Association between Smoking and Depression among University Students in Bangladesh

Association between Smoking and Depression among University Students in Bangladesh

Dr. Mehbuba Shaid¹, Prof. Dr. Sayed Shamsuddin Ahmed², *Dr. Md. Alahi Khandaker³, Sanchita Sayeed Preity⁴, Tasnuva Sayeed⁵, Dr. Md. Mohi Uddin⁶

¹Principal-Cum-Superintendent, Government Unani and Ayurvedic Medical College Hospital, Dhaka, Bangladesh

²Burn and Plastic Surgeon, Former Head of Department of Burn, Plastic Surgery Unit, Dhaka Medical College Hospital, Dhaka, Bangladesh.

³Health Policy Analyst, Bangladesh Center for Health Studies, Dhaka, Bangladesh.

⁴Student, University of Wollongong, Australia

⁵Student Services Officer, Central Quinsland University, Australia

⁶IMO, Government Unani and Ayurvedic Medical College Hospital, Dhaka, Bangladesh

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2025.12150009P

Received: 11 January 2024; Accepted: 15 January 2025; Published: 19 February 2025

ABSTRACT

Background:  Smoking has some terrible consequences on human health, and it has become a major public health concern around the globe. Currently one of the leading preventable causes of premature death and disability in the world is smoking. Depression is a serious problem for young people leads to suicide. Therefore, this study aimed to find out the association between smoking and depression.

Materials and Methods: This cross-sectional study was conducted at two universities in Dhaka, Bangladesh among 401 students aged 18-26 years. Centre for Epidemiologic Studies Depression scale (CES_D) was used for the evaluation of depression status of the respondents. Statistical analysis was performed to see the association between outcome and predictors by using SPSS version 22 software package.

Result: Among total students, 301 students lived in nuclear families, and 84.0% of the student’s monthly family income was above 20,000 takas. Although 78.1% were smokers among depressed respondents, there was no significant association between smoking and depression. Significant associations were also not found in the subgroups of males, females, those aged 18-23 years and those aged 24-26 years.

Conclusion: There may be heterogeneity in the association between smoking and depression among different culture, different society, different stage of life, etc. Since the association between smoking and depression is an important public health issue, the heterogeneity should be examined by large scale studies.

Keywords: smoking, depression, university students, stress, Bangladesh

INTRODUCTION

Smoking has some terrible consequences on human health and it becomes a major public health concern around the world.[1] Currently, one of the leading preventable causes of premature death and disability in the world is smoking.[2] Based on the latest estimation, ten percent of the causes of cardiovascular disease (CVD) are due to smoking.[3] Almost 5 million people die every year from tobacco related diseases and it will be doubled by the year 2020.[4]Smoking habit is raising among university students in both developing and developed countries.[5] A report of WHO Department of Mental Health and Substance Abuse defined the depression as “Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration”.[6] World Health Organization (WHO) refers adolescence as the period in human growth and development from the ages 10 to 19 as the peak age of depression.[7] Due to genetic predisposition to a positive parental or family history and chronic illnesses such as diabetes, asthma and heart disease, young people could become depressed. During puberty hormonal changes can lead depression. Nicotine stimulates the release of the chemical dopamine in the brain. Nicotine causes changes to neurotransmitter activity in the brain, leading to increased risk of depression. Youth tobacco use is a raising problem in Bangladesh. More than 100,000 people die in Bangladesh in each year from diseases caused by consumption of tobacco. [8] In Bangladesh, about 20 million people use tobacco in several different methods with five million women in share. [4] Smoking prevalence among male is 48.3%, among female is 20.9%. [4] Depression leads younger part of the society to start smoking or drug addiction. [9] Global Adult Tobacco Survey, Bangladesh report 2009 found that the peak age of depression was 15 years or above which accounted for 23.0%. [7] Bangladesh voluntarily participates in the FCTC (Framework Convention on Tobacco Control) on 16^th June, 2003, there has been few advances in tobacco control policy, mostly the Smoking and Tobacco Product Usage (Control) Act, 2005. The national agency for tobacco control in Bangladesh has an objective of tobacco prevention, but there is still a long road ahead to reach the set of strong, comprehensive policies which basically recommended by the World Health Organization. The studies conducted in Nepal, Pakistan and India found that 78%, 39% and 97.6% of university students were smokers. [10] A study in Bangladesh showed that 21.2% of university students have smoking habit and it is increasing in a risky manner due to over anxiety and tension, feeling of maturity, symbol of manliness and it can help one to forget the unhappy family environment.¹⁰⁾ Anxiety and depression were remarkably higher in current cigarette smokers than non-smokers and former smokers. [11] Many studies approved that there was an association between major depression and smoking.¹²⁾ However, to my knowledge, there were no studies in Bangladesh to examine the association between smoking and depression among the youth. This study aimed to examine the association between smoking and depression among university students in Bangladesh, adjusting for the factors associated with depression by multivariate analysis.

MATERIALS AND METHODS

Study design

This cross-sectional study was conducted at two universities (Dhaka University and United International University) in Dhaka, Bangladesh from June to September, 2016. The subjects were students aged 18-26 years; 306 students from Dhaka University and 95 students from United International University. Purposive sampling was used for the selection of universities and respondents. The students who did not agree the participation were excluded.

Data Collection

Self-administered anonymous questionnaire was used for data collection after acquiring informed consent from each student. The questionnaire was prepared with the help of opinion of relevant expert and literature review. It was translated into Bengali. Researcher provided the questionnaires to the students. The questionnaire was pre-tested among 30 students. After the pre-test, the questionnaire was modified for appropriate context and lingual meaning. The questionnaire was again retested to finalize the questionnaire to adjust internal consistency and construct validity and reliability of the questionnaire. The questionnaire included three parts: 1) socio demographic status of students, 2) information related to smoking (tobacco), 3) information related to depression. Smokers were defined as those who had tried or experimented with cigarette smoking, even a few puffs and who had smoked a cigarette in past thirty days. The 20-items self-report version of the Centre for Epidemiologic Studies Depression scale (CES-D) was used for the evaluation of depression status of the respondents.¹³⁾    The scores ranged from 0 to 60. The cutoff score for clinical depression in adult according to American Psychological Association (16 or greater) ¹³⁾ was adopted in this study.

Statistical analysis

Collected data was checked, rechecked, edited, coded and recoded for quality management. Percentage, mean, median, mode, range and standard deviation (SD) were calculated for descriptive purposes. A chi-square test was used to examine the significance of associations. A logistic regression model was applied for the estimation of odds ratio (OR) and 95% confidence interval (CI), using SPSS version 22 software package. Subgroup analysis was also done in gender and age subgroups for the associations between smoking and depression. Age was divided into two groups; 18- 23 year and above, and 24-26 years. P-value less than 0.05 was regarded to be significant

RESULTS

Table 1: Socio-demographic features of university students

*S.S.C= Secondary School Certificate, **H.S.C= Higher Secondary Certificate

*1 taka= 0.013 USD

The respondents were 18 to 26 years age group, with an average 23.19±1.73 years. Among all of the respondents, 311 were male and remaining 90 were female (Table 1). Mainly Muslims 78.8% and mostly living in nuclear family 75.1% consisting of at least 3 members, while 24.4% came from joint family with highest 27 members. 84.0% of the student’s monthly family income was above 20,000 takas. Most of the respondents’ fathers were well educated; 24.9% for those with higher secondary certificate and 51.6% for those graduated from a university. On the other hand, the corresponding education of their mothers were 25.4% and 28.7%, respectively.  Most of their fathers (55.6%) were doing business and 35.2 % were service holder. Most of their mothers (77.8%) were home makers. The study found that 77.3% of the respondents were depressed.

Table 2: Distribution of factors according to depression status among the university students

Table 2 shows distribution of the factors according to depression status among the university students. Among the depressed students, 49.0% were at the age between 21 year and 23 year. The majority of the respondents (75.8%) studied in bachelor degree. Although 78.1% of the depressed students were smoker, the association between depression and smoking was not significant (p=0.669). The study showed that 39.4% of the parents were smokers. History of community stress had 54.0% of depressed respondents. Among depressed respondents, 69.0% respondents lived together with family members who were regular smokers. It found that 61.9% respondents experienced stressful life event in last year among depressed respondents. Best friends smoking status also was found high and it accounted for 67.7% and the smoking habit of majority of the respondents (78.8%) were influenced by their friend, followed by watching others to smoke (15.2%), and their family member (6.0%).

Table 3: Odds ratio (OR) and 95% confidence interval (CI) of depression for significant factors as well as smoking starting age (N=401)

Table 3 shows ORs and 95% CIs of smoking and significant factors for depression. The students whose father was alive were 3.15 times more likely to be depressed. The respondents who experienced stressful life event in last year were 3.24 times more likely to be depressed and 6.59 times more depressed those who faced violence at home.

Table 4: Odds ratio (OR) and 95% confidence interval (CI) of smoking for depression relative to non-smoking

* adjusted for age, sex, smoking status, residence, father alive, mother alive, monthly income, parent’s smoker, best friend smoker, violence in home, stressful life event, long physical illness, familial disharmony, broken family, step parents, victim violence, community stress, anyone smoke at home regularly, starting age of smoking.

Table 4 presents OR and 95% CI of depression for smoking relative to non-smoking among all subjects and subgroups of gender and age. All of the OR were not significant.

DISCUSSION

Our study findings did not reveal that the depression significantly predicted smoking onset and progression. However, it identified that depression became a remarkable problem among young generation. It also found that the associated factors for depression. Fathers alive, step parents, stressful life events and domestic violence were significantly associated with depression. It indicates that the respondents whose father’s alive were more depressed. It may be due to father who is the leader of the household has higher expectation for children and they may make their children stressful by urging to get higher grades. Step parents were brought sad and depression for them also. The respondents who experienced stressful life event in last year become more depressed. Violence at home was also the reason of depression. A study conducted in public schools of northern Virginia showed that current smoker students had the highest odds ratio for depression than former and nonsmokers.[14] A study of Bangladesh, which was conducted to find the socio-demographic factors related to smoking among rural adolescent, found that the depression was significantly associated with smoking, even after adjusting for socioeconomic and cultural factors.³⁾ The other four studies also revealed the evidence for a bi-directional relationship between adolescent depression and smoking.[14-17] Our study found that amongst all respondents, 77.6% were smokers and 39.4% of the respondent’s parents were smokers. A study done in Bangladesh, which showed that the starting time of smoking of children was associated with parent’s smoking.[18] This finding also consistent with another study that was conducted at rural Bangladesh.[19] Self- efficacy was identified as the single most significant predictor of smoking.[20] Amongst all the reasons for smoking, study conducted in Bangladesh determined that initiation of smoking due to peer pressure followed by curiosity, for relieving anxiety and tension, feeling of maturity, symbol of manliness, lower level of self-efficacy and unhappy family environment. [19] Several studies showed that smoking was significantly associated with age, sex, educational level, residence, religion, family size, occupation, parental literacy, parental and siblings smoking status. [19,21-26] Peer smoking is a crucial factor for starting smoking. Our study also found that 78.8% of the respondents were influenced about smoking by their friends. This finding is in line with a study conducted on tobacco consumption among the college students of University of Delhi, India in 2010. [27] Similar findings were found in another study, which revealed stronger association between smoking and friend’s smoking status. [28] To our knowledge, this was the first study to examine the association between cigarette smoking and depression among the university students in Bangladesh. As like as other studies, our study had some limitations which may have affected the quality of the study. It was a cross sectional study, so we cannot determine causality. The study place was selected purposively due to time limitation and it was an urban-based study. Therefore, the study findings do not reflect the situation of the whole country. Friend selection, parent’s supervision, environment of home, school, college and university all those play important role to stop smoking. We suggest establishing the universities with environment free of smoking and to start stress management program to reduce stress and relive the need of smoking. A chapter on smoking and its adverse effects on health should be added in current curriculum. Hospitals and social organization should participate to raise awareness among the people. Most of the students believe that they can stop smoking easily. [20,29] Stress and depression will also be reduced and the mood will be changed to normal state by discontinuing smoking because nicotine is a source of stress and depression. Cessation of smoking may be more challenging for those who experiencing psychiatric illness like schizophrenia or mania because smoking is more prevalent among those patients. [30-32] Therefore, the family, teachers and friends should not only encourage but also support the students to quit smoking. Smoking leads to a wide range of health hazards like lung cancer and COPD (chronic obstructive pulmonary disease). Although smoking trend declines a little, it is still difficult to reduce smoking more because of some culture and socio-economic factors. Raising taxation, bans on tobacco advertisement, promotion and sponsorship should also be enforced for prevention of smoking.

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