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Smoking among Nepali youth - Prevalence and predictors

• Department of Data Science, Manipal
• Department of Health Information Management, Manipal College of Health Professions, Manipal
• Manipal College of Health Professions, Manipal

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Tobacco is the single largest risk factor for various diseases and its presence in the young heralds more serious problems as they may be exposed for longer periods. Prevalence and predictors of smoking among youth will aid in formulating effective preventive and control measures. A cross-sectional study was therefore conducted among 816 students selected from five colleges of Western Nepal using a self-administered questionnaire. Prevalence of ever smoking was 34.2% (males 47.6% and females 18.4%) and for current smoking was 17%. It was higher among youth belonging to 21 years or older as compared to younger age groups. Mean age of initiation was 16.8 years (standard deviation 2.8 years) and the most common reasons cited for smoking were; like it, to feel more relaxed, out of boredom and to look more mature. Proportion of youth who said they felt they were addicted was 43.1% and 64.7% said that they had tried to quit the habit. Most important predictors having independent effects on youth being ever smokers were having three or more smoker friends (OR=18), their own chewing (OR=4.8) or alcohol use (OR=4.2), male gender (OR=3.65) and the type of course they were pursuing, with professional course students having higher risk. With almost one fifth of college-going youth smoking and a higher prevalence in older age groups within them, smoking is a serious concern for young people in Western Nepal.

All Science Journal Classification (ASJC) codes

• Epidemiology
• Public Health, Environmental and Occupational Health
• Cancer Research

This output contributes to the following UN Sustainable Development Goals (SDGs)

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• risks INIS 100%
• colleges INIS 100%
• males INIS 100%
• age groups INIS 100%
• nepal INIS 100%
• Prevalence Biochemistry, Genetics and Molecular Biology 100%
• Alcohol Abuse Psychology 100%
• people INIS 50%

T1 - Smoking among Nepali youth - Prevalence and predictors

AU - Binu, V. S.

AU - Subba, S. H.

AU - Menezes, R. G.

AU - Kumar, Ganesh

AU - Ninan, Jefy

AU - Rana, M. S.

AU - Chhetri, Shovit Khadka

AU - Sabu, K. M.

AU - Nagraj, K.

PY - 2010/1/1

Y1 - 2010/1/1

N2 - Tobacco is the single largest risk factor for various diseases and its presence in the young heralds more serious problems as they may be exposed for longer periods. Prevalence and predictors of smoking among youth will aid in formulating effective preventive and control measures. A cross-sectional study was therefore conducted among 816 students selected from five colleges of Western Nepal using a self-administered questionnaire. Prevalence of ever smoking was 34.2% (males 47.6% and females 18.4%) and for current smoking was 17%. It was higher among youth belonging to 21 years or older as compared to younger age groups. Mean age of initiation was 16.8 years (standard deviation 2.8 years) and the most common reasons cited for smoking were; like it, to feel more relaxed, out of boredom and to look more mature. Proportion of youth who said they felt they were addicted was 43.1% and 64.7% said that they had tried to quit the habit. Most important predictors having independent effects on youth being ever smokers were having three or more smoker friends (OR=18), their own chewing (OR=4.8) or alcohol use (OR=4.2), male gender (OR=3.65) and the type of course they were pursuing, with professional course students having higher risk. With almost one fifth of college-going youth smoking and a higher prevalence in older age groups within them, smoking is a serious concern for young people in Western Nepal.

AB - Tobacco is the single largest risk factor for various diseases and its presence in the young heralds more serious problems as they may be exposed for longer periods. Prevalence and predictors of smoking among youth will aid in formulating effective preventive and control measures. A cross-sectional study was therefore conducted among 816 students selected from five colleges of Western Nepal using a self-administered questionnaire. Prevalence of ever smoking was 34.2% (males 47.6% and females 18.4%) and for current smoking was 17%. It was higher among youth belonging to 21 years or older as compared to younger age groups. Mean age of initiation was 16.8 years (standard deviation 2.8 years) and the most common reasons cited for smoking were; like it, to feel more relaxed, out of boredom and to look more mature. Proportion of youth who said they felt they were addicted was 43.1% and 64.7% said that they had tried to quit the habit. Most important predictors having independent effects on youth being ever smokers were having three or more smoker friends (OR=18), their own chewing (OR=4.8) or alcohol use (OR=4.2), male gender (OR=3.65) and the type of course they were pursuing, with professional course students having higher risk. With almost one fifth of college-going youth smoking and a higher prevalence in older age groups within them, smoking is a serious concern for young people in Western Nepal.

UR - http://www.scopus.com/inward/record.url?scp=77955809454&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77955809454&partnerID=8YFLogxK

M3 - Article

C2 - 20593960

AN - SCOPUS:77955809454

SN - 1513-7368

JO - Asian Pacific Journal of Cancer Prevention

JF - Asian Pacific Journal of Cancer Prevention

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• v.11(8); 2021

Original research

Burden of tobacco in nepal: a systematic analysis from the global burden of disease study 1990–2017, gambhir shrestha.

1 Department of Community Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal

Prabin Phuyal

2 B.P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal

Rabin Gautam

3 World Health Organization Country Office for Nepal, Kathmandu, Nepal

Rashmi Mulmi

4 Department of Cancer Prevention, Control and Research, B.P. Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Nepal

Pranil Man Singh Pradhan

Associated data.

bmjopen-2020-047847supp001.pdf

Data are available in a public, open access repository ( http://ghdx.healthdata.org/ ). All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article and can be assessed through the website http://ghdx.healthdata.org/ .

This study systematically reviews the data extracted from the Global Burden of Disease Study and sets out to assess the age-specific and sex-specific mortality and disability attributable to different forms of tobacco from 1990 to 2017, for Nepal.

This cross-sectional study extracted data from the Institute for Health Metrics and Evaluation’s Global Burden of Disease database, then was quantitatively analysed to show the trends and patterns of prevalence of tobacco use, deaths and disability-adjusted life-years (DALYs) attributable to tobacco use from different diseases from the year 1990 to 2017 in Nepal.

In between 1990 and 2015, the age-standardised prevalence of daily tobacco smoking decreased by 33% in males, 48% in females and 28% in both. By 2017, the age-standardised mortality rate and DALYs attributable to tobacco use, including any form, decreased by 34% and 41%, respectively, with tobacco smoking having the most contribution. However, the absolute number of deaths and DALYs increased by 39% and 3%, respectively. An increasing rate of deaths and DALYs attributable to tobacco was noted with an increase in age. Non-communicable diseases were responsible for most deaths and disabilities attributable to tobacco use.

The prevalence of smoking along with the age-standardised mortality rate and DALYs shows a decreasing trend. However, attention should be made to implement a strong plan to control all forms of tobacco including secondhand exposure.

Strengths and limitations of this study

• This study is one of the first studies in Nepal to extracts Global Burden of Disease Study data to present nationally representative data on mortality and disability attributable to tobacco by age, sex and disease.
• This study informs the policy-makers on further strategies to control tobacco use including secondhand smoking.
• This study analyses the secondary data of the Global Burden of Disease Study and hence it has all the limitations pertaining to the data.
• The prevalence of smoking could have been underestimated as the Global Burden of Disease data only takes into account the prevalence of daily smoking and lacked the data for the prevalence of smokeless tobacco and secondhand exposure.

Introduction

To date, tobacco remains a major public health issue worldwide because of its associated high morbidity and mortality rate. Any forms of tobacco use are harmful to health and kill millions of people every year. 1 The use of tobacco products in any form either smoking or smokeless or exposure to secondhand smoke has been implicated in many health issues like cardiovascular diseases, respiratory diseases, cancers, non-communicable diseases (NCD) and many more. 2 3 There is no safety margin for exposure to secondhand smoke or tobacco smoking and secondhand smoke exposure is equally harmful to health.

According to World Health Organization (WHO), about 1.3 billion people in the world used tobacco products among which more than one billion people were smokers. 4 Almost 80% of smokers reside in low-income and middle-income countries. The last two decades have seen a decreasing trend towards the consumption of tobacco in all age groups. In 2000, almost one-third of the world’s population (33.3%) aged 15 and more used some form of tobacco products, 50% in males and 16.7% in females. While, in 2015, the prevalence of tobacco use dropped to nearly a quarter of the world’s population (24.9%), 40.3% in males and 9.5% in females. 1 Despite the decreasing prevalence of tobacco use globally, the absolute number of male smokers is growing continuously in South-East Asian, African and Eastern Mediterranean regions. The South-East Asian region has the highest prevalence of tobacco use (31% in 2015) compared with other regions, 49.4% in males and 12.9% in females. 1 According to recent findings from STEPwise approach to surveillance (STEPS) survey 2019 in Nepal, around 29% of adults (48% male and 12% female) within the age group 15–69 years used any form of tobacco. 5 In recent times, people have shown a growing preference for smokeless tobacco over smoking in South-East Asia including Nepal. 6–8 In Nepal, the use of smokeless tobacco is much more common than tobacco smoking and is more prevalent among males (33%) compared with females (5%). 5

Despite decreasing prevalence, the number of deaths due to tobacco use continues to rise. Tobacco kills more than 8 million people every year. Among them, about 7 million people die from direct tobacco use while the deaths of about 1.2 million people result from secondhand smoke exposure. 4 In 2015, smoking alone was responsible for 11.5% and 6% of global deaths and disability-adjusted life-years (DALYs), respectively. 9 Deaths of about 65 000 children per year can be attributed to exposure to secondhand smoke. 4 The recent estimates show around US$1.4 trillion of total economic loss results globally from tobacco use which is equivalent to 1.8% of the world’s annual Gross Domestic Product (GDP). 10 About 40% of this cost occurred in low-income and middle-income countries. In Nepal, around 27 000 deaths occur annually from tobacco use, which comprises about 14.9% of all deaths. 11

Given such a significant negative impact of tobacco on public health, navigation of the outcomes of tobacco use in a low-income country like Nepal is of the essence. The issue of tobacco usage has received considerable attention. In response, Nepal implemented the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2006 12 and passed Tobacco Control and Regulatory Bill in 2011 by Parliament. 5 So far, however, there has been little discussion about trends and patterns of tobacco use and its outcomes in Nepal. Such approaches have an unsatisfactory description of the burden of tobacco in the Nepalese population. This study systematically reviews the data extracted from the Global Burden of Disease (GBD) Study 2017 and sets out to assess the trends in prevalence, mortality and disability attributable to different forms of tobacco in Nepal from 1990 to 2017. Therefore, the findings of this study will make a major contribution informing the policy-makers and public health professionals by providing important insights into evidence for an effective tobacco control programme in Nepal.

Data sources and study settings

The GBD study 2017 was a comprehensive epidemiological study that reported the trends and patterns in morbidity and mortality in 195 countries from major injuries, diseases and risk factors to health at the global, regional and national level. The study design, metrics and analysis are published elsewhere. 13 The Institute for Health Metrics and Evaluation (IHME) coordinated the GBD study 2017 and used the data from several published and unpublished literature, survey and surveillance data, hospital and clinics data to estimates the deaths and disability attributable to 84 risk factors for 195 countries by age and sex. 13 14

The Nepal GBD 2017 study used data from over 90 000 sources covering the years between 1990 and 2017. These data sources included in Nepal’s burden of disease estimates mainly data from the 1971 to 2011 Nepal Population and Housing Census, disease registries such as the Kidney Disease Data Centre maintained by the International Society of Nephropathy, epidemiological surveillance such as the WHO Disease Observatory, periodic and ad hoc large household surveys such as Nepal Demographic Health Surveys, Multiple Indicator Cluster Surveys and Nepal STEPS Non-Communicable Risk Factor Surveys, Nepal Global Youth Tobacco Survey, Nepal Behavioural Surveillance Survey, Nepal Hospital Inpatient Discharges Record, Health Management Information System, published scientific literature, reports and administrative records. 15

The GBD database was used for the extraction of data related to mortality and DALYs of all causes and other major public health issues of Nepal like cardiovascular diseases, NCDs, diabetes and kidney disease, all neoplasms including benign and malignant, and tuberculosis from the year 1990 to 2017. 16

Patient and public involvement statement

This study used the data freely available from the IHME’s GBD database. Patients were not involved in the design, recruitment or conduct of the study. Results of this study will be made publicly available through publication.

Definition of terminology

Years of life lost (YLLs) are calculated by multiplying the number of deaths at each age by a standard life expectancy at that age. Years lived with disability (YLDs) is the number of years of life lived with health loss weighted by the severity of the disabling sequelae of diseases and injuries. DALY is the key summary measure of population health used in GBD to quantify health loss which allows comparison of health loss across different diseases and injuries. They are a measure of the number of years of healthy life that are lost due to death, nonfatal illness or impairment, and thus, they are calculated as the sum of YLLs and YLDs. 14 17

Uncertainty interval (UI) is a range of values that is likely to include the correct estimate of disease burden for a given cause. Narrow UIs indicate that evidence is strong, while wide UIs show that evidence is weaker. 14 17

The term tobacco includes tobacco use in all forms either smoking or smokeless or both.

Statistical analysis

The extracted data from IHME were imported into Microsoft Excel, then were quantitatively analysed and presented in the graphical, tabular forms and histograms to show the trends and patterns in age-sex-specific mortality and DALYs in Nepal. The age-standardised prevalence of tobacco use only in form of daily tobacco smoking was available up to the year 2015. A percentage change was calculated to present the difference in mortality and DALYs between 1990 and 2017. An UI of 95% was presented to show the strength of the estimates.

Here, we report the GBD study results for Nepal on the prevalence of tobacco use, mortality and burden caused by different forms of tobacco, smoking and smokeless tobacco, between 1990 and 2017.

Tobacco smoking

The trend of daily tobacco smoking is in decreasing trend during the period 1990–2015 in both sexes. In 1990, the age-standardised prevalence of tobacco smoking at all ages was 27.5% for both sexes. The prevalence was more for males (35.6%) than the females (19.8%). In 2015, the prevalence of tobacco smoking decreased to 19.7% in both sexes at all ages, with male 23.7% and female 10.3% ( figure 1 ).

Prevalence of smoking from the year 1990 to 2015 in Nepal.

Deaths and DALYs

In Nepal, both the age-standardised mortality rate and the DALYs attributable to tobacco are in decreasing trend from 1990 to 2017 ( figure 2 ). The age-standardised attributable deaths to tobacco use, including all forms, decreased (34.5%) in the general population from 216 (95% UI 183–258) per 100 000 in 1990 to 141 (95% UI 120–163) per 100 000 in 2017. While DALYs decreased by 41.3% from 5474 per 100 000 in 1990 to 3216 per 100 000 in 2017. This finding was found in both males and females. Similarly, over the same time, the age-standardised deaths and DALYs attributable to tobacco smoking, chewing tobacco, secondhand smoking, showed a falling trend for both sexes and males and females separately ( table 1 ). In absolute terms, the attributable deaths at all ages to tobacco use, including all forms, increased (38.99%) in the general population (both male and female) from 19 372 (95% UI 16 060–23310) in 1990 to 26926 (95% UI 22 826–31135) in 2017. While DALYs for all ages due to tobacco use increased (10.52%) in males from 403 665 (95% UI 3 19 794–5 12 870) in 1990 to 4 46 132 (95% UI 3 64 622–5 24 648) in 2017, it decreased (8.78%) in females from 280 977 (95% UI 2 05 487–3 73 384) in 1990 to 2 56 301 (95% UI 2 05 569–3 16 573) in 2017 ( online supplemental table 1 ).

Trend of age-standardised mortality rate and DALYs attributable to tobacco from 1990 to 2017 in Nepal. DALYs, disability-adjusted life-years.

Age-standardised deaths and DALYs for different diseases attributable to tobacco and their percentage change in Nepal, 1990–2017

DALYs, disability-adjusted life-years; UI, uncertainty interval.

Supplementary data

Figure 3 demonstrates a clear trend of the increasing rate of deaths and DALYs attributable to tobacco with an increase in age. Around 27 000 deaths are attributable to tobacco comprising 90% deaths due to NCDs. Similarly, more than 702 000 DALYs were attributable to tobacco use comprising 89% DALYs for NCDs ( figure 4 ).

Agewise deaths (A) and DALYs (B) rates in all causes in both sexes attributable to tobacco, including all types, in 2017. DALYs, disability-adjusted life-years.

All-age deaths (A) and DALYs (B) from different diseases attributable to tobacco use (including all types) in Nepal in 2017. CVD, cardiovascular disease; DALYs, disability-adjusted life-years; NCDs, non-communicable diseases.

Cardiovascular diseases

The age-standardised deaths from cardiovascular diseases showed falling trends in both sexes due to tobacco use (of all types), tobacco smoking and in females due to secondhand smoking, while age-standardised deaths showed increasing trends in males from secondhand smoking. The age-standardised DALYs from cardiovascular diseases showed falling trends in both sexes due to tobacco use, tobacco smoking and secondhand smoking. The major cause of deaths and DALY in cardiovascular disease attributable to tobacco was found to be smoking.

Diabetes and kidney diseases

The attributable deaths and DALYs from diabetes and kidney diseases showed rising trends in both sexes due to tobacco smoking and secondhand smoking in both sexes.

The age-standardised deaths and age-standardised DALYs from all neoplasms showed falling trends in both sexes due to tobacco use, tobacco smoking, chewing tobacco and secondhand smoking.

Non-communicable diseases

The attributable age-standardised death from NCD due to tobacco use decreased (29%) from 180 (95% UI 115–216) in 1990 to 128 (95% UI 108–148) in 2017 in both sexes, with deaths occurring mostly from tobacco smoking. The DALYs also decreased by 31%from 4171 (95% UI 3197–4911) in 1990 to 2880 (95% UI 2423–3338) in 2017 in both sexes, with disability mostly resulting from smoking. Over the same period, deaths and DALYs from NCDs showed decreasing trends in both sexes due to tobacco smoking, secondhand smoking and chewing tobacco,

Tuberculosis

The attributable age-standardised deaths and DALYs from tuberculosis due to tobacco use showed falling trends in both sexes.

Prevalence and patterns of tobacco use

The GBD study results indicate that throughout the time between 1990 and 2015, the prevalence of daily tobacco smoking decreased by 33% in male (35.6% in 1990 and 23.7% in 2015), by 48% in female (19.8% in 1990 and 10.3% in 2015) and by 28% in the general population (27.5% in 1990 and 19.7% in 2015). One reason for the decrease in the prevalence of daily tobacco use could be Nepal’s implementation of WHO FCTC in 2006 12 and Tobacco Control and Regulatory Bill in 2011, 5 which regulate the law of tobacco use in Nepal. In reviewing previous literature, it is evident that gender, geographical and socioeconomic variation do play a role in observed differences in the pattern of tobacco use. In Nepal, the use of tobacco products is practised extensively in the elderly population, males, people with lower education levels, rural areas, mountainous areas than in plain areas, and Far-western and Mid-western regions than in Eastern, Central and Western regions. 18 In addition to that, in Nepal, people in mountainous areas tend to smoke more while, people in plain areas tend to chew tobacco more. 18 19 Elderly people have different beliefs around tobacco use, like continuing tobacco does no harm and stopping tobacco does not improve health status. 20 People who are less educated might have a lower level of awareness of the harmful hazards of tobacco use. However, in recent times, males of the young age group have high tobacco consumption. 6 A similar pattern of variation in tobacco use was noticed in the Southeast Asian population. The higher prevalence of smoking in males was observed in Asian countries like Malaysia, the Philippines, Singapore, Vietnam, Indonesia, Maldives and Bangladesh. 21 22 In these countries, gender seems to be an important determinant of the initiation of the smoking habit and for perpetuating it. Social norms and the prohibition of tobacco use can be one of the factors responsible for the lower prevalence of tobacco use in the female population in Southeast Asian countries. 23 Smokeless form of tobacco was common in countries like India, Nepal, Bangladesh, Maldives and Cambodia. 22 Increasing age, poverty and poor education were associated with higher consumption of tobacco in these countries.

It was evident from the results that, age-standardised rates of death and disability due to smokeless tobacco are in decreasing, however, the absolute number of deaths and disabilities due to smokeless tobacco is increasing. In recent years in the Southeast Asia region, including Nepal, there is a clear increase in preference to using smokeless tobacco over tobacco smoking, with a higher prevalence of smokeless tobacco in males. 6–8 24 Smokeless tobacco is associated with a higher risk of getting cancer 25 and cardiovascular risk factors like hypertension, metabolic syndrome and cardiovascular events like acute coronary syndrome 26 than non-tobacco users, although less than tobacco smoking. The increased prevalence of smokeless tobacco in the Nepalese population and the potential increase in the risk of cancer associated with it might be the reason for the increase in disability rate from all neoplasms due to chewing tobacco. According to a study in Nepal, most of the consumers of smokeless tobacco are unaware of its harmful health hazards. 27 Studies have shown that smokers tend to perceive smokeless tobacco as less harmful than smoking. 28 This belief might exist among smokers in Nepal and the extent of such beliefs needs to be explored in detail. The production of smokeless tobacco products is unhindered in Nepal and the increased import of smokeless from the neighbouring country, India made the products easily accessible all over the country. 27 And, owing to the government’s lower taxation imposed on smokeless products compared with smoking tobacco products, smokeless tobacco products have an added affordability. 6 Tobacco products such as bidis and smokeless tobacco are perceived as ‘hard to tax’ due to their more informal nature. Thus, all these factors with more emphasis on tobacco control policy on tobacco smoking over smokeless tobacco with lack of awareness towards the hazards of smokeless tobacco products seem to be the cause for shifting the preference of consumers from smoking to smokeless tobacco.

The results indicate that the age-standardised rates of death among males due to cardiovascular diseases, and age-standardised deaths and disability due to diabetes and kidney diseases in both sexes, attributable to secondhand smoking are in the increasing pattern. At the global level, around 40% of children, 33% of male non-smokers and 35% of female non-smokers are estimated to have been exposed to secondhand smoke regularly, with Southeast Asia and the Western Pacific region accountable for 50% of the globe’s total burden from secondhand smoke exposure. 29 Most of the deaths attributable to secondhand smoke occurred from ischaemic heart disease in adults and lower respiratory tract infections in children, women having the greatest burden among all. Most DALYs lost secondary to secondhand smoke exposure occurred due to lower respiratory tract infections and ischaemic heart diseases, children being the most affected ones. 29 In Nepal, public transports and restaurants are the major areas of secondhand smoke exposure in public places, while homes and workplaces are indoor areas of secondhand smoke exposure. 5

Deaths and DALYs attributable to tobacco

Tobacco use was the second most common risk factor for deaths and the third most common risk factor for total DALYs in Nepal in 2017. 30 In numbers, 14.73% (95% UI 12.52–16.58) of total deaths and 7.8% (95% UI 6.68–9.06) of total DALYs were attributed to tobacco use in 2017. 30 In between 1990 and 2017, the total deaths attributable to tobacco use, including any form, in all ages increased by 39% in the general population (both males and females) and DALYs attributable to tobacco use, including any form, in all ages increased by 11% males but decreased by 9% in females, with tobacco smoking having the most contribution. Also, in 2017 most of the tobacco attributable deaths were due to cardiovascular disease, diabetes, neoplasm and kidney disease. Between 1990 and 2017, tobacco attributable disease occupied a larger proportion of cause of death in Nepal. In contrary to an overall decrease in the prevalence of tobacco use and age-standardised deaths and DALYs in both males and females in recent decades, the total deaths and DALYs were higher in 2017 compared with 1990. One plausible explanation for this pattern could the population growth in Nepal, 29 million in 2019 compared with 18.9 million in 1990. 31 The rising number of tobacco consumers despite the overall decrease in the prevalence of tobacco use can be attributed to population growth compared with 1990. Furthermore, the elderly population tends to have smoked for more decades considering they started consuming tobacco from an early age. Thus, they tend to have the highest exposure to tobacco which can support a fact that the mortality attributable to tobacco becomes evident usually after 2–3 decades of tobacco use. 32 This evidence also explains the reason why there are increasing deaths and disabilities with an increase in age. Consequently, the deaths attributed to tobacco use may continue to rise in the long run despite the decrease in the prevalence of tobacco use.

Policy related to tobacco in Nepal

In response to the global tobacco epidemic, WHO launched a global public health treaty in 2003 named WHO FCTC. 33 Nepal signed the WHO FCTC in 2003 with the ratification of the treaty in 2006. 12 In 2008, to efficiently implement the FCTC, WHO launched the MPOWER policy to lower the tobacco demand in individual countries, 34 which was adopted by Nepal. The Parliament of Nepal passed the Tobacco Control and Regulatory Bill in 2011 incorporating the provisions of WHO FCTC which is currently the primary law that governs tobacco use. This act regulates the use of tobacco in public workplaces and public transport, advertisement and promotion of any kind of tobacco products, and packaging and labelling of tobacco products. However, the question that arises is how effective the law is, and how effective we have been in protecting people from tobacco use, tobacco-related deaths and disability. The decreasing trends in the prevalence of tobacco use and age-standardised deaths and DALYs attributable to tobacco suggest that tobacco control has been effective so far. Nepal received a Bloomberg Philanthropies Award for Global Tobacco Control in 2015 for its work in control and reduction of tobacco product use by warning people about the hazards of tobacco use. 35 The tobacco act has emphasised more on packaging and promotion to abate the consumption of tobacco products. In the STEPS survey conducted in 2019, 75.7% of adults noticed health warnings on tobacco packages and 44.8% of current users thought of quitting because of such warnings. However, the tobacco act is limited by a lack of knowledge on the implementation of regulations in public places and around the educational hubs. Though the control of tobacco use in Nepal appears well in the last few decades, the progress seems static in recent times. The STEPs survey conducted in Nepal in 2019 showed only a minor drop in the prevalence of former smokers or former smokeless tobacco users in comparison to 2013. 5 Tobacco control contributes to improving the health of its consumers and is very important for economic development. On average, the average amount of money spent per year on cigarettes is around 11% of GDP per capita. 5 Nepal currently imposes a tobacco tax of just 15.5% of retail price (excluding value-added tax (VAT)) which is the lowest among the South Asian countries and far below the WHO guideline of 70% of the retail price. 36 Tobacco taxation increases the retail price of tobacco products and reduces the demand therefore is considered to be the most cost-effective method in tobacco control. 37 A 10% increase in the price of tobacco products is expected to reduce the demand by 5%–10% in lower-income and middle-income countries. 4 Given the high burden of tobacco use in Nepal, an increment of the tax on tobacco products should be given high priority.

Limitations of study

There are a few limitations to the study. First is the lack of primary data sources from Nepal and those included sources used in GBD are limited in scope, coverage and quality. Nepal also lacks a cause of death surveillance system to document disease-related deaths. However, in resource-limited countries like Nepal, where reliable health statistics are limited, the GBD data provide nationally representative findings, providing evidence-based strategies for policy-making. Second, the prevalence of smoking could have been underestimated as the GBD data only takes into account the prevalence of daily smoking and lacked the data for the prevalence of smokeless tobacco and secondhand exposure. This could have resulted in an underestimation of attributable disease burden especially in populations who tend to use less tobacco every day. Also, the data did not account for the duration and intensity of tobacco use. Third, the burden estimates are limited by not considering indoor and outdoor air pollution. Nepal has experienced a massive increase in air pollution during the time in most of the cities, which could confound the findings.

Conclusions

This study is one of the first studies in Nepal to show the trend of mortality and DALY attributable to tobacco use. There is a decreasing trend in the prevalence of smoking, age-standardised mortality and DALYs between 1990 and 2017. However, there was a more than one-third increase in crude mortality rate. NCDs contributed the most deaths and disabilities attributable to tobacco. There is a huge increase in deaths and DALY due to chewing tobacco from 1990 to 2017. Awareness along with the strong implementation of tobacco control strategies on all forms of tobacco including secondhand exposure and increasing taxation can further help to decrease the trend in the future. There is also a need for a robust and reliable data representative of all regions in Nepal to understand the effect of tobacco control policies.

Supplementary Material

Acknowledgments.

We would like to thank The Institute for Health Metrics and Evaluation’s Global Burden of Disease for the data for this study.

Twitter: @gamvir_shrestha, @PranilMSPradhan

Contributors: GS: conceptualisation, methodology, software, formal analysis, supervision, writing-original draft preparation. PP: software, formal analysis, visualisation, writing-original draft preparation. RG: conceptualisation, methodology, software, formal analysis, writing-original draft preparation. RM: conceptualisation, Visualisation, writing-reviewing, and editing. PMSP: methodology, visualisation, writing-reviewing and editing. All authors revised, read and approved the final version of the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

World No Smoking Day

World No Tobacco Day or World No Smoking Day is celebrated and observed around the world on May 31 every year. On this day the public is exposed to the dangers of tobacco products such as cigarettes, tobacco, and tobacco-related products. The commercial practices of tobacco companies, along with the diffusion of information as to what WHO is doing to fight various tobacco-related diseases and what people around the world can do to protect their health and well-being, etc through various of its publications. It provides information on various information such as what the WHO is doing to combat the tobacco epidemic, and what people around the world can do to protect their health, the right to a healthy life and healthy lifestyles of the future generations.

The World Health Organization (WHO) member states established World No Smoking Day in 1987 to draw global attention to the tobacco epidemic and its preventable deaths and diseases. The day was set up with the aim of spreading awareness against tobacco and its negative health effects.

According to the World Health Organization, tobacco use kills more than 1.5 to 2 million people worldwide each year, and non-smokers are even more affected by secondhand smoke. Thus, World No Tobacco Day was established in 1988 by the member nations of the World Health Organization (WHO). Over the past few years, the day has been enthusiastically received around the world by the Government of Nepal, public health organizations, smokers around the world, and some voices of resistance have also been raised by tobacco growers and the tobacco industry.

World No-Tobacco Day/ World No Smoking Day

Tobacco has been used for a long time in the early United States, mainly in the South, where tobacco was used extensively by herdsmen also known as cowboys. Spain’s arrival into the international scenario introduced tobacco to other nearby European countries, and it became an attractive, and heavily traded plus lucrative commodity in support of the popular smoking habit.

After the Industrial Revolution of 1760-1820, cigarettes became very popular worldwide especially in the EU. However, in the middle of the 20th century, there were various medical researches that revealed the serious and negative health effects of tobacco and tobacco use on human organs including lungs, throat and tongue which study when published leads to a sharp decline in tobacco use.

In 1987, the World Health Assembly of the World Health Organization (WHO) designated the WHO’s annual celebration, April 1, 1988, as World No-Tobacco Day. The purpose of World No-Tobacco Day was to encourage all smokers worldwide to quit smoking for at least 24 hours. Extensive press coverage of the event was inspired and identified policies were made along with health education activities related to the program, with the special theme “Tobacco or Health: Choose Health.” Activities featured in WHO-selected countries were included, various countries perform programs as: smoking cessation in public places by Ethiopia, suspension of government tobacco sales by Cuba, government ban on radio and printed tobacco message broadcasting in Lebanon, poster competition in Spain, public cigarette burning ceremony by Nepal, and large public information campaigns by China. It has been seen that all these various activities have been really informative and in the following days a lot of public awareness has been developed about the harms of tobacco.

The Second World No-Smoking Day, held on May 31, 1989, focused on “Women and Tobacco – Women Smokers: Added Risks.” with added emphasis on the harm of using tobacco and its related products. In preparation for the event, the WHO Director-General requested all major UN agencies to assist his office in declaring World No-Smoking Day and it distributed worldwide press kits, videotapes, and radio programs. Following the event, the WHO’s Tobacco or Health Program documented World No Smoking Day-related activities and received newspaper coverage from more than 300 countries around the world. In some countries these ceremonies were led by the President in Bangladesh, former Prime Minister of Sudan, or Health Ministers Nigeria, Fiji, Oman, and many others.

On World No Smoking Day, the United States focuses on tobacco use worldwide through events such as the Great American Smokeout day. On May 1, 1990, the WHO celebrated the Third World No-Smoking Day with the theme of the event being “Childhood and Youth Without Tobacco”.

Thus, every year on May 1, as in other countries, the World No Smoking Day is observed in Nepal by the Government of Nepal, public health organizations, local and central level with various public awareness programs such as decreasing of smoking tobacco and tobacco related products to prevent dangerous diseases such as cancer. The government has brought a law banning smoking in public places in Nepal about 10 years ago, but it would be meaningful to celebrate World No-Smoking Day if the entire public is aware of it, and awareness to those who even know the law are not obeying them due to the lack of its implementations. Then only the celebration of World No Smoking Day would be of true meaning by completely eradicating non law abiding acts and such mentality.

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• Afghanistan
• Antigua and Barbuda
• Bolivia (Plurinational State of)
• Bosnia and Herzegovina
• Brunei Darussalam
• Burkina Faso
• Central African Republic
• Cook Islands
• Côte d’Ivoire
• Democratic People’s Republic of Korea
• Democratic Republic of the Congo
• Dominican Republic
• El Salvador
• Equatorial Guinea
• Guinea-Bissau
• Iran (Islamic Republic of)
• Lao People’s Democratic Republic
• Marshall Islands
• Micronesia (Federated States of)
• Netherlands
• New Zealand
• North Macedonia
• Occupied Palestinian territory
• Papua New Guinea
• Philippines
• Republic of Korea
• Republic of Moldova
• Russian Federation
• Saint Kitts and Nevis
• Saint Lucia
• Saint Vincent and the Grenadines
• Sao Tome and Principe
• Saudi Arabia
• Sierra Leone
• Solomon Islands
• South Africa
• South Sudan
• Switzerland
• Syrian Arab Republic
• Timor-Leste
• Trinidad and Tobago
• Turkmenistan
• United Arab Emirates
• United Kingdom of Great Britain and Northern Ireland
• United Republic of Tanzania
• United States of America
• Venezuela (Bolivarian Republic of)

Strong tobacco control policies:

High youth smoking prevalence:, major recent decreases in smoking:.

How many people die from smoking in Nepal each year?

What is the economic cost of smoking and tobacco use in Nepal each year?

57,670,287,360

Nepalese rupees

Tobacco use continues to be an epidemic in Nepal. Government complacency in the face of the tobacco epidemic protects the tobacco industry in Nepal as the death toll grows each year. Proponents of healthier societies must push for the implementation of evidence-based best practices in tobacco control to create change and reduce the negative effects of tobacco use.

Adult Smoking Prevalence in Nepal

15+ years old; 2019

Adult smoking prevalence in Nepal is 22%.

Number of Adult Smokers in Nepal

Number of adult smokers in Nepal is 4,279,973.

Youth Smoking Prevalence in Nepal

10-14 years old; 2019

Youth smoking prevalence in Nepal is 3%.

Adult Smokeless Tobacco Use in Nepal

15+ years old; smokeless tobacco includes snus, chewing tobacco, gutkha, etc.; 2019

Both Men and Women

Adult smokeless tobacco use prevalence in Nepal is 18%.

Deaths Caused by Tobacco in Nepal

% deaths attributable to tobacco use in 2019

19% of all deaths in Nepal are caused by tobacco use.

Learn more about global Prevalence , Youth Smoking and Deaths .

Negative Effect of Tobacco Use in Nepal

Tobacco use harms both the public and fiscal health of Nepal, threatening efforts to improve equity, alleviate poverty, and protect the environment.

Societal Harms

The economic cost of smoking Nepal is 57,670,287,360 Nepalese rupees. This includes direct costs related to healthcare expenditures and indirect costs related to lost productivity caused by illness and premature death.

Harms Development

Tobacco spending diverts funds from the resources that families need to rise out of poverty. On average in Nepal, a smoker must spend 21.90% of GDP per capita to buy 100 packs of the most popular cigarettes in a year.

Environmental Harms

Cigarette butts are the most commonly discarded pieces of waste worldwide. It is estimated that 1,102,311 tons of butts wind up as toxic trash in the world each year, equal to 416,667 female African elephants.

Harms Health Equity

The tobacco industry markets its products aggressively to lower-income populations and youth in Nepal.

Not only is smoking a major risk factor for the 4 largest noncommunicable diseases (cancer, heart diseases, respiratory diseases, and diabetes), but people living with mental illness are nearly 2x as likely to smoke as other individuals.

Learn more about Health Effects .

Impact of the Tobacco Supply Chain on Nepal

The tobacco industry profits significantly from producing and selling tobacco. At the same time, across the tobacco supply chain, there are significant negative health and economic repercussions for Nepal.

Tobacco Production

There were more than 5,000,000,000,000 cigarettes produced in the world in 2019, or nearly 2 cigarettes per person per day.

Tobacco Industry

The total revenue of the 6 largest tobacco companies in the world was USD 336 billion in 2019, about the same as Viet Nam's Gross National Income (GNI), 5x Ghana's GNI and 9x Paraguay's GNI.

Tobacco Growing

There were 1062 tons of tobacco produced in Nepal in 2019 on 935 hectares of quality agricultural land that could have been used to grow food.

Learn more about global Product Sales and Growing .

Ending the Tobacco Epidemic in Nepal

Fortunately, there are evidence-based—i.e. proven—solutions to the challenges posed by tobacco use. For several decades, governments around the world have been introducing a set of policies that address the demand for tobacco products, particularly among youth. These policies effectively reduce consumption and are cost-effective because they save goverments enormous amounts of money in health care spending and increase economic productivity.

Current Tobacco Control Policies in Nepal

Designated smoke-free areas in nepal.

Healthcare Facilities

Educational Facilities

Universities

Government Facilities

Indoor Offices

Restaurants

Pubs and Bars

Public Transport

All Other Indoor Public Places

Funds for Enforcement

Availability of Cessation Services in Nepal

Quitting Resources

National Quit Line

Learn more about best practices in Cessation .

Tobacco Packaging Regulations in Nepal

Quality of Tobacco Packaging Regulation

Text warning label only

Graphic warning label only

Plain Packaging with graphic warning label

% of Pack Covered

Learn more about best practices in Counter Marketing .

Tobacco Control Mass Media Campaigns in Nepal

Ran a National Anti-Tobacco Campaign

Part Of A Comprehensive Tobacco Control Program

Pre-Tested With The Target Audience

Target Audience Research Was Conducted

Aired On Television And/Or Radio

Utilized Media Planning

Earned Media/Public Relations Were Used To Promote The Campaign

Process Evaluation Was Used To Assess Implementation

Outcome Evaluation Was Used To Assess Effectiveness

Learn more about best practices in Mass Media .

Tobacco Tax Policies in Nepal

Using evidence-based international recommendations/best practices, the Tobaccononomics Cigarette Tax Scorecard assesses four components of tax systems — price, change in affordability, tax share, and structure — on a scale of 0 to 5, where a higher score is preferred.

Overall Score

The overall score is an average of the four component scores.

Cigarette Price

Consumers respond to higher prices by decreasing consumption and some quit using tobacco.

Change in Affordability Over Time

In addition to price, change in affordability is critical. Cigarettes need to become less affordable for consumption to decline.

Tax Share of Price

Large tax shares of price are usually a good indicator that taxes are working.

Tax Structure

Best practices include relying more on uniform specific excise taxes that are adjusted regularly to outpace growth and inflation.

Learn more about the Scorecard in Nepal.

Regulations on Tobacco Advertising, Promotion, and Sponsorship (TAPS) in Nepal

Marketing is the key avenue that tobacco companies use to reach consumers, new and old. Restricting or eliminating marketing is key to tobacco control success.

Direct Bans 7 out of 7 direct bans implemented

National TV and radio

International TV and radio

Local magazines and newspapers

International magazines and newspapers

Billboard and outdoor advertising

Advertising at point of sale

Advertising on internet

Ad Ban Compliance: 95%

Indirect Bans 9 out of 10 indirect bans implemented

Free distribution in mail or through other means

Promotional discounts

Non-tobacco products identified with tobacco brand names

Brand name of non-tobacco products used for tobacco product

Appearance in TV and/or films: tobacco brands (product placement)

Appearance in TV and/or films: tobacco products

Prescribed anti-tobacco ads required for any visual entertainment media product that depicts tobacco products, use or images

Complete ban on sponsorship

Any form of contribution (financial or other support) to any event, activity or individual

Ban on the publicity of financial or other sponsorship or support by the tobacco industry of events, activities, individuals

Source: GTCR

World No Tobacco Day 2021: Remarks by WHO Representative to Nepal

Every year, on 31 May, the World Health Organization (WHO) and its partners mark World No Tobacco Day with the aim of raising awareness on the harmful and deadly effects of tobacco use and second-hand smoke exposure, discourage the use of tobacco in any form by highlighting the catastrophic impact tobacco has on health and development and advocating for effective policies to reduce tobacco consumption.

Tobacco use causes life-threatening diseases like lung cancer, respiratory disease, cancer of the mouth and esophagus. It also reduces fertility. Tobacco kills one person every four seconds. More than 8 million people each year due to tobacco. 1.2 million deaths are due to second-hand smoke exposure. Tobacco-related respiratory diseases are responsible distress caused by millions of deaths, illness and debilitating effects on the quality of life of people of all ages, across the globe.

The WHO South-East Asia Region is among the largest producers and consumers of tobacco products. Globally, it accounts for 81 per cent of smokeless tobacco users; more than 22 percent of adult smokers (15 years and above) and over 34% percent of children (13 to 15 years) using various forms of tobacco products. Tobacco kills 1 .6 million people in the South-East Asia Region.

This year the theme is “ Commit to Quit” .

The fact that smoking is associated with increased severity of disease and death in hospitalized COVID-19 patients has triggered millions of smokers to want to quit tobacco. Of the 1.3 billion tobacco users globally, 60% have expressed the desire to quit – but only 30% have access to the tools to help them to do so successfully.

Nepal is experiencing an increasing burden of non-communicable diseases such as cardiovascular disease and cancers, which account for 66% of all deaths. The nationwide NCD risk factors surveys have documented the co-existence of deleterious multiple factors in the population. Among risk factors, 48% per cent of men use tobacco and 34% consume alcohol. The NCD STEPS survey results show that tobacco use remains high and has not changed much over time between 2008 and 2019. Nearly one in two men consume some form of tobacco products. One in three are exposed to secondhand smoke at home (Nepal NCD STEPS survey 2019). Cigarette smoking is on the rise among the youth. Alcohol and tobacco-related death and illness are drivers of poverty, leaving households without breadwinners, diverting limited household resources to purchase tobacco and alcohol products rather than food and school materials, and forcing many people to pay for medical expenses.

WHO urges governments to help tobacco users quit by providing the support, services, policies and tobacco taxes that enable people to quit. Nicotine in tobacco is highly addictive and creates dependence. In the absence of adequate support, quitting can be incredibly challenging. Currently, over 70% of the 1.3 billion tobacco users worldwide lack access to the tools they need to quit successfully. This gap in access to cessation services is only further exacerbated in the last year as the health workforce has been mobilized to handle the pandemic.

With professional support and cessation services, tobacco users double their chances of quitting successfully. Appropriate cessation services are an essential component of any comprehensive tobacco control strategy. WHO recommends offering cessation services as a part of primary health care. The WHO-PEN package provides a platform for including tobacco cessation interventions that include smokeless tobacco and betel nut use (known carcinogen, IARC).

Health professionals play a key role in tobacco control. Health Professionals include medical doctors, nurses, dentists, midwives, psychologists and psychiatrists, physicists, pharmacists and other health-related professions. Health Professionals have a fundamental role in:

• Prevention: through education and communication; and
• Pharmacological therapy: Clinical cessation treatment.

Studies have shown that even brief counselling by Health Professionals on the dangers of smoking and the importance of quitting is one of the most cost-effective methods of reducing smoking. Health Professionals can use their influence in their local and national communities to encourage preventive tobacco control measures to be put in place.

There has never been a better time to quit tobacco, and commitment to helping tobacco users quit is critical to improving health and saving lives. Tobacco costs economies over US$ 1.4 trillion in health expenditures and lost productivity, which is equivalent to 1.8% of annual global GDP. In 2017 it was estimated that tobacco cost Nepal NPR 47 billion every year which is equal to 1.8% of GDP.

Increasing tobacco taxes helps make these lethal products less affordable and helps cover healthcare costs for the diseases they create.

It is important to remember that e-cigarettes have been continuously promoted by the industry as cessation aids. This is just an attempt by the tobacco industry to subvert life-saving public health measures and a strategic marketing tactic to hook children on this same portfolio of products, making them available in over 15,000 attractive flavours. E-cigarettes generate toxic chemicals, which have been linked to harmful health effects such as cardiovascular disease & lung disorders. Nicotine in e-cigarettes is a highly addictive drug and can damage children’s developing brains. Smoking shisha is just as harmful as other forms of tobacco use. Smokeless doesn’t mean that it’s harmless.

The benefits of quitting tobacco are almost immediate. After just 20 minutes of quitting smoking, your heart rate drops. Within 12 hours, the carbon monoxide level in your blood drops to normal. Within 2-12 weeks, your circulation improves and lung function increases. Within 1-9 months, coughing and shortness of breath decrease. Within 5-15 years, your stroke risk is reduced to that of a non-smoker. Within 10 years, your lung cancer death rate is about half that of a smoker. Within 15 years, your risk of heart disease is that of a non-smoker. If that’s not enough here are a few more reasons!

प्रत्येक वर्ष मे ३१ मा विश्व स्वास्थ्य संगठन (डब्लु एच ओ) र संगठनका साझेदारले सुर्ती सेवन र धूम्रपानले व्यक्ति स्वयं  र वरपरका व्यक्तिमाथि पार्ने हानिकारक तथा घातक प्रभाव र जोखिमबारे जागरूकता फैलाउने उदेश्यकासाथ विश्व धूम्रपान तथा सुर्ती विरुद्धको दिवस मनाउने गर्छन् जसअन्तर्गत यिनले त्यस्ता प्रभावहरूमाथि प्रकाश पार्दै सुर्तीको प्रयोगलाई निरुत्साहित गर्छन् र सुर्तीजन्य पदार्थको खपतलाई घटाउन प्रभावकारी नीतिहरूको पैरवी गर्छन् ।

सुर्तीजन्य पदार्थको सेवनले फोक्सोको क्यान्सर, श्वासप्रणालीका रोग र मुख तथा अन्न नलीको क्यान्सर जस्ता गम्भीर रोग निम्त्याउनुका साथै प्रजनन क्षमतामा समेत ह्रास ल्याउँछ । विश्वभरमा सुर्तीजन्य पदार्थको सेवनकै कारण प्रत्येक चार सेकेन्डमा एक व्यक्तिको र वर्षेनी ८० लाख भन्दा बढी मानिसको मृत्यु हुने गर्दछ । धूम्रपान गर्ने व्यक्तिको नजिक बसेर प्रत्यक्षरूपमा धुवाँ सेवन गर्ने व्यक्तिहरूमध्ये १२ लाखको वर्षेनी मृत्यु हुने गरेको पाइएको छ । सुर्तीजन्य पदार्थको सेवनले निम्त्याउने श्वासप्रणालीका रोगहरूले विश्वभर सबै उमेरका मानिसहरूको जीवनलाई अत्यन्त कष्टकर बनाएका छन् र करोडौँलाई मृत्युको मुखमा पुर्‍याएका छन् ।

विश्व स्वास्थ्य संगठनको दक्षिण पूर्वी एशिया क्षेत्र सुर्तीजन्य पदार्थहरूको उत्पादन र खपतका लागि विश्वमै अग्रपंक्तिमा छ । विश्वभरका धुवाँरहित सुर्तीजन्य पदार्थका प्रयोगकर्ताहरूमध्ये ८१ प्रतिशत; धूम्रपान गर्ने वयस्क (१५ वर्षभन्दा माथिका) व्यक्तिहरूमध्ये २२ प्रतिशतभन्दा बढी; र विभिन्न सुर्तीजन्य पदार्थ सेवन गर्ने १३ देखि १५ वर्ष उमेरका बालबालिकामध्ये ३४ प्रतिशत यसै क्षेत्रमा बस्छन् । सुर्तीले दक्षिण पूर्वी एशिया क्षेत्रमा हरेक वर्ष १६ लाख मानिसको ज्यान लिने गरेको छ । 

यो वर्षको नारा “लत त्याग्ने प्रतिबद्बता” हो । धूम्रपान गर्ने व्यक्तिहरू कोभिड–१९बाट संक्रमित भएमा उनीहरू गम्भीर बिरामी पर्ने तथा उनीहरूको मृत्यु हुने जोखिम उच्च हुने तथ्यले लाखौँलाई धूम्रपान र सुर्ती सेवन छोड्न प्रेरित गरेको छ । सुर्तीजन्य पदार्थका १.३ अर्ब प्रयोगकर्तामध्ये ६० प्रतिशतले त्यस्ता पदार्थको लत छोड्ने चाहना व्यक्त गरेका छन् तर तीमध्ये ३० प्रतिशतका लागि मात्र लत छुटाउन मद्दत गर्ने प्रभावकारी साधन-सेवाहरू उपलब्ध छन् ।

नेपालमा मुटुका रोग र क्यान्सरजस्ता नसर्ने रोगबाट पीडित हुनेहरूको संख्यामा वर्षेनी  बृद्दि देखिँदै छ र नेपालभरमा मृत्यु हुने मानिसमध्ये ६६ प्रतिशतको यिनै रोगका कारण मृत्यु हुने गरेको पाइएको छ । नसर्ने रोगहरूको राष्ट्रव्यापी जोखिम कारकहरू सम्बन्धी सर्वेक्षणहरूले विभिन्न कारकहरूको अभिलेख राखेको छ । यी सर्वेक्षणले देखाएअनुसार ४८ प्रतिशत पुरुषले सुर्तीजन्य पदार्थको सेवन गर्छन् र ३४ प्रतिशतले मदिरापान गर्छन् । नसर्ने रोगहरूका लागि गरिएको क्त्भ्एक् सर्वेक्षणले देखाएअनुसार नेपालमा सुर्तीजन्य पदार्थको खपत उच्च छ र २०६४-६५ (२००८) देखि २०७५-७६ (२०१९) का बीच तिनको खपतमा धेरै परिवर्तन आएको पाइएको छैन । हरेक दुई पुरुषमा एक जनाले कुनै न कुनै सुर्तीजन्य पदार्थको सेवन गर्ने गरेको पाइएको छ । हरेक तीन व्यक्तिमध्ये एक जनाले घरका कुनै सदस्यले गर्ने धूम्रपानले गर्दा प्रत्यक्षरूपमा धुवाँ लिइरहेको पाइएको छ (नेपालमा नसर्ने रोगहरूका लागि STEPS सर्वेक्षण २०१९) । त्यसैगरी, युवाहरूमाझ चुरोटको लत बढेको पाइएको छ । मदिरा र सुर्तीजन्य पदार्थले निम्त्याउने रोग तथा मृत्युका कारण धेरै परिवारले आय आर्जन गर्ने मुख्य व्यक्ति गुमाउनु परेको छ र धेरै मानिस महङ्गो उपचार खर्चका कारण गरीबीमा धकेलिएका छन् ।  यस्ता पदार्थमा हुने खर्चले शैक्षिक तथा खाद्य सामग्री समेतको ठाउँ लिएको छ ।

विश्व स्वास्थ्य संगठनले सदस्य राष्ट्रका सरकारलाई सुर्तीजन्य पदार्थको लत बसेका मानिसलाई सेवा, समर्थन,  नीति र सुर्तीजन्य पदार्थमा लाग्ने करको व्यवस्था गरी लत छुटाउन मद्दत गर्न आग्रह गरेको छ । सुर्तीजन्य पदार्थमा हुने निकोटिनले लत बसाउन ठूलो भूमिका खेल्ने पाइएको छ । पर्याप्त साथ नपाएमा यस्तो लत छोड्नु कठिन र चुनौतीपूर्ण हुनसक्छ । हाल सुर्तीजन्य पदार्थका १.३ अर्ब विश्वव्यापी उपभोक्तामध्ये ७० प्रतिशत भन्दा बढीसँग यस्ता पदार्थ छोड्नका लागि आवश्यक प्रभावकारी साधन÷सेवा उपलब्ध छैनन् । गत वर्षदेखि स्वास्थ्यकर्मीहरूलाई कोभिड–१९ महामारीको व्यवस्थापनका लागि व्यापक रूपमा खटाइएकाले यस्ता साधन÷सेवाहरूको पहुँचमा अझ कमी आएको छ ।

दक्ष समर्थन र समाप्ति सेवा (लत छुटाउने सेवा)हरू पाएमा सुर्तीजन्य पदार्थ प्रयोग गर्ने व्यक्तिहरूले आफ्नो लत छोड्ने सम्भावना दोब्बर हुन जान्छ । लत छुटाउने सेवाहरू कुनै पनि बृहत सुर्ती नियन्त्रण रणनीतिका अनिवार्य हिस्सा हुन् । विश्व स्वास्थ्य संगठनले प्राथमिक स्वास्थ्य सेवाको एउटा हिस्साको रूपमा लत छुटाउने सेवाहरू उपलब्ध गराउने सल्लाह दिएको छ । विश्व स्वास्थ्य संगठनले जारी गरेको ‘नसर्ने रोगहरूका लागि आवश्यक हस्तक्षेपको प्याकेज (ध्ज्इ–एभ्ल्)ले धुवाँरहित सुर्तीजन्य पदार्थ र सुपारी (क्यान्सरका कारक, क्यान्सर अनुसन्धानका लागि अन्तर्राष्ट्रिय निकाय/IARC) लगायतका सुर्तीजन्य पदार्थको लत हटाउने हस्तक्षेपका लागि मञ्च प्रदान गर्छ ।

सामान्य चिकित्सक, नर्स, दन्त चिकित्सक, सुँडेनी, मनोवैज्ञानिक-मनोचिकित्सक, औषधी विज्ञ (फार्मासिस्ट) आदिजस्ता स्वास्थ्यकर्मीहरूले सुर्तीजन्य पदार्थको लत तथा प्रयोगलाई नियन्त्रणमा ल्याउन महत्वपूर्ण भूमिका खेल्छन् । स्वास्थ्यकर्मीहरूले निभाउने भूमिकाहरूः

• रोकथामः शिक्षा तथा सञ्चार; 
• औषधी उपचारः चिकित्सकिय समाप्ति (लत छुटाउने) उपचार ।

अध्ययनहरूले देखाएका छन् कि धूम्रपानबाट हुने खतरा तथा धूम्रपान त्याग्नुको महत्वका बारेमा स्वास्थ्यकर्मीहरूले छोटो परामर्श दिँदा पनि यसले धूम्रपान कम गर्नमा धेरै मद्दत गर्दछ र यो धूम्रपान घटाउने सबैभन्दा लागत प्रभावकारी उपायहरू मध्येको एक हो । स्वास्थ्यकर्मीहरूले आफ्ना स्थानीय तथा राष्ट्रिय समुदायमा सुर्ती नियन्त्रणका उपायहरू लागू गर्नका लागि आफ्नो प्रभाव प्रयोग गरी प्रोत्साहन गर्न सक्दछन् । 

सुर्तीजन्य पर्दाथको सेवन त्याग्ने अहिले सबैभन्दा अुनुकूल समय हो र सुर्ती सेवन गर्नेहरूलाई मद्दत गर्ने प्रतिवद्धता स्वास्थ्य सुधार गर्नका लागि र जीवनहरू बचाउनका लागि अन्यन्त महत्वपूर्ण छ । सुर्तीको सेवनले गर्दा स्वास्थ्यसम्बन्धी व्यय तथा उत्पादकत्व ह्रास जस्ता कारणले गर्दा अर्थतन्त्रहरूले १४ खर्ब डलर बराबरको रकम गुमाइराखेका छन् । यो रकम विश्वको कुल गार्हस्थ उत्पादनको १.८ प्रतिशत हो । सन् २०१७ मा सुर्तीजन्य पदार्थको सेवनले नेपाललाई वार्षिक ४७ अर्ब नेपाली रूपैयाँ बराबारको क्षति भइराखेको अनुमान थियो जुन नेपालको कुल गार्हस्थ उत्पादनको १.८ प्रतिशत हुन आउँछ ।

सुर्तीजन्य पर्दाथमाथिको कर बढाउनाले त्यसले हानिकारक उत्पादनहरूलाई महङ्गो बनाउँछ र सोबाट प्राप्त आम्दानीले तिनले सिर्जना गर्ने स्वास्थ्य स्याहारको लागत ब्यहोर्न मद्दत गर्दछ ।

प्रायः उत्पादकले ई—सिगरेटलाई चुरोट छोड्न सहयोग गर्ने सामग्रीको रूपमा निरन्तर रूपमा प्रवद्र्धन गरिरहेको कुरा सम्झनु महत्वपूर्ण हुन्छ । यस्तो प्रचार भनेको जीवन रक्षा गर्ने जनस्वास्थ्यका उपायहरूलाई नजरअन्दाज गर्ने सुर्ती उद्योगहरूको चेष्टा मात्रै हो र १५,००० भन्दा बढी स्वादहरू उपलब्ध गराएर बालबालिकाहरूलाई तिनै सुर्तीजन्य पदार्थहरूमा अल्झाउने बजारीकरणको रणनीतिक दाउपेच हो । ई—सिगरेटले विषाक्त रसायनको उत्पादन गर्छ र यी रसायनहरूको सम्बन्ध मुटु रोग तथा फोक्सोसम्बन्धी समस्या जस्ता स्वास्थ्यमा पर्नजाने हानिकारक प्रभाव रहेको पाइएको छ । ई—सिगरेटमा हुने निकोटिन लत लगाउने क्षमता उच्च भएको पदार्थ हो र यसले बालबालिकाहरूको विकास हुँदै गरेको दिमागलाई क्षति पु¥याउन सक्छ । हुक्का (सिसा)को सेवन गर्नु पनि सुर्तीको अन्य कुनै पदार्थको सेवन गर्नु जत्तिकै हानिकारक हुन्छ । धुँवारहित सुर्तीजन्य पदार्थको सेवन पनि हानिविहीन हुन्छ भन्ने हुँदैन । 

सुर्तीजन्य पदार्थको सेवन छोड्नुको फाइदा तत्कालै हुन्छ । धूम्रपान गर्न छोडेको २० मिनेटभित्रै, तपाईँको मुटुको चालको दर घट्छ । छोडेको १२ घण्टाभित्रमा, तपाईँको रगतमा भएको कार्बनमोनोअक्साइडको मात्रा सामान्य स्तरमा आउँछ । अर्को २—१२ हप्तामा, तपाईँको रक्त सञ्चारमा सुधार आउँछ र फोक्सोको कार्यक्षमता बढ्छ । १ देखि ९ महिनाभित्रमा, खोकी र सास बढ्ने कम हुन्छ । धूम्रपान गर्न छोडेको ५ देखि १५ वर्षमा, तपाईँलाई स्ट्रोक हुने जोखिम धूमपान नगर्ने व्यक्तिको समान हुन्छ । १० वर्षभित्रमा, तपाईँलाई फोक्सोको क्यान्सर हुने जोखिम धूम्रपान गर्ने व्यक्तिको भन्दा आधा हुन्छ । धूम्रपान छोडेको १५ वर्षभित्रमा, तपाईँलाई मुटु रोग लाग्ने जोखिम धूम्रपान गर्ने व्यक्ति सरह हुन्छ । यदि यी कारण पनि सुर्ती छोड्नका लागि अपर्याप्त छन् भने, हामीले अझै धेरै कारण यहाँ पस्केकाछौँ ।

Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

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Translation of "smoking" into Nepali

धूम्रपान is the translation of "smoking" into Nepali. Sample translated sentence: This is mainly because of the Witnesses’ Bible-based position on such matters as blood transfusions, neutrality, smoking, and morals. ↔ यस्तो आरोप विशेष गरी साक्षीहरूको रक्तक्षेपण, तटस्थता, धूम्रपान र नैतिकताको सन्दर्भमा बाइबल आधारित अडानको कारण आएको हो।

Present participle of smoke. [..]

English-Nepali dictionary

practice in which a substance is burned and the resulting smoke breathed in to be tasted and absorbed into the bloodstream

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Automatic translations of " smoking " into Nepali

Images with "smoking", phrases similar to "smoking" with translations into nepali.

• smoke धुँवा · धूवाँ
• smoking pipe सुल्पा

Translations of "smoking" into Nepali in sentences, translation memory

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• Volume 11, Issue 8
• Burden of tobacco in Nepal: a systematic analysis from the Global Burden of Disease Study 1990–2017
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• http://orcid.org/0000-0002-9975-9804 Gambhir Shrestha 1 ,
• Prabin Phuyal 2 ,
• Rabin Gautam 3 ,
• Rashmi Mulmi 4 ,
• http://orcid.org/0000-0002-0066-8583 Pranil Man Singh Pradhan 1
• 1 Department of Community Medicine, Maharajgunj Medical Campus , Institute of Medicine, Tribhuvan University , Maharajgunj, Kathmandu , Nepal
• 2 B.P. Koirala Institute of Health Sciences , Dharan, Sunsari , Nepal
• 3 World Health Organization Country Office for Nepal , Kathmandu , Nepal
• 4 Department of Cancer Prevention, Control and Research , B.P. Koirala Memorial Cancer Hospital , Bharatpur, Chitwan , Nepal
• Correspondence to Dr Gambhir Shrestha; gamvir.stha{at}gmail.com

Objective This study systematically reviews the data extracted from the Global Burden of Disease Study and sets out to assess the age-specific and sex-specific mortality and disability attributable to different forms of tobacco from 1990 to 2017, for Nepal.

Design This cross-sectional study extracted data from the Institute for Health Metrics and Evaluation’s Global Burden of Disease database, then was quantitatively analysed to show the trends and patterns of prevalence of tobacco use, deaths and disability-adjusted life-years (DALYs) attributable to tobacco use from different diseases from the year 1990 to 2017 in Nepal.

Setting Nepal.

Results In between 1990 and 2015, the age-standardised prevalence of daily tobacco smoking decreased by 33% in males, 48% in females and 28% in both. By 2017, the age-standardised mortality rate and DALYs attributable to tobacco use, including any form, decreased by 34% and 41%, respectively, with tobacco smoking having the most contribution. However, the absolute number of deaths and DALYs increased by 39% and 3%, respectively. An increasing rate of deaths and DALYs attributable to tobacco was noted with an increase in age. Non-communicable diseases were responsible for most deaths and disabilities attributable to tobacco use.

Conclusion The prevalence of smoking along with the age-standardised mortality rate and DALYs shows a decreasing trend. However, attention should be made to implement a strong plan to control all forms of tobacco including secondhand exposure.

• epidemiology
• preventive medicine

Data availability statement

Data are available in a public, open access repository ( http://ghdx.healthdata.org/ ). All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article and can be assessed through the website http://ghdx.healthdata.org/ .

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-047847

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Strengths and limitations of this study

This study is one of the first studies in Nepal to extracts Global Burden of Disease Study data to present nationally representative data on mortality and disability attributable to tobacco by age, sex and disease.

This study informs the policy-makers on further strategies to control tobacco use including secondhand smoking.

This study analyses the secondary data of the Global Burden of Disease Study and hence it has all the limitations pertaining to the data.

The prevalence of smoking could have been underestimated as the Global Burden of Disease data only takes into account the prevalence of daily smoking and lacked the data for the prevalence of smokeless tobacco and secondhand exposure.

Introduction

To date, tobacco remains a major public health issue worldwide because of its associated high morbidity and mortality rate. Any forms of tobacco use are harmful to health and kill millions of people every year. 1 The use of tobacco products in any form either smoking or smokeless or exposure to secondhand smoke has been implicated in many health issues like cardiovascular diseases, respiratory diseases, cancers, non-communicable diseases (NCD) and many more. 2 3 There is no safety margin for exposure to secondhand smoke or tobacco smoking and secondhand smoke exposure is equally harmful to health.

According to World Health Organization (WHO), about 1.3 billion people in the world used tobacco products among which more than one billion people were smokers. 4 Almost 80% of smokers reside in low-income and middle-income countries. The last two decades have seen a decreasing trend towards the consumption of tobacco in all age groups. In 2000, almost one-third of the world’s population (33.3%) aged 15 and more used some form of tobacco products, 50% in males and 16.7% in females. While, in 2015, the prevalence of tobacco use dropped to nearly a quarter of the world’s population (24.9%), 40.3% in males and 9.5% in females. 1 Despite the decreasing prevalence of tobacco use globally, the absolute number of male smokers is growing continuously in South-East Asian, African and Eastern Mediterranean regions. The South-East Asian region has the highest prevalence of tobacco use (31% in 2015) compared with other regions, 49.4% in males and 12.9% in females. 1 According to recent findings from STEPwise approach to surveillance (STEPS) survey 2019 in Nepal, around 29% of adults (48% male and 12% female) within the age group 15–69 years used any form of tobacco. 5 In recent times, people have shown a growing preference for smokeless tobacco over smoking in South-East Asia including Nepal. 6–8 In Nepal, the use of smokeless tobacco is much more common than tobacco smoking and is more prevalent among males (33%) compared with females (5%). 5

Despite decreasing prevalence, the number of deaths due to tobacco use continues to rise. Tobacco kills more than 8 million people every year. Among them, about 7 million people die from direct tobacco use while the deaths of about 1.2 million people result from secondhand smoke exposure. 4 In 2015, smoking alone was responsible for 11.5% and 6% of global deaths and disability-adjusted life-years (DALYs), respectively. 9 Deaths of about 65 000 children per year can be attributed to exposure to secondhand smoke. 4 The recent estimates show around US$1.4 trillion of total economic loss results globally from tobacco use which is equivalent to 1.8% of the world’s annual Gross Domestic Product (GDP). 10 About 40% of this cost occurred in low-income and middle-income countries. In Nepal, around 27 000 deaths occur annually from tobacco use, which comprises about 14.9% of all deaths. 11

Given such a significant negative impact of tobacco on public health, navigation of the outcomes of tobacco use in a low-income country like Nepal is of the essence. The issue of tobacco usage has received considerable attention. In response, Nepal implemented the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2006 12 and passed Tobacco Control and Regulatory Bill in 2011 by Parliament. 5 So far, however, there has been little discussion about trends and patterns of tobacco use and its outcomes in Nepal. Such approaches have an unsatisfactory description of the burden of tobacco in the Nepalese population. This study systematically reviews the data extracted from the Global Burden of Disease (GBD) Study 2017 and sets out to assess the trends in prevalence, mortality and disability attributable to different forms of tobacco in Nepal from 1990 to 2017. Therefore, the findings of this study will make a major contribution informing the policy-makers and public health professionals by providing important insights into evidence for an effective tobacco control programme in Nepal.

Data sources and study settings

The GBD study 2017 was a comprehensive epidemiological study that reported the trends and patterns in morbidity and mortality in 195 countries from major injuries, diseases and risk factors to health at the global, regional and national level. The study design, metrics and analysis are published elsewhere. 13 The Institute for Health Metrics and Evaluation (IHME) coordinated the GBD study 2017 and used the data from several published and unpublished literature, survey and surveillance data, hospital and clinics data to estimates the deaths and disability attributable to 84 risk factors for 195 countries by age and sex. 13 14

The Nepal GBD 2017 study used data from over 90 000 sources covering the years between 1990 and 2017. These data sources included in Nepal’s burden of disease estimates mainly data from the 1971 to 2011 Nepal Population and Housing Census, disease registries such as the Kidney Disease Data Centre maintained by the International Society of Nephropathy, epidemiological surveillance such as the WHO Disease Observatory, periodic and ad hoc large household surveys such as Nepal Demographic Health Surveys, Multiple Indicator Cluster Surveys and Nepal STEPS Non-Communicable Risk Factor Surveys, Nepal Global Youth Tobacco Survey, Nepal Behavioural Surveillance Survey, Nepal Hospital Inpatient Discharges Record, Health Management Information System, published scientific literature, reports and administrative records. 15

The GBD database was used for the extraction of data related to mortality and DALYs of all causes and other major public health issues of Nepal like cardiovascular diseases, NCDs, diabetes and kidney disease, all neoplasms including benign and malignant, and tuberculosis from the year 1990 to 2017. 16

Patient and public involvement statement

This study used the data freely available from the IHME’s GBD database. Patients were not involved in the design, recruitment or conduct of the study. Results of this study will be made publicly available through publication.

Definition of terminology

Years of life lost (YLLs) are calculated by multiplying the number of deaths at each age by a standard life expectancy at that age. Years lived with disability (YLDs) is the number of years of life lived with health loss weighted by the severity of the disabling sequelae of diseases and injuries. DALY is the key summary measure of population health used in GBD to quantify health loss which allows comparison of health loss across different diseases and injuries. They are a measure of the number of years of healthy life that are lost due to death, nonfatal illness or impairment, and thus, they are calculated as the sum of YLLs and YLDs. 14 17

Uncertainty interval (UI) is a range of values that is likely to include the correct estimate of disease burden for a given cause. Narrow UIs indicate that evidence is strong, while wide UIs show that evidence is weaker. 14 17

The term tobacco includes tobacco use in all forms either smoking or smokeless or both.

Statistical analysis

The extracted data from IHME were imported into Microsoft Excel, then were quantitatively analysed and presented in the graphical, tabular forms and histograms to show the trends and patterns in age-sex-specific mortality and DALYs in Nepal. The age-standardised prevalence of tobacco use only in form of daily tobacco smoking was available up to the year 2015. A percentage change was calculated to present the difference in mortality and DALYs between 1990 and 2017. An UI of 95% was presented to show the strength of the estimates.

Here, we report the GBD study results for Nepal on the prevalence of tobacco use, mortality and burden caused by different forms of tobacco, smoking and smokeless tobacco, between 1990 and 2017.

Tobacco smoking

The trend of daily tobacco smoking is in decreasing trend during the period 1990–2015 in both sexes. In 1990, the age-standardised prevalence of tobacco smoking at all ages was 27.5% for both sexes. The prevalence was more for males (35.6%) than the females (19.8%). In 2015, the prevalence of tobacco smoking decreased to 19.7% in both sexes at all ages, with male 23.7% and female 10.3% ( figure 1 ).

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Prevalence of smoking from the year 1990 to 2015 in Nepal.

Deaths and DALYs

In Nepal, both the age-standardised mortality rate and the DALYs attributable to tobacco are in decreasing trend from 1990 to 2017 ( figure 2 ). The age-standardised attributable deaths to tobacco use, including all forms, decreased (34.5%) in the general population from 216 (95% UI 183–258) per 100 000 in 1990 to 141 (95% UI 120–163) per 100 000 in 2017. While DALYs decreased by 41.3% from 5474 per 100 000 in 1990 to 3216 per 100 000 in 2017. This finding was found in both males and females. Similarly, over the same time, the age-standardised deaths and DALYs attributable to tobacco smoking, chewing tobacco, secondhand smoking, showed a falling trend for both sexes and males and females separately ( table 1 ). In absolute terms, the attributable deaths at all ages to tobacco use, including all forms, increased (38.99%) in the general population (both male and female) from 19 372 (95% UI 16 060–23310) in 1990 to 26926 (95% UI 22 826–31135) in 2017. While DALYs for all ages due to tobacco use increased (10.52%) in males from 403 665 (95% UI 3 19 794–5 12 870) in 1990 to 4 46 132 (95% UI 3 64 622–5 24 648) in 2017, it decreased (8.78%) in females from 280 977 (95% UI 2 05 487–3 73 384) in 1990 to 2 56 301 (95% UI 2 05 569–3 16 573) in 2017 ( online supplemental table 1 ).

Supplemental material

Trend of age-standardised mortality rate and DALYs attributable to tobacco from 1990 to 2017 in Nepal. DALYs, disability-adjusted life-years.

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Age-standardised deaths and DALYs for different diseases attributable to tobacco and their percentage change in Nepal, 1990–2017

Figure 3 demonstrates a clear trend of the increasing rate of deaths and DALYs attributable to tobacco with an increase in age. Around 27 000 deaths are attributable to tobacco comprising 90% deaths due to NCDs. Similarly, more than 702 000 DALYs were attributable to tobacco use comprising 89% DALYs for NCDs ( figure 4 ).

Agewise deaths (A) and DALYs (B) rates in all causes in both sexes attributable to tobacco, including all types, in 2017. DALYs, disability-adjusted life-years.

All-age deaths (A) and DALYs (B) from different diseases attributable to tobacco use (including all types) in Nepal in 2017. CVD, cardiovascular disease; DALYs, disability-adjusted life-years; NCDs, non-communicable diseases.

Cardiovascular diseases

The age-standardised deaths from cardiovascular diseases showed falling trends in both sexes due to tobacco use (of all types), tobacco smoking and in females due to secondhand smoking, while age-standardised deaths showed increasing trends in males from secondhand smoking. The age-standardised DALYs from cardiovascular diseases showed falling trends in both sexes due to tobacco use, tobacco smoking and secondhand smoking. The major cause of deaths and DALY in cardiovascular disease attributable to tobacco was found to be smoking.

Diabetes and kidney diseases

The attributable deaths and DALYs from diabetes and kidney diseases showed rising trends in both sexes due to tobacco smoking and secondhand smoking in both sexes.

The age-standardised deaths and age-standardised DALYs from all neoplasms showed falling trends in both sexes due to tobacco use, tobacco smoking, chewing tobacco and secondhand smoking.

Non-communicable diseases

The attributable age-standardised death from NCD due to tobacco use decreased (29%) from 180 (95% UI 115–216) in 1990 to 128 (95% UI 108–148) in 2017 in both sexes, with deaths occurring mostly from tobacco smoking. The DALYs also decreased by 31%from 4171 (95% UI 3197–4911) in 1990 to 2880 (95% UI 2423–3338) in 2017 in both sexes, with disability mostly resulting from smoking. Over the same period, deaths and DALYs from NCDs showed decreasing trends in both sexes due to tobacco smoking, secondhand smoking and chewing tobacco,

Tuberculosis

The attributable age-standardised deaths and DALYs from tuberculosis due to tobacco use showed falling trends in both sexes.

Prevalence and patterns of tobacco use

The GBD study results indicate that throughout the time between 1990 and 2015, the prevalence of daily tobacco smoking decreased by 33% in male (35.6% in 1990 and 23.7% in 2015), by 48% in female (19.8% in 1990 and 10.3% in 2015) and by 28% in the general population (27.5% in 1990 and 19.7% in 2015). One reason for the decrease in the prevalence of daily tobacco use could be Nepal’s implementation of WHO FCTC in 2006 12 and Tobacco Control and Regulatory Bill in 2011, 5 which regulate the law of tobacco use in Nepal. In reviewing previous literature, it is evident that gender, geographical and socioeconomic variation do play a role in observed differences in the pattern of tobacco use. In Nepal, the use of tobacco products is practised extensively in the elderly population, males, people with lower education levels, rural areas, mountainous areas than in plain areas, and Far-western and Mid-western regions than in Eastern, Central and Western regions. 18 In addition to that, in Nepal, people in mountainous areas tend to smoke more while, people in plain areas tend to chew tobacco more. 18 19 Elderly people have different beliefs around tobacco use, like continuing tobacco does no harm and stopping tobacco does not improve health status. 20 People who are less educated might have a lower level of awareness of the harmful hazards of tobacco use. However, in recent times, males of the young age group have high tobacco consumption. 6 A similar pattern of variation in tobacco use was noticed in the Southeast Asian population. The higher prevalence of smoking in males was observed in Asian countries like Malaysia, the Philippines, Singapore, Vietnam, Indonesia, Maldives and Bangladesh. 21 22 In these countries, gender seems to be an important determinant of the initiation of the smoking habit and for perpetuating it. Social norms and the prohibition of tobacco use can be one of the factors responsible for the lower prevalence of tobacco use in the female population in Southeast Asian countries. 23 Smokeless form of tobacco was common in countries like India, Nepal, Bangladesh, Maldives and Cambodia. 22 Increasing age, poverty and poor education were associated with higher consumption of tobacco in these countries.

It was evident from the results that, age-standardised rates of death and disability due to smokeless tobacco are in decreasing, however, the absolute number of deaths and disabilities due to smokeless tobacco is increasing. In recent years in the Southeast Asia region, including Nepal, there is a clear increase in preference to using smokeless tobacco over tobacco smoking, with a higher prevalence of smokeless tobacco in males. 6–8 24 Smokeless tobacco is associated with a higher risk of getting cancer 25 and cardiovascular risk factors like hypertension, metabolic syndrome and cardiovascular events like acute coronary syndrome 26 than non-tobacco users, although less than tobacco smoking. The increased prevalence of smokeless tobacco in the Nepalese population and the potential increase in the risk of cancer associated with it might be the reason for the increase in disability rate from all neoplasms due to chewing tobacco. According to a study in Nepal, most of the consumers of smokeless tobacco are unaware of its harmful health hazards. 27 Studies have shown that smokers tend to perceive smokeless tobacco as less harmful than smoking. 28 This belief might exist among smokers in Nepal and the extent of such beliefs needs to be explored in detail. The production of smokeless tobacco products is unhindered in Nepal and the increased import of smokeless from the neighbouring country, India made the products easily accessible all over the country. 27 And, owing to the government’s lower taxation imposed on smokeless products compared with smoking tobacco products, smokeless tobacco products have an added affordability. 6 Tobacco products such as bidis and smokeless tobacco are perceived as ‘hard to tax’ due to their more informal nature. Thus, all these factors with more emphasis on tobacco control policy on tobacco smoking over smokeless tobacco with lack of awareness towards the hazards of smokeless tobacco products seem to be the cause for shifting the preference of consumers from smoking to smokeless tobacco.

The results indicate that the age-standardised rates of death among males due to cardiovascular diseases, and age-standardised deaths and disability due to diabetes and kidney diseases in both sexes, attributable to secondhand smoking are in the increasing pattern. At the global level, around 40% of children, 33% of male non-smokers and 35% of female non-smokers are estimated to have been exposed to secondhand smoke regularly, with Southeast Asia and the Western Pacific region accountable for 50% of the globe’s total burden from secondhand smoke exposure. 29 Most of the deaths attributable to secondhand smoke occurred from ischaemic heart disease in adults and lower respiratory tract infections in children, women having the greatest burden among all. Most DALYs lost secondary to secondhand smoke exposure occurred due to lower respiratory tract infections and ischaemic heart diseases, children being the most affected ones. 29 In Nepal, public transports and restaurants are the major areas of secondhand smoke exposure in public places, while homes and workplaces are indoor areas of secondhand smoke exposure. 5

Deaths and DALYs attributable to tobacco

Tobacco use was the second most common risk factor for deaths and the third most common risk factor for total DALYs in Nepal in 2017. 30 In numbers, 14.73% (95% UI 12.52–16.58) of total deaths and 7.8% (95% UI 6.68–9.06) of total DALYs were attributed to tobacco use in 2017. 30 In between 1990 and 2017, the total deaths attributable to tobacco use, including any form, in all ages increased by 39% in the general population (both males and females) and DALYs attributable to tobacco use, including any form, in all ages increased by 11% males but decreased by 9% in females, with tobacco smoking having the most contribution. Also, in 2017 most of the tobacco attributable deaths were due to cardiovascular disease, diabetes, neoplasm and kidney disease. Between 1990 and 2017, tobacco attributable disease occupied a larger proportion of cause of death in Nepal. In contrary to an overall decrease in the prevalence of tobacco use and age-standardised deaths and DALYs in both males and females in recent decades, the total deaths and DALYs were higher in 2017 compared with 1990. One plausible explanation for this pattern could the population growth in Nepal, 29 million in 2019 compared with 18.9 million in 1990. 31 The rising number of tobacco consumers despite the overall decrease in the prevalence of tobacco use can be attributed to population growth compared with 1990. Furthermore, the elderly population tends to have smoked for more decades considering they started consuming tobacco from an early age. Thus, they tend to have the highest exposure to tobacco which can support a fact that the mortality attributable to tobacco becomes evident usually after 2–3 decades of tobacco use. 32 This evidence also explains the reason why there are increasing deaths and disabilities with an increase in age. Consequently, the deaths attributed to tobacco use may continue to rise in the long run despite the decrease in the prevalence of tobacco use.

Policy related to tobacco in Nepal

In response to the global tobacco epidemic, WHO launched a global public health treaty in 2003 named WHO FCTC. 33 Nepal signed the WHO FCTC in 2003 with the ratification of the treaty in 2006. 12 In 2008, to efficiently implement the FCTC, WHO launched the MPOWER policy to lower the tobacco demand in individual countries, 34 which was adopted by Nepal. The Parliament of Nepal passed the Tobacco Control and Regulatory Bill in 2011 incorporating the provisions of WHO FCTC which is currently the primary law that governs tobacco use. This act regulates the use of tobacco in public workplaces and public transport, advertisement and promotion of any kind of tobacco products, and packaging and labelling of tobacco products. However, the question that arises is how effective the law is, and how effective we have been in protecting people from tobacco use, tobacco-related deaths and disability. The decreasing trends in the prevalence of tobacco use and age-standardised deaths and DALYs attributable to tobacco suggest that tobacco control has been effective so far. Nepal received a Bloomberg Philanthropies Award for Global Tobacco Control in 2015 for its work in control and reduction of tobacco product use by warning people about the hazards of tobacco use. 35 The tobacco act has emphasised more on packaging and promotion to abate the consumption of tobacco products. In the STEPS survey conducted in 2019, 75.7% of adults noticed health warnings on tobacco packages and 44.8% of current users thought of quitting because of such warnings. However, the tobacco act is limited by a lack of knowledge on the implementation of regulations in public places and around the educational hubs. Though the control of tobacco use in Nepal appears well in the last few decades, the progress seems static in recent times. The STEPs survey conducted in Nepal in 2019 showed only a minor drop in the prevalence of former smokers or former smokeless tobacco users in comparison to 2013. 5 Tobacco control contributes to improving the health of its consumers and is very important for economic development. On average, the average amount of money spent per year on cigarettes is around 11% of GDP per capita. 5 Nepal currently imposes a tobacco tax of just 15.5% of retail price (excluding value-added tax (VAT)) which is the lowest among the South Asian countries and far below the WHO guideline of 70% of the retail price. 36 Tobacco taxation increases the retail price of tobacco products and reduces the demand therefore is considered to be the most cost-effective method in tobacco control. 37 A 10% increase in the price of tobacco products is expected to reduce the demand by 5%–10% in lower-income and middle-income countries. 4 Given the high burden of tobacco use in Nepal, an increment of the tax on tobacco products should be given high priority.

Limitations of study

There are a few limitations to the study. First is the lack of primary data sources from Nepal and those included sources used in GBD are limited in scope, coverage and quality. Nepal also lacks a cause of death surveillance system to document disease-related deaths. However, in resource-limited countries like Nepal, where reliable health statistics are limited, the GBD data provide nationally representative findings, providing evidence-based strategies for policy-making. Second, the prevalence of smoking could have been underestimated as the GBD data only takes into account the prevalence of daily smoking and lacked the data for the prevalence of smokeless tobacco and secondhand exposure. This could have resulted in an underestimation of attributable disease burden especially in populations who tend to use less tobacco every day. Also, the data did not account for the duration and intensity of tobacco use. Third, the burden estimates are limited by not considering indoor and outdoor air pollution. Nepal has experienced a massive increase in air pollution during the time in most of the cities, which could confound the findings.

Conclusions

This study is one of the first studies in Nepal to show the trend of mortality and DALY attributable to tobacco use. There is a decreasing trend in the prevalence of smoking, age-standardised mortality and DALYs between 1990 and 2017. However, there was a more than one-third increase in crude mortality rate. NCDs contributed the most deaths and disabilities attributable to tobacco. There is a huge increase in deaths and DALY due to chewing tobacco from 1990 to 2017. Awareness along with the strong implementation of tobacco control strategies on all forms of tobacco including secondhand exposure and increasing taxation can further help to decrease the trend in the future. There is also a need for a robust and reliable data representative of all regions in Nepal to understand the effect of tobacco control policies.

Ethics statements

Patient consent for publication.

Not required.

Acknowledgments

We would like to thank The Institute for Health Metrics and Evaluation’s Global Burden of Disease for the data for this study.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Twitter @gamvir_shrestha, @PranilMSPradhan

Contributors GS: conceptualisation, methodology, software, formal analysis, supervision, writing-original draft preparation. PP: software, formal analysis, visualisation, writing-original draft preparation. RG: conceptualisation, methodology, software, formal analysis, writing-original draft preparation. RM: conceptualisation, Visualisation, writing-reviewing, and editing. PMSP: methodology, visualisation, writing-reviewing and editing. All authors revised, read and approved the final version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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