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Educational and wealth inequalities in tobacco use among men and women in 54 low-income and middle-income countries
  1. Chandrashekhar T Sreeramareddy1,
  2. Sam Harper2,
  3. Linda Ernstsen3
  1. 1 Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia
  2. 2 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
  3. 3 Department of Nursing Science, Faculty of Health and Social Sciences, Norwegian University of Science and Technology, Trondheim, Norway
  1. Correspondence to Dr Chandrashekhar T Sreeramareddy, Department of Community Medicine, International Medical University, Jalan Jalil Perkasa, Bukit Jalil, Kuala Lumpur 43000, Malaysia; chandrashekharats{at}


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 Caused Disease
  • Disparities
  • Low/Middle income country
  • Global health
  • Socioeconomic status

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  • Contributors CTS, SH and LE conceptualised the study, CTS and SH analysed the data and prepared graphs and tables, LE wrote the results, CTS and SH revised the results and interpretations. CTS wrote the first draft of the manuscript, SH and LE revised the manuscript and finalised the manuscript. All authors read the final manuscript submitted for publication.

  • Competing interests None declared.

  • Ethics approval Institutional review boards of the DHS programme and participating institutions in each country.

  • Provenance and peer review Not commissioned; externally peer reviewed.