Findings Overall households reported positive expenditure
Findings Overall, 8693 (71·02 %) households reported positive expenditure on tobacco (smoking, smokeless, or both), and were classified as any-tobacco users. Of these 8693 households, 2061 (16·8%) used smoking tobacco only, 3284 (26·8%) used smokeless tobacco only, and 3348 (27·4%) used both. After controlling for household expenditure, household size, place of residence, and education, any-tobacco users consumed significantly lower amounts of vegetables per household (β=–18·35 g/day; p<0·0001), milk and dairy (−12·83 g/day; p<0·0001), fish (−11·19 g/day; p<0·0001), meat (−7·60 g/day; p<0·0001), legumes (−3·31g/day; p<0·0001), eggs (−1·60 g/day; p<0·0001) compared with tobacco non-user households. However, mean daily intake of cereal products (β=24·744 g/day; p<0·0001) was significantly higher in any-tobacco users than in non-user households. We observed similar significant associations for users of smokeless tobacco versus non-users.
Interpretation The project provides evidence to support policy recommendations for addressing poor dietary intakes and the malnutrition burden in tobacco-user households in developing countries such as Bangladesh. Addressing tobacco use in relation to malnutrition would make tobacco control a higher priority for developing countries and for meeting the post-2015 development agenda of eradicating extreme poverty and hunger.
Declaration of interests
Acknowledgments An abstract based on this sodium salt study also appears in Cancer Epidemiol Biomarkers Prev March 2016; 25: 561.
Abstract Background In 2009, Uganda implemented a programme of indoor residual spraying of insecticide (IRS) in ten districts in the Northern Region with historically high malaria transmission intensity. This programme was successful in reducing the burden of malaria; however, in May, 2014, IRS was discontinued, to be replaced by universal distribution of long-lasting insecticide-treated bednets. The aim of this study was to assess changes in malaria morbidity during and after IRS discontinuation in one district in Uganda. Methods We gathered individual-level malaria surveillance data from one outpatient department and one paediatric inpatient setting in Apac District. Data collected included whether malaria was suspected and the results of laboratory testing. Primary outcome was the test positivity rate (TPR), defined as the proportion of people tested who had laboratory-confirmed malaria. We evaluated temporal changes in TPR as a categorical variable, taking in to account baseline, initial period of effective IRS, sustained IRS, and discontinuation of IRS and using an interrupted time series analysis controlling for method of testing, seasonality, and autocorrelation with calendar time. Findings Outpatient visits were recorded over a 77-month period and included 126 260 patient encounters: 67 634 patients (53·6%) had suspected malaria and 65 421 (96·7%) of patients with suspected malaria underwent laboratory testing. In children under 5 years, baseline TPR was 60–80% with an initial decrease of 5·95% per month (CI −8·46 to −3·44%, p<0·0001) after implementation of effective IRS followed by a sustained decrease of 0·42% per month (CI −0·70 to −0·14%, p=0·004). From month 4 to month 18 after discontinuation of IRS, TPR increased by an average of 3·30% per month (CI 1·88–4·73%, p<0·0001), eventually returning to baseline levels. Similar trends were seen in patients older than 5 years. For the 14 595 inpatient admissions, TPR increased by an average of 6·5% per month (CI 4·34–8·66%, p<0·0001) between month 4 and month 18 after discontinuation of IRS, reaching a point where almost 100% of children tested positive for malaria. Interpretation The discontinuation of IRS in an area with historically high transmission intensity was associated with a significant increase in malaria morbidity, reaching pre-IRS levels within 18 months, despite universal distribution of long-lasting insecticide-treated bednets. These findings have important policy implications for sustaining reductions in the burden of malaria in high transmission settings.