Psychosocial and socio-environmental factors associated with adolescents' tobacco and other substance use in Bangladesh.

BACKGROUND: Tobacco, alcohol, and marijuana are the top three substances used by adolescents. The adverse health effects of these three substances are well documented in epidemiological literature, yet little is known about the substance use and associated factors among adolescents in Bangladesh. This study examines the risk factors for tobacco and other substances use among school-going adolescents in Bangladesh.
METHODS: We analyzed data from the 2014 Bangladesh Global School-based Student Health Survey (GSHS) of adolescents aged 13-17 years. We used two outcome measures: tobacco use (TU) and other substance use (SU; alcohol and/or marijuana). We examined a set of reported psychosocial and socio-environmental adverse events as risk factors. Logistic regression analyses were used to identify associations.
RESULTS: The prevalence of TU and other SU among school-going adolescents was 9.6% and 2.3%, respectively. The likelihood of TU and other SU was higher among adolescents who reported being bullied (TU: adjusted odd ratio [AOR]: 1.93; 95% confidence interval [CI]: 1.24-3.00; and other SU: AOR: 3.43; 95% CI: 1.46-7.99) and having sexual history (TU: AOR: 19.38; 95% CI: 12.43-30.21; and other SU: AOR: 5.34; 95% CI: 2.17-13.29). Moreover, anxiety-related sleep loss was associated with adolescents' TU (AOR: 2.41; 95% CI: 1.02-5.82) whereas the likelihood of other SU (AOR: 3.27; 95% CI: 1.14-9.44) was higher among lonely adolescents. Experience of adverse socio-environmental factors, such as parental substance use (TU: AOR: 7.81; 95% CI: 5.08-12.01), poor monitoring (TU: AOR: 1.96; 95% CI: 1.16-3.31) and poor understanding (TU: AOR: 2.22; 95% CI: 1.36-3.65), and lack of peer support (TU: AOR: 3.13; 95% CI: 1.84-5.31; and other SU: AOR: 2.45; 95% CI: 1.02-5.91), and truancy (other SU: AOR: 4.29; 95% CI: 1.81-10.12) were also positively associated with TU and/or other SU. Additionally, higher odds of tobacco use were observed among adolescents who reported 1 (AOR: 4.36 times; 95% CI: 1.34-14.24), 2 (AOR: 8.69 95% CI: 1.67-28.23), and ≥3 (AOR: 17.46; 95% CI: 6.20-49.23) adverse psychosocial experiences than who did not report any psychosocial events.
CONCLUSIONS: Tobacco and other substance use among school-going adolescents are prevalent in Bangladesh. Several psychosocial and socio-environmental events are associated with TU and other SU, which should be incorporated into adolescent substance use and health promotion programs.

Introduction

Unhealthy behaviors, such as tobacco use, drinking alcohol, and the use of illicit drugs, particularly among adolescents, are crucial global public health issues [1]. Worldwide, around 7.6% of adolescents are found as current smokers (smoked in the past 30 days), and more than a quarter (26.5%, 155 million) are current drinkers [2]. Around 35% of the total population in Bangladesh use either smoked cigarettes or bidis or smokeless tobacco products (tobacco flakes known as Zarda, betel leaf quid or paan, and gul [3]. In Bangladesh, tobacco use contributes to approximately 1.6 million deaths every year (19% of all deaths) [4]. The 2013 Global Youth Tobacco Survey of Bangladesh reported that 6.9% of adolescents (9.2% males and 2.8% females) were tobacco users [5]. The prevalence of alcohol drinking across age groups is less than one percent (0.8%; men 1.5% and women 0.1%) [6]. A recent report documents that more than 7 million people suffer from drug addiction in Bangladesh, of whom 25% are below 15 years old [7]. Bangladesh is a route of illicit drug trafficking as its geographical location is in between the “golden triangle” (Myanmar, Thailand, and Laos) and “golden crescent” (Pakistan, Afghanistan, and Iran), which makes the drugs available to people in all segment of the society [7].

Tobacco and other substance (which includes alcohol and/or marijuana in this study) use in a key period of transition, such as adolescence, has been the cause of increasing concern. Adolescence might be a vulnerable time for the development of substance dependence [8]. Substance use cause problems at all age levels but appears to be more dangerous in adolescence [9], contributing nearly half of the morbidities among adolescents [10]. Substance use has adverse consequences on individuals, families, and communities, which contribute to negative physical and mental health as well as social problems [11]. Specifically, it is found to be a major contributing factor for non-communicable diseases, poor health, mental illness, suicidal behaviors, and decreased life expectancy [12, 13]. Therefore, understanding the underlying factors associated with tobacco and other substance use among adolescents is essential for developing prevention strategies and to attain the global sustainable goals (SDGs) related to reducing premature mortality from non-communicable diseases, and non-intentional deaths, and injuries [14].

Several risk and protective factors for substance use among adolescents and young adults have been identified around the globe. For example, previous studies have documented several individual and interpersonal risk factors for substance use among adolescents, such as abuse or neglect [15], stressful life events [15], poor family relations [15, 16], internalizing and externalizing behaviors [15, 17], adolescent employment [15], and lower educational attainment [18, 19]. Moreover, family relationships (eg., guidelines and monitoring) [15, 20], being married or in a stable relationship [15], are identified as protective factors for these unhealthy behaviors. Adolescents’ tobacco and other substance use are also highly associated with availability and access to drugs and alcohol [15, 21], peer smoking, peer norms and attitudes [15, 22], and school factors [23, 24]. There is a large body of literature that highlights psychosocial factors such as loneliness, stress, depression, anxiety, hyperactivity/inattention, and low self-esteem as risk factors for substance use. For example, Page et. al. [25] reported in a four country study (Philippines, China, Chile, and Namibia) that among adolescents often feeling lonely, worried, sad/hopeless, or having a suicide plan were associated with current smoking and drinking alcohol. Findings from a longitudinal study in Australia suggest that psychosocial risk factors, such as truancy, hyperactivity/inattention, and behavior problems are associated with adolescent binge drinking and cannabis use [26]. A recent review concludes that psychosocial risk factors of adolescent substance use are closely related to peer influence, and that parents tend to have the strongest effect on adolescents’ substance use behavior [27].

Only a few studies in Bangladesh focused to identify the factors associated with adolescents’ tobacco use. For example, Kabir et al. [28] reported that friends’ tobacco use, receiving pocket money, receiving free tobacco products from vendors, and exposure to advertisements and promotions of tobacco products increase the likelihood of adolescents’ tobacco use. These findings are also supported by a study among adolescent in South-Asian countries [29]. Furthermore, smoking by teachers and peer influence strongly associated with smoking among secondary school going adolescents [30]. Ullah et al. [31] documented that perceived knowledge on severity of tobacco use and barrier of using tobacco are protective for adolescents’ smokeless tobacco use. However, all these studies are either limited to only tobacco (smoke or smokeless) use or used rural samples only. Moreover, none of these studies have taken into account psychosocial factors (such as loneliness, bullying victimization, etc.) as the factors associated with adolescents’ tobacco, alcohol or marijuana use. Therefore, how psychosocial factors, which are found to be risk factors in some global studies [25-27], are associated with tobacco and other substance use among adolescents in Bangladesh is unknown. To address this knowledge gap using nationally representative data, this study estimates the prevalence and factors associated with tobacco and other substance use (alcohol and/or marijuana) among school-going adolescents in Bangladesh, with a particular focus on adverse psychosocial and socio-environmental factors. A growing number of studies document a graded relationship between adverse life circumstances and negative health outcomes, including health risk behaviors, such as substance use [32, 33]. Therefore, we also examine to what extent multiple adverse experiences (MAE) affect tobacco and other substance use behaviors among the adolescent population. Identifying these relationships will be crucial for developing effective anti-substance use programs in Bangladesh.

Data and methods

Sample design

Data for current analyses were extracted from the most recent Global School-based Student Health Survey (GSHS) of Bangladesh, 2014. The GSHS is a population-based survey of school-going adolescents around the world, which is conducted by the World Health Organization (WHO) in collaboration with the Center for Disease Control and Prevention (CDC). The GSHS collects information regarding different aspects of adolescent health and behaviors with the aim to help countries in developing appropriate school and adolescent health policies and programs as well as facilitating comparison of collected information across countries. The GSHS used a clustered sampling technique via a standardized scientific sample selection process with a conventional school-based methodology. The 2014 Bangladesh GSHS is a cross-sectional survey of a two-stage stratified cluster sampling design, conducted among students in grades 7, 8, 9, and 10. At the first stage, schools were selected based on a probability proportional to size sampling, and at the second stage, grade levels within each of those schools were selected randomly, and all students in selected classes were included in the sampling frame. Participants completed a self-administered questionnaire and recorded their responses on a computer scannable answer sheet. Participants were only allowed to use pencils that were provided to them to answer the questions. The questionnaire consisted of 80 core, expanded and country specific questions. The survey used the Bengali version of the questionnaire [34] A total of 3,180 eligible students were selected to participate; 2,989 (94%) of these students were interviewed. This study was approved by the Ministry of Health and Family Welfare and the Ministry of Education in Dhaka, Bangladesh. To ensure voluntary participation, privacy, and confidentiality, informed consent was obtained from the students, parents and/or school officials [35]. Further details of the GSHS sampling and data are available at:

https://extranet.who.int/ncdsmicrodata/index.php/catalog/485 and https://www.cdc.gov/gshs/countries/seasian/bangladesh.htm

Outcomes

Adolescents’ tobacco use (smoking cigarette and/or using other tobacco products) and other substance use (drinking alcohol and/or using marijuana) were the two primary outcomes of interest. Tobacco use (TU) was assessed by adding the response of two items: “During the past 30 days, on how many days did you smoke cigarettes?” and “During the past 30 days, on how many days did you use any tobacco products other than cigarette, such as biri, jarda, tobacco leaf, gul, or shisha?” For either item, those who responded using it for one or more days were considered to be tobacco users and coded 1, and coded 0 if they responded zero days to both the items. Other substance use (SU) was assessed combining the use of two illegal substances- alcohol and marijuana [36]. Alcohol and marijuana use were measured based on the response to the items: “During the past 30 days, on how many days did you have at least one drink containing alcohol?” and “During the past 30 days, how many times have you used marijuana (also called ganja or weed)?” Adding up the responses of these two items, other SU was recoded as: 0 = never use alcohol and/or marijuana; and 1 = drink alcohol and/or use marijuana at least one day.

Explanatory variables

Based on reviewing prior literature [37, 38], a set of socio-demographic, psychosocial, and socio-environmental factors were used as explanatory variables in this study to examine how they are associated with adolescents’ tobacco and other substance use. Categories and coding of these explanatory variables are presented in Table 1.

Table 1

The complete list of independent variables.

Variables	Survey question	Coding
Socio-demographic factors
Age	How old are you?	11–18 years (coded categorically)
Gender	What is your sex?	1 = Male
		2 = female
Food insecurity (Proxy of socioeconomic status)	How often did you go hungry because of there was not enough food in your home?	0, No = Never/rarely/sometimes
		1, Yes = Most of the time/always
Psychosocial factors
Loneliness	How often have you felt lonely?	0, No = Never/rarely/sometimes
Anxiety	How often have you been so worried about something that you could not sleep?	1, Yes = Most of the time/always
Bullied	How many days you were bullied?	0, No = Never
		1, Yes = One or more days
No close friends	How many close friends do you have?	0, No = Have at least one close friend
		1, Yes = No close friends
Physically abused	How often you were physically attacked?	0, No
		1, Yes = One or more times
Sexual history	Have you ever had sexual intercourse?	0 = No
		1 = Yes
Socio-environmental factors
People use tobacco in presence of adolescents	Do people smoke in your presence?	0, No
Parental tobacco use	Do any of your parents or guardians use any forms of tobacco?	1, Yes
Parents rarely check homework	How often did your parents check to see if your homework was done?	0, No = Most of the time/always
Poor understanding with parents	How often did your parents or guardians understand your problems and worries?	1, Yes = Never/rarely/sometimes
Poor parental monitoring	How often your parents or guardians really know about what you were doing with your free time?
Lack of peer support	During the past 30 days, how often were most of the students in your school kind and helpful?	0, No = Most of the time/always
		1, Yes = Never/rarely/sometimes
Truancy	During the past 30 days, on how many days did you miss classes of school without permission?	0 = 0 days
		1 = 1 or more days

Calculation of multiple adverse experience (MAE) scores

We followed the Kaiser Permanente Childhood Adverse Experience (ACE) study to calculate the multiple adverse experience (MAE) score [39]. We divided adolescents’ adverse experiences into two categories: psychosocial and socio-environmental factors. Details of these two categories are presented in Table 1. The MAE score for each adverse category was calculated by summing up the responses on the adverse experience questions. For each adverse experience, the response 0 meant the participant never or rarely experienced the adversity, while 1 meant the participant always or sometimes experienced that specific adversity. Higher MAE meant greater experience of adverse events. As for example, if an individual has experienced three adverse events, then the MAE score is 3.

Statistical analysis

Data of this study were analyzed using STATA 14.0 SE (StataCorp. LP, College Station, TX, USA). The prevalence of tobacco and other substance use were assessed for total sample and by subgroups. Chi-squared tests were used to assess bivariate comparisons. Assessment of the extent to which various adverse psychosocial and social-environmental factors are associated with adolescents' tobacco and other substance use were carried out using a logistic regression approach. We estimated both unadjusted and adjusted odds ratios and their 95% confidence intervals were calculated. In all statistical analyses, we set α = 0.05. Imputation using a logistic regression model was used to estimate missing values from known values to account for missing data, most frequently for sexual history (i.e., for 11.6% of respondents) [40]. Age, gender, and school grade were included as covariates in the imputation. Multicollinearity of the variables was checked using variance inflation factor (VIF), and in all cases, the values of VIF were found less than 2, indicating multicollinearity was not an issue. In all analyses, the complex survey design and sampling weights were considered.

Results

Table 2 presents the sample characteristics and the prevalence of TU and other SU by selected characteristics. Majority of the students were male (65.3%), and 14.3% of respondents had food insecurity at home (a proxy of socioeconomic status). Among psychosocial factors, 10.9% of adolescents reported being lonely, 24.5% reported being bullied, and 9.3% of adolescents reported having sexual history. In addition, among socio-environmental factors, more than two-third (70.3%) of adolescents’ parents used tobacco or drug, more than half of the adolescents had poor understanding with their parents (52.4%), and had poor parental monitoring (56.7%). Nearly one in three adolescents reported truancy (30.9%), and 44% reported lack of peer support at school (Table 2).

Table 2

Prevalence of tobacco and other substance use according to different socio-demographics and adolescent’s adverse experiences in Bangladesh: Global School-Based Health Survey (GSHS), 2014.

Characteristics	Total (N = 2989) n (%)*	Tobacco use % (95% CI)	P-value (χ2-test)	Substance use % (95% CI)	P-value (χ2-test)
Total		9.6 (6.3–14.3)		2.3 (1.2–4.3)
Age			0.001		0.265
11–12	104 (2.6)	3.0 (0.5–16.4)		2.9 (0.4–15.9)
13	612 (25.1)	4.2 (2.2–7.8)		3.1 (1.1–8.3)
14	1093 (38.0)	6.6 (4.5–9.5)		2.2 (1.1–4.4)
15	952 (25.9))	16.6 (8.7–29.2)		0.7 (0.3–2.0)
16–18	221 (8.5)	16.0 (8.1–29.3)		4.1 (1.1–14.4)
School grade			0.032		0.580
Class VII	859 (31.2)	4.3 (2.1–8.8)		2.9 (1.1–7.7)
Class VIII	328 (25.8)	5.0 (2.7–9.0)		2.6 (1.0–6.7)
Class IX	1478 (21.8)	14.9 (9.1–23.6)		0.7 (0.3–1.7)
Class X	305 (21.3)	16.1 (5.8–37.5)		2.3 (0.4–12.9)
Gender			<0.001		0.013
Male	1192 (65.3)	13.4 (8.1–21.3)		3.2 (1.5–6.3)
Female	1788 (34.7)	1.9 (1.1–3.4)		0.5 (0.2–1.5)
Food insecuritya			0.439		0.654
No	2488 (85.7)	9.7 (6.3–14.5)		2.2 (1.1–4.1)
Yes	426 (14.3)	10.9 (5.2–21.2)		1.9 (0.6–5.9)
Psychosocial factors
Lonelinessb			0.009		<0.001
No	2695 (89.1)	8.4 (4.9–14.1)		1.4 (0.6–2.9)
Yes	281 (10.9)	16.7 (9.9–26.8)		9.1 (4.4–17.4)
Anxiety-related sleep lossb			0.012		<0.001
No	2840 (95.3)	8.9 (5.5–13.9)		1.6 (0.9–3.0)
Yes	138 (4.7)	20.5 (11.7–33.3)		14.3 (6.0–30.3)
Bullieda			0.014		0.001
No	2367 (75.5)	6.4 (4.2–9.9)		0.9 (0.5–1.8)
Yes	608 (24.5)	18.4 (8.6–35.1)		6.3 (2.9–12.8)
No close friends			0.098		0.899
No	2701 (91.5)	9.7 (6.2–14.8)		2.3 (1.2–4.3)
Yes	256 (8.5)	5.4 (2.3–11.9)		2.2 (0.4–9.6)
Sexual history			<0.001		<0.001
No	2425 (90.1)	5.7 (2.8–11.3)		1.2 (0.6–2.2)
Yes	218 (9.3)	47.2 (31.1–64.0)		12.6 (4.9–28.7)
Physically abusedb			0.631		0.089
No	1298 (36.5)	10.5 (6.0–17.8)		1.2 (0.5–2.5)
Yes	1654 (63.6)	8.9 (4.9–15.4)		2.9 (1.3–5.9)
No. of adverse psychosocial factors			0.024		0.001
0	828 (25.6)	1.1 (0.3–3.7)		0.9 (0.3–2.3)
1	1077 (44.3)	8.8 (4.8–15.6)		0.1 (0.03–06)
2	492 (21.6)	16.4 (5.7–38.8)		2.3 (0.9–5.9)
≥3	176 (8.5)	19.3 (10.9–32.1)		14.7 (7.4–27.2)
Socio-environmental factors
People use tobacco in presence of adolescents			0.659		0.766
No	1973 (68.8)	9.2 (6.2–13.5)		2.3 (1.0–4.9)
Yes	946 (31.2)	10.5 (5.0–20.6)		2.6 (1.3–5.1)
Parental tobacco or drug use			<0.001		0.001
No	2177 (70.3)	3.3 (2.0–5.4)		1.2 (0.5–2.6)
Yes	784 (29.7)	23.4 (14.5–35.4)		4.8 (2.5–8.8)
Poor understanding with parentsa			0.003		0.788
No	1430 (47.6)	4.5 (2.4–8.5)		2.3 (1.1–4.6)
Yes	1441 (52.4)	14.1 (8.6–22.4)		2.2 (1.1–4.3)
Poor parental monitoringa			0.003		0.524
No	1342 (43.4)	4.5 (2.6–7.7)		2.0 (0.8–4.6)
Yes	1521 (56.7)	13.3 (7.9–21.5)		2.4 (1.3–4.6)
Lack of peer supporta			0.169		0.001
No	1784 (56.0)	8.5 (5.1–13.8)		1.6 (0.8–2.9)
Yes	1062 (44.0)	13.4 (7.1–23.9)		6.0 (2.8–12.3)
Truancya			0.029		<0.001
No	1856 (69.1)	6.7 (3.3–13.2)		0.8 (0.4–1.6)
Yes	1026 (30.9)	15.9 (9.9–24.2)		5.5 (2.6–11.3)
No. of adverse socio-environmental factors			<0.001		0.001
0	356 (10.2)	0.7 (0.1–2.9)		1.4 (0.2–6.2)
1	609 (21.7)	2.9 (1.3–6.6)		1.4 (0.7–2.7)
2	662 (28.2)	4.7 (2.4–9.2)		0.5 (0.1–2.3)
≥3	1097 (39.8)	18.9 (11.2–30.1)		4.4 (2.2–8.8)

‘Note:

*Numbers are unweighted and percentages are weighted. Percentages may not total 100.0 because of rounding.

aIn the past 12 months

bin the past 30 days.

The prevalence of TU and other SU among this sample was 9.6% and 2.3%, respectively. The prevalence of TU and other SU were significantly higher among adolescents who reported loneliness (TU: 16.7%; 95% CI [9.9–26.8] vs. 8.4%; 95% CI [4.9–14.1]; P = 0.009; and other SU: 9.1%; 95% CI [4.4–17.4] vs. 1.4%; 95% CI [0.6–2.9]; P<0.001), anxiety-related sleep loss (TU: 20.5%; 95% CI [11.7–33.3] vs. 8.9%; 95% CI [5.5–13.9]; P = 0.012; and other SU: 14.3%; 95% CI [6.0–30.3] vs. 1.6%; 95% CI [0.9–3.0]; P<0.001), being bullied (TU: 18.4%; 95% CI [8.6–35.1] vs. 6.4%; 95% CI [4.2–9.9]; P = 0.014; and other SU: 6.3%; 95% CI [2.9–12.8] vs. 0.9%; 95% CI [0.5–1.8]; P = 0.001) and having sexual history (TU: 47.2%; 95% CI [31.1–64.1] vs. 5.7%; 95% CI [2.8–11.3]; P<0.001; and other SU: 12.6%; 95% CI [4.9–28.7] vs. 1.2%; 95% CI [0.5–2.5]; P<0.001) than their respective counterparts. Similarly, the prevalence of TU (19.3%; 95% CI [10.9–32.1] vs. 1.1%; 95% CI [0.3–3.7]; P = 0.024) and other SU (14.7%; 95% CI [7.4–27.2] vs. 0.9%; 95% CI [0.3–2.3]; P<0.001) was significantly higher among adolescents who experienced ≥3 adverse psychosocial factors than those who did not experience any such factors. Again, higher prevalence of TU and other SU were also observed among adolescents who reported their parents’ use of tobacco or drug (TU: 23.4%; 95% CI [14.5–35.4] vs. 3.3%; 95% CI [2.0–5.4]; P<0.001; and other SU: 4.8%; 95% CI [2.5–8.8] vs. 1.2%; 95% CI [0.5–2.6]; P = 0.001), lack of peer support (TU: 13.4%; 95% CI [7.1–23.9] vs. 8.5%; 95% CI [5.1–13.8]; P = 0.169; and other SU: 6.0%; 95% CI [2.8–12.3] vs. 1.6%; 95% CI [0.8–2.9]; P0.001); and being truant (TU: 15.9%; 95% CI [9.9–24.2] vs. 6.7%; 95% CI [3.3–13.2]; P = 0.029; and other SU: 5.5%; 95% CI [2.6–11.3] vs. 0.8%; 95% CI [0.4–1.6]; P<0.001). The prevalence of TU was higher among adolescents who experienced ≥3 adverse socio-environmental adversities than those who didn’t experience any such adversities. Prevalence of tobacco and other substance use among adolescents by gender is displayed in Fig 1. The proportions of using tobacco and other substances were higher among boys than girls (Fig 1).

Fig 1

Prevalence of tobacco and other substance use among adolescents by gender, the 2014 Global School-based Student Health Survey (GSHS), Bangladesh.

Table 3 presents the factors associated with tobacco and substance use. Results showed that females were significantly less likely to TU (Adjusted odds ratio [AOR]: 0.21; 95% confidence interval [CI]: 0.13–0.34) and other SU (AOR: 0.42; 95% CI: 0.25–0.70), compared to males. The likelihood of TU and other SU was higher among adolescents who reported being bullied (TU: AOR: 1.93; 95% CI: 1.24–3.00; and other SU: AOR: 3.43; 95% CI: 1.46–7.99) and having sexual history (TU: AOR: 19.38; 95% CI: 12.43–30.21; and other SU: AOR: 5.34; 95% CI: 2.17–13.29). Moreover, anxiety-related sleep loss was significantly associated with adolescents’ TU behavior (AOR: 2.41; 95% CI: 1.02–5.82) whereas the likelihood of other SU (AOR: 3.27; 95% CI: 1.14–9.44) was higher among adolescents reporting loneliness. Among adverse socio-environmental factors, parental tobacco or drug use (AOR: 7.81; 95% CI: 5.08–12.01), poor understanding with parents (AOR: 2.22; 95% CI: 1.36–3.65), poor parental monitoring (AOR: 1.96; 95% CI: 1.16–3.31), and lack of peer support (AOR: 3.13; 95% CI: 1.84–5.31) were significatly associated with higher likelihood of adolescents’ tobacco use. However, adolescents with lack of peer support (AOR: 2.45; 95% CI: 1.02–5.91) and higher truancy (AOR: 4.29; 95% CI: 1.81–10.12) were more likely to use other substances (Table 3).

Table 3

Results of the logistic regression analyses of the relationship between socio-demographics and adolescent’s adverse experiences, and tobacco and other substance use in Bangladesh: Global School-Based Health Survey (GSHS), 2014.

Risk factors	Tobacco use	Other substance use
	AOR (95% CI)a	AOR (95% CI)a
Age
11–12 years(RC)	1.00	1.00
13 years	6.03 (1.49–25.36) *	2.91 (0.59–14.36)
14 years	2.91 (0.63–12.59)	1.04 (0.18–5.87)
15 years	3.82 (0.79–18.50)	0.97 (0.15–6.57)
16–18 years	3.25 (0.64–16.49)	1.81 (0.26–12.76)
School grade
Class 7(RC)	1.00	1.00
Class 8	1.72 (0.59–4.99)	1.15 (0.41–3.28)
Class 9	3.09 (1.17–8.12) *	0.34 (0.13–0.93)
Class 10	5.00 (1.75–14.28) **	0.73 (0.17–3.14)
Gender
Male(RC)	1.00	1.00
Female	0.21 (0.13–0.34) ***	0.42 (0.25–0.70) ***
Food insecurity
No(RC)	1.00	1.00
Yes	0.72 (0.43–1.21)	0.92 (0.33–2.55)
Adverse Psychosocial Factors
Loneliness
No(RC)	1.00	1.00
Yes	1.51 (0.77–2.96)	3.27 (1.14–9.44) *
Anxiety
No(RC)	1.00	1.00
Yes	2.41 (1.02–5.82) *	2.61 (0.77–8.85)
Bullied
No(RC)	1.00	1.00
Yes	1.93 (1.24–3.00) **	3.43 (1.46–7.99) **
No close friends
No(RC)	1.00	1.00
Yes	0.47 (0.18–1.22)	0.34 (0.05–2.11)
Sexual history
No(RC)	1.00	1.00
Yes	19.38 (12.43–30.21) ***	5.34 (2.17–13.29) ***
Physically abused
No(RC)	1.00	1.00
Yes	0.80 (0.52–1.23)	1.76 (0.63–4.87)
Adverse Socio-Environmental Factors
People use tobacco in presence of adolescents
No(RC)	1.00	1.00
Yes	0.88 (0.59–1.28)	1.28 (0.59–2.79)
Parental tobacco or drug use
No(RC)	1.00	1.00
Yes	7.81 (5.08–12.01) ***	1.62 (0.72–3.63)
Poor understanding with parents
No(RC)	1.00	1.00
Yes	2.22 (1.36–3.65) **	1.05 (0.43–2.53)
Poor parental monitoring
No(RC)	1.00	1.00
Yes	1.96 (1.16–3.31) **	0.81 (0.35–1.88)
Lack of peer support
No(RC)	1.00	1.00
Yes	3.13 (1.84–5.31) ***	2.45 (1.02–5.91) *
Truancy
No(RC)	1.00	1.00
Yes	1.08 (0.70–1.65)	4.29 (1.81–10.12) **

Note:

aModel was adjusted for all the variables included in this table. Values with superscript asterisks *, **, and *** indicate p<0.05, p<0.01, and p<0.001, respectively. (RC): Reference category, AOR: adjusted odds ratio, CI: confidence interval.

Experience of increased number of adverse psychosocial adversities was found to be associated with greater tobacco use in a graded manner (Table 4). After adjusting for age, gender, grade and food insecurity, higher odds of tobacco use were observed among adolescents who reported 1 (AOR: 4.36 times; 95% CI: 1.34–14.24), 2 (AOR: 8.69 95% CI: 1.67–28.23), and ≥3 (AOR: 17.46; 95% CI: 6.20–49.23) adverse psychosocial experiences than who did not report any psychosocial events. Additionally, adolescents who experienced 2 and ≥3 adverse socio-environmental events were 5.94 times and 27.85 times, respectively, more likely to report using tobacco. The likelihood of other substance use was found to be higher among adolescents who experienced ≥3 (AOR: 13.71, 95% CI: 3.19–58.93) adverse psychosocial events. However, multiple adverse socio-environmental experience was not found to be associated with adolescents’ other substance use.

Table 4

Association between multiple adverse experiences and adolescents’ tobacco and other substance use in Bangladesh, 2014.

Multiple Adverse Experiences	Tobacco use	Other substance use
	AOR (95% CI) a	AOR (95% CI) a
No. of adverse psychosocial factors
0(RC)	1.00	1.00
1	4.36 (1.34–14.24) **	0.13 (0.18–1.00)
2	8.69 (1.67–28.23) ***	2.26 (0.54–9.44)
≥3	17.46 (6.20–49.23) ***	13.71 (3.19–58.93) **
No. of adverse socio-environmental factors
0(RC)	1.00	1.00
1	4.42 (0.77–25.38)	0.92 (0.14–6.05)
2	5.94 (1.14–31.06) *	0.08 (0.01–1.00)
≥3	27.85 (5.77–134.52) ***	3.34 (0.49–22.73)

Note:

aModel was adjusted for age, gender, school grade and food insecurity. Values with superscript asterisks *, **, and *** indicate p<0.05, p<0.01, and p<0.001, respectively. (RC): Reference category, AOR: adjusted odds ratio, CI: confidence interval.

Discussion

In this study, using a nationally representative data, we estimate the prevalence and factors associated, psychosocial and socio-environmental factors particularly, with tobacco and other illegal substances use among school-going adolescents in Bangladesh. Our findings showed that 9.6% adolescents use any form of tobacco (smoke cigarette or use other tobacco products), and 2.3% use any other substance (alcohol and/or marijuana). The prevalence of tobacco use found in this study is consistent with the findings from earlier studies in Bangladesh [5, 28–30]. Although there is no study that estimated the prevalence of other substance use in Bangladesh, the prevalence reported in this study is much lower than that of other Asian [25, 41] and African countries [42, 43]. This difference could be due to underreporting that could be explained by two factors: strong social stigma and legal prohibition of alcohol use and other illicit drug use in Bangladesh [44]. Moreover, Bangladesh is a predominantly Muslim country, and Islam provides clear ruling against using any intoxicants [45]. Nonetheless, the findings of this study represent a matter of great concern because adolescent tobacco use control is critical to the control of overall tobacco use in the country. Moreover, starting tobacco use at adolescence provides some insights into the potential developmental sequence of various drug dependence. For example, smoking or drinking alcohol precedes the use of marijuana, which in turn precedes the use of other illicit substances, such as cocaine or heroin [46]. Therefore, these findings highlight the importance of early prevention and intervention strategies.

This study identified several socio-demographic, psychosocial, and socio-environmental risk factors that are associated with adolescents’ tobacco and other substance use in Bangladesh. Consistent to a prior study in Bangladesh [30], and other studies across the world [47, 48], this study found that male adolescents are more likely to use tobacco or other substances than female adolescents. One of the reasons could be gender norms and that male adolescents are less monitored or supervised than females. Earlier studies documented that boys are generally less monitored by parents than girls [49], and low parental monitoring and supervision are associated with higher tobacco and alcohol use among adolescents [15, 20]. However, some studies in Bangladeshi did not find any significant relationship between gender and tobacco use in adolescence [28, 29]. More research in gender differences in tobacco use is needed to clarify the inconsistence in findings.

Consistent with earlier studies [25, 50], this study observed an increased likelihood of substance use (alcohol or marijuana) among lonely adolescents. Adolescents who are isolated from peers may exhibit greater anti-social behaviors and deviance than socially connected adolescents [51], which, in turn, can manifest in increased substance use [52]. We also found that anxiety-related sleep loss was associated with adolescents’ higher tobacco use, which is supported by earlier studies [53, 54]. Perhaps, adolescents with persistent sleep loss due to anxiety or stress may smoke or use other tobacco products to self-medicate with mild stimulant effect of nicotine to improve their mood [55].

Bullying victimization was found to be significantly associated with both tobacco use and other substance use in this study. The possible reasons could be bullying victimization may cause severe anxiety and depression [56]. To reduce the anxiety or to increase their social image among their peers, victims may use tobacco or other substances [57]. Victimized adolescents may also use tobacco, alcohol, or marijuana to alleviate the isolation, helplessness, and low self-esteem associated with victimization [58]. Sexual history was also found to be strongly associated with tobacco and other substance use among adolescents. Engaging in sexual activity in early adolescence has been seen as a problem behavior, because those adolescents often face challenges in many areas of life [59]. Particularly, problem arises when sexual activity took place prematurely. Certain emotional maturity might be lacking among young adolescents that increases their risks of engaging in unsafe sexual contacts [60]. Sexual activity in these periods can make adolescents vulnerable to developing mental disorder like depression or anxiety [61, 62], which, in turn, could lead them to use tobacco or other substances [63, 64].

We found that several socio-environmental factors are likely to be associated with adolescents’ unhealthy behaviors. For instance, we found that parental tobacco or drug use is a risk factor for offspring tobacco and other substance use, which is in parallel with prior studies across the world [33, 65–67]. Possible explanations could be normalization of smoking in the home environment and easy access to these substances at home [66, 67]. We also found that truancy is positively associated with adolescents’ substance use. Substance use is expected to be higher among truant adolescents than their counterparts because truant adolescents may have more unsupervised time, less parental monitoring, and spend more time with deviant peers [68], all of which could lead to problem behaviors.

We found adolescents’ experience of adverse events, both psychosocial and socio-environmental, to be associated with tobacco use in a graded manner. For example, the experience of one or more psychosocial events was associated with a stepwise elevation in the likelihood of adolescents’ tobacco use. This finding corroborates with a recent study which documented that every additional psychosocial risk factor was associated with an estimated 100% increase in the odds using tobacco [69]. These finding highlights the importance of considering the co-occurring risk factors associated with tobacco use. However, we did not find statistically significant association between experience of multiple adverse socio-environmental events and adolescents’ other substance use, which could be due to very few positive responses in the multiple adverse socio-environmental categories.

This study has several strengths. Firstly, we used a nationally representative large sample with appropriate statistical methods by taking into account complex survey design and sample weights. Secondly, the GSHS uses same standardized methods regarding the sample (school-based), data collection, and wording of questions across surveys, which enables international comparisons of the results. However, this study is not without limitations. First, because GSHS is a cross-sectional survey, directionality of the assessed relationship cannot be ascertained. Second, since adolescents were asked to report tobacco, alcohol and marijuana use within the past 30 days, the results are subject to recall bias. In addition, Bangladesh is a Muslim country where alcohol consumption and marijuana use are illegal; therefore, an underestimate of the prevalence of these substances is possible due to social desirability bias [70]. Moreover, adolescent tobacco, alcohol or marijuana use may be underreported, because the GSHS was restricted to adolescents who attended school and were present on the day of the survey. Third, as we used secondary data, analyses were limited to the variables that were available. We were unable to include other relevant variables such as, availability, accessibility, and price of substances, etc. Finally, since the sample only included school-going adolescents, findings may not be generalizable to out-of-school adolescents.

Limitations notwithstanding, this study has the potential to inform the development and/or modification of prevention strategies. Teachers, parents or other school personnel could play important role in early identification of adolescents with these emotional and behavioral problems. However, they would require appropriate training (e.g. mental health training) and professional development opportunities to build their skills and self-efficacy to be able to recognize, and appropriately respond to the adolescents with these problems. Furthermore, the findings suggest the need for incorporating mental health education programs in school-curricula; and the importance of the family and social connections among these populations [71]. Findings of this study underscore the importance of parental awareness to help and support adolescents in problems. Finally, since parental smoking increases the likelihood of adolescent smoking, universal prevention approaches which combine tobacco cessation campaign through mass media, including school- and community-based programs could be effective [72].

Conclusions

This study, using a nationally representative data, estimates the prevalence and risk factors associated with tobacco and other substance use among school-going adolescents in Bangladesh. The findings of this study have important implications for public health professionals and practitioners who work on adolescent substance use programs. Several adverse psychosocial (loneliness, anxiety, bullying, and sexual history), and socio-environmental factors (parental tobacco use, lack of peer support, and poor parental monitoring) were found to be significantly associated with adolescents’ tobacco and other substance use. Although the relationships are naturally complex, some patterns are discernible. Further studies with longitudinal data are needed to determine the mechanisms, processes and directionality of these relationships.

13 Aug 2020

PONE-D-20-18742

Psychosocial and socio-environmental factors associated with adolescents’ tobacco and substance use in Bangladesh

PLOS ONE

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Reviewer #2: Partly

**********

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Reviewer #2: I Don't Know

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Reviewer #1: This is a study using on the psychosocial and socio-environmental factors associated with tobacco use and substance use (combined alcohol and/or marijuana use). They find a dose-response relationship between adverse psychosocial factors and tobacco use. The likelihood of substance use (alcohol and/or marijuana) was higher among adolescents who experienced 3+ adverse psychosocial events. Tobacco and substance use in an adjusted logistic analysis, those who were bullied, and had ‘adverse sexual history’ whatever that means. Substance use is associated was associated with loneliness, lack of peer support and higher. Tobacco use was associated with anxiety-related sleep loss parental tobacco or drug use, poor parental understanding, poor parental monitoring and lack of peer support.

This study is an important update of data from 2014 to the previously published papers on adolescent tobacco and substance use using the 2007 data from the Global School-based Student Health Survey for Bangladesh.

1. You must say where the publicly available database is located and how to access it

2. CDC is Centers for Disease Control and Prevention

3. Explain what you mean by adverse sexual history. If it means yes = have had sex, no = have not had sex, then you should call the variable sexual history or something less loaded than adverse sexual history. I see that you do that in Table 1. Call the variable sexual history or some other less loaded term throughout the text

4. Line 247: male adolescents are less monitored or supervised.

5. Table 3: Physical abused should be physically abused

6. Explain why you decided to lump together alcohol and marijuana use into substance use. For a general reader from a non-Muslim majority country, this may seem strange

7. Table 2: the subscripts that you give to the table – a) in past 12 months, b) in past 30 days – are never used in Table 2.

Reviewer #2: Psychosocial and socio-environmental factors associated with adolescents’ tobacco

and substance use in Bangladesh

Reviewer comments to authors

Overall, this is an important study that examines adolescent substance use and tobacco use, and underlying factors of such use among adolescents in Bangladesh. The manuscript would benefit from a more in-depth description of the problem and context. The manuscript is lacking several aspects of the literature, importantly, the gaps that the study data fill and how the approach in this study will help future research, policy and practice. Since the data are from 2014, the authors may need to justify why they sought to study prevalence when more recent data have already been published from 2017-18. Several aspects of the methods could include greater detail and justification. The study would also do well to include more details in the Discussion based on comparisons with other low-and middle-income countries or other similar socio-religious contexts. Specifically, the authors should modify their conclusion that this study provides information about predictors of tobacco and substance use as it is a cross-sectional study and not a longitudinal one.

Abstract

The authors may want to be consistent in saying use/ misuse/ abuse.

At the outset in the abstract, it is unclear as to how the authors’ have used a cross-sectional study design to ascertain predictors of tobacco and substance use. The description of results indicates that the authors have assessed associations/ relationships between such use (TU and SU) and factors. In multiple places the authors have stated that they determined predictors, which is not feasible using this study design.

Provide Odds Ratios for: “Experience of adverse socio-environmental factors, such as parental substance use, poor monitoring and understanding, and lack of peer support were also positively

associated with TU and/or SU.”

It is not clear what the authors mean by: “Additionally, multiple adverse psychosocial factors were associated with TU in a graded manner.”

It is not clear what the authors mean by: “Tobacco and substance use among school-going adolescents in Bangladesh are relatively prevalent.” Relative to what percentage, what age group, and where?

Why was “substance use” created as an outcome measure? Why did the authors not use any other validated measure on substance use? What forms of marijuana use were included?, since ‘drinking’ alcohol is specified, it would be good to maintain parallelism in the sentence.

Introduction

If it is known that 6.9% of adolescents are tobacco users, and 2% are alcohol users from 2017-2018 data, which is based on more recent data than the study under review, what is the justification for this study based on data from 2014? What is the gap that the current study fills in terms of assessing prevalence?

Suggestion to include a description of the types of tobacco use in Bangladesh, as there may be many diverse forms of use. Line 99 – “limited to only tobacco (smoke or smokeless)”

What makes the authors believe that the reasons for adolescents using tobacco in global studies differ from the reasons why adolescents use in Bangladesh?

Line 98-99 What is the reason why the authors want to include an urban sample on tobacco users? What proportion of Bangladesh is urban?

Line 100: What is the evidence that psychosocial factors are important? Perhaps the authors would like to define these factors, explain briefly how they are likely interlinked. In the paragraph on global studies (line 78-89) the authors mention many factors, but latel them interpersonal risk factors, protective factors, psychosocial distress, and so one is not sure what psychosocial factors entail exactly?

Line 106: MAE – Multiple adverse experiences – This construct is mentioned without any citation or background information. It seems like it is better suited as a measure rather than mentioned in passing at the end of the introduction.

Data and Methods

Line 119: What is the disadvantage of using a school-based sample? What is the proportion of adolescents in Bangladesh who do not go to school and are using tobacco?

How long was the self-administered questionnaire?

What steps were taken by the study team to manage adolescent distress while answering questions on Multiple adverse experiences?

Was student assent collected?

What language was the survey completed in and was it in the local language? Do participating adolescents understand and use the term marijuana colloquially?

In the creation of age-standardized weights, what specific marginal population proportions were used from the population and housing census, and why? Please provide this information in a supplemental table. Or is it just based on age?

See Line 160-164: Multiple imputation will not likely make the sample more representative. The citation does not match the text preceding it and it is indistinct why multiple imputation was used. It would also be useful to explain why “ever had sexual intercourse” was included in this context: “To ensure representativeness and to prevent misinterpretation or any form of biases in the analysis, the allocation of missing values was done through a multiple imputation method using a logistic regression model by taking into account the known values, most frequently for “ever had sexual intercourse” [34].”

The measures include no mention of MAE.

On what basis were the measures selected? And why are they appropriate in Bangladesh? The adverse events description and combination of measures in Table 1 appear a bit arbitrary and not evidence-based. Suggestion to add a justification and description of how these measures were categorized and used based on the literature.

Results

Line 175-176: Please clarify what is meant by “more than half of the adolescents had poor parental understanding?”

Line 179-189: Are these differences significant, if so please provide summary of test statistics (Confidence Intervals and p-values)?

Line 185 - factors than (those) who did not experience any (such factors).

Figure 1 does not show that boys are significantly more likely to use tobacco and substances. It only shows that the proportion of boys using tobacco is higher than girls, and only marginally so for substances.

How are the authors defining an adverse sexual history? The measures in Table 1 do not include this – it just asks, ‘Have you ever had sexual intercourse?’

Line 209: The use of dose-response relationship appears inappropriate in this context as there is no experiment underway. The analysis shows an additive negative effect of adverse experiences.

Line 210-211: Why were both age and grade adjusted for as confounders?

Tables 2 should provide sample N and counts in a column on unweighted data.

Line 220: This seems like a sentence more appropriate as an explanation in the Discussion section.

Discussion

Line 227-229: Reference 26-28 are much more dated than prevalence rates reported in the Introductory paragraph.

Line 233: remove extra space before period

Line 267-270: It may be useful to bring this point earlier in the paper, maybe as a footnote to Table 1.

Line 275- predictors is not an accurate description of this study’s findings

Line 280-289 and line 242-252: The idea of parental involvement/ monitoring and understanding is repetitive and may be combined effectively.

Study strengths and implications should be described in greater detail.

Please review: https://www.childwelfare.gov/topics/preventing/preventionmonth/resources/ace/

For other descriptions of adverse childhood events and categorization.

Line 314 – The authors themselves provide other prevalence estimates from Bangladesh, so it may seem prudent to avoid saying it is the first or even most recent?

It may be useful to discuss mental health promotion opportunities in light of psychosocial findings.

**********

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7 Sep 2020

September 8, 2020

Prof. Stanton A. Glantz

Academic Editor

PLOS ONE

Re: Manuscript Number PONE-D-20-18742

Dear Prof. Stanton A. Glantz,

Thank you very much for your kind consideration of our manuscript entitled, “Psychosocial and socio-environmental factors associated with adolescents’ tobacco and substance use in Bangladesh”. We have revised the manuscript according to the journal’s requirements, editor’s comments and to the comments by the reviewers. Their useful and productive comments helped us to improve the clarity and quality of the manuscript. Where we have changed the text, the corresponding sentences in the text have been highlighted with the track changes function. The page and line numbers referred to are those in the margins of our clean revised manuscript. Where textual changes are included in this response to reviewer, we have indented and italicized them, and removed references.

It is important to mention here that this study did not receive grant from any funding agency. Unfortunately, we provided the following statement while submitting the manuscript initially: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Since we did not receive any grant please fill-up the appropriate option for that.

We hope that the revisions are satisfactory in addressing the issues raised by the editor and the reviewers, and look forward to hearing your decision about this article.

Yours sincerely,

Md. Mosfequr Rahman, PhD

Department of Population Science and Human Resource Development

University of Rajshahi

Rajshahi-6205, Bangladesh.

E-mail: mosfeque@ru.ac.bd

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Response: The authors received no specific funding for this work.

Reviewer #1

This is a study using on the psychosocial and socio-environmental factors associated with tobacco use and substance use (combined alcohol and/or marijuana use). They find a dose-response relationship between adverse psychosocial factors and tobacco use. The likelihood of substance use (alcohol and/or marijuana) was higher among adolescents who experienced 3+ adverse psychosocial events. Tobacco and substance use in an adjusted logistic analysis, those who were bullied, and had ‘adverse sexual history’ whatever that means. Substance use is associated was associated with loneliness, lack of peer support and higher. Tobacco use was associated with anxiety-related sleep loss parental tobacco or drug use, poor parental understanding, poor parental monitoring and lack of peer support.

This study is an important update of data from 2014 to the previously published papers on adolescent tobacco and substance use using the 2007 data from the Global School-based Student Health Survey for Bangladesh.

Response: Thank you for your appreciations.

1. You must say where the publicly available database is located and how to access it

Response: Thank you very much. We have provided the following links in the text for the location of GSHS data (Page 7; Lines: 143-144).

A detailed description of the GSHS and data used in this study are available at: https://extranet.who.int/ncdsmicrodata/index.php/catalog/485 and https://www.cdc.gov/gshs/countries/seasian/bangladesh.htm

2. CDC is Centers for Disease Control and Prevention

Response: Yes, it is. We have corrected it in the manuscript.

3. Explain what you mean by adverse sexual history. If it means yes = have had sex, no = have not had sex, then you should call the variable sexual history or something less loaded than adverse sexual history. I see that you do that in Table 1. Call the variable sexual history or some other less loaded term throughout the text

Response: Thank you. We called this variable as “sexual history” and corrected accordingly throughout the text and tables.

4. Line 247: male adolescents are less monitored or supervised.

Response: We have revised it accordingly.

5. Table 3: Physical abused should be physically abused

Response: We have corrected it accordingly.

6. Explain why you decided to lump together alcohol and marijuana use into substance use. For a general reader from a non-Muslim majority country, this may seem strange

Response: Thank you very much. We have added alcohol and marijuana use together and named the variables as “substance use”, because both of these substances are illegal in Bangladesh. Smoking cigarette is not illegal but against the cultural norms and also unacceptable. We wanted to differentiate these two. The following sentence is added to the text for clarifying it (Page 8, Lines 153-154):

“Substance use (SU) was assessed combining the use of two illegal substances- alcohol and marijuana”

7. Table 2: the subscripts that you give to the table – a) in past 12 months, b) in past 30 days – are never used in Table 2.

Response: Thank you. We are sorry for such unintentional mistakes. We have corrected it in Table 2.

Reviewer #2

Overall, this is an important study that examines adolescent substance use and tobacco use, and underlying factors of such use among adolescents in Bangladesh. The manuscript would benefit from a more in-depth description of the problem and context. The manuscript is lacking several aspects of the literature, importantly, the gaps that the study data fill and how the approach in this study will help future research, policy and practice. Since the data are from 2014, the authors may need to justify why they sought to study prevalence when more recent data have already been published from 2017-18. Several aspects of the methods could include greater detail and justification. The study would also do well to include more details in the Discussion based on comparisons with other low-and middle-income countries or other similar socio-religious contexts. Specifically, the authors should modify their conclusion that this study provides information about predictors of tobacco and substance use as it is a cross-sectional study and not a longitudinal one.

Response: Thank you very much. We have addressed the issues one by one in the following sections.

Abstract

The authors may want to be consistent in saying use/ misuse/ abuse.

Response: Thank you very much. We have used ‘use’ consistently in the abstract and text, and corrected accordingly.

At the outset in the abstract, it is unclear as to how the authors’ have used a cross-sectional study design to ascertain predictors of tobacco and substance use. The description of results indicates that the authors have assessed associations/ relationships between such use (TU and SU) and factors. In multiple places the authors have stated that they determined predictors, which is not feasible using this study design.

Response: Thank you. Yes, predictors should not be used in cross-sectional study design. We have corrected it throughout the manuscript where we use predictors.

Provide Odds Ratios for: “Experience of adverse socio-environmental factors, such as parental substance use, poor monitoring and understanding, and lack of peer support were also positively associated with TU and/or SU.”

Response: We have provided odds ratios in abstract in our revised manuscript.

It is not clear what the authors mean by: “Additionally, multiple adverse psychosocial factors were associated with TU in a graded manner.”

Response: While we examined the relationship between adolescents’ multiple adverse experiences with TU and SU, we observed a graded relationship between psychosocial factors and TU. This means that the odds of TU are gradually increasing with the increment of multiple experiences of adverse psychosocial events. We have corrected the sentence as follows for clear understanding (Page 3, Lines 45-46).

“Additionally, adolescents’ multiple adverse experience of psychosocial factors was found to be associated with TU in a graded manner.”

It is not clear what the authors mean by: “Tobacco and substance use among school-going adolescents in Bangladesh are relatively prevalent.” Relative to what percentage, what age group, and where?

Response: Thank you. The prevalence TU and SU that we found in our study was much lower than the prevalence found in some other developing countries like Ethiopia, Ghana, Philippines, Namibia, Chili etc (References given below). These studies were also used the data of respective country’s GSHS. Therefore, we wrote relatively. Since it creates confusion, we deleted the term ‘relatively’ from the sentence.

Page, R.M., et al., Psychosocial distress and substance use among adolescents in four countries: Philippines, China, Chile, and Namibia. Youth & society, 2011. 43(3): p. 900-930.

Pengpid, S. and K. Peltzer, Alcohol use and misuse among school-going adolescents in Thailand: results of a national survey in 2015. International journal of environmental research and public health, 2019. 16(11): p. 1898

Birhanu, A.M., T.A. Bisetegn, and S.M. Woldeyohannes, High prevalence of substance use and associated factors among high school adolescents in Woreta Town, Northwest Ethiopia: multi-domain factor analysis. BMC public health, 2014. 14(1): p. 1186.

Hormenu, T., et al., Psychosocial Determinants of Marijuana Utilization Among Selected Junior High School Students in the Central Region of Ghana. Journal of Preventive Medicine and Care, 2018. 2(2): p. 43.

Why was “substance use” created as an outcome measure? Why did the authors not use any other validated measure on substance use?

Response: Thank you. Alcohol, marijuana, and tobacco are substances most commonly used by adolescents (References below).

Johnson LD, O’Malley PM, Bachman JG, Schulenberg JE, Miech RA. Monitoring the Future national survey results on drug use, 1975-2013: Volume 1, Secondary school students. Ann Arbor, MI: Institute for Social Research, University of Michigan, 2014: 32-36.

Latimer, W. and J. Zur, Epidemiologic trends of adolescent use of alcohol, tobacco, and other drugs. Child and Adolescent Psychiatric Clinics, 2010. 19(3): p. 451-464.

World Drug Report 2018 (United Nations publication, Sales No. E.18.XI.9)

Ramo, D.E., H. Liu, and J.J. Prochaska, Tobacco and marijuana use among adolescents and young adults: a systematic review of their co-use. Clinical psychology review, 2012. 32(2): p. 105-121.

We could use separate variables for alcohol drinking and marijuana use, however, alcohol drinking and marijuana use is strictly prohibited by law in Bangladesh. So information on these is rare. Therefore, we have combined these two and named it ‘substance use’. Since we want to assess how psychosocial and environmental factors are associated with adolescents’ substances use (smoking, alcohol drinking and marijuana use), therefore we use these as outcomes.

What forms of marijuana use were included?, since ‘drinking’ alcohol is specified, it would be good to maintain parallelism in the sentence.

Response: Thank you. Yes it would be nice to have similar structure of the questionnaire. However, we used a nationally representative secondary data (GSHS), so we have to use the questionnaire and the data as they collected. The questionnaire of the GSHS can be found in the following link:

https://www.cdc.gov/gshs/questionnaire/index.htm

Introduction

If it is known that 6.9% of adolescents are tobacco users, and 2% are alcohol users from 2017-2018 data, which is based on more recent data than the study under review, what is the justification for this study based on data from 2014? What is the gap that the current study fills in terms of assessing prevalence?

Response: Thank you for your query. Actually, the references (4 and 5, in earlier version of the manuscript) used for documenting the prevalence were published in 2018 and 2017; but they used data from Global Youth Tobacco Survey (GYTS), Bangladesh 2013, and the WHO STEPwise Surveillance (STEPS) data in 2010, respectively. And this current analysis is based on data collected in 2014, therefore, the prevalence reported in this current study is from the latest data. However, to avoid confusion we have rewritten the sentence as follows and used the original references:

“The 2013 Global Youth Tobacco Survey of Bangladesh reported that 6.9% of adolescents (9.2% males and 2.8% females) are currently tobacco users. The prevalence of alcohol use across age groups is less than one percent (0.8%; men 1.5% and women 0.1%.”

Suggestion to include a description of the types of tobacco use in Bangladesh, as there may be many diverse forms of use. Line 99 – “limited to only tobacco (smoke or smokeless)”

Response: Thank you. We have added the following sentence in the first paragraph describing types of tobacco use in Bangladesh (Page 4, Lines 59-61)

“Around 35% of the total population in Bangladesh use either smoked cigarettes or bidis or smokeless tobacco products (tobacco flakes known as Zarda, betel leaf quid or paan, and gul”

What makes the authors believe that the reasons for adolescents using tobacco in global studies differ from the reasons why adolescents use in Bangladesh?

Response: Although there are some restrictions of smoking in public places and selling cigarettes to the minors; tobacco smoking or using other forms of tobacco is not prohibited by law in Bangladesh. Like many other countries, using tobacco, specifically smoking among adolescents is also socially and culturally unacceptable in Bangladeshi. The numbers of tobacco smokers are increasing rapidly because of the availability of cheap tobacco products, lack of strong tobacco control regulations, and weak enforcement of existing regulations. However, alcohol drinking and using marijuana is prohibited by law in Bangladesh. Since using these substances has enormous health impact among the adolescent, therefore more studies are required to identify whether the same factors contributes to substances use in Bangladesh and in other settings. Factors those are found to be associated with tobacco use in global studies might be true for Bangladesh. However, if data is available, it would be better to find out whether these factors that are actually associated or not with respective country’s data. It would help formulate appropriate culturally acceptable interventions. That’s why our study is important and has implication for Bangladesh.

Line 98-99 What is the reason why the authors want to include an urban sample on tobacco users? What proportion of Bangladesh is urban?

Response: Thank you. The proportion of urban population in Bangladesh is around 37% (According to statista in 2018; link below). Some earlier studies in Bangladesh did not use country representative sample, rather used only rural sample. Therefore, it is not possible to generalize the findings to the whole country. To get the whole picture of substance use, we need country representative data, not partial one. We, in our study, fill that gap by identifying factors associated with substance use using nationally representative sample which represents the whole country.

https://www.statista.com/statistics/761021/share-of-urban-population-bangladesh/

Line 100: What is the evidence that psychosocial factors are important? Perhaps the authors would like to define these factors, explain briefly how they are likely interlinked. In the paragraph on global studies (line 78-89) the authors mention many factors, but latel them interpersonal risk factors, protective factors, psychosocial distress, and so one is not sure what psychosocial factors entail exactly?

Response: Thank you. For addressing this issue we have added the following sentences in the text (Page 5 Line 92-101).

“There is a large body of literature that highlights psychosocial factors such as, loneliness, stress, depression, anxiety, hyperactivity/inattention, and low self-esteem as risk factors for substance abuse. For example, Page et. al. reported in a four country study (Philippines, China, Chile, and Namibia) that among adolescents often feeling lonely, worried, sad/hopeless, or having a suicide plan were associated with current smoking and drinking alcohol. Findings from a longitudinal study in Australia suggest that psychosocial risk factors, such as truancy, hyperactivity/inattention, and behavior problems, are associated with adolescent binge drinking and cannabis use. A recent review concludes that psychosocial risk factors of adolescent substance use are closely related to peer influence, and that parents tend to have the strongest effect on adolescents’ substance use behavior”

Line 106: MAE – Multiple adverse experiences – This construct is mentioned without any citation or background information. It seems like it is better suited as a measure rather than mentioned in passing at the end of the introduction.

Response: We have added following sentence in the introduction section justifying the inclusion of MAE here (Page 6 Lines 116-118).

“A growing number of studies document a graded relationship between adverse life circumstances and negative health outcomes, including health risk behaviors, such as substance use. Therefore, we examine to what extent multiple adverse experiences (MAE) affect tobacco and substance use behaviors among the adolescent population.”

We also have discussed briefly about the calculation procedure of MAE scores in our methodology section. Following paragraph is added to the text (Page 8-9, Lines 165-174)

“Calculation of multiple adverse experience (MAE) scores

We followed the Kaiser Permanente Childhood Adverse Experience (ACE) study to calculate the multiple adverse experience (MAE) score. We divided adolescents’ adverse experiences into two categories: psychosocial and socio-environmental factors. Details of these two categories are presented in Table 1. The MAE score for each adverse category was calculated by summing up the responses on the adverse experience questions. For each adverse experience, the response 0 meant the participant never or rarely experienced the adversity, while 1 meant the participant always or sometimes experienced that specific adversity. Higher MAE meant greater experience of adverse events. As for example, if an individual has experienced three adverse events, then the MAE score is 3.”

Data and Methods

Line 119: What is the disadvantage of using a school-based sample?

Response: Thank you. The GSHS was conducted by WHO in collaboration with CDC. They have adopted this school-based methodology in collecting data. We are just using the secondary data of GSHS. There might be several disadvantages of using school-based sample which are reported in earlier studies. These includes: difficult to recruit school, increasing non-response rate, excluding students who are absent in the survey day (references below). With high nonresponse rates, the validity of population measurement is questionable. High nonresponse rate also increase the likelihood of sample bias because whole school may represent a specific segment of society. Moreover, while studying health risk behaviors using school-based sample, studies have documented that prevalence of health risk behaviors to be higher among absent respondents. These disadvantages might be considered while collecting sample.

Hallfors D, Iritani B. Local and state school-based substance use surveys—availability, content, and quality. Eval Rev. 2002;26(4):418-437.

White DA, Morris AJ, Hill KB, Bradnock G. Consent and schoolbased surveys. Br Dent J. 2007;202(12):715-717.

Thorlindsson T, Bjarnason T, Sigfusdottir ID. Individual and community processes of social closure: a study of adolescent academic achievement and alcohol use. Acta Sociol. 2007;50: 161-178.

Bovet P, Viswanathan B, Faeh D, Warren W. Comparison of smoking, drinking, and marijuana use between students present or absent on the day of a school-based survey. J Sch Health. 2006;76(4):133-137.

Michaud PA, Delbos-Piiot I, Narring F. Silent dropouts in health surveys: are nonrespondent absent teenagers different from those who participate in school-based surveys? J Adolesc Health. 1998;22(4):326-333.

However, to accommodate the disadvantage of using school-based sample, we have added the following limitation in study limitations in the discussion section (Page 15, Lines 337-339).

“Moreover, adolescent tobacco and substance use may be underreported, because the GSHS was restricted to adolescents who attended school and were present on the day of the survey.”

What is the proportion of adolescents in Bangladesh who do not go to school and are using tobacco?

Response: According to Bangladesh Demographic Health Survey 2014, the proportion of the population that do not attends school is 18% (boys: 21.7%, girls: 15%) for children age 11-15 in Bangladesh.

The 2013 Global Youth Tobacco Survey of Bangladesh reported that 6.9% of adolescents (9.2% males and 2.8% females) are currently tobacco users.

However, we have included the information of the prevalence of tobacco use in the 1st paragraph of the introduction section.

How long was the self-administered questionnaire?

Response: The self-administered questionnaire was consisted of a total of 80 core, expanded and country-specific questions. The Bengali version of the questionnaire was used in the survey (Reference below).

Report of first Global School-based Student Health Survey (GSHS), Bangladesh, 2014. New Delhi: World Health Organization; 2018. World Health Organization, Regional Office for South-East Asia and National Centre for Control of Rheumatic Fever and Heart Disease, Ministry of Health & Family Welfare, Dhaka, Bangladesh Licence: CC BY-NC-SA 3.0 IGO.

What steps were taken by the study team to manage adolescent distress while answering questions on Multiple adverse experiences?

Response: To ensure privacy and confidentiality the survey was anonymous and voluntary.

Was student assent collected?

Response: Yes, it was. Informed consent from the students, parents, and/or school officials, as appropriate, was obtained.

We have already included this information in method section.

What language was the survey completed in and was it in the local language?

Response: The Bengali version of the questionnaire was used in the survey (Reference below).

Report of first Global School-based Student Health Survey (GSHS), Bangladesh, 2014. New Delhi: World Health Organization; 2018. World Health Organization, Regional Office for South-East Asia and National Centre for Control of Rheumatic Fever and Heart Disease, Ministry of Health & Family Welfare, Dhaka, Bangladesh Licence: CC BY-NC-SA 3.0 IGO.

Do participating adolescents understand and use the term marijuana colloquially?

Response: Marijuana is not familiar word in Bangladesh. In Bengali it is well known as Ganja or weed.

Bangladesh specific item used to measure marijuana use in the GSHS: “During the past 30 days, how many times have you used marijuana (also called ganja or weed)?”

We have corrected it in the text.

In the creation of age-standardized weights, what specific marginal population proportions were used from the population and housing census, and why? Please provide this information in a supplemental table. Or is it just based on age?

Response: Thank you. We used total population of the age-group 11to18 years to standardize the prevalence. We did the direct method of age-adjusted prevalence to eliminate differences in crude prevalence in populations of interest that result from differences in the populations’ age distributions. However, it is usually done when we compare two or more populations at one point in time or one population at two or more points in time. Since we are using nationally representative data, and not comparing the prevalence with other sub-group of the population; we think this age-adjusted prevalence is not necessary for the current study. Therefore, we decided to remove the age-adjusted prevalence from the table as well as from the manuscript. We think deleting these prevalence would not affect the quality of the manuscript.

See Line 160-164: Multiple imputation will not likely make the sample more representative. The citation does not match the text preceding it and it is indistinct why multiple imputation was used. It would also be useful to explain why “ever had sexual intercourse” was included in this context: “To ensure representativeness and to prevent misinterpretation or any form of biases in the analysis, the allocation of missing values was done through a multiple imputation method using a logistic regression model by taking into account the known values, most frequently for “ever had sexual intercourse” [34].”

Response: Thank you very much. We apologize for such mistakes. We have corrected it. Since the response of the variable “sexual history” (‘ever had sexual intercourse’ in earlier version of the manuscript) contains 11.6% missing values, we imputed these missing values. That’s why we included sexual history there. We have corrected the sentence in the following way so that it would be clearly understand by the readers (Page 9, Lines 182-185).

“Imputation using a logistic regression model was used to estimate missing values from known values to account for missing data, most frequently for sexual history (i.e., for 11.6% of respondents). Age, gender, and school grade were included as covariates in the imputation.”

The measures include no mention of MAE. On what basis were the measures selected? And why are they appropriate in Bangladesh? The adverse events description and combination of measures in Table 1 appear a bit arbitrary and not evidence-based. Suggestion to add a justification and description of how these measures were categorized and used based on the literature.

Response: Thank you. We have just followed the calculation procedure of the Adverse Childhood Experience (ACE). We just wanted to see to what extent the experience of one or more than one psychosocial or socio-environmental events are associated with substance use among adolescents. Therefore, we adopted the procedure of calculating ACE and calculated the MAE score for this study. We also inserted a paragraph describing the calculation procedure, which we indicated in responding a comment earlier. The same was followed in an earlier published article.

Khan, M.M.A., et al., Suicidal behavior among school-going adolescents in Bangladesh: findings of the global school-based student health survey. Social psychiatry and psychiatric epidemiology, 2020: p. 1-12. DOI: https://doi.org/10.1007/s00127-020-01867-z

Results

Line 175-176: Please clarify what is meant by “more than half of the adolescents had poor parental understanding?”

Response: Thank you. We have revised the sentence in the text.

Line 179-189: Are these differences significant, if so, please provide summary of test statistics (Confidence Intervals and p-values)?

Response: We have revised it in the text according to your suggestion.

Line 185 - factors than (those) who did not experience any (such factors).

Response: Thank you. We have corrected it in our revised manuscript.

Figure 1 does not show that boys are significantly more likely to use tobacco and substances. It only shows that the proportion of boys using tobacco is higher than girls, and only marginally so for substances.

Response: We have revised it accordingly.

How are the authors defining an adverse sexual history? The measures in Table 1 do not include this – it just asks, ‘Have you ever had sexual intercourse?’

Response: Sexual intercourse outside marriage is considered as great sin and socially unacceptable. Therefore, we defined ‘adverse sexual history’ by using the item from GSHS ‘ever had sexual intercourse’. However, the 1st reviewer suggested changing the variable name ‘adverse sexual history’ to ‘sexual history’, and we did it according to him in the revised manuscript.

Line 209: The use of dose-response relationship appears inappropriate in this context as there is no experiment underway. The analysis shows an additive negative effect of adverse experiences.

Response: Thank you. We have changed the sentence as follows (Page 12, Lines 245-246):

“Experience of increased number of adverse psychosocial adversities was found to be associated with greater tobacco use in a graded manner”

Line 210-211: Why were both age and grade adjusted for as confounders?

Response: Thank you. While assessing the relationship of various socio-demographic, psychosocial and socio-environmental factors with tobacco and substance use using multivariable analysis, we checked the multicollinearity among the variables. We checked the value of Variance Inflation Factors (VIF), and found that in all cases the VIF values were less than 2. This indicates that multicollinearity is not a problem. Therefore, multivariable analyses were adjusted for all the socio-demographic variables included in this study. However, in some recent analyses (given below) using data from the GSHS, multivariable analyses were adjusted for both age and school grade.

Tang, J.J., et al., Global risks of suicidal behaviours and being bullied and their association in adolescents: School-based health survey in 83 countries. EClinicalMedicine, 2020. 19: p. 100253.

Xi, B., et al., Tobacco use and second-hand smoke exposure in young adolescents aged 12–15 years: data from 68 low-income and middle-income countries. The Lancet Global Health, 2016. 4(11): p. e795-e805.

Tables 2 should provide sample N and counts in a column on unweighted data.

Response: We have revised Table 2 accordingly. Thank you.

Line 220: This seems like a sentence more appropriate as an explanation in the Discussion section.

Response: Thank you. We have deleted that sentence from the result section and the following sentence is added in the discussion section (Page 15, Lines 324-327)

“However, we did not find statistically significant association between experience of multiple adverse socio-environmental events and adolescents’ substance use, which could be due to very few positive responses in the multiple adverse socio-environmental categories.”

Discussion

Line 227-229: Reference 26-28 are much more dated than prevalence rates reported in the Introductory paragraph.

Response: Although the references for prevalence of tobacco use in Bangladesh provided in the earlier version of the manuscript were published recently, they actually used data from 2013 GYTS or 2010 STEPS. We have changed those references to actual report published after those surveys in 2015 or 2011. Now those references are same.

Line 233: remove extra space before period

Response: Thank you. We have removed the extra space.

Line 267-270: It may be useful to bring this point earlier in the paper, maybe as a footnote to Table 1.

Response: Thank you for the suggestion. For the flow of the reading, we think those two sentences could be fine here as it is.

Line 275- predictors is not an accurate description of this study’s findings

Response: Thank you. We have revised it throughout the manuscript.

Line 280-289 and line 242-252: The idea of parental involvement/ monitoring and understanding is repetitive and may be combined effectively.

Response: Thank you. We have deleted some repetitive/abundant explanations from the indicated lines.

Study strengths and implications should be described in greater detail.

Response: Thank you. We have rewritten the strengths of this study in the text and added the following paragraph describing the implications of this study (Page 16, Lines 344-355).

“Limitations notwithstanding, this study has the potential to inform the development and/or modification of prevention strategies. Teachers, parents or other school personnel could play important role in early identification of adolescents with these emotional and behavioral problems. However, they would require appropriate training (e.g. mental health training) and professional development opportunities to build their skills and self-efficacy to be able to recognize, and appropriately respond to the adolescents with these problems. Furthermore, the findings suggest the need for incorporating mental health education programs in school-curricula; and the importance of the family and social connections among these populations. Findings of this study underscore the importance of parental awareness to help and support adolescents in problems. Finally, since parental smoking increases the likelihood of adolescent smoking, universal prevention approaches which combine tobacco cessation campaign through mass media, including school- and community-based programs could be effective.”

Please review:

https://www.childwelfare.gov/topics/preventing/preventionmonth/resources/ace/

For other descriptions of adverse childhood events and categorization.

Response: Thank you very much.

Line 314 – The authors themselves provide other prevalence estimates from Bangladesh, so it may seem prudent to avoid saying it is the first or even most recent?

Response: Thank you. We have revised it and re-written the conclusion section as follows (Page 16, Lines 357-366).

“This study, using a nationally representative data, estimates the prevalence and risk factors associated with tobacco and substance use among school-going adolescents in Bangladesh. The findings of this study have important implications for public health professionals and practitioners who work on adolescent substance abuse programs. Several adverse psychosocial (loneliness, anxiety, bullying, and sexual history), and socio-environmental factors (parental tobacco use, lack of peer support, and poor parental monitoring) were found to be significantly associated with adolescents’ tobacco and substance use. Although the relationships are naturally complex, some patterns are discernible. Further studies with longitudinal data are needed to determine the mechanisms, processes and directionality of these relationships.”

It may be useful to discuss mental health promotion opportunities in light of psychosocial findings.

Response: Thank you. We have mention about the necessity of mental health in the implication section.

Submitted filename: Response to Reviewers.docx

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30 Oct 2020

PONE-D-20-18742R1

Psychosocial and socio-environmental factors associated with adolescents’ tobacco and substance use in Bangladesh

PLOS ONE

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Reviewer #1: This was an interesting study using the latest interation of Global School-Based Student Health Survey in Bangladesh to examine association between childhood risk factors and tobacco use and substance use, which was a combined metric of alcohol and/or cannabis use. There was a big improvement from the last draft

Reviewer #2: There are some minor issues that remain in the manuscript, that the authors must address:

1. Below table 3, the authors still use the word predictors in the manuscript- "Model was adjusted for all the predictors included in this table."

2. Table 2 p-values and chi-square test values are presented in a slightly unusual format, with p-value at the base of each characteristic. Could the authors explore an alternative way of presenting whether participant characteristics are significant by tobacco users and substance users? Also, it would be useful if the authors would clarify that this table relates only to tobacco use and substance use and not tobacco use disorder or substance use disorder.

3. Use of the terms "substance abuse" remains in lines- 49, 85, 94, 121, 227, 360. If both use and abuse are being used in the manuscript, the authors may specify in the manuscript how these concepts differ and why they are both important for their study.

4. Suggestion to clarify in the manuscript - “Additionally, adolescents’ multiple adverse experience of psychosocial factors was

found to be associated with TU in a graded manner.” Perhaps the authors could say - For every additional adverse psychosocial experience there appeared to be an incremental association with increasing TU or it may work to give the exact increased odds of TU in the text. I believe the addition of MAE-relevant information in the manuscript after the initial review feedback is adequate, but in the abstract there needs to be greater clarity.

5. The rationale that alcohol and marijuana are strictly prohibited in Bangladesh does not appear to justify the creation of new substance use questions when other validated measures on substance use, including both alcohol and marijuana exist. For example, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) developed by the World Health Organization (WHO) is widely used.

6. Please indicate if all 6 questions on alcohol use and all 4 questions on drug use from the GSHS were used. Please add a sentence on the use of the Bengali version of the questionnaire with its citation in the manuscript.

7. It may be suitable for the authors to acknowledge in the manuscript that there is no existing evidence to suggest that the reasons for adolescents using tobacco in Bangladesh are similar/different from the reasons why adolescents use in global studies.

8. Given that different tobacco prevalence studies captured varying distributions of urban-rural populations, the authors should mention what proportion of their study is an urban/ rural population in the manuscript.

9. It would help readers to understand the survey, if the authors would add details to the manuscript about the length of the self-administered questionnaire with references and mode (pen and pencil/ online).

10. As the survey asks adolescents about multiple adverse experiences, were there any events during survey administration where participant distress was voiced/reported/observed and what did authors do as a response? Was a counsellor/ psychosocial support available? The authors should add this information to the manuscript for the benefit of readers.

11. It is not clear whether student assent was collected in addition to informed consent. The authors may clarify in the manuscript.

12. Please add to the measures in the manuscript why 'adverse' was a word the authors used to describe sexual history in the Bangladeshi context.

**********

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Reviewer #1: No

Reviewer #2: No

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9 Nov 2020

November 9, 2020

Prof. Stanton A. Glantz

Academic Editor

PLOS ONE

Re: Manuscript Number PONE-D-20-18742R1

Dear Prof. Stanton A. Glantz,

Thank you very much for your kind consideration of our manuscript entitled, “Psychosocial and socio-environmental factors associated with adolescents’ tobacco and other substance use in Bangladesh”. We have revised the manuscript according to the comments by the reviewers. Their useful and productive comments helped us to improve the clarity and quality of the manuscript. Where we have changed the text, the corresponding sentences in the text have been highlighted with the track changes function. The page and line numbers referred to are those in the margins of our clean revised manuscript. Where textual changes are included in this response to reviewer, we have indented and italicized them, and removed references.

We hope that the revisions are satisfactory in addressing the issues raised by the editor and the reviewers, and look forward to hearing your decision about this article.

Yours sincerely,

Md. Mosfequr Rahman, PhD

Department of Population Science and Human Resource Development

University of Rajshahi

Rajshahi-6205, Bangladesh.

E-mail: mosfeque@ru.ac.bd

Reviewer #1

This was an interesting study using the latest interation of Global School-Based Student Health Survey in Bangladesh to examine association between childhood risk factors and tobacco use and substance use, which was a combined metric of alcohol and/or cannabis use. There was a big improvement from the last draft

Response: Thank you very much.

Reviewer #2

There are some minor issues that remain in the manuscript, that the authors must address:

Response: Thank you very much. We have addressed the issues one by one in the following sections.

1. Below table 3, the authors still use the word predictors in the manuscript- "Model was adjusted for all the predictors included in this table."

Response: Thank you very much. We have revised it.

2. Table 2 p-values and chi-square test values are presented in a slightly unusual format, with p-value at the base of each characteristic. Could the authors explore an alternative way of presenting whether participant characteristics are significant by tobacco users and substance users? Also, it would be useful if the authors would clarify that this table relates only to tobacco use and substance use and not tobacco use disorder or substance use disorder.

Response: Thank you. We have revised Table according to your suggestion. We have mentioned in both the title of the table 2 and in the text that we are assessing the prevalence of tobacco use and other substance use among the adolescents, not the disorders.

3. Use of the terms "substance abuse" remains in lines- 49, 85, 94, 121, 227, 360. If both use and abuse are being used in the manuscript, the authors may specify in the manuscript how these concepts differ and why they are both important for their study.

Response: We had tried to be consistent in using the term ‘use’ throughout the manuscript; however, unintentionally in some places we missed to change it. We have revised it. However, the term ‘abuse’ in line number 89 (page line of the current version) is appeared as a risk factor of substance use; this ‘abuse’ is the experience of violence. So we keep it as it was.

4. Suggestion to clarify in the manuscript - “Additionally, adolescents’ multiple adverse experience of psychosocial factors was

found to be associated with TU in a graded manner.” Perhaps the authors could say - For every additional adverse psychosocial experience there appeared to be an incremental association with increasing TU or it may work to give the exact increased odds of TU in the text. I believe the addition of MAE-relevant information in the manuscript after the initial review feedback is adequate, but in the abstract there needs to be greater clarity.

Response: Thank you. We have rewritten the mentioned line from the abstract as follows:

“Additionally, higher odds of tobacco use were observed among adolescents who reported 1 (AOR: 4.36 times; 95% CI: 1.34-14.24), 2 (AOR: 8.69 95% CI: 1.67-28.23), and ≥3 (AOR: 17.46; 95% CI: 6.20-49.23) adverse psychosocial experiences than who did not report any psychosocial events.”

5. The rationale that alcohol and marijuana are strictly prohibited in Bangladesh does not appear to justify the creation of new substance use questions when other validated measures on substance use, including both alcohol and marijuana exist. For example, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) developed by the World Health Organization (WHO) is widely used.

Response: Thank you. To avoid confusion and conflict with other validated measures, and for better understanding of the readers we have change ‘substance use’ as ‘other substance use’ throughout the manuscript. Other substance use includes the use of alcohol and/or marijunana.

6. Please indicate if all 6 questions on alcohol use and all 4 questions on drug use from the GSHS were used. Please add a sentence on the use of the Bengali version of the questionnaire with its citation in the manuscript.

Response: Thank you. We assessed the current use (in past 30 days) of tobacco (in the form of smoking or smokeless), alcohol and/or marijuana among the adolescents. Therefore, we only used those questions (2 for current tobacco user, 1 for current alcohol use, and 1 for marijuana use) which are given in the outcome section in the text (Page Lines,) to measure the current users of these substances. We have clearly mentioned it in the outcome section.

We have added a sentence in method section (Page 7, Line 147) indicating that the Bengali version of the questionnaire was used in the survey with a reference.

7. It may be suitable for the authors to acknowledge in the manuscript that there is no existing evidence to suggest that the reasons for adolescents using tobacco in Bangladesh are similar/different from the reasons why adolescents use in global studies.

Response: Thank you. We have added the following sentence in the introduction (Page 6, Line 117-119)

“Therefore, how psychosocial factors, which are found to be risk factors in some global studies, are associated with tobacco and other substance use among adolescents in Bangladesh is unknown.”

8. Given that different tobacco prevalence studies captured varying distributions of urban-rural populations, the authors should mention what proportion of their study is an urban/ rural population in the manuscript.

Response: Thank you for your query. We use the secondary data from GSHS, Bangladesh, and there no information in GSHS on Rural-Urban sample. Data were not disaggregated by rural and urban. Therefore, we are unable to provide such information. However, the method section of GSHS only reported that it is a nationally representative survey.

9. It would help readers to understand the survey, if the authors would add details to the manuscript about the length of the self-administered questionnaire with references and mode (pen and pencil/ online).

Response: Thank you. We have added the following sentences in the method section (Page , Lines )

“The questionnaire consisted of 80 core, expanded and country specific questions. The survey used the Bengali version of the questionnaire.”

10. As the survey asks adolescents about multiple adverse experiences, were there any events during survey administration where participant distress was voiced/reported/observed and what did authors do as a response? Was a counsellor/ psychosocial support available? The authors should add this information to the manuscript for the benefit of readers.

Response: Thank you. We also think this information would benefit the readers for better understanding the survey. Since we are using secondary data from the GSHS and no such information is available in the GSHS methodology. Therefore, we are unable to include this information in the manuscript.

11. It is not clear whether student assent was collected in addition to informed consent. The authors may clarify in the manuscript.

Response: Thank you. We have revised the sentence as follows (Page Line 150-11). And this is the information available in the GSHS methodology.

“To ensure voluntary participation, privacy, and confidentiality, informed consent was obtained from the students, parents and/or school officials”

12. Please add to the measures in the manuscript why 'adverse' was a word the authors used to describe sexual history in the Bangladeshi context.

Response: Thank you. For addressing this issue we have added the following sentences in the text (Page 5 Line 92-101).

Earlier studies documented that early sexual initiation (i.e., sexual initiation before 16 years old) has been associated with adverse sexual health outcomes at the time of first intercourse and also later in life with an increased risk of having multiple lifetime sexual partners, unprotected sex, acquiring sexually transmitted infections (STIs), unwanted pregnancy, and undesirable sexual outcomes, such as problems with orgasm and sexual arousal. Moreover, adolescents may not be equipped to manage the psychological consequences of sexual activity; experiencing regret and having a higher risk of depression.

In addition, Bangladesh is a Muslim majority country and Islamic principles play a pivotal role in one’s life. Early and premarital sexual intercourse is not accepted and objectionable on social, religious, or moral grounds. A national survey reported that 13% of unmarried Bangladeshi male adolescents had sexual intercourse and much of this experience involves unprotected sexual intercourse with commercial sex workers. Moreover, religious, cultural and social norms are not in favor of the issue of sex education in schools, so Bangladeshi adolescents have very little knowledge on sexual and reproductive health. Bearing all these in mind, we use the term ‘averse’ while defining experience of sexual intercourse variable as ‘adverse sexual history’ in this study. However, it already creates confusion and another reviewer suggested to remove the term ‘adverse’. So we have deleted ‘adverse’. We also think global readers may get confused with the term “adverse”, so we have decided delete it. Therefore, we do not include any further description about it in the method section.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

11 Nov 2020

Psychosocial and socio-environmental factors associated with adolescents’ tobacco and other substance use in Bangladesh

PONE-D-20-18742R2

Dear Dr. Rahman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Stanton A. Glantz

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

13 Nov 2020

PONE-D-20-18742R2

Psychosocial and socio-environmental factors associated with adolescents’ tobacco and other substance use in Bangladesh

Dear Dr. Rahman:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Stanton A. Glantz

Academic Editor

PLOS ONE