In 2020, it is estimated that nearly one billion people worldwide smoke tobacco and 336 million use smokeless tobacco (chewing tobacco or snuff), with most living in low- and middle-income countries (LMICs). ). Although the prevalence of tobacco use (both smoked and smokeless) in low- and middle-income countries has declined over the past 20 years, in the coming years it is expected to exceed 20% in middle-income countries and 12% in low-income countries.
A study published in the British Medical Journal[1] pooled data from more than 80 national surveys representative of the country’s population, covering 1,231,068 people aged 15 or over in 82 low- and middle-income countries (India and China were not included in the study). The researchers sought to determine the prevalence of smoking as a whole and the profile of smokers.
Significant disparities in consumption by gender and country
Across all 82 low- and middle-income countries, the weighted average prevalence of current smoking was 16.5%. The prevalence was higher in men than in women (33.2% versus 3.3%). In most (60 (73%) of 82) of the low- and middle-income countries in the study, smoking prevalence among women was below 5%. The only country where tobacco use was higher among women than men is Nauru.
Nationally, smoking prevalence ranged from 1.1% in Ghana to 50.6% in Kiribati. Sao Tome and Principe, Nigeria and Ethiopia were the countries with the lowest prevalence (less than 5%). Four of the ten countries with the highest smoking prevalence were small islands in the Pacific, with high prevalence among both men and women. In other cases, country-level prevalence hides notable gender disparities. Indonesia or Armenia, for example, have an exceptionally high smoking prevalence among men (more than 60%), but smoking is rare among women (less than 3%), giving an average smoking prevalence weaker.
At the WHO region level, smoking prevalence was highest in the Europe region (28.0%) and the Western Pacific (26.1%). Africa had by far the lowest smoking prevalence at 5.9%.
Manufactured cigarettes are the most commonly consumed tobacco product
In all countries, cigarettes were the product most commonly consumed by male and female smokers (95.6% and 85.2% respectively). The only two exceptions were Papua New Guinea, where a relatively large share of smokers smoked brus (a local tobacco), and Lesotho, where cigarillo smoking was relatively common. In all countries where data were available, more male and female smokers smoked manufactured cigarettes (male 73.5%; female 55.8%) than hand-rolled cigarettes (male 30.7 %; women 38.7%).
Prevalence and frequency of smokeless tobacco use
In the 72 countries surveyed that collected information on current smokeless tobacco use, the prevalence was 7.7% (11.1% of men and 4.8% of women). Among male users of smokeless tobacco products, chewing tobacco was the product most commonly used, by 49.5% of them and on average 5 times a day. Among women users of smokeless tobacco products, betel nut with or without tobacco (40.8%) and oral snuff (40.0%) were the most consumed products (4x per day on average) .
Smokeless tobacco use was significantly higher in Southeast Asia than in other regions, where prevalences ranged from 0.5% to 6%.
Papua New Guinea and Myanmar are the countries with the most smokeless tobacco users with 64.5% and 29.3% respectively (male and female of all tobacco users in the country).
Five (Myanmar, Bangladesh, India, Nepal and Bhutan) of the 10 countries with the highest prevalence of smokeless tobacco use were also among the 10 countries with the highest overall tobacco prevalence among men and women.
Low education and low income linked to higher consumption
Combining data from all the countries studied, residing in a rural area was associated with a higher prevalence of smoking than in urban areas. In most of the countries studied, smoking prevalence was higher among people with less education and lower economic classes. In Romania, for example, the smoking rate rises to 60% among people with no diploma compared to 30% of people with at least a secondary school diploma. In Laos, less than 10% of people with a secondary school diploma are smokers compared to regarding 30% of people with no diploma. Also in Laos, 35% of people with the lowest incomes are smokers compared to less than 15% of the wealthiest. A similar gap according to income is observed in many Asian countries (Philippines, Vietnam, Thailand, etc.).
Important data for targeting tobacco control measures
According to the authors of the study, these data can contribute to the monitoring of international objectives in terms of reducing tobacco use and non-communicable diseases that are linked to tobacco consumption. The health consequences of tobacco use can pose a risk to the already fragile health systems of these countries, as many of them are not well prepared to deal with the increase in tobacco-related diseases, such as cancers and cardiovascular diseases.
The tobacco industry particularly targets LMICs, which have become essential markets for manufacturers since 80% of smokers live there. She deploys a major lobby there to counter the adoption and implementation of proven measures to reduce tobacco consumption.[2]. This study highlights the issues involved.
Keywords: low- and middle-income countries, LMICs, smoking, prevalence, smokeless tobacco, cigarettes
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[1] Theilmann M, Lemp J M, Winkler V, Manne-Goehler J, Marcus M E, Probst C et al. Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries BMJ 2022; 378 :e067582 doi:10.1136/bmj-2021-067582
[2] Tobacco Free Generation, Tobacco industry interference in low- and middle-income countriespublished April 2, 2021, accessed August 31, 2022
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