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A systematic review on tobacco use among civilian populations affected by armed conflict
  1. Janice Lo1,
  2. Preeti Patel2,
  3. Bayard Roberts1
  1. 1Faculty of Public Health and Policy, ECOHOST—The Centre for Health and Social Change, The London School of Hygiene and Tropical Medicine, London, UK
  2. 2Department of War Studies, King's College London, London, UK
  1. Correspondence to Dr Bayard Roberts, Faculty of Public Health and Policy, ECOHOST—The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine. 15–17 Tavistock Place, London WC1H 9SH, UK; bayard.roberts{at}


Objective To systematically examine evidence on tobacco use among conflict-affected civilian populations.

Data sources Primary quantitative and qualitative studies published in English up to April 2014. Bibliographic databases searched were EMBASE, Global Health, MEDLINE, PsycEXTRA, PsycINFO, Web of Science, Cochrane; with the main terms of: (Smoke*, tobacco*, cigarette*, nicotine, beedi, bidi, papirosi, dip, chew, snuff, snus, smokeless tobacco) AND (armed-conflict, conflict-affected, conflict, war, refugee, internally displaced, forcibly displaced, asylum, humanitarian). Grey literature was searched using humanitarian databases, websites and search engines.

Study selection Studies were independently selected by two reviewers, with a study outcome of tobacco use and a population of conflict-affected civilian populations such as internally displaced persons, refugees, residents in conflict-affected areas, residents and returning forcibly displaced populations returning in stabilised and postconflict periods. 2863 studies were initially identified.

Data extraction Data were independently extracted. The Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Programme for qualitative studies were used to assess study quality.

Data synthesis 39 studies met inclusion criteria and descriptive analysis was used. Findings were equivocal on the effect of conflict on tobacco use. Evidence was clearer on associations between post-traumatic stress and other mental disorders with nicotine dependence. However, there were too few studies for definitive conclusions. No study examined the effectiveness of tobacco-related interventions. The quantitative studies were moderate (N=13) or weak (N=22) quality, and qualitative studies were moderate (N=3) or strong (N=2).

Conclusions Some evidence indicates links between conflict and tobacco use but substantially more research is required.

  • Priority/special populations
  • Global health
  • Low/Middle income country

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