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

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.