Abstract
Bidis, or hand-rolled, filterless tobacco cigarettes, are largely marketed to and consumed by the poor in Bangladesh. In exploring perceived rationales and the situational contexts of smoking, this study identifies the crucial connections between bidi smoking and the social and economic forces that influence choices and shape the contexts of individual suffering. Ethnographic research in Netrakona District revealed that inexpensive bidis were used to gain relief from physical ailments specific to the poor, such as hunger, indigestion and constipation. Bidis were found to be a socially accepted mood-altering drug that symbolizes relief from their everyday tensions, angers, perceived exploitations and disappointments. I argue that both cultural norms of reciprocity and hierarchy as well as the socio-economic structure of Bangladesh with its inequality, poverty and exploitation contribute to the tobacco consumption and related health problems of the poor.
Tobacco use today may be considered in terms of a global outbreak. Tobacco-related morbidity has been referred to as ‘a world epidemic’ (Jha, 2009; World Health Organization, 2008: 8). There are an estimated 1.1 billion smokers worldwide, among whom 80 percent live in low and middle income countries. Sixty percent of all smokers live in the following 10 countries (listed in order of population): China, India, Indonesia, Russian Federation, the United States, Japan, Brazil, Bangladesh, Germany and Turkey (Jha, 2009). This particular ethnographic study, which was conducted in Bangladesh, aims to provide insight into bidi smokers and their smoking habits, linking individual habit and cultural norms with an international political economy of tobacco and the national political economy of labour exploitation. The smoking of bidis, which take the form of factory-rolled, filterless cigarettes, is very popular among the poor of Bangladesh (Ali et al., 2003). 1
Annually, some five to six million deaths are attributed to tobacco smoking, a greater rate than that of tuberculosis, HIV/AIDS and malaria combined. It is estimated that the number will reach more than 10 million by 2030, and that 80 percent of all deaths will occur in developing countries (Jha, 2009). Worldwide, tobacco use has contributed substantially to an epidemiological shift from infectious to chronic diseases. A World Health Organization (2009b) report shows that 71 percent of lung cancer cases, 42 percent of chronic respiratory diseases and 10 percent of cardiovascular diseases are attributable to tobacco use. But, the effects of widespread tobacco consumption are not immediately obvious; it takes years, even decades after the commencement of tobacco use, for symptoms to appear. For this reason, current data on tobacco-related deaths represent previous tobacco consumption. Data suggest that because tobacco consumption is rising globally, the future will see an increase in the death toll. This is particularly relevant to developing countries, which are considered a lucrative market by international tobacco companies seeking to make up for the decreasing sales in their home countries (Stebbins, 1991; Stebbins, 1994 in Baer et al., 1997).
The entrance of foreign cigarettes into what were formerly domestic markets places them in competition with local tobacco companies, for example, bidi companies. Whereas the high price of manufactured cigarettes puts the product beyond the reach of the poor, bidis are very cheap: six taka per pack of 25 bidis versus 17 taka per 20 stick pack of the cheapest foreign cigarettes. 2 While bidi companies’ promotional strategies mainly target the poor, cigarette companies tend to target middle and upper-class consumers, who have the means to buy expensive cigarettes. In other global contexts, it has been shown that minority and economically disadvantaged people choose the cheaper forms of tobacco. For example, African Americans who cannot afford to purchase expensive cigarettes opt to buy cheaper products such as cigarillos and a particular brand targeting them is ‘Black & Mild’ (Page and Evans, 2004; Singer et al., 2008).
When the poverty level in the South Asian countries and the popularity of bidis among the poor are taken into account, bidi smoking merits special attention, particularly as the focus of most tobacco control policies is on commercially produced cigarettes. It has been estimated that 50 percent of male and 80 percent of female smokers in South Asia smoke bidis and that the remainder smoke cigarettes (Gajalakshmi et al., 2000). While the harmful effects of bidi smoking have been documented by many scholars (Asma and Gupta, 2008; Malson et al., 2001; Ray and Gupta, 2009), it seems indefensible that so little attention has been paid to the habit by tobacco control agencies in the Bangladeshi context, particularly in light of the practice’s potentially grave health consequences.
With 168 signatories, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), signed by Bangladesh in 2003 and ratified in 2004, is considered the most widely embraced treaty in UN history. 3 In accordance with the provisions of the Convention, the National Assembly of Bangladesh enacted the Smoking and Tobacco Product Usage (Control) Act 2005. A National Strategic Plan of Action for Tobacco Control 2007–2010 was also formulated with the support of the WHO. However, neither the legislation nor the Strategic Plan has any special provision for bidis. The Act mostly emphasizes prohibiting smoking in public places, banning the promotion and advertising of tobacco, and the effects of inhaling and exhaling the smoke of tobacco products. Bidi smoking was classified under the broad rubric of ‘smoking and tobacco use’, together with cigarettes, cheroots, cigars and pipe tobacco. Yet, bidi smokers are different from consumers of other forms of tobacco. In addition, there is considerable variation in the prices and availability of the different forms of tobacco: bidis are much cheaper than cigarettes and are more widely available.
The organization of bidi production also differs from cigarette production in some key ways. Women and child labourers who work in bidi factories are not only susceptible to various tobacco-related illnesses (see John, 2008) but are prone to various physical and work-related problems (Blanchet, 2000). As well as the direct health consequences of bidis, there are other social issues that deserve special scrutiny. For example, rather than being involved in a typical factory owner–labourer relationship, women and children typically serve as bidi workers based on oral contracts, and are thus subject to exploitation (Blanchet, 2000). For all of the above reasons, the widespread popularity of bidi smoking among the poor in Bangladesh demands special attention vis-à-vis tobacco control and social justice strategies.
In order to understand individual patterns of smoking initiation, continuation and cessation attempts, it is important to explore the ‘interaction between individual and contextual factors’ (Nichter, 2003: 139). This study attempts to understand the perceptions of bidi smokers regarding their smoking habits. Its broad objective is narrowed down to two specific tasks: first, to ascertain their perceived rationale for smoking, and second, to gain an understanding of the situational contexts that influence bidi smoking. In attempting to explore the situational contexts of smoking, this study seeks to identify the crucial connections between bidi smoking and the social and economic forces which influence individual lives and shape the contexts of suffering (Farmer, 2003).
The place and the people
Netrakona, a northern district of Bangladesh with an area of 2810 square kilometres, is bounded by India on its north and on its other three sides by the three districts Sunamganj, Mymensingh and Kishorgonj. According to the 2001 census data, this densely populated district is home to 1,987,188 people. The literacy rate for males is 31.2 percent; for females, it is 20.4 percent. Netrakona lacks an effective communications infrastructure and has few urban facilities. For example, a sub-district named Khaliajuri does not have direct road connections with Netrakona Sadar, the central part of the district where most of the government offices are established. The district has no large industries, only oil mills and a few factories, for example, bidi and ice factories. These two cottage industries provide many jobs in the area. The majority of the people (approximately 54%) are involved in agriculture; the remainder engage in various occupations such as fishing, wage labour, small business and service jobs.
I conducted my fieldwork in Netrakona Sadar and Khaliajuri sub-district from June to August 2008. Employing purposive sampling (Bernard, 2006), I selected my informants based upon their tobacco consumption status. I approached them and asked them to participate in the study when they were alone, in order to encourage individual responses uninhibited by the presence of others. Most of my informants agreed to be interviewed ‘on the spot’; in a few cases, interviews were rescheduled for other times in places such as tea stalls or in the individual’s home. Observation was mostly conducted in tea stalls located adjacent to paan (smokeless tobacco or betel quid 4 ) and bidi shops. As the focus of this study is bidi smoking, most of the informants were selected after I observed them smoking bidis. However, some cigarette smokers and betel quid users were also interviewed in an attempt to elicit their views about bidi smoking. Most of my informants were male; smoking among females in Bangladesh is socially unacceptable. Twenty-three interviews were conducted with male smokers and seven with female tobacco users. Among the female informants, three were bidi smokers and the other four used smokeless tobacco. Previous studies undertaken in the home country (Ali et al., 2003) and among Bangladeshis living abroad (Ahmed et al., 1997; Summers et al., 1994) suggest a low prevalence of smoking among women. Semi-structured interviews were conducted based upon an interview guide (Bernard, 2006), and, although the sequential ordering of questions during the interviews was not strictly adhered to, all of the questions and topics drawn from the interview guide were covered during each interview. In total, 30 interviews were conducted; and, as repetition of the same themes was observed, thematic saturation was considered to have been reached.
Based upon information collected during the in-depth interviews, street-side tea stalls were selected as potential sites for observational data collection. Daily labourers, rickshaw pullers and other daily wage earners were among those who frequented the tea stalls regularly. In addition to selling tea, the stalls also sold bidis, betel quids and candies; thus, the informants considered them to be places where they could take a break and refresh themselves. Observations for this study focused on whether the smoker was alone or accompanied by companions, the length of time they had smoked, and whether other substances (tea, for example) were taken while smoking. Five days of observation totalling 25 hours were undertaken in five tea stalls.
This study has several limitations. As this study was conducted in one district only, it does not address any regional variations in tobacco use (Singer et al., 2008). Given the limited timeframe and scope of the study, the bidi workers’ experiences have not been as well explored as they could be with an extensive period of participant observation. This study also lacks extensive information on the expenses incurred by bidi smokers, that is, percentage of budget spent on smoking versus everyday household goods. It also does not address the impact of passive smoking on society. I attempt to explore these issues in a study supported by HealthBridge and The International Union Against Tuberculosis and Lung Disease (Roy et al., 2010, Roy et al., in press).
Society, culture and tobacco use
Simply emphasizing the behavioural psychology of smokers and the science of addiction does not address the myriad risks and realities involved. Cultural meaning, personal and collective mediation of symbolic systems, situational context and contingency, and the influence of political and economic environments, which taken together create ‘a broader constellation of influences’ on individuals' smoking behaviour (Willms and Stebbins, 1991: 1315), must of necessity be considered. By exploring cultural meaning, studies have described how several factors such as class, ethnicity, modernity and popular culture influence people’s smoking behaviour (Nichter, 2003). As ‘a culturally created behaviour’, cigarette smoking is found to be associated with social identities such as adulthood and the concept of independence (McGraw et al., 1991: 1359). Marshal (2005: 367) argues that anthropologists should pay special attention to tobacco use not only because of its enormous effects on health but because its consumption is ‘embedded in and encoded with cultural meanings’; tobacco consumption is a widely used global commodity, and, as such, is a ‘learned, patterned and typically social behaviour’.
The cultural context of smoking behaviour may be linked to local and global politico-economic structures. For example, Mehl et al.’s (1999) study of Sri Lankan male adolescents, which examines the national and local context of smoking, attempts to identify the common settings of smoking initiation and tobacco use by exploring ‘the frames of reference’ that smokers observe in their interpretation and internalization of the smoking experience (p. 339). At the macro-level, young Sri Lankans’ smoking behaviour was influenced by ‘the depressed economy and unemployment rates’, the high average age of marriage, increased cigarette prices, and widespread promotional activities (Seimon and Mehl, 1998 in Mehl et al., 1999: 340). At the micro-level, their culture, along with the activities the Sri Lankan youths engaged in, were found to provide a key setting for tobacco initiation.
The association of smoking behaviour with the structural forces that shape people’s lives was also found in the context of the world’s developed countries. For example, based on her survey of more than 900 working-class mothers in Britain, Graham (1994) shows how the smoking behaviour of women of low socio-economic status was influenced by factors such as poor socio-economic circumstances, everyday responsibilities, social support, social networks, and personal and health resources. Female smoking behaviour may also be influenced by a sense of morality; for example, some pregnant women quit smoking from ‘a strong sense of moral identity as a mother’ (Nichter et al., 2007: 761). Several studies have shown that an individual’s smoking behaviour may often be influenced by his/her social networks, for example, friends and peers (see Nichter et al., 2004; Thrasher and Bentley, 2006). Moreover, individuals’ smoking behaviour influences households, especially poor households, in multiple ways. Smoking can both induce and exacerbate sickness in adults, rendering them unable to care for their children; money spent on smoking could be spent more productively; and, passive smoking inhalation causes many diseases including respiratory illnesses among family members (Nichter and Cartwright, 1991).
The cultural context and multidimensional impacts of tobacco use make the issue a vital area of anthropological study, an important contribution to the study of health behaviour and drug use. According to Marshall (2005), while tobacco has gained some attention from anthropologists over the past 20 years, the negative health consequences of tobacco are yet to receive in-depth attention, especially at the micro-level. Despite the huge death toll attributed to tobacco, it has been relatively ignored compared with the number of studies exploring alcoholic beverages and illegal drug use (see Marshall, 1981 in Marshall, 2005). Anthropological studies undertaken outside the US have mostly focused on issues at the macro-level, that is, examination of national, regional and global trends of tobacco, often leaving micro-perspectives unexplored (Marshall, 2005).
Anthropologists can perform an effective role in tobacco control by exploring tobacco users’ misconceptions; for example, diabetic patients in Kerala were unable to realize the link between their tobacco use and diabetes complications (Thresia et al., 2009). Most importantly, anthropologists can contribute by developing culturally appropriate tobacco cessation programs aimed at encouraging people to quit (Nichter, 2006; Nichter et al., 2009a).
The history and context of tobacco consumption in Bangladesh
Commercial cigarettes were introduced into the region by the British at the end of the 19th century. Initially they remained beyond the purchasing ability of the poor, whohad their own forms of smoking, for example, bidis. However, according to Habibullah (2008), bidis were not produced on a large scale until the Second World War, linking the large-scale production of bidis with the post-colonial situation in the region. Increasing urbanization, together with a decline in the previous subsistence economy, led to factory production of bidis, by extension replacing home production. As a consequence, bidi consumption increased due to its easy availability.
Bangladesh: basic statistics
Source: aUNFPA (2009)
While Bangladesh does not officially export tobacco products, some products, for example, bidis are smuggled into the Middle Eastern countries. In addition to consuming domestically produced tobacco, Bangladesh also imports tobacco products, mainly cigarettes. Of tobacco consumption in Bangladesh, 70 percent is consumed in the form of cigarettes or bidis, 20 percent is chewed, and the remainder is either ingested as hukka, 5 smoked in pipes, as cigars, or taken as snuff (Ali et al., 2003). The Global Adult Tobacco Survey (GATS) shows that 41.3 million Bangladeshi adults (15+) consume tobacco either by smoking or in smokeless form: this constitutes 43.3 percent of the total adult population (World Health Organization, 2009a). Although overall smoking prevalence is 23 percent, there is a marked difference when gender is considered: 44.7 percent of men and only 1.5 percent of women smoke. The WHO found the overall consumption rate of smokeless tobacco to be 27.2 percent, which is more evenly distributed by gender, with a slightly higher rate for women (27.9%) than men (26.4%). The smoking rates in the country’s rural and urban areas are 23.6percent and 21.3 percent respectively and the prevalence of bidi smoking in rural areas (13.5%) is significantly higher than in urban areas (4.7%) (World Health Organization, 2009a).
Annually, the direct cost of medical care due to tobacco-related illness has been estimated at 50.3 billion taka; the indirect cost is 59.8 billion taka, and the total cost imposed on society is approximately 110 billion taka 6 (Barkat, 2008). In 2004, tobacco-related illnesses in Bangladesh imposed a cost of 50.9 billion taka while the total benefits from tobacco in terms of tax and wages was 24.8 billion taka. So clearly, harm outweighed the benefits by 26.1 billion taka or US$442 million (World Health Organization, 2007, 2009a). The GATS report shows a higher smoking prevalence among the lower socio-economic strata and people living in the rural areas. The cost of tobacco-related illnesses cannot be met by a large portion of the total population (81.3%), that is, by those whose income is less than US$2 per day (UNDP, 2009). Early death from tobacco consumption exacts another economic toll, taking into account the dominance of agriculture in the national economy and that the workforce in the rural areas is the main contributor to the economy.
Given all of the above, bidi smoking requires special attention for various reasons. The social acceptance of bidis as the smoking habit of the underprivileged may have created a moral attachment to bidis in the poor. Within Bangladesh, it is widely perceived that bidis will be marketed to and consumed by the socio-economically disadvantaged groups of society. According to the available data on the production of bidis and cigarettes from 1988 to 2000, the production rate of cigarettes increased by approximately 40 percent while bidi production increased by approximately 295 percent (Ali et al., 2003). This high volume of bidi production over the years, the extremely low price compared to cigarettes, and its popularity amongst the poor should make bidi smoking of special interest to the social sciences, with particular application to public health agendas.
Bidi workers and consumers
Bidi factories are often found in small urban and peri-urban areas (see Blanchet, 2000, 2002). In 2008, I visited a bidi factory – Binod Bidi – located in Netrakona. The locals considered the family that owned the factory to be very rich. The brand was named after the original factory owner, the late Mr Binod; today, his eldest son runs the family business. The factory buys tobacco leaf from Rangpur, a district famous for tobacco growing. As the price of the best quality tobacco powder is high, the company buys very little; during the production process, they mix it with other types of tobacco powder. I observed women making bidi thosh, the cylindrical paper into which tobacco powder is placed. After making approximately 500 to 1000 cylinders, they filled them with tobacco powder, and then they sealed one end of the thosh. Workers receive 13 taka for every 1000 bidis they make, an absurdly low wage even by Bangladeshi standards. They are paid based upon the number of bidis they make, not the hours they work. Workers are not provided with meals by the factory. I met one woman who was working while taking care of her infant. When asked, she said that there was no one at home to care for her child, so she brought him with her to work. Many children, some of whom were around eight to ten years of age, worked alongside their mothers. An important anthropological study conducted by the UNICEF on children working in the bidi industry showed similar findings (Blanchet, 2000). It has also been noted that by locating in economically depressed zones, factory employers can more easily gain access to a cheap labour force drawn from disadvantaged populations (Blanchet, 2000, 2002; Efroymson and Fitzgerald, 2002).
My conversations with residents of the district revealed a general perception that daily labourers such as rickshaw pullers, who made little money, generally preferred to smoke bidis. Bidi smoking practices have become associated with poverty to such a degree that if wealthy people buy bidis, bidi sellers or casual observers assume that the wealthy are buying them for someone else to distribute free of cost (to labourers, for example), or that they temporarily lack cash and are desperate for ‘a smoke’. Although my male informants were more highly educated than their female counterparts, none had completed their Secondary School Certificate (SSC) examination, the first public examination that all who finish 10th grade are required to sit. Most of the informants had very low incomes (approximately US$2 per day); none of their family members was earning an income. Few among them owned land for cultivation; some owned their houses, but most were living in rented accommodations. Some female informants, who were beggars, were provided with a place to live in other villagers’ houses in return for helping with the household chores. Not one of the village houses, whether rented or self-owned, was made of brick: most were made of tin, a cheap building material. Tin was used mostly for roofing, and occasionally as a wall (although more typically, cheaper bamboo strips are used). The majority had a mud floor. These types of houses are at great risk of collapsing during the rainy season; sometimes rain leaks into the houses, flooding the floor. In most cases, five or six people – or more – live in one room. These people are particularly vulnerable to the elements; a combination of high density, poor quality housing, and overall poverty puts them at increased risk of disease.
Female bidi workers are busy in making bidis inside a factory, Photograph: Anupom Roy, 2008. A female child working inside a factory, Photograph: Anupom Roy, 2008.
Bidi smoking
As bidi smoking is seen as the smoking habit of both the poor and working-class people in Bangladeshi society, cigarette smokers reacted strongly when they were asked whether they smoked bidis. They responded that I (the researcher) should have immediately intuited that they smoked cigarettes after observing their clothes and hearing their way of speaking. According to them, people who smoke bidis rarely wear pants and shirts; they wear lungi 7 and speak a village dialect of Bangla rather than the urban formal dialect. In this context, a person’s economic situation indicates the behaviour society expects of him with regard to smoking. Because bidi smoking is associated with poverty, cigarette smokers feel ashamed when asked if they smoke bidis, as confirmation automatically signals that they are poor and of low social status. Yet when I asked bidi smokers whether bidis are only for the poor, many reacted strongly, insisting that bidis were also consumed by rich people. One of my informants, a rickshaw puller, said: ‘Not only rickshaw pullers but many good people smoke bidis. I know a cigarette seller who has the ability to smoke cigarettes but he prefers Akij Bidis.’ When my informant said ‘good people’, he meant people in better socio-economic circumstances, a comparison that conveyed his perceptions vis-à-vis his own social status. Further inquiry revealed that the association of low status with bidis angered some; one informant said: ‘If the rich people were not rich they would also smoke bidis.’ In this way, the association between bidis and socio-economic status is seen by bidi smokers as a continuum of honour and shame, with moral status conferred by socioeconomic status and symbolized by the form of tobacco one smokes.
Initiation into smoking often has deep familial and social roots. Elderly Kamruddin, grandfather of Saiful, always smokes a hukka, sitting either in the yard or in the rice field. Saiful spends most of his time with his grandfather; sometimes, Kamruddin tells his grandson to light his hukka with a piece of burning firewood from the kitchen. Then he asks him to take the first one or two puffs, to make sure it is properly lit. The culturally engendered, amicable, and often humorous relationship between the grandfather and his grandson may have initiated Saiful’s own smoking although the latter claimed that he smoked his first bidi with friends. Many of my informants had similar family-related smoking experiences. Stealing rice from home and giving it to village bidi sellers in exchange for bidis or stealing bidis from their fathers’ pockets were the most common ways of accessing bidis during childhood. Bidis were smoked in the rice field or in other hiding places, out of their parents’ sight.
Unlike Saiful, Shahin was introduced to bidi smoking by his fellow workers. Although Shahin is a rickshaw puller, he also works as a hired farmer during the cultivation season. On one occasion, he, along with some of his fellow villagers, went to Chittagong for four months to work as hired farmers for a landlord there. On his first day, the landlord called all of the workers to his room and gave each a bidi. Shahin took one when his turn came; he did not refuse the landlord, nor did hetell him that he was a non-smoker. When all of the other hired farmers accepted the bidi they were offered and lit it, Shahin did likewise, fearing that refusing the landlord’s offer would create a negative image of himself.
Thereafter, each worker was provided with two packets of Abul Bidi on a daily basis: Abul Bidi was a famous brand in Chittagong. Shahin realized that he was the only non-smoker among all 40 people gathered there. He was facing his own difficulties. He felt strange being in a new place, with people who spoke different dialects. He remembers that he was unable to understand their language for the first few days. The landlord had a sizable backyard in which five big tin sheds had been built to house the farmers. Fortunately, Shahin’s nine roommates were from his own village; so, they all became friends after staying a few days together. His wish to fit in may have underpinned his decision not to divulge the fact that he was a non-smoker. He thought that his co-workers might think him ‘different’, so he started smoking. When inhaling initially caused him to cough, he told the others that he had a cold. He smoked more at night while chatting with his roommates before going to bed. He also smoked during breaks while working in the rice field.
The free distribution of bidis by the landlord can be analysed as an attempt to enhance the labour performance of the farmers. Jankowiak and Bradburd (1996), who explored how ‘drug foods’ are used as ‘inducers’ and ‘enhancers’ of labour performance, argue that colonial agents (traders, merchants, settlers) faced problems in persuading native populations to perform new forms of labour. They overcame these problems by fostering chemical dependency in their workers. Alcohol and tobacco were identified as the most frequently used labour inducers. But, in the story about Shahin, we see not only how tobacco works to solidify the patron–client ties between landlord and labourers and enhance their labour but also how it has become part of a shared ritual of commensality and collegiality between workers in the fields and in their temporary living quarters. For Shahin, the outcome was tobacco dependence by the end of the harvest season.
Kuddus’s experience with regard to smoking was quite different. A 70-year-old rickshaw puller, Kuddus had a problem with pet fapa (gas and bloating in the abdomen) in his childhood. His father took him to their village doctor who prescribed various medicines, but the problem persisted. One day, the doctor advised his father to let Kuddus smoke the hukka. After smoking for one week, Kuddus started to feel better and continued to smoke the hukka with his father in the house. But, it was not long before he realized that he had developed an appetite for smoking even when he was not at home. It is not possible to smoke the hukka outside of the home because of the elaborate preparation procedure. He thus found bidis to be a cheap alternative.
Jabeda, a 40-year-old female scrap metal collector, 8 had an experience similar tothat of Kuddus. By the time she was 12, she was experiencing stomach ache andabdominal gas. Her grandfather allowed her to chew the ash from the hukka and this made her feel much better. After the death of her grandfather, she consulted the village doctor, who was her late grandfather’s friend. Because of the unavailability of the hukka due to the complex procedure involved in lighting it, the doctor suggested that she take one or two puffs of bidis whenever she had stomach pain. During the first few days she felt dizzy and started to cough, but after a few days, she noticed that she was smoking even when she had no gas or stomach pain. Now she considers herself addicted to bidis.
Amena, a 55-year-old female day labourer, has to look for a new job every day. She usually finds work on construction sites, breaking bricks into small pieces manually; later, the pieces are used in the construction of high-rise buildings. Amena earns approximately 145 taka per day: she thinks that Allah does not like her and is taking everything she has. She lost her parents when she was very young and was reared by her aunt. After being married for a year, she gave birth to a son, much to the delight of all. Everything went well until her husband fell in love with another woman and abandoned Amena and her seven-year-old son. The following year, her son died in a road accident when he was coming home from school. Her son – her only child – was her hope for the future; understandably, his death left her constantly sad. Frustration engulfs her when she thinks about how she will have no one to take care of her in her old age when she will no longer have enough strength to work.
A few years earlier, she, along with five other women, was working on a construction site. After working all day, they all waited to be paid, a time they spent smoking and chatting among themselves. Armena joined in their chatting and one day was invited to try a bidi. She initially pondered whether she should try (what she perceived as) a ‘male’ thing. The other women told her that smoking bidi would make her feel better: ‘just try one puff’. After a moment’s indecision, she decided to try one. It tasted unpleasant and made her feel dizzy. She returned the bidis to her workmate; but, the woman said she would like it after smoking a while longer. Amena continued to work on the construction site for a few days and continued to smoke bidis with her workmates.
Unlike the ways in which males were introduced to smoking the hukka, female smokers’ initiation into smoking was mostly influenced by neighbourhood women of the same age. All informants had a habit of chewing paan (betel quid), which has social acceptability among all ages and genders. There was no attempt by the female informants to hide the fact that tobacco was chewed with paan, a form of smokeless tobacco consumption. They did, however, hide their bidis in the presence of men.
Some clear themes and patterns emerge in the cases presented above. All of the participants in my study had at least one family member who smoked. In most cases, he/she was head of the family; that is, responsible for feeding the whole family. Informants also acknowledged the possibility of familial influence: the smoker had the respect of all members of the family. Earlier studies have specified parental smoking behaviour as an important factor for young family members’ smoking initiation (see Haddad and Malak, 2002; Nichter et al., 2004). Most of my informants reported that their first experience of smoking was tinged with the fear of being caught by their parents, suggesting another link between social hierarchy and smoking patterns: smoking by people at the top of the social register is generally acceptable just as it is among the aged, but it is discouraged amongst others. Informants also reported similar physical effects attributable to first time smoking: dizziness, headaches and thirst, combined with a powerful feeling of nervousness lest any senior person of the village should see them smoking and tell their parents. After initiation into smoking, several factors were found to influence the continuation of the habit. Informants listed various physical and socio-cultural problems as reasons for smoking. Stomach ache, abdominal bloating and constipation were seen by informants as a reason for continuing to smoke. Informants argued that these symptoms became unbearable if they quit smoking. Beyond these physical issues, social issues created influential contexts for smoking. As I will delineate later, being tense and anxious about family expenses, experiencing disputes with fellow workers and family members, and being underpaid at the end of the day all influenced them to smoke more.
Familial and societal experience
Forty-year-old Shahidullah often thinks about what he has done in his life and how he may have been in a better position had he made sounder decisions. Shahidullah works for a local NGO as a security guard. The low wages make him ashamed of this profession. His family had earlier been rich, but, after his father passed away, he and three of his brothers divided the family land into four parts after deciding to live separately. Shahidullah thinks that he was given a part of the land which was not fertile, but he could not complain as his eldest brother worked for the police department. He feared that he might be imprisoned by his brother if he did not acquiesce. Being the youngest son of the family, he had never worked with his father in the fields; he did not know how to hire farmers and make them work efficiently. He tried for two years, during which time he borrowed a large amount of money for family expenses and fertilizer. But he was unable to repay the loan because he was not making any profit from the land, so he decided to sell some ofhis land to repay the loan and then get a job. Shahidullah had few choices asheonly had a 10th-grade education. Finally, he accepted a job as a security guard.
Around that time, Shahidullah decided to compete in the Union Parishad 9 member election; in hindsight, he sees it as the worst decision of his life. He stood for election three times. Each time, he sold a part of his remaining land in order to meet election campaign expenses. It was during the election campaign that he started smoking: he provided the voters in the village with bidis and betel quid, at the same time asking them to elect him. During bidi distribution, he started smoking as a gesture of friendship towards voters who smoked. However, after three election failures, he became disappointed and frustrated. He had not only lost most of his land and his salary but was no longer happy with his wife, who disagreed with him regarding the way he ran the family and quarrelled with him every day. Unlike his brothers, the couple do not own their own house; for this and other reasons, his wife always calls him ‘the biggest failure in the world’. He has two daughters and one son but cannot earn enough money to build a house and secure a good future. His brothers, apart from not providing any financial help, on occasion behave badly towards him.
The combination of these factors has exacerbated his smoking habit; in addition to smoking two and half packets of bidis per day he also smokes ganja (cannabis) during the evening when he finishes work. There is a tea stall in the bazaar where people congregate after the magrib azan (Muslim evening prayer) to smoke ganja. He smokes both forms together; according to Shahidullah, if he doesn’t combine the two, ‘the real feeling of ganja cannot be felt’. He cannot smoke ganja during thedaytime because it is not socially acceptable and people might see him. So, he smokes bidis during the daytime. He prefers Akij Bidi brand, the one he considers the ‘most powerful brand’: ‘The tobacco in Akij is very good and gives a feeling similar to that of ganja.’ Although his problems persist, smoking bidis allows himtime to think, to reflect on his life and to contemplate what he can do in the future.
Other informants reported various issues which had made them feel frustrated and influenced them to smoke. Such frustrations emerged from their everyday tensions and problems. For example, one informant named Shahin fell in love with a girl whose father was a very rich person in the village. Because Shahin was a poor rickshaw puller, he could not marry her. He thinks that had he had enough money, he would have proposed to her. But, he is the only provider for a family of seven consisting of two brothers, two sisters and his parents. He has an older brother who distanced himself after he married; this brother does not give any economic support to the family. It is time now for his sisters to marry and Shahin is worried because he is incapable of providing each with a dowry in order to attract good bridegrooms. Although one of his two younger brothers works in an ice cream factory, he does not provide any economic support to the family. Shahin is reluctant to ask him for support because his brother is younger than him; it is Shahin’s responsibility as head of the family to feed the family. Most of the informants reported similar tensions arising from household and other expenses. For them, the price of daily goods was too high to allow a decent life. When family members became ill, they had to borrow from others to meet the medical costs. This means that they have to work even harder to repay their debts. Together, these problems make them feel angry and drive them to smoke more.
Although smoking has greater social acceptance than other drugs, in Bangladesh it is still stigmatized to a degree. In Bangladeshi culture, smoking in the presence of the elderly suggests lack of respect and honour. Many informants insisted that they try to avoid smoking in front of the elderly. However, it seemed that avoidance is practised mainly when the elderly people are known to the smoker or are from the same village. One of my informants stated that if the elderly people were from his village, they knew his parents. After seeing him smoking, they might comment to each other that his parents had failed to socialize him correctly.
A variety of influences combined to create an appetite for smoking. Most of the informants were involved in work involving physical labour. Nearly all of them had experienced disappointment at being underpaid on completion of their work. In many cases, they were not given the amount of money they were promised. On occasion, a rickshaw puller might not be given the correct fare. But, in the context of Bangladeshi rickshaw pullers, it is difficult to determine what payment is correct given there is no standardized fare chart for rickshaw pulling. Passengers bargain with the puller before climbing into the rickshaw, both parties attempting to fix the fare prior to departing. On occasion, passengers do not discuss the fare; they simply tell the puller that (what they consider) an adequate fare will be paid. If the offered fare is agreed upon, both parties are happy. If a decision is not reached prior to riding, the rickshaw puller might feel he is being underpaid or the passenger might feel he is being overcharged. Like rickshaw pullers, daily labourers too feel ‘short-changed’ when they are paid less than satisfactory wages.
No standard wage chart exists for daily labourers: exploitation leaves both groups of workers feeling helpless. Informants’ perceptions in this regard were related to their socio-economic status. Because they are poor and are perceived to have little social leverage, they cannot stand up to their passengers or employers. Some rickshaw pullers who attempted to resist exploitation were physically abused by passengers. The anger my informants suffered as a result was relieved by smoking several bidis in rapid succession, using the content as a calming mechanism. The smoking of bidis under these circumstances contributed to the symbolic ‘destruction’ of the person who initiated the problem. The Bangladeshi term for anger is matha gorom, literally meaning ‘hot brain’. Informants suggested that matha gorom occurs in a variety of situations. Male informants claimed that disputes with their wives, tension over family expenses, and quarrels with fellow workers were the situations that angered them most and provoked smoking. Nichter et al. (2009b) have also discussed the calming effects of smoking on anger in other developing countries.
Smoking and coping
Helal, a 25-year-old rickshaw puller, smokes two packets of Akij Bidi daily and considers himself addicted. His father, a hukka smoker, has had a cough for a long time. The family members cannot sleep at night because of the father’s coughing. Helal attributes his father’s cough to the latter’s smoking of the hukka. When comparing bidis with the hukka, he feels bidis are less harmful. But, he is aware that smoking bidis over a long period of time could cause him to cough like his father. For this reason, he wants to quit. In fact, he tried to quit, but, after three days he resumed smoking because he said he could not breathe properly and that his stomach had become bloated with gas. His stomach looked like a balloon and felt extremely uncomfortable after he had not smoked for three days. He thought of consulting a doctor, but one of his fellow rickshaw pullers suggested that it was not a serious problem and advised him to resume smoking bidis. Considering the doctors’ consultation fees and other associated costs, he decided that bidis were a good alternative. He started smoking again and the following day he felt much better. For Helal, bidis represented a viable (and more enjoyable) alternative to seeing a doctor. But, he believes that he may eventually contract TB (tuberculosis) unless he stops smoking bidis. Somewhat ironically, he is not very worried about contracting tuberculosis as most of the government hospitals and branches of BRAC 10 provide free and readily available treatment for the disease. He thinks that by the time he turns 30, his ‘blood will be cold’. He will lose his current strength and finally his body will no longer be able to tolerate bidi smoking. His perception is that ‘cold blood’ is associated with weakness and age and that ‘hot blood’ is associated with strength and youth. So, he plans to quit smoking when he reaches 30.
Also supporting the general theme of bidis as a quick and efficient treatment for pet fapa is Kadir, a 54-year-old daily labourer, who reported that bidis work as a remedy for people who are constipated. Kadir has found them very helpful in this regard for nearly 10 years. But, he claims, if he runs out of bidis in the morning, he cannot defecate properly and this makes his day very uncomfortable. He tries to make sure that he has an adequate stock of bidis before he goes to bed; if he forgets, he has to go to the village bazaar in the early morning to get a further supply. He also habitually smokes one or two after each meal. In his view, bidis help to digest his food: if he fails to smoke after each meal he feels uncomfortable; he feels that he will develop abdominal gas resulting from indigestion. Similarly, female informants, irrespective of whether they were smokers or smokeless tobacco users, reported that they used tobacco to prevent and cure abdominal gas and aid digestion.
Hakmat, a 40-year-old daily labourer, said: ‘If I smoke 2 to 3 bidis [in the morning] and have a cup of tea, I do not have to eat anything until 1 o’clock.’ For many years, Hakmat has gone without breakfast. It has become his routine to smoke a few bidis and drink a cup of tea at the sidewalk tea stall on his way to work. Previously when he felt hungry, he did not always have enough money to buy food. He realized that drinking two cups of tea (which is cheaper than breakfast) would help to suppress his appetite. Hakmat explained that one cup of tea from a sidewalk tea stall costs two taka while breakfast costs at least 10 taka. He enjoys smoking with a cup of tea. Rather than spend two taka on one cup of tea, he prefers to get 25 sticks of bidis for six taka. Considering that his daily income is approximately 150 taka and that he has to support a family of nine, he tries to save on the cost of breakfast. Hakmat’s lunch break is at 1 pm. Along with most of his fellow workers, he goes to one of the open sidewalk restaurants where an elderly woman cooks a porridge of rice and potato. Her food is cheaper than in other restaurants. After working the whole day, he collects his wages and goes to the bazaar to buy rice, pulses, and sometimes vegetables for the family dinner.
Many informants in this study reported pursuing the same routine for their meals. Symptoms of belching and abdominal gas were common. Several biomedical studies have reported a close association between tobacco consumption and dyspepsia, arguing an increased rate of gastrointestinal disorders among people who consume tobacco (Crean et al., 1994; Häuser and Grandt, 2002; Nandurkar et al., 1998; Shah et al., 2001). It is striking to note the differences between the biomedical research findings and the smokers’ own perceptions. Smokers believed that they were gaining relief from the physical symptoms alluded to above whereas biomedical research found tobacco consumption to be a causal factor in dyspepsia. However, some scholars have found a link between lifestyle and dyspepsia. For example, Mediås and Rutle (1993) show that patients with dyspepsia tend to divulge a high degree of economic worry and stress over occupational and family issues. Upon comparing dyspeptic patients with another group with no dyspeptic symptoms, this study, although small, did not find any significant difference vis-à-vis eating habits or alcohol consumption but they did establish a link with tobacco consumption. Several studies undertaken in South Asia also detected an inverse relationship between smoking and the socio-economic status of the population (see Efroymson et al., 2001; Sorensen et al., 2005).
These studies may shed light on the experiences of my informants, most of whom were poor and marginalized and faced continual hardship in their everyday lives. Their economic circumstances constrained their lifestyle choices. They suffered from physical ailments such as stomach aches and abdominal gas but were unable to afford to see doctors. Some of their dyspepsia may have been caused byhunger. With their limited incomes, they struggled to feed their families. Both women and men informants argued that smoking bidis, consuming betel quid and drinking tea helped suppress their appetites. As smoking is not socially acceptable among women, smokeless tobacco, that is, betel quid provided an effective alternative – another way of suppressing hunger. Male informants also consumed smokeless tobacco, especially betel quid, but smoking bidis was the most commonly noted form of tobacco consumption among males. Having a few bidis and a few cups of tea in the morning was positively regarded by informants as it saved them the cost of breakfast and kept them from feeling hungry until the afternoon. Nevertheless, when I enquired directly about the link between hunger and smoking, the informants were initially reluctant to admit that they smoked bidis in the morning as a way of suppressing hunger. Their reluctance may have been attributable to feelings of shame, of being poor and having to admit it. They seemed to have internalized the realities of poverty and hunger: their coping strategy was to suppress both their physical feelings of hunger as well as their mental awareness of it.
Prostitutes and grandmas
Attitudes towards women smokers amongst the informants varied and were even contradictory. Whereas young women smokers were regarded very negatively, the cultural prohibition on women smoking was weaker in the case of elderly women smokers. In a group interview with male bidi smokers that Iinitiated, all of the participants reacted very strongly when discussing women smokers. They stated that ‘good women do not smoke’. After I questioned them several times, one of them defined ‘bad women’, speaking in a low voice so that other people standing adjacent to the tea stall could not hear his comments. According to him, ‘bad women’ were involved with prostitution. I was somewhat taken aback. To date during my fieldwork in Bangladesh, I had never encountered anyone who spoke openly about sex or prostitution. An unwritten social taboo forbids discussion of such topics. The other participants smiled, showing support for his judgment of such girls. One man said: ‘In our area (village), some women like bad women – women hawkers and Bede women 11 – smoke bidis. They have relations with various men other than their husbands. They even drink alcohol. Can you imagine?’ Some participants became angry when discussing women’s smoking, arguing that it was totally unacceptable for a woman to smoke. Another of the men being interviewed responded angrily, saying: ‘Women who smoke bidis, they should eat shit rather than our bidis.’ In a separate in-depth interview, a young labourer compared women’s smoking to women wearing men’s clothing. Just as society would never accept a woman wearing a lungi because it would look ugly on her, he argued, so too was the sight of a woman smoking ugly. He also argued that religious and social learning are important to understanding women’s smoking. He said:
Our women are good, they do not smoke. But I have seen many Christian women in Chittagong district smoke. I heard that those Christian women also drink alcohol. Besides I have seen a few women smokers in the city who wear pants and shirts. They are not good. But you [the researcher] will hardly find any good women in our area [village] who smoke.
This informant used to work as a hired farmer: he went to Chittagong to work for a landlord. Chittagong, a hilly coastal area in southeast Bangladesh, is home to many small ethnic communities, all of which have their own languages and lifestyles which differ from those of the mainstream dominant Bangladeshi people, who live in the relatively flat land that covers most of the country. Mainstream people who visit Chittagong and observe the lifestyles of the above small ethnic groups are frequently shocked by the contrast with their own beliefs and values.
Women’s smoking was strongly opposed by all of the male informants who participated in the study. However, the level of opposition seemed less severe when discussing elderly women smokers, who are usually referred to as nanis (grandmothers). While my informants did not support smoking among elderly women, their position regarding them seemed less condemnatory than that regarding younger girls’ smoking. One of the informants said:
I know an elderly woman in our village, we call her nani. She smokes bidis. Sometimes I give her some bidis from my stock when she has run out and asks me for some. The way nani smokes bidis is funny (laugh …). I told her to quit as it is bad for her health. [But], she has become addicted … and cannot give up ….
Women also condemned tobacco smoking by other women. Most of my female informants argued that smoking tobacco brought great shame upon women. Nasima, an 80-year-old female beggar, has only one son; he does not provide her with any economic assistance. Being elderly, she is unable to do physical work. A few years ago, after her son abandoned her, she started begging. She earns around 60 to 80 taka per day. Her doctor prescribed her two tablets daily for her gastric problem. Uncertainty about her income always keeps her mood tense. Her first priority is to get money for her medicine, then for her food. She goes without breakfast, arguing that she does not feel hungry if she smokes two or three bidis after waking up. Nevertheless, critical of her own habit, she commented: ‘It is a great shame for women to smoke. People will see and they will say a lot of bad things. If women badly want to smoke they should smoke inside the house or in a place where males will not see.’
Men and women both stated that smoking is a ‘male thing’: women who smoke may be seen as ‘disrupting the attributes’ of the extant, social feminine ideal. In a patriarchal society, perceptions of this ‘disruption’ among men are very strong; for example, as suggested above, one male informant participating in a group discussion angrily compared women’s smoking to eating shit. However, as the ethnographic data show, men’s perceptions of young and elderly women smokers are related to sexuality, reproductive status and age status. Young women smokers were considered ‘bad women’ (prostitutes), but, this judgement was not applied to elderly women. In contrast to young women, elderly women are not considered sexually attractive: this may explain the contradiction between tolerance of elderly women smokers and the condemnation labelled at young women smokers. Despite this strong social disapproval of women smoking, women, along with children and other household members, are regularly exposed to second-hand smoke, as is the case in many other countries (see Nichter and Cartwright, 1991).
Perceived consequences of smoking
Some informants considered cigarette smoking more dangerous than bidi smoking. One respondent stated: ‘Cigarettes have something else than just tobacco for sure, they have some substance like heroin so that people would get addicted and they must buy those expensive cigarettes.’ These informants viewed bidis as less harmful: smoking bidis would create ‘only a cough’, which could be treated by taking a common cough syrup bought from the chemist. However, smoking bidis over a long period was believed to lead to tuberculosis. One informant explained his folk theory regarding how tuberculosis occurs: ‘Smoking one bidi creates one spot on your lung; smoking bidis for a longer period of time creates lots of spots, and the accumulation of those spots comes out of the mouth as blood and it is called tuberculosis.’
In an attempt to explain how the whole principle worked, he provided a theatrical demonstration. First, he took a deep puff from a bidi and then exhaled the smoke directly onto his left thumbnail; then, he took another deep puff from a (regular) cigarette and exhaled it onto his right thumbnail. Then he held up both thumbnails together for me to see and videotape. Comparing both thumbnails, he pointed out that the spot on the right thumb was more scattered and covered most of the nail, while the spot on the left thumb was more concentrated and covered only a very small portion of the nail. He argued that this illustrated that smoking cigarettes reached and destroyed a wide area of the lungs, whereas bidi smoke only accumulated in a small portion of the lungs and would be expelled by coughing.
However, some male informants want to quit smoking because they know they will eventually develop a persistent cough; they know this having experienced sleepless nights caused by the coughing of their uncles or fathers. Changing one’s bidi brand is also thought to cause a cough; thus, my informants thought it was advisable to always smoke the same brand.
Tobacco in Bangladesh
Studies have shown that if Bangladesh’s smokers were to redirect their smoking expenditure to food, this would be sufficient to prevent 127,750 child deaths (under five years of age) from malnutrition each year: 10.5 million malnourished people could enjoy an adequate diet (Efroymson et al., 2001). Additionally, it has been estimated that every year Bangladeshi bidi smokers spent 29.12 billion taka on bidis (Roy et al., 2010, Roy et al., in press). Thus, an effective tobacco control strategy could have a significant impact on the overall socio-economic situation. WHO MPOWER advocates a package of six tobacco control policies: 1) monitoring tobacco use; 2) protect people from tobacco smoke; 3) offer people help to quit tobacco use; 4) warning about the dangers of tobacco; 5) enforcing bans on tobacco advertising, promotion and sponsorship; and 6) raising taxes on tobacco. All of these are considered ‘proven policies aimed at reversing the global tobacco epidemic’ (World Health Organization, 2009a: 3). On an individual level, studies have argued the effectiveness of the active role of physicians in encouraging individuals to quit smoking, especially among the sick (Ng et al., 2008; Pradeepkumar et al., 2008; Thankappan et al., 2009). To ensure this role of physicians, it is imperative that the harmful effects of tobacco use are included in the medical curriculum, and that physicians and other healthcare services personnel themselves quit smoking (Mohan et al., 2006). However, in the case of bidi smokers, the roles of formal medical doctors are only tangentially relevant considering the fact that these smokers generally lack access to formal medical doctors, and as the case studies presented here show, some individuals turn to bidis for relief from medical problems as a cheaper alternative to visiting a physician.
In light of the unique demographic characteristics of bidi users, popular misperceptions about the relative harms of bidi versus cigarette smoking, and their widespread availability and use, bidi smoking requires special attention when it comes to tobacco control strategies, especially if the country is to achieve the United Nations Millennium Development Goals (MDGs). Esson and Leeder’s (2004) study shows how each of the eight MDGs is closely related to tobacco consumption. A large proportion of smokers worldwide are middle-aged and living in low and middle-income countries; their illnesses reduce the productive workforce by extension, slowing efforts at poverty eradication. Achieving universal primary education is hampered by the utilization of child labour in tobacco cultivation and production. Esson and Leeder further argue that tobacco advertising in developing countries encourages women to smoke as a symbol of success and independence, thereby endangering their own and their family’s health. Passive smoking in the family disproportionately affects women and children: women who use tobacco tend to give birth to smaller and weaker babies. Smoking exacerbates illnesses in people with HIV/AIDS, creates conditions that facilitate the development of tuberculosis, and increases the risk of death. Tobacco growing contributes to deforestation, especially in developing countries; this, in turn, threatens environmental sustainability. Finally, Esson and Leeder contend that failure to include tobacco control in global development actions will seriously threaten sustainable development in the world’s poorest countries through disability and premature death (Esson and Leeder, 2004).
While Esson and Leeder’s argument is compelling, we need to go beyond it to gain a deeper understanding of tobacco consumption in Bangladesh. Their discussion about the relations between achieving MDGs and tobacco control does not take into account the everyday lived reality of the country’s poorest consumers. The central issue here is much deeper and more structural, namely extreme poverty and the socio-economic status of the country’s poorest and most marginalized consumers, many of whom smoke to curb hunger. Many of my informants reported that smoking bidis and drinking tea in the morning was a cheap way of suppressing their appetites for breakfast. Rickshaw pullers in particular, who often felt cheated by the low fares they were paid, smoked to relieve their frustration. Poverty works as a catalyst minimizing the mental strength to fight against injustice. Smoking offers relief from – and provides symbolic resistance to – all of the above disappointments and frustrations (see also Singer, 2008). Bidis, which are considered a socially acceptable, mood-altering drug (at least more acceptable than other drugs such as cannabis), symbolize relief from everyday tension, anger, perceived exploitation and disappointment. In addition, the price and availability of bidis provide an ‘affordable’ type of smoking. The wide acceptance of bidis as the smoking habit of the poor may also influence poor people to initiate bidi smoking, which is then accelerated by the everyday experience of a range of disappointments. For all of these reasons, bidi consumption has become deeply embedded in patterns of sociability linked with poverty.
In addition to these economic and structural reasons, it is important to look at other complex ways in which tobacco is culturally embedded in people’s lives and not a simple matter to extricate, from the way it symbolizes hierarchies and social stratification to the important role it plays in hospitality and reciprocity. Current legislation and tobacco control strategies assume that restricting tobacco consumption and convincing poor people to quit smoking will reduce smoking prevalence, but smokers’ everyday lived experiences reveal more of the complex features of tobacco consumption behaviour. Simply enacting stronger legislation cannot address the myriad associated ways that drug use is embedded in social structures and cultural norms.
When examining tobacco control strategies from the perspective of the cultural, social and economic structures in poor countries, it is also important to look at the global expansion of cigarette companies. In the 15th century, Christopher Columbus (1451–1506) brought tobacco to Europe as a medicinal drug, but by 1600, smoking had become a common practice among Europe’s poor and working classes because of its mood-altering properties and recreational use. In time, the English turned to other countries for the marketing of their surplus production (Baer et al., 1997; Singer, 2004). Today, the sizeable populations of developing countries make such countries an irresistible lucrative market for multinational cigarette companies eager to expand their sales. The use of local cultural features in attractive advertisements contributes to a normalization of smoking behaviour by these companies (see Nichter et al., 2009b).
Nevertheless, focusing on the profit-making strategies of multinational cigarette companies is not enough to understand the global political economy of tobacco consumption. The focus of all of these promotional campaigns is upon commercially produced cigarettes, simultaneously neglecting other forms of tobacco consumption. It is true that the consumption of commercially produced cigarettes is increasing in developing countries, and requires proper attention and intervention. Other forms of tobacco consumption, such as bidis and other smokeless tobacco products, although ‘highly addictive and high in carcinogens’ (Ray and Gupta, 2009: 1324), have not received the same degree of attention from international campaigns and strategies as commercially produced cigarettes.
Two particular areas merit future investigation. First, the perceptions of betel quid users are virtually unrepresented in the current literature. Studies undertaken among immigrant Bangladeshis show that most informants are unaware of the fact that chewing betel is carcinogenic (Ahmed et al., 1997; Summers et al., 1994). Second, as this study suggests, tobacco users may also use other drugs (such as ganja), which makes issues of co-occurrence and co-morbidity, and their embeddedness within structural inequalities, a further area of inquiry. The impact of co-occurrence and co-morbidity may be worse in poor countries such as Bangladesh than in others, due to the limited resources of the former.
In sum, the socio-economic structure of Bangladesh with its inequality, poverty and exploitation contributes to the tobacco consumption habits and related health problems of the poor (for a similar framework, see Bourgois, 1995; Farmer, 2003, 2004; Scheper-Hughes, 1992; Singer, 2008; Singer and Baer, 1995). Any investigation of tobacco consumption in the world’s poorest countries requires a holistic approach, exploration of the links between cultural forms of gifting and sociability, embedded structures that perpetuate poverty and inequality, and the global context of expanding tobacco companies. Consideration of tobacco use goes far beyond health to aspects of education and social justice: it is on the wane amongst the wealthy and on the rise amongst the poor, and profits from its production are heavily concentrated amongst the elitist few. Meanwhile, the workers – who represent so many of the users – live in abject poverty.
Footnotes
Acknowledgement
I am greatly indebted to Dr. Lisa L. Wynn, Dr. Estelle Dryland and Debra Efroymson for their comments on an earlier version of this article. I thank the five anonymous reviewers for their valuable suggestions and comments. I thank my research assistants Avijit Roy and Lutfur Rahman for their assistance during the fieldwork.