 3 chiwogs were

selected with probability proportional to size; roughly equal numbers of households were to be sampled

from all 9 chiwogs. Thus the formula above was used.

Bumthang urban: As anticipated, 2 gewogs (Bapalathang/Jakar, Chamkhar) were selected with

probability proportional to size. The first had one subdivision, and the second had two subdivisions.

Thus these subdivisions are selected with certainty. The number of households per subdivision was

varied to make the weights closer to uniform.

In each of these gewogs, the middle factor of the formula above was replaced by 1; in the first gewog,

Ngew= Ncw.

Chukha rural: At the outset, 5 gewogs were eliminated from the frame. Three gewogs were selected

with probability proportional to size from the remaining 6.

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In the first (Geling), the 3 chiwogs were taken with certainty. The middle factor of the formula above

was replaced by 1.

In the second gewog (Bjachho), two very large chiwogs were selected with certainty, and one was

selected from the remaining three with probability proportional to size. In the first two chiwogs, the

middle factor of the formula above was replaced by 1.

In the third, in the middle factor was replaced by (Ngew minus the sum of the sizes of the first two

chiwogs), and nch set equal to 1.

In the third gewog (Sampheling), 1 very large chiwog was selected with certainty, and the other two

were selected from the remaining 16 with probability proportional to size. The number of households

per chiwog were varied to make the weights closer to uniform. In the first chiwog, the middle factor of

the formula above was replaced by 1. In the other two, Ngew in the middle factor was replaced by (Ngew

minus the size of the first chiwog), and nch set equal to 2.

Chukha urban: At the outset, Phuentsoling was selected with certainty, and two other gewogs were

selected with probability proportional to size. Within Phuentsoling, 6 blocks were chosen with

probability proportional to size, with roughly the same number of households in each. In Phuentsoling

the first factor in the above formula was replaced by 1.

In the first gewog (Chukha), two large blocks were chosen with certainty and a third from the remaining

2 by probability proportional to size. In the above formula, for the first two blocks the middle factor was

replaced by 1; for the third block, Ngew in the middle factor was replaced by ( Ngew minus the sum of the

sizes of the first two blocks), and nch set equal to 1. In these cases ng =2.

In the second gewog (Gedu), three blocks were chosen with probability proportional to size, and roughly

the same numbers of households were to be taken from each. Thus the normal formula above could be

used.

Thimphu rural: At the outset, 4 gewogs were removed from the sampling frame, and 3 were sampled

with probability proportional to size from the remaining 4. It was found not to be practical to select

more than 2 chiwogs per gewog.

In the first gewog (Geney), one large chiwog was chosen with certainty and the other chosen with

probability proportional to size from the remaining 2. Thus for the first chiwog, the middle term in the

above formula was replaced by 1; for the second chiwog,

Ngew in the middle factor was replaced by (Ngew minus the sum of the size of the first chiwog), and nch set

equal to 1.

In the second gewog (Kawang), two large chiwogs were chosen with certainty. For both of these, the

middle term of the above formula was set equal to 1, and Ngew in the first factor was replaced by the

sum of the two chiwogs chosen with certainty.

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In the third gewog (Mewang), two chiwogs were selected with probability proportional to size. In these

chiwogs, the normal formula above could be used.

Thimphu urban: Ten blocks were chosen with probability proportional to size, with roughly equal

numbers of households to be sampled from each. The first factor in the formula above was replaced by

1.

Trashigang rural: At the outset, 6 gewogs were removed from the sampling frame, and 3 were selected

with probability proportional to size from the remaining 9.

The first gewog (Bidung) was composed of a large number of small chiwogs, and 6 of these were

selected with certainty. The case was similar for the other two gewogs (Radhi, Samkhar), in which 5 and

4 chiwogs were selected with certainty, respectively. Numbers of households to be taken from chiwogs

were varied accordingly. For each of these gewogs, the middle factor of the above formula was

replaced by 1, and Ngew in the denominator of the first factor was replaced by the sum of the sizes of the

chiwogs chosen in the gewog.

Trashigang urban: Here the design was implemented as expected. Two gewogs (Khaling, Trashigang)

were selected with probability proportional to size, and two chiwogs were selected with probability

proportional to size within each. The normal formula above could be used.

6.4 Prevalence Estimation

The enumerated household weights can be used for the estimation of prevalence of tobacco use. For

example, the estimate of the proportion of adult males who use tobacco over the four districts would be

given by

EHWT j t jj

EHWT jm jj

where EHWTj is the weight for enumerated household j, mj is the number of adult males in household

j, and tj is the number of adult males who are reported in the enumeration to use tobacco in household

j. The sums are over all enumerated households.

If we sum the EHWT weight over all enumerated households with tobacco users, we obtain an estimate

of the number of households with tobacco users in the four districts, minus their inaccessible areas.

6.5 Computation of Individual Weights

The intention was to interview in each household all ever-(monthly)-users of tobacco (including ex-users)

and one never-(monthly)-user of tobacco selected at random. Some people may have been

misclassified by the informants, and some people may not have made themselves available for interview.

Step I1: Each interviewed individual was given a household level weight W1. This is interpreted as the

number of people in the same household in the same sampling category represented by the respondent.

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For an adult male tobacco ever-user, W1 is the number of adult male tobacco ever-users in the same

household, divided by the number of adult male tobacco ever-users interviewed in the household.

For an adult female tobacco user, W1 is the number of adult female tobacco ever-users in the same

household, divided by the number of adult female tobacco ever-users interviewed in the household.

For an adult never-user of tobacco, W1 is the number of adult never-users of tobacco in the same

household, capped at 3 to control the variability of the weights.

The interviewed individuals were classified according to their tobacco use status in the enumeration for

purposes of calculating W1. For those interviewed individuals with unknown tobacco use status at the

enumeration phase, W1 was set equal to 1.

Step I1a: Each interviewed individual has been given an adjusted household level weight W1a. This

adjustment guarantees that the prevalence estimates based on the EHWTs and on the individuals

would be the same, before calibration of the individual weights, if tobacco use status were the same as

at the enumeration phase.

Let ATcw and ANcw be respectively the numbers enumerated in the chiwog of adult tobacco ever-users

and adult never-users of tobacco, according to tobacco use status at the enumeration phase.

For an adult tobacco ever-user, W1a is given by

W1a ATcw W1/ W1tcw

where the sum in the denominator is the sum of W1 over all interviewed adult tobacco ever-users in the

chiwog. A similar calculation applies for never-users of tobacco. For those interviewed individuals with

unknown tobacco use status at the enumeration stage, W1a was set equal to 1.

Step I2: Each interviewed individual was given a preliminary district-level weight W4 which is thought of

as the number of people in the district represented by that individual.

The weight W4 is given by

.

If we sum W4 over all tobacco ever-users interviewed, we should get an estimate of the number of

tobacco ever-users in the 4 districts, minus their inaccessible areas. Similarly if we sum W4 over all

never-user individuals interviewed, we should get an estimate of the number of never-users in the 4

districts, minus their inaccessible areas. (For these calculations we would likely want to use tobacco use

status as corrected from the interview data.)

We calibrated the weights to census-based estimates of the adult population numbers in the target

areas.

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demstr

demstr WWNW,

, 4/46

where Nstr,dem is the number of adults in the stratum (district crossed with urban/rural) and demographic

group (gender crossed with age group), and the sum in the denominator is taken over interviewed

individuals in the same stratum and demographic group. The age groups were taken to be under 35

years of age, and 35 years of age or older. W6 is variable aDE64915v in the data set.

6.6 Rescaling

Finally, the weights were rescaled to sum to country sample size within each of the following categories,

for use in regression analyses: district crossed with tobacco use status (ever-user vs. never-user,

according to tobacco use status as corrected from the interview data). The rescaled weight is

aDE64919v in the data set.

6.7 Screener Weights

Some important variables were collected in the screener administered to each individual. Unfortunately,

about 20 percent of screener records were detached from the corresponding questionnaire records. For

descriptive analyses involving only screener data, we have constructed screener weights as follows.

1) For individuals whose screener data are linked to their questionnaire data, we set W7 = W6; for records with questionnaire data but no attached screener, we set W7 = 0.

2) For a detached screener record, we set W7 = AVEdem,tob where AVEdem,tob is the average of W6 over that records demographic group and tobacco use status (gender crossed with age group (< 35, 35 or older) crossed with current user vs. current non-user of tobacco), among individuals with NO linked screener data.

3) Finally, set

W 8 W 7*

W 6al l

W 7al l

The screener weight W8 is aDE64910v in the data set.

6.7.1 Note on descriptive analyses involving screener data

The survey weight variable aDE64915v is meant for descriptive analyses (one-way tables, cross tabs,

means) involving only the main survey data, while the screener weight variable aDE64910v is meant for

descriptive analyses involving only the screener data.

For descriptive analyses which involve relationships between screener and main survey, there are 1291

records available out of the 1806 with main survey data. Since most of the respondents who must be

omitted are from Trashigang, with only 9 respondents in Trashigang remaining, we can think of the

sample of 1291 as being representative mainly of the other 3 districts. We would recommend using

aDE64915v for such descriptive analyses, and noting that they apply to a smaller population.

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Appendix A: Sample of Bhutan Household Enumeration Form

23

24

25

Appendix B: Sample of Bhutan Wave 1 Screener Survey

ITC Bhutan Survey: Screener Respondent ID# _______ Gender: M F Age: _______ Date: ____/ ____/ 2009

Read out the information sheet and obtain verbal consent before proceeding with the survey.

CONSENT: 1. Obtained 2. Not Obtained Terminate interview

SALES BAN

1 In this survey, we are going to be asking you about tobacco use. As far as you know, are people in Bhutan allowed to use tobacco products?

1 Yes If YES: Thats correct; there is no law against using or possessing tobacco products. 2 No If NO: Provide explanation. Actually, there is no law against using or possessing tobacco products.

2 Are you aware that there is a ban on the sale of tobacco product in Bhutan? 1 Yes 2 No 88 Refused (Dont read out) GO to next sub-section: (Tobacco use Screener) Q7 99 Dont Know (Dont read out)

3 In your opinion, how well is the ban on sale of tobacco products in Bhutan enforced? 1 Well enforced, 2 Somewhat enforced, or

3 Poorly enforced. 88 Refused (Dont read out) 99 Dont Know (Dont read out)

4 How easy is it to buy tobacco in Bhutan? 1 Very easy,

2 Generally easy, 3 Somewhat difficult 4 Very difficult. 5 Cant say. (Dont read out)

5 Based on your observation, do you think less people are using tobacco products because of the ban, or has it made no difference?

1 Less, 2 No difference, or

3 More. 5 Cant say (Dont read out)

6 Do you support or not support the ban on sale of tobacco products? 1 Support, 2 Neither support nor not support, 3 Not support, or have 4 No opinion. 8 Refused (Dont read out) 9 Dont Know (Dont read out)

Tobacco Use Screener : Questions for all respondents

7 I would now like to ask you some questions about the use of tobacco products. Do you smoke tobacco at lease once a month? (Including manufactured and hand-rolled cigarettes, bidis, cigars, pipes)

1 Yes

2 No

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8 Do you use smokeless tobacco at lease once a month? (Including: khaini, zarda and snuff.)

1 Yes 2 No

Routing:

If use both forms of tobacco (Yes to both Q7 and Q8) Go to Mixed User Survey If only smoked (Yes to Q7 and No to Q8) Go to Smoker survey If only smokeless (No to Q7 and Yes to Q8) Go to Smokeless survey If uses neither (No to both Q7 and Q8) Go to Non-User/Ex-User survey

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Appendix C: Sample of Bhutan Wave 1 Mixed User Survey

ITC Bhutan: Mixed User Survey

Respondent ID# _________________ Gender: M F Age: ______ Date: ___/ ____/ 2009

Tobacco Use Behavior: Questions for All Respondents

1

We are going to read out a list of tobacco products and would like to know how often you use each of these products. Do you smoke/use daily, at least weekly, less than weekly or not at all? Circle appropriate number in USAGE Column 3 (0 = Not used, 1 = Less than Weekly, 2 = Weekly, 3 = Daily)

For smoked: How many do you smoke per day/week/month? (use appropriate interval)

For smokeless: How long a pack or tin lasts and record in appropriate column.

Smoked Usage Number per day

Number per week

Number per month

a. Manufactured cigarettes 0 1 2 3

b. Hand-rolled cigarettes 0 1 2 3

c. Bidis 0 1 2 3

d. Any other smoked products? Specify:

0 1 2 3

Smokeless Usage Days per packet/tin

Weeks per packet/tin

Months per packet/tin

e. Khaini/surti 0 1 2 3

f. Zarda 0 1 2 3

g. Snuff 0 1 2 3

h. Any other smokeless products? Specify:

0 1 2 3

Routing: If more than one product is used: Continue If not daily and NO products are used per day: Go to Q3 If respondent is daily user and only uses one product: Go to Q7

2 Ask if respondent uses more than one product in table above.

Is the main reason you use a variety of products because you like the variety or because you use what is available, or is it or for some other reason?

1 Variety 2 Availability 3 Both, or 4 Some other reason (specify)____________________________________ 88 Refused (Don't read out) 99 Don't Know (Don't read out)

If any daily use in Q1 Go to Q5, else continue

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Appendix D: Sample of Consent Form

CONFIRMATION OF VERBAL CONSENT FORM (VCF1)*

CURRENT AND MIXED TOBACCO USERS

Research Project: International Tobacco Control Policy Evaluation Project in Bhutan

(The ITC Bhutan Project)

Bhutan Ministry of Health Ethics Clearance

Human Research Ethics Committee of the University of Waterloo Clearance Number: ORE #15706

*NOTE: This form should be completed by the interviewer if the participant agrees to

participate in the study.

I, , have provided the study participant with the following [INTERVIEWER NAME please print]

Information, describing the international research project conducted in Bhutan by a research

team at the Bhutan Ministry of Health:

This project is being conducted for research purposes.

Participation in the research is voluntary. Participants are free to withdraw from the research at

any time or to withdraw any information previously supplied, without penalty.

Participation in this research involves completing a face-to-face interview lasting about 35 to 45

minutes today and at least once more, approximately one year from now.

Only those people involved with this research will have access to any information that

participants supply. After 2 years, researchers interested in tobacco control will have access to

the survey data, but this data will not include participants names or any other identifying

information.

All the information participants provide is treated as strictly confidential.

Participants will be given a participant information sheet to keep for their records.

After receiving the above information, has provided verbal

[PARTICPANT NAME please print]

consent to take part in this research.

Signed: .. Date: ../.../...

[Interviewer signature] (mm) (dd) (yyyy)

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7. References

1. Map of Bhutan. http://www.infoplease.com/atlas/country/bhutan.html

2. Administrative map of Bhutan. http://swedish-bhutan-society.org/en/fakta/