Elsevier

Drug and Alcohol Dependence

Volume 139, 1 June 2014, Pages 60-70
Drug and Alcohol Dependence

Full length article
Poly-tobacco use among adults in 44 countries during 2008–2012: Evidence for an integrative and comprehensive approach in tobacco control

https://doi.org/10.1016/j.drugalcdep.2014.03.003Get rights and content

Abstract

Introduction

The concurrent use of multiple tobacco products (i.e., poly-tobacco use) might hinder efforts to reduce overall tobacco use, particularly considering that use of some non-cigarette tobacco products may be popular in some regions due to social, cultural, or economic reasons. This study assessed poly-tobacco use patterns among persons aged ≥15 years old from 44 countries.

Methods

Data from 44 countries in all six World Health Organization regions were obtained from the 2008 to 2012 Global Adult Tobacco Surveys (n = 19 countries), and the Special Eurobarometer 385 (77.1) survey, 2012 (n = 25 countries). Correlates of poly-tobacco use were assessed using multivariate logistic regression analyses (p < 0.05).

Results

Overall prevalence of poly-tobacco use ranged from 0.8% (Mexico) to 11.9% (Denmark). In 28 countries, 20% or more of current smokers of manufactured cigarettes concurrently used at least one other tobacco product and this proportion was highest in India (66.2%) and lowest in Argentina (4.4%). After adjusting for other factors, the likelihood of being a poly-tobacco user among all respondents was lower among females (aOR = 0.09; 95% CI: 0.08–0.11), and among respondents from upper-middle-income (aOR = 0.53, 95% CI: 0.43–0.66), and lower-middle-income countries (aOR = 0.64; 95% CI: 0.51–0.81) compared to high-income countries. Increased likelihood of poly-tobacco use was observed among respondents from the South-East Asian region compared to those from the European region (aOR = 1.58, 95% CI: 1.35–1.85), as well as among respondents aged ≥65 years (aOR = 2.10; 95% CI: 1.73–2.54), compared to those aged <25 years.

Conclusions

The pattern of tobacco use varied widely, underscoring the need for intensified efforts towards implementing policies that address all tobacco products, not only manufactured cigarettes.

Introduction

Manufactured cigarettes are the most commonly used tobacco products in most parts of the world. However, cultural, social and economic factors may influence popularity of other tobacco products in certain regions, as is evident in the popularity of kreteks in Indonesia, hand-rolled cigarettes in Europe, water-pipes in North Africa, Middle East and parts of Asia, and bidis in South Asia (Eriksen et al., 2012, European Commision, 2012, Giovino et al., 2012, Maziak et al., 2013, Morton et al., 2013, Palipudi et al., 2012, Prignot et al., 2008). Meanwhile, smokeless tobacco products, such as snuff and chewing tobacco are also showing increasing popularity outside South Asia where they are traditionally used (Eriksen et al., 2012, Maziak et al., 2013, Prignot et al., 2008).

Tobacco products other than factory manufactured cigarettes may be used by smokers as a strategy to minimize the cost of smoking (Licht et al., 2011), or to circumvent smoking bans in public places in the case of smokeless tobacco (and recently in some places – electronic cigarettes; McClave-Regan and Berkowitz, 2011). The concurrent use of multiple tobacco products might hinder efforts to reduce overall tobacco use, especially considering that most interventions and tobacco control policies in several regions of the world tend to focus on a specific tobacco product – usually manufactured cigarettes. Understanding local patterns in the use of different tobacco products, as well as regional or cross-country variations in their use may equip policy makers with a more nuanced knowledge of the health and economic burden arising from predominant tobacco use patterns. Such information may also enhance regional integration of tobacco control policies to strengthen their impact across countries and within regions.

The proliferation of newer tobacco products and brands in several countries, coupled with the increasing expenditures on global marketing of tobacco products (e.g., through the internet; Federal Trade Commission; FTC, 2013a, FTC, 2013b), may be contributors to poly-tobacco use. Notably however, it is difficult to compare poly-tobacco use patterns between different studies since differences in the number or types of tobacco products assessed may preclude comparability of estimates (Klesges et al., 2011). Thus, to provide a global overview of poly-tobacco use among adults and the implications for tobacco control policy, surveillance and clinical practice, we analyzed data for 44 countries using the 2008–2012 Global Adult Tobacco Survey (GATS) (n = 19 countries) and the Special Eurobarometer 385 (77.1) survey, 2012, (n = 25 countries).

Section snippets

Data source

Data were obtained from the 2008 to 2012 GATS, and the Special Eurobarometer 385 (77.1). As all analyses were performed on de-identified publicly available data, this secondary analysis was deemed as exempt from the Harvard School of Public Health, Institutional Review Board (IRB), with IRB protocol number 14-0346.

Results

The proportion of female respondents in all countries ranged from 48.3% (India) to 55.7% (Estonia). The overall response rate for the Global Adult Tobacco Survey ranged from 65.1% (Poland) to 97.3% (Egypt).

Discussion

This study, using data from 44 countries, showed striking variations in tobacco use patterns, even between countries of similar income level or geographical location. While manufactured cigarettes dominated the market in countries such as China and Mexico, use of non-cigarette tobacco products was more popular in others. These findings thus imply that except in the context of a specific population with predominant cigarette smoking, the use of the term “alternative tobacco products” as a

Conclusion

This study demonstrated that poly-tobacco use is common in the majority of countries assessed. This underscores the need for comprehensive and integrative tobacco control programs that address not only cigarettes but also other tobacco products as well.

Role of funding source

There were no sources of funding, direct or indirect, for the reported research.

Contributors

AIT designed the study, analyzed the data, and participated in writing of the manuscript. FTF contributed in writing the first draft of the manuscript as well as in data analyses and interpretation. CIV, AJA, OAA-Y, OOO and GNC contributed to data interpretation and were involved with writing and editing of the paper. All authors contributed to and have approved the final manuscript.

Conflict of interest

The authors have no conflicts of interest relevant to this article to disclose.

Acknowledgments

Dr. Israel Agaku initiated the reported research while affiliated with the Center for Global Tobacco Control at Harvard University. He is currently affiliated with the Centers for Disease Control and Prevention's Office on Smoking and Health. The research in this report was completed and submitted outside of the official duties of his current position and does not reflect the official policies or positions of the Centers for Disease Control and Prevention.

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