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Smokeless tobacco (SLT) use is associated with multiple adverse health effects. It is prominent in Bangladesh, India, and Pakistan, but disparities in use within and across these countries are not well documented or understood. This study assessed the prevalence, patterns, and correlates of SLT use in these three countries. Data came from the Global Adult Tobacco Survey, a household survey of adults aged ≥15 years. Data were collected in 2014 (Pakistan), 2017 (Bangladesh), and India (2016-2017). Current SLT use (nasal or oral use) was defined as reported SLT use daily or less than daily at the time of the survey. Prevalence of both overall and specific SLT types were assessed. Multivariate logistic regression was used to assess correlates of SLT use. Overall, SLT use among adults ≥15 years of age was 20.6% in Bangladesh, 21.4% in India, and 7.7% in Pakistan, corresponding to 22.0 million SLT users in Bangladesh, 199.4 million in India, and 9.6 million in Pakistan. Among current tobacco users overall, the percentage of those who used SLT was 58.4% (CI: 56.0-60.7) in Bangladesh, 74.7% (CI: 73.4-76.0) in India, and 40.3% (CI: 36.2-44.5) in Pakistan. The most commonly used oral SLT product was Zarda (14.5%) in Bangladesh, Khaini (11.2%) in India, and Naswar (5.1%) in Pakistan. Females had greater odds of SLT use than males in Bangladesh, but lower odds of SLT use than males in India and Pakistan. In all three countries, the odds of SLT use was higher among those 25 years and older, lower education, lower wealth index, and greater exposure to SLT marketing. An estimated 231 million adults aged 15 years or older currently use SLT in Bangladesh, India, and Pakistan, comprising 40.3%-74.7% of overall tobacco product use in these countries. Moreover, marked variations in SLT use exist by population groups. Furthermore, exposure to pro-SLT marketing was found to be associated with higher SLT use compared to non-exposed. It is important that tobacco control strategies address all forms of tobacco product use, including SLT.

ObjectiveChildren are vulnerable to secondhand smoke (SHS) exposure because of limited control over their indoor environment. Homes remain the major place where children may be exposed to SHS. Our study examines the magnitude, patterns and determinants of SHS exposure in the home among children in 21 countries (19 low-income and middle-income countries and 2 high-income countries).MethodsGlobal Adult Tobacco Survey (GATS) data, a household survey of people 15 years of age or older. Data collected during 2009–2013 were analysed to estimate the proportion of children exposed to SHS in the home. GATS estimates and 2012 United Nations population projections for 2015 were also used to estimate the number of children exposed to SHS in the home.ResultsThe proportion of children younger than 15 years of age exposed to SHS in the home ranged from 4.5% (Panama) to 79.0% (Indonesia). Of the approximately one billion children younger than 15 years of age living in the 21 countries under study, an estimated 507.74 million were exposed to SHS in the home. China, India, Bangladesh, Indonesia and the Philippines accounted for almost 84.6% of the children exposed to SHS. The prevalence of SHS exposure was higher in countries with higher adult smoking rates and was also higher in rural areas than in urban areas, in most countries.ConclusionsA large number of children were exposed to SHS in the home. Encouraging of voluntary smoke-free rules in homes and cessation in adults has the potential to reduce SHS exposure among children and prevent SHS-related diseases and deaths.

Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs. Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008-2011) and the International Tobacco Control Surveys (2009-2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country. Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10). Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

The implementation of several tobacco control policies in the Philippines may have contributed to a decrease in secondhand smoke (SHS) exposure. We examined changes in SHS exposure at work and in public places between 2009 and 2015 among adults aged ≥15 years and interpreted these results within the tobacco policy landscape in the Philippines. We analyzed the Philippines Global Adult Tobacco Survey 2009 and 2015 data. We examined marginal effects in logistic regression to get the adjusted prevalence of SHS exposure at five work and public places, controlling for selected characteristics. We calculated adjusted prevalence ratios and adjusted prevalence differences between 2009 and 2015. Adjusted prevalence of SHS exposure decreased from 2009 to 2015 by 19% (5.7 percentage points) at work, 45% (11.2 percentage points) in government buildings, 48% (3.2 percentage points) in healthcare facilities, 29% (8.2 percentage points) in restaurants, and 33% (19.9 percentage points) on public transportation. Although the prevalence of SHS exposure at work and in public places decreased significantly between 2009 and 2015, a substantial proportion of adults remain exposed to SHS. This study highlights the importance of continued implementation, enforcement, monitoring, and evaluation of tobacco control and prevention measures in the Philippines.

Increases in electronic cigarette (e-cigarette) awareness and current use have been documented in high income countries but less is known about middle and low income countries. Nationally representative household survey data from the first four Global Adult Tobacco Surveys to assess e-cigarettes were analyzed, including Indonesia (2011), Malaysia (2011), Qatar (2013), and Greece (2013). Correlates of e-cigarette awareness and current use were calculated. Sample sizes for Greece and Qatar allowed for further analysis of e-cigarette users. Awareness of e-cigarettes was 10.9% in Indonesia, 21.0% in Malaysia, 49.0% in Qatar, and 88.5% in Greece. In all four countries, awareness was higher among male, younger, more educated, and wealthier respondents. Current e-cigarette use among those aware of e-cigarettes was 3.9% in Malaysia, 2.5% in Indonesia, 2.2% in Greece and 1.8% in Qatar. Across these four countries, an estimated 818 500 people are currently using e-cigarettes. Among current e-cigarette users, 64.4% in Greece and 84.1% in Qatar also smoked cigarettes, and, 10.6% in Greece and 6.0% in Qatar were never-smokers. E-cigarette awareness and use was evident in all four countries. Ongoing surveillance and monitoring of awareness and use of e-cigarettes in these and other countries could help inform tobacco control policies and public health interventions. Future surveillance should monitor use of e-cigarettes among current smokers and uptake among never-smokers and relapsing former smokers.

BackgroundThere is little information on cigarette-purchasing behaviour among smokers globally. Understanding cigarette purchase and point-of-sale patterns can help guide the development and implementation of tobacco-control strategies in retail environments.ObjectiveThe purpose of this study was to identify where adults in 19 countries last purchased cigarettes.MethodsData were from 19 low-income and middle-income countries that conducted the Global Adult Tobacco Survey (GATS) during 2008–2012. GATS is a nationally representative household survey of adults aged 15 years or older using a standardised protocol to measure tobacco-related behaviours. Data were weighted to yield nationally representative estimates within each country and summarised by using descriptive statistics.ResultsOverall prevalence of current cigarette smoking ranged from 3.7% in Nigeria to 38.5% in the Russian Federation. Among current cigarette smokers, locations of last purchase were as follows: stores, from 14.6% in Argentina to 98.7% in Bangladesh (median=66.8%); street vendors, from 0% in Thailand to 35.7% in Vietnam (median=3.0%); kiosks, from 0.1% in Thailand to 77.3% in Argentina (median=16.1%); other locations, from 0.3% in China and Egypt to 57.5% in Brazil (median=2.6%).ConclusionCigarettes are purchased at various retail locations globally. However, stores and kiosks were the main cigarette purchase locations in 18 of the 19 countries assessed. Knowledge of where cigarette purchases occur could help guide interventions to reduce cigarette accessibility and use.

Introduction: The long-term health effects of e-cigarettes are uncertain, and data on e-cigarette use among Chinese adults are limited. This study examined the prevalence and correlates of e-cigarette awareness and use among urban residents in China. Data came from the China City Adult Tobacco Survey (CCATS), a city-representative household survey conducted using electronic tablets during 2013 – 2014 in 14 major Chinese cities. Methods: CCATS used multistage geographically clustered samples with standardized survey protocols and questionnaire to ensure data comparability. Overall, 31151 adults completed the survey, with sample size varying from 1977 to 3838 across cities, and survey response rates ranging from 79.8% to 97.5%. Respondents were considered current e-cigarette users if they self-reported using e-cigarettes ‘daily’ or ‘less than daily’ at the time of the survey. Descriptive statistics and multivariate logistic regression were conducted. Assessed correlates included: age, education, quit attempts in past 12 months, cigarettes smoked per day, and monthly expenditures on cigarettes. Results: Overall, 46.7% of respondents were aware of e-cigarettes, 2.9% ever used, and 0.8% currently used. Most current e-cigarette users (93.0%) also currently smoked tobacco. Among male current tobacco smokers, adjusted odds ratio (AOR) of current e-cigarette use was higher among those aged 15 – 29 (AOR=2.5; 95% CI: 1.5 – 4.3) or 30 – 49 (AOR=1.9; 95% CI: 1.0 – 3.4) than those ≥ 50 years; those who attempted to quit in the past 12 months than those who did not (AOR=4.7; 95% CI: 2.2 – 10.1); those with a college degree (AOR=3.4; 95% CI: 1.9 – 6.2) or just finished high school (AOR=2.2; 95% CI: 1.2 – 4.2) than those who did not finish high school; and those who smoked ≥ 15 cigarettes per day (AOR=2.8; 95% CI: 1.4 – 5.6) than those who smoked fewer. Conclusions: These findings reveal that during 2013 – 2014, many urban Chinese adults were aware of e-cigarettes, while use was relatively low and most current users also smoked tobacco. Continued monitoring of e-cigarettes could help inform public health policy, planning, and practice.

Over one billion of the world’s population are smokers, with increasing tobacco use in low- and middle-income countries. However, information about the methodology of studies on tobacco control is limited. We conducted a literature search to examine and evaluate the methodological designs of published tobacco research in Sub-Saharan Africa (SSA) over the past 50 years. The first phase was completed in 2015 using PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. An additional search was completed in February 2017 using PubMed. Only tobacco/smoking research in SSA countries with human subjects and published in English was selected. Out of 1796 articles, 447 met the inclusion criteria and were from 26 countries, 11 of which had one study each. Over half of the publications were from South Africa and Nigeria. The earliest publication was in 1968 and the highest number of publications was in 2014 (n = 46). The majority of publications used quantitative methods (91.28%) and were cross-sectional (80.98%). The commonest data collection methods were self-administered questionnaires (38.53%), interviews (32.57%), and observation (20.41%). Around half of the studies were among adults and in urban settings. We conclud that SSA remains a “research desert” and needs more investment in tobacco control research and training.

Background: Secondhand smoke (SHS) causes approximately 600,000 deaths annually worldwide. Timely surveillance can inform the development and enforcement of comprehensive smoke-free policies in indoor public places; yet, in many African countries, there is limited data on SHS exposure in this environment. This study examined self-reported SHS exposure in public places in five African countries. Methods: Data from the Global Adult Tobacco Survey (GATS) were analyzed for Cameroon (2013), Kenya (2014), Nigeria (2012), Senegal (2015), and Uganda (2013). GATS is a standardized, nationally representative household survey of individuals aged ≥15 years. Point prevalence estimates for past 30-day SHS exposure were assessed for the following environments: bars/nightclubs, restaurants, government buildings, public transportation, and healthcare facilities. Analyses were restricted to persons who reported visiting each environment. Estimates were calculated separately for all adults and nonsmokers; nonsmokers were defined as those who answered “not at all” to the question, “Do you currently smoke tobacco on a daily basis, less than daily, or not at all?” Data were weighted and analyzed using SPSS V.24. Results: Among all adults who visited each environment, country-specific SHS exposure ranged as follows: bars/nightclubs, 86.1% (Kenya) to 62.3% (Uganda); restaurants, 31.9% (Cameroon) to 16.0% (Uganda); government buildings, 24.2% (Senegal) to 5.7 % (Uganda); public transportation, 22.9% (Cameroon) to 7.8% (Uganda); and healthcare facilities, 10.2% (Senegal) to 4.5% (Uganda). SHS exposure among nonsmokers was as follows: bars/nightclubs, 85.6% (Kenya) to 60.9% (Uganda); restaurants, 32.0% (Cameroon) to 16.1% (Uganda); government buildings, 24.2% (Senegal) to 5.8 % (Uganda); public transportation, 22.2% (Cameroon) to 7.7% (Uganda); and healthcare facilities, 9.9% (Senegal) to 4.5% (Uganda). Conclusions: In the assessed African countries, SHS exposure was lowest in healthcare facilities and highest in bars/nightclubs. Smoke-free policies in indoor public places, consistent with the World Health Organization's MPOWER framework, are important to protect nonsmokers from SHS exposure.

Introduction: Hardened smokers are those who do not want to quit, or find it very difficult to quit. This study assessed the prevalence and predictors of hardened smokers in 19 low- and middle-income countries (LMICs). Methods: We used nationally representative data from 19 LMICs that conducted the Global Adult Tobacco Survey during 2009 – 2013. Our analysis is restricted to adults aged ≥ 25 years. Hardened smokers were defined as daily smokers who smoked for 5 or more years, and who reported the following: no quit attempt in the past year that lasted 24 or more hours; no interest in quitting, or not planning to quit in the next year; and currently smoked within 30 minutes after waking. For each country, the prevalence of hardened smokers was analyzed by sex, age, residence (urban or rural), educational attainment, wealth index, and knowledge of the danger of smoking. Multivariable logistic regression was used to assess predictors of hardened smoking. Results: Prevalence of hardened smokers among adults (aged ≥ 25 years) ranged from 1.1% (Panama) to 14.3% (Russia). Among current smokers (aged ≥ 25 years), the proportion of hardened smokers ranged from 7.5% (Mexico) to 38.4% (Romania). Adjusted odds of hardened smokers were significantly higher for males (9 of 19 countries), smokers aged 65 years or older (12 of 19 countries), adults with lower educational attainment (9 of 19 countries), and no knowledge of the danger of smoking (8 of 19 countries). Conclusions: The spectrum of smokers in the LMICs includes hardened smokers and prevalence varies across population groups. Full implementation of proven tobacco control strategies could reduce hardened smoking in LMICs.