Global socioeconomic inequalities in tobacco use: internationally comparable estimates from the World Health Surveys

High prevalence of current tobacco smoking among patients with tuberculosis and people living with HIV in Jordan: A cross-sectional survey

INTRODUCTION

Continued smoking by patients with tuberculosis (TB) and people living with HIV (PLHIV) leads to adverse treatment outcomes. Estimates of tobacco use among the population are scarce in the Eastern Mediterranean region, where the burden of TB and HIV is also low but highly variable. This study determined the prevalence of current smoking and assessed factors associated with current smoking among patients with TB and PLHIV in Jordan.

METHODS

We analyzed data from the Jordan Knowledge, Attitude, and Practices survey in 2021. Information on current tobacco use, including products and frequency of smoking, was collected from 452 patients with TB and 152 PLHIV. We performed multivariable logistic regression to assess the sociodemographic characteristics independently associated with current smoking.

RESULTS

Prevalence of current smoking was 43.8% among TB patients and 67.8 % among PLHIV, and conventional cigarettes were the most used tobacco products. The prevalence of current smoking among patients with TB was higher among males (AOR=8.20; 95% CI: 5.05-13.32), Jordanians (AOR=5.37; 95% CI: 2.66-10.86) and Syrians (AOR=4.13; 95% CI: 1.60-10.67), and those experiencing financial difficulties (AOR=2.83; 95% CI: 1.69-4.74). The prevalence of current smoking among PLHIV was higher in those with financial difficulties (AOR=3.13; 95% CI: 1.19-8.27).

CONCLUSIONS

Nearly half of the patients with TB and PLHIV were current tobacco smokers, higher than the general population. There is an urgent need to investigate the reasons for such a high smoking prevalence and introduce and strengthen smoking cessation services under the TB and HIV control programs.

Perceptions of friendship, peers and influence on adolescent smoking according to tobacco control context: a systematic review and meta-ethnography of qualitative research

BACKGROUND

A relationship between smoking and interpersonal influences has been well established within the literature. There have been cultural shifts in denormalisation and a reduction in tobacco smoking in many countries. Hence there is a need to understand social influences on adolescents' smoking across smoking normalisation contexts.

METHODS

The search was conducted in July 2019 and updated in March 2022 within 11 databases and secondary sources. Search terms included schools, adolescents, smoking, peers, social norms and qualitative research. Screening was conducted by two researchers independently and in duplicate. Study quality was assessed using the eight-item Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-centre) tool for the appraisal of qualitative studies. Results were synthesised using a meta-narrative lens for meta-ethnography and compared across smoking normalisation contexts.

RESULTS

Forty one studies were included and five themes were developed, mapping onto the socio ecological model. The social processes by which adolescents take up smoking differed according to a mixture of school type, peer group structure and the smoking culture within the school, as well as the wider cultural context. Data available from smoking denormalised contexts, described changes in social interactions around smoking to cope with its stigmatisation. This was manifested through i) direct peer influence, whereby subtle techniques were employed, ii) group belonging whereby smoking was less likely to be seen as a key determinant of group membership and smoking was less commonly reported to be used as a social tool, and iii) popularity and identity construction, whereby smoking was perceived more negatively in a denormalised context, compared with a normalised context.

CONCLUSIONS

This meta-ethnography is the first study to demonstrate, drawing on international data, that peer processes in adolescent smoking may undergo changes as smoking norms within society change. Future research should focus on understanding differences across socioeconomic contexts, to inform the adaptation of interventions.

Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries

OBJECTIVES

To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries.

DESIGN

Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020.

SETTING

Population based survey data.

PARTICIPANTS

1 231 068 individuals aged 15 years and older.

MAIN OUTCOME MEASURES

Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco).

RESULTS

The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age.

CONCLUSIONS

Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review

BACKGROUND

Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions.

METHODS

The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position.

RESULTS

Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after.

CONCLUSIONS

Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Impact of tobacco price and taxation on affordability and consumption of tobacco products in the South-East Asia Region: A systematic review

INTRODUCTION

The objective of the review was to study the impact of tobacco taxes or prices on affordability and/or consumption of tobacco products in WHO South-East Asia Region (SEAR) countries, overall and by socioeconomic status; and change in consumption of one tobacco product for a given change in price/tax on another tobacco product.

METHODS

The searches were made in five databases (Medline, Embase, Cinahl, EconLit, Tobacconomics) using keywords such as 'tobacco', 'tax', 'price', 'impact' with their synonyms. Additionally, the first 100 articles through google search and e-reports from targeted sources were also reviewed. Studies illustrating the impact of prices/taxes on consumption/affordability of tobacco products in SEAR, in English and with no limitation on year, were included in the review. After two steps of screening, data from 28 studies were extracted using a structured and pre-tested data extraction form.

RESULTS

Of the 28 studies, 12 studies reported an inverse association between price and consumption/affordability, while 11 studies reported no or positive association between price and consumption/affordability of tobacco products. Five studies had unclear interpretations. The majority of studies estimated that the less affluent group were more price responsive compared to the more affluent group. Some studies indicated increased consumption of one product in response to price rise of another product, although, the findings were inconsistent.

CONCLUSIONS

The findings of our review support the use of tobacco tax and price measures as effective tools to address the tobacco epidemic. Our findings, however, also emphasize the importance of increasing tobacco product taxes and prices sufficiently to outweigh the effects of income growth, in order for the measures to be effective in reducing the affordability and consumption of tobacco products.

Socioeconomic inequalities in tobacco smoking in women aged 15-54 in Iran: a multilevel model

Significant evidence suggests an inverse relationship between socioeconomic status and tobacco smoking, where inequality is visible among different social and economic strata. The aim of this study was to investigate the prevalence and economic and social inequalities in tobacco smoking in women aged 15-54 in Iran. This study is a cross-sectional study. Sampling in this study was a randomized clustered multistage sampling with equal clusters. A total of 35,305 women aged 15-55 enrolled in the study. Data analysis was in two stages. In the first stage, the social and economic inequalities were investigated using the concentration index and concentration curve method, and in the second method, and multilevel method was used to identify the determinants. The prevalence of tobacco smoking in women was 12.24%. The concentration index for smoking was CI = -0.07 [95% CI (-0.09, -0.05)], which represents smoking in people with low socioeconomic status. The results of the multilevel analysis indicated that the marital status of people over the age of 35 and the economic class was related to smoking in women. Inequality in tobacco smoking in women is to the interest of the well-off group, and this inequality varies in different provinces. Marital status, place of residence, age and socioeconomic status of women are factors influencing the prevalence of tobacco smoking in women, and these issues should be noticed to reduce inequalities.

Daily tobacco consumption and associated socioeconomic factors in the Portuguese population: National Health Interview Survey data 1987-2014

INTRODUCTION AND OBJECTIVES

Smoking patterns inform tobacco control policies. This study aimed to assess trends in smoking prevalence and associated socioeconomic factors in Portugal between 1987 and 2014.

METHODS

We used data from National Health Interview Surveys (NHIS) conducted in 1987, 1995/96, 1998/99, 2005/06 and 2014/15. For each NHIS, we estimated gender-specific and age-standardized smoking prevalences, stratified by education, occupation, marital status and region. We constructed NHIS- and gender-specific logistic regression models, adjusting for the above-mentioned variables. We describe changes in smoking prevalence and inequalities in associated socioeconomic factors between 1987 and 2014.

RESULTS

In men, smoking prevalence (32.2% and 26.7%, respectively) and inequalities for all factors except for education decreased between 1987 and 2014. For women, inequalities decreased for region, age and occupation, and these changes occurred through increasing smoking prevalence in all groups. For marital status and education, inequalities were stable but smoking prevalence increased for all groups within these variables. In both sexes, the unemployed (adjusted odds ratio [aOR] 2014: men 2.33, women 2.76) and divorced (aOR 2014: men 2.12, women 3.18) consistently had the highest prevalences and aORs of smoking. For the first three NHIS higher aORs of smoking were observed among less-educated men and highly-educated women, while for the last two the higher odds were for the less-educated in both sexes.

CONCLUSIONS

Smoking trends among men showed decreasing prevalences and diminishing inequalities. For women, inequalities were stable but there was an overall increase in prevalence. The unemployed and divorced had the highest smoking prevalences in both sexes. Smoking prevention and cessation policies in Portugal should take into consideration inequalities, particularly among men, and increasing consumption among women.

Pattern and Predictors of Tobacco Use in India: Evidence from National Family Health Survey (2015–2016)

Tobacco use continues to be of research interest due to the significant amount of tobacco-attributable non-communicable diseases and deaths in India. This study examines the pattern and predictors of smoking, chewing, and any tobacco use among adults of age 15–49 years in India. This study used secondary data from the fourth round of the National Family and Health Survey (NFHS, 2015–2016) which collected information on tobacco use from men and women in the age group 15–49 ( n = 803097). Bivariate and multivariate analyses were conducted to understand the socio-economic and demographic predictors. GIS maps have been used to show inter-state variation in smoking, chewing, and any tobacco use by gender. About one out of every ten adults aged 15–49 use any tobacco, predominantly in chewing forms. Women are significantly less likely to smoke (odds ratio [OR]: 0.05, confidence interval [CI]: 0.04–0.05), chew (OR: 0.25, CI: 0.24–0.25), and use any tobacco (OR: 0.14, CI: 0.13–0.14) compared with men. Tobacco usage was found more common among the uneducated and economically weak people. There is considerable inter-state heterogeneity in the prevalence and type of tobacco use, and adults in the north-east region are among the most vulnerable population subgroups. Tobacco use continues to be a significant burden due to its magnitude and different forms of use in India. The higher use among males, illiterates, economically weak, socially backward and alcohol users suggest the need for targeted efforts to improve their knowledge and awareness about the harmful effects of tobacco use and stronger enforcement of tobacco control policies.

Spatial analysis of cases of Tuberculosis with Mental Disorders in São Paulo

ABSTRACT Objective: To analyze the spatial distribution of Tuberculosis cases with Mental Disorders, identifying factors that determine its occurrence. Method: Ecological study, conducted in the municipalities of São Paulo State. Secondary data were used, with the incidence of Tuberculosis and Mental Disorders as dependent variables in the years 2012 to 2015 and independent variables, socioeconomic, health and income transfer data. The Geographically Weighted Regression was applied in this study. Results: It was observed a distinct distribution between cases of Tuberculosis and Mental Disorders in the municipalities of São Paulo State. Among the explanatory factors, the Primary Care Coverage, population of freedom and income inequality were spatially associated with Mental Illness (R2= 0.12); Alcoholism (R2= 0.12) Illicit Drugs (R2= 0.50) and Smoking (R2= 0.50). Conclusion / Final considerations: The study advances in knowledge by evidencing the spatial distribution of cases of Tuberculosis and Mental Disorders, evidencing the determining factors for its occurrence in São Paulo State.

Educational and Wealth Inequalities in Smokeless Tobacco Use: An Analysis of Rural-Urban Areas of Bangladesh and India

This study aims to investigate the educational and wealth inequalities in smokeless tobacco (SLT) use in rural and urban areas of Bangladesh and India, the 2 largest global SLT users. Using the Global Adult Tobacco Survey, both absolute and relative measures of inequality were estimated. The analysis reveals that the educational inequalities in SLT use were higher in urban areas of India and in rural areas of Bangladesh, whereas the wealth inequalities in SLT use were higher in urban areas of both the countries. Moreover, the logit model showed that the odds of SLT use declined with an increase in the level of education and wealth in rural and urban areas of India. However, no consistent pattern was observed in rural and urban areas of Bangladesh. The findings clearly delineate the subgroups which require immediate attention for SLT cessation interventions in these 2 countries.

Active smoking among people with diabetes mellitus or hypertension in Africa: a systematic review and meta-analysis

The objective was to summarize existing data on the prevalence of active tobacco smoking among patients with hypertension or diabetes mellitus in Africa. We searched PubMed, EMBASE, and AJOL to include studies published from January 01, 2000 to August 23, 2017 reporting on the prevalence of active smoking in individuals aged ≥15 years with hypertension or diabetes mellitus residing inside Africa. We used a random-effects meta-analysis model to pool studies. The pooled prevalence of active smoking among patients with hypertension or diabetes was 12.9% (95%CI: 10.6–15.3; 50 studies; 16,980 patients) and 12.9% (95%CI: 9.6–16.6; 42 studies; 18,564 patients), respectively. For both conditions, the prevalence of active smoking was higher in males than in females (p < 0.001), and in Northern compared to sub-Saharan Africa (p < 0.001). There was no difference between urban and rural settings, and between community-based and hospital-based studies, except for patients with diabetes for whom the prevalence was higher in hospital-based studies (p = 0.032). The prevalence of active smoking is high among patients with hypertension or diabetes mellitus in Africa, with the heaviest burden in Northern Africa. Interventions for smoking prevention or cessation should be implemented in these high risk populations, targeting particularly the males.

Socio-Economic Inequalities in Tobacco Consumption of the Older Adults in China: A Decomposition Method

Background: In China, tobacco consumption is a leading risk factor for non-communicable diseases, and understanding the pattern of socio-economic inequalities of tobacco consumption will, thus, help to develop targeted policies of public health control. Methods: Data came from the China Health and Retirement Longitudinal Study in 2013, involving 17,663 respondents aged 45 and above. Tobacco use prevalence and tobacco use quantities were defined for further analysis. Using the concentration index (CI) and its decomposition, socio-economic inequalities of tobacco consumption grouped by gender were estimated. Results: The concentration index of tobacco use prevalence was 0.044 (men 0.041; women −0.039). The concentration index of tobacco use quantities among smokers was 0.039 (men 0.033; women 0.038). The majority of the inequality could be explained by educational attainment, age, area, and economic quantiles. Conclusions: Tobacco consumption was more common among richer compared to poorer people in China. Gender, educational attainments, age, areas, and economic quantiles were strong predictors of tobacco consumption in China. Public health policies need to be targeted towards men in higher economic quantiles with lower educational attainment, and divorced or widowed women, especially in urban areas of China.

Educational and wealth inequalities in tobacco use among men and women in 54 low-income and middle-income countries

BACKGROUND

Socioeconomic differentials of tobacco smoking in high-income countries are well described. However, studies to support health policies and place monitoring systems to tackle socioeconomic inequalities in smoking and smokeless tobacco use common in low-and-middle-income countries (LMICs) are seldom reported. We aimed to describe, sex-wise, educational and wealth-related inequalities in tobacco use in LMICs.

METHODS

We analysed Demographic and Health Survey data on tobacco use collected from large nationally representative samples of men and women in 54 LMICs. We estimated the weighted prevalence of any current tobacco use (including smokeless tobacco) in each country for 4 educational groups and 4 wealth groups. We calculated absolute and relative measures of inequality, that is, the slope index of inequality (SII) and relative index of inequality (RII), which take into account the distribution of prevalence across all education and wealth groups and account for population size. We also calculated the aggregate SII and RII for low-income (LIC), lower-middle-income (lMIC) and upper-middle-income (uMIC) countries as per World Bank classification.

FINDINGS

Male tobacco use was highest in Bangladesh (70.3%) and lowest in Sao Tome (7.4%), whereas female tobacco use was highest in Madagascar (21%) and lowest in Tajikistan (0.22%). Among men, educational inequalities varied widely between countries, but aggregate RII and SII showed an inverse trend by country wealth groups. RII was 3.61 (95% CI 2.83 to 4.61) in LICs, 1.99 (95% CI 1.66 to 2.38) in lMIC and 1.82 (95% CI 1.24 to 2.67) in uMIC. Wealth inequalities among men varied less between countries, but RII and SII showed an inverse pattern where RII was 2.43 (95% CI 2.05 to 2.88) in LICs, 1.84 (95% CI 1.54 to 2.21) in lMICs and 1.67 (95% CI 1.15 to 2.42) in uMICs. For educational inequalities among women, the RII varied much more than SII varied between the countries, and the aggregate RII was 14.49 (95% CI 8.87 to 23.68) in LICs, 3.05 (95% CI 1.44 to 6.47) in lMIC and 1.58 (95% CI 0.33 to 7.56) in uMIC. Wealth inequalities among women showed a pattern similar to that of men: the RII was 5.88 (95% CI 3.91 to 8.85) in LICs, 1.76 (95% CI 0.80 to 3.85) in lMIC and 0.39 (95% CI 0.09 to 1.64) in uMIC. In contrast to men, among women, the SII was pro-rich (higher smoking among the more advantaged) in 13 of the 52 countries (7 of 23 lMIC and 5 of 7 uMIC).

INTERPRETATION

Our results confirm that socioeconomic inequalities tobacco use exist in LMIC, varied widely between the countries and were much wider in the lowest income countries. These findings are important for better understanding and tackling of socioeconomic inequalities in health in LMIC.

[Smoking prevalence and associated factors among tobacco farmers in southern Brazil]

This study aimed to describe the prevalence of smoking and associated factors in a cross-sectional population-based sample of 2,464 tobacco farmers in 2011. Multivariate analysis in men assessed the association between smoking and socioeconomic, behavioral, and occupational variables. Some 31.2% of men and 3.1% of women were current smokers. In men, smoking was directly associated with age, schooling, income, heavy drinking, time at work in tobacco farming, and time of exposure to pesticides. Employment relationship was a risk factor for smoking, and participation in religious activities was a protective factor. Male tobacco farmers showed multiple risk behaviors and higher smoking prevalence than other farmers. Ignoring the risk and cultural legacy may be common factors for these behaviors and suggest combined approaches.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions

Background & objectives:

India is a large country with each State having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various States of India.

Methods:

Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across States and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation.

Results:

Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the States. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33)

Interpretation & conclusions:

The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the States in India.

Changes Over Time in Absolute and Relative Socioeconomic Differences in Smoking: A Comparison of Cohort Studies From Britain, Finland, and Japan

INTRODUCTION

Socioeconomic differences in smoking over time and across national contexts are poorly understood. We assessed the magnitude of relative and absolute social class differences in smoking in cohorts from Britain, Finland, and Japan over 5-7 years.

METHODS

The British Whitehall II study (n = 4350), Finnish Helsinki Health Study (n = 6328), and Japanese Civil Servants Study (n = 1993) all included employed men and women aged 35-68 at baseline in 1997-2002. Follow-up was in 2003-2007 (mean follow-up 5.1, 6.5, and 3.6 years, respectively). Occupational social class (managers, professionals and clerical employees) was measured at baseline. Current smoking and covariates (age, marital status, body mass index, and self-rated health) were measured at baseline and follow-up. We assessed relative social class differences using the Relative Index of Inequality and absolute differences using the Slope Index of Inequality.

RESULTS

Social class differences in smoking were found in Britain and Finland, but not in Japan. Age-adjusted relative differences at baseline ranged from Relative Index of Inequality 3.08 (95% confidence interval 1.99-4.78) among Finnish men to 2.32 (1.24-4.32) among British women, with differences at follow-up greater by 8%-58%. Absolute differences remained stable and varied from Slope Index of Inequality 0.27 (0.15-0.40) among Finnish men to 0.10 (0.03-0.16) among British women. Further adjustment for covariates had modest effects on inequality indices.

CONCLUSIONS

Large social class differences in smoking persisted among British and Finnish men and women, with widening tendencies in relative differences over time. No differences could be confirmed among Japanese men or women.

IMPLICATIONS

Changes over time in social class differences in smoking are poorly understood across countries. Our study focused on employees from Britain, Finland and Japan, and found relative and absolute and class differences among British and Finnish men and women. Key covariates had modest effects on the differences. Relative differences tended to widen over the 4- to 7-year follow-up, whereas absolute differences remained stable. In contrast, class differences in smoking among Japanese men or women were not found. Britain and Finland are at the late stage of the smoking epidemic model, whereas Japan may not follow the same model.

Socioeconomic Determinants of Inequality in Smoking Stages: A Distributive Analysis on a Sample of Male High School Students

The effect of socioeconomic status on adolescent smoking behaviors is unclear, and sparse studies are available about the potential association. The present study aimed to measure and explain socioeconomic inequality in smoking behavior among a sample of Iranian adolescents. In a cross-sectional survey, a multistage sample of adolescents ( n = 1,064) was recruited from high school students in Zanjan city, northwest of Iran. Principal component analysis was used to measure economic status of adolescents. Concentration index was used to measure socioeconomic inequality in smoking behavior, and then it was decomposed to reveal inequality contributors. Concentration index and its 95% confidence interval for never, experimental, and regular smoking behaviors were 0.004 [-0.03, 0.04], 0.05 [0.02, 0.11], and -0.10 [-0.04, -0.19], respectively. The contribution of economic status to measured inequality in experimental and regular smoking was 80.0% and 68.8%, respectively. Household economic status could be targeted as one of the relevant factors in the unequal distribution of smoking behavior among adolescents.

Prevalence, distribution, and social determinants of tobacco use in 30 sub-Saharan African countries

BACKGROUND

Although the Framework Convention on Tobacco Control prioritizes monitoring of tobacco use by population-based surveys, information about the prevalence and patterns of tobacco use in sub-Saharan Africa is limited. We provide country-level prevalence estimates for smoking and smokeless tobacco (SLT) use and assess their social determinants.

METHODS

We analyzed population-based data of the most recent Demographic Health Surveys performed between 2006 and 2013 involving men and women in 30 sub-Saharan African countries. Weighted country-level prevalence rates were estimated for 'current smoking' (cigarettes, pipe, cigars, etc.) and 'current SLT use' (chewing, snuff, etc.). From the pooled datasets for men and women, social determinants of smoking and SLT use were assessed through multivariate analyses using a dummy country variable as a control and by including a within-country sample weight for each country.

RESULTS

Among men, smoking prevalence rates were high in Sierra Leone (37.7%), Lesotho (34.1%), and Madagascar (28.5%); low (<10%) in Ethiopia, Benin, Ghana, Nigeria, and Sao Tome & Principe; the prevalence of SLT use was <10% in all countries except for Madagascar (24.7%) and Mozambique (10.9%). Among women, smoking and SLT prevalence rates were <5% in most countries except for Burundi (9.9%), Sierra Leone (6%), and Namibia (5.9%) (smoking), and Madagascar (19.6%) and Lesotho (9.1%) (SLT use). The proportion of females who smoked was lower than SLT users in most countries. Older age was strongly associated with both smoking and SLT use among men and women. Smoking among both men and women was weakly associated, but SLT use was strongly associated, with education. Similarly, smoking among men and women was weakly associated, but SLT use was strongly associated, with the wealth index. Smoking and SLT use were also associated with marital status among both men and women, as well as with occupation (agriculturists and unskilled workers).

CONCLUSIONS

Prevalence of smoking among women was much lower than in men, although the social patterns of tobacco use were similar to those in men. Tobacco control strategies should target the poor, not/least educated, and agricultural and unskilled workers, who are the most vulnerable social groups in sub-Saharan Africa.

Smoking and smokeless tobacco use in nine South and Southeast Asian countries: prevalence estimates and social determinants from Demographic and Health Surveys

Background

In South and Southeast Asian countries, tobacco is consumed in diverse forms, and smoking among women is very low. We aimed to provide national estimates of prevalence and social determinants of smoking and smokeless tobacco use among men and women separately.

Methods

Data from Demographic and Health Surveys completed in nine countries (India, Pakistan, Nepal, Bangladesh, Maldives, Philippines, Cambodia, Indonesia, and Timor Leste) were analyzed. Current smoking or smokeless tobacco use was assessed as response “yes” to one or more of three questions, such as “Do you currently smoke cigarettes?” Weighted country-level prevalence rates for socio-economic subgroups were calculated for smoking and smokeless tobacco use. Binary logistic regression analyses were done on STATA/IC (version 10) by ‘svy’ command.

Results

Prevalence and type of tobacco use among men and women varied across the countries and among socio-economic sub groups. Smoking prevalence was much lower in women than men in all countries. Smoking among men was very high in Indonesia, Maldives, and Bangladesh. Smokeless tobacco (mainly chewable) was used in diverse forms, particularly in India, among both men and women. Chewing tobacco was common in Nepal, Bangladesh, Maldives, and Cambodia. Both smoking and smokeless tobacco use were associated with higher age, lower education, and poverty, but their association with place of residence and marital status was not uniform between men and women across the countries.

Conclusion

Policymakers should consider type of tobacco consumption and their differentials among various population subgroups to implement country-specific tobacco control policies and target the vulnerable groups. Smokeless tobacco use should also be prioritized in tobacco control efforts.

Socioeconomic inequality in the prevalence of smoking and smokeless tobacco use in India

BACKGROUND

Tobacco consumption has been identified as the single biggest cause of inequality in morbidity and mortality. Understanding pattern of socioeconomic equalities in tobacco consumption in India will help in designing targeted public health control measures.

MATERIALS AND METHODS

Nationally representative data from the India Global Adult Tobacco Survey (GATS) conducted in 2009-2010 was analyzed. The survey provided information on 69,030 respondents aged 15 years and above. Data were analyzed according to regions for estimating prevalence of current tobacco consumption (both smoking and smokeless) across wealth quintiles. Multiple logistic regression analysis predicted the impact of socioeconomic determinants on both forms of current tobacco consumption adjusting for other socio-demographic variables.

RESULTS

Trends of smoking and smokeless tobacco consumption across wealth quintiles were significant in different regions of India. Higher prevalence of smoking and smokeless tobacco consumption was observed in the medium wealth quintiles. Risk of tobacco consumption among the poorest compared to the richest quintile was 1.6 times higher for smoking and 3.1 times higher for smokeless forms. Declining odds ratios of both forms of tobacco consumption with rising education were visible across regions. Poverty was a strong predictor in north and south Indian region for smoking and in all regions for smokeless tobacco use.

CONCLUSIONS

Poverty and poor education are strong risk factors for both forms of tobacco consumption in India. Public health policies, therefore, need to be targeted towards the poor and uneducated.

Asian American, Native Hawaiian and Pacific Islander tobacco use patterns

OBJECTIVES

To provide a national depiction of Asian American (AA) and Native Hawaiian/Pacific Islander (NHPI) tobacco use and highlight considerations for targeted interventions.

METHODS

We analyzed data from the 2009-2010 National Adult Tobacco Survey for subgroup differences in prevalence and consumption of various tobacco products.

RESULTS

Use varies considerably by ethnic subgroups for cigarette smoking (including menthol) and other forms of tobacco. Despite being lighter, less frequent, and seemingly less dependent smokers, AANHPIs had similar quit ratios as non-AANHPIs.

CONCLUSIONS

AA and NHPI disparities in tobacco use may be due to underutilization of cessation resources, including those for non-cigarette tobacco products, and lack of availability of culturally-appropriate resources. Community-based and regulatory approaches should be employed to reduce use of all tobacco products, especially among high prevalence subgroups.

Socioeconomic inequalities in smoking in low and mid income countries: positive gradients among women?

BACKGROUND

In Southern Europe, smoking among older women was more prevalent among the high educated than the lower educated, we call this a positive gradient. This is dominant in the early stages of the smoking epidemic model, later replaced by a negative gradient. The aim of this study is to assess if a positive gradient in smoking can also be observed in low and middle income countries in other regions of the world.

METHODS

We used data of the World Health Survey from 49 countries and a total of 233,917 respondents. Multilevel logistic regression was used to model associations between individual level smoking and both individual level and country level determinants. We stratified results by education, occupation, sex and generation (younger vs. older than 45). Countries were grouped based on GDP and region.

RESULTS

In Eastern Europe and the Eastern Mediterranean, we observed a positive gradient in smoking among older women and a negative gradient among younger women. In Sub-Saharan Africa and Latin America no clear gradient was observed: inequalities were relatively small. In South-East Asia and East Asia a strong negative gradient was observed. Among men, no positive gradients were observed, and like women the strongest negative gradients were seen in South-East Asia and East Asia.

CONCLUSIONS

A positive socio-economic gradient in smoking was found among older women in two regions, but not among younger women. But contrary to predictions derived from the smoking epidemic model, from a worldwide perspective the positive gradients are the exception rather than the rule.

Associations between macrolevel economic factors and weight distributions in low- and middle-income countries: a multilevel analysis of 200,000 adults in 40 countries

OBJECTIVES

We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200,796 men and women from 40 low- and middle-income countries.

METHODS

We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight.

RESULTS

In multilevel analyses adjusting for individual-level characteristics, a 1-standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI] = 0.76, 0.99), 17% (95% CI = 0.71, 0.96), 13% (95% CI = 0.76, 1.00), and 14% (95% CI = 0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1-standard-deviation increase in foreign direct investment was associated with 17% (95% CI = 1.02, 1.35) higher odds of overweight relative to normal weight.

CONCLUSIONS

Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight.

Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys

BACKGROUND

Despite the high global burden of diseases caused by tobacco, valid and comparable prevalence data for patterns of adult tobacco use and factors influencing use are absent for many low-income and middle-income countries. We assess these patterns through analysis of data from the Global Adult Tobacco Survey (GATS).

METHODS

Between Oct 1, 2008, and March 15, 2010, GATS used nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam). We compared weighted point estimates and 95% CIs of tobacco use between these 14 countries and with data from the 2008 UK General Lifestyle Survey and the 2006-07 US Tobacco Use Supplement to the Current Population Survey. All these surveys had cross-sectional study designs.

FINDINGS

In countries participating in GATS, 48·6% (95% CI 47·6-49·6) of men and 11·3% (10·7-12·0) of women were tobacco users. 40·7% of men (ranging from 21·6% in Brazil to 60·2% in Russia) and 5·0% of women (0·5% in Egypt to 24·4% in Poland) in GATS countries smoked a tobacco product. Manufactured cigarettes were favoured by most smokers (82%) overall, but smokeless tobacco and bidis were commonly used in India and Bangladesh. For individuals who had ever smoked daily, women aged 55-64 years at the time of the survey began smoking at an older age than did equivalently aged men in most GATS countries. However, those individuals who had ever smoked daily and were aged 25-34-years when surveyed started to do so at much the same age in both sexes. Quit ratios were very low (<20% overall) in China, India, Russia, Egypt, and Bangladesh.

INTERPRETATION

The first wave of GATS showed high rates of smoking in men, early initiation of smoking in women, and low quit ratios, reinforcing the view that efforts to prevent initiation and promote cessation of tobacco use are needed to reduce associated morbidity and mortality.

FUNDING

Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, Bill and Melinda Gates Foundation, Brazilian and Indian Governments.