ORI GI NAL PAPER

Global socioeconomic inequalities in tobacco use: internationally

comparable estimates from the World Health Surveys
Sam Harper

Brittany McKinnon
Received: 7 September 2011 / Accepted: 21 January 2012
Springer Science+Business Media B.V. 2012
Abstract
Objective To produce internationally comparable esti-
mates of socioeconomic differences in tobacco exposure
within low and middle-income countries.
Methods We used data from 50 countries that partici-
pated in the World Health Surveys in 20022003.
We measured two aspects of smoking: current smoking
prevalence and accumulated pack-years of smoking. We
used an asset-based approach to estimate permanent
income. We measured absolute inequalities, separately by
gender, across the entire socioeconomic distribution by
using the concentration index and summarized the results
and explored heterogeneity by meta-analysis.
Results The overall prevalence of current smoking was
highest in Southeast Asia, the Western Pacic, and Europe,
and lowest in Africa. Pack-years among current male
smokers were highest in Europe. Wealthier men were
generally less likely to be current smokers in all regions.
However, there was substantial heterogeneity within each
region, and in some countries (Georgia, Mexico, Maurita-
nia) current smoking was greater among the more advan-
taged. Among currently smoking men socioeconomic
differences for pack-years of smoking were generally much
weaker than for smoking prevalence. Among women the
concentration index in current smoking was largest and
favored the poor in Europe (1.4, 95% CI 0.8, 2.1) but
favored the rich in Southeast Asia and the Western Pacic.
National income was generally not associated with the
magnitude of socioeconomic gradients.
Conclusions In low and middle-income countries there is
substantial between and within-region heterogeneity in
socioeconomic inequality in tobacco exposure that is not
explained by national income. Our results imply that the
relationship between socioeconomic position and smoking
in poorer countries is dynamic and may not reect the
historical pattern in wealthier countries.
Keywords Tobacco Health inequalities
Socioeconomic position Smoking
Low- and middle-income countries
Introduction
Consumption of tobacco remains one of the worlds leading
contributors to premature mortality and a range of disabili-
ties. Tobacco use is currently estimated to account for 18%of
deaths and 11% of disability-adjusted life years in high-
income countries, compared with 7% and 3%, respectively,
for lowand middle-income countries (LMICs) [1]. However,
because of the approximately 30-year time lag between peak
tobacco consumption and peak tobacco-related mortality,
this global pattern largely reects past tobacco use in high-
income countries, and the future burden of tobacco will
largely fall on LMICs. Previous surveys suggest the preva-
lence of tobacco use has been increasing rapidly in LMICs,
notably in populous countries such as India, China, and
Indonesia; without intervention it is estimated that over 1
billion deaths may be caused by tobacco during the twenty-
rst century [25].
Estimates of the impact of tobacco in poorer countries
has mostly relied on a variety of techniques of indirect
S. Harper (&) B. McKinnon
Department of Epidemiology, Biostatistics and Occupational
Health, McGill University, 1020 Pine Avenue West, Room 34B,
Montreal, QC, Canada
e-mail: sam.harper@mcgill.ca
1 3
Cancer Causes Control
DOI 10.1007/s10552-012-9901-5
estimation, for example smoking-impact ratios (observed
over expected lung cancer deaths) that use mortality data
to measure the accumulated impact of tobacco [6, 7].
Although such indirect measures provide a more compre-
hensive summary of the impact of tobacco, there is also a
need to understand the distribution and determinants of
tobacco use among current smokers, given that 50% of
future deaths will come from current smokers [2, 8, 9].
Additionally, smoking impact ratios are typically only
estimated for countries as a whole or, in some cases, for
gender groups. Other characteristics, for example urban/
rural location, education, or income, are also relevant
correlates of tobacco consumption.
In addition to concerns about the overall impact of the
spread of tobacco to LMICs, the widespread existence
of socioeconomic differences in smoking that have been
observed in higher-income nations [1012] has raised
concerns that similar patterns may be likely to develop in
LMICs, adding additional burdens to already disadvan-
taged populations. However, information about the socio-
economic distribution of tobacco consumption in LMICs
has been severely limited by a lack of routine sources of
data, the use of non-comparable measures of socioeco-
nomic position (education, literacy, income, occupation)
[13, 14], and the wide range of tobacco products used
within and between countries.
More recent attempts to obtain comparable estimates
of tobacco use across countries, for example the WHOs
MPOWER report [15], typically do not provide estimates of
tobacco use by urban/rural, socioeconomic, or marital status,
and there remains little information about the extent of var-
iation across countries in the effects of demographic factors
and smoking. Additionally, virtually all previous studies
have focused primarily on the prevalence of smoking, with
less emphasis on measures of accumulated exposure.
The objective of this paper is to contribute to the evi-
dence base on global inequalities in tobacco consumption
in four ways.
First, we utilize cross-population-comparable measures
of both tobacco use and of socioeconomic position.
Second, rather than simply compare prevalence of
smoking among the most disadvantaged with the
prevalence among the least disadvantaged [13, 14],
we evaluate the socioeconomic pattern of smoking
across the entire range of socioeconomic position.
Third, we go beyond simple measures of prevalence to
measure accumulated tobacco exposure across socio-
economic groups.
Fourth, we make some attempts to quantify and
explain heterogeneity in socioeconomic gradients
across regions and countries, because some previous
work suggests socioeconomic differences are largest in
poorer countries [13].
Materials and methods
Data and sample
We used data from 53 countries that participated in the
World Health Surveys (WHS), a series of large cross-sec-
tional studies conducted by the World Health Organization
(WHO) in 20022003. The WHS collected information
covering a wide range of topics related to population
health, including socio-demographics, adult and child
morbidity and mortality, risk factors, and health-care
expenditures [16]. Comprehensive information about the
surveys can be found on the WHS website [17], and the
specic countries included in the survey are given in
Table 3, in the Appendix, according to WHO geo-
graphic region and 2003 World Bank income classication.
Figure 3, in the Appendix, shows the WHO geographic
regions. We excluded three countries (Slovenia, Spain,
United Arab Emirates) that were classied as high-income
countries in 2003. Briey, the survey was administered in-
person to adults ages 18 and over who were living in
private households. Interviewers were trained and all
questionnaires were translated into local languages and
modied for cultural appropriateness according to standard
WHO procedure. The WHSs sampling framework covered
100 percent of a countrys eligible population, and random
national samples were obtained in all countries except
China, Comoros, the Republic of Congo, Cote dIvoire,
India, and the Russian Federation, by using a multistage
cluster design. The target population included any men or
women adult aged 18 or over, present in the country and
residing in a private household during the survey period.
Survey weights were available for all countries except
Guatemala.
Measures
Individuals were asked, Do you currently smoke any
tobacco products such as cigarettes, cigars, or pipes?,
were queried about other tobacco types, and responded as
either daily, non-daily, or non-smokers. We dened current
smokers (yes/no) as daily or non-daily smokers of any
tobacco products (cigarettes, cigarillos, cigars, cheroots,
chuttas, bidis, goza/hookah, pipes, or other local tobacco
products). The WHS also asked individuals about average
daily consumption of each tobacco product (manufactured
cigarettes, hand-rolled cigarettes, pipefuls of tobacco, other
tobacco products) and for how many years individuals
considered themselves daily smokers. From this informa-
tion we calculated a measure of accumulated exposure
among current smokers. We estimated pack-years among
current smokers from the total number of all types of
cigarettes and other forms of tobacco smoked daily, plus
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twice the number of pipefuls (if applicable), divided by 20
[18]. Because pack-years are partially a function of age, we
used age-adjusted estimates of pack-years of smoking to
produce estimates of pack-years at age 40.
To estimate socioeconomic position, we used an asset-
based approach to compute an index of permanent house-
hold income [19]. This approach assumes economic status
is an unobserved latent variable, and it is estimated by
use of a random-effects probit model using measures
of household ownership of country-specic assets (e.g.,
refrigerator, radio, car, etc.), access to services (e.g.,
drinking water), and known predictors of income (e.g., age
and education). Table 4, in the Appendix, contains a list
of assets used in calculating the index. This model pro-
duces asset thresholds on the latent income scale, and if a
households estimated permanent income is greater than
the asset threshold, there is a greater than 0.5 probability
they own the item. This asset scale is then applied to each
household to estimate permanent income. The validity of
this approach has been examined in several countries, with
studies nding moderate to high correlations between
estimated permanent income and both reported household
income and expenditures [1921]. For descriptive analyses,
estimates of household permanent income were catego-
rized into quintiles within each country.
Given the strong global patterning of tobacco con-
sumption by gender [15, 22], we present estimates of
tobacco exposure separately for men and women.
Missing data
The total sample size was 247,421, and information on
smoking variables and permanent income was missing for
4.8 and 3.8% of the sample, respectively. To account for
missing data, we performed multiple imputation using the
ice procedure in Stata 11, which uses an iterative multi-
variable regression procedure to generate distributions for
each variable with missing data that are conditional on all
other variables in the imputation models [23]. All variables
with missing data were imputed using smoking and other
demographic predictors and a total of ten imputed datasets
were generated. Linear, logistic, ordered logistic, multi-
nomial logistic, and negative binomial regressions were
used to model the distributions of the imputed variables, as
necessary. Where possible, analysis and pooling of results
across the imputed datasets was done using the mi estimate
procedures in Stata 11 [24].
Statistical methods
Measuring health inequalities across multiple groups (such
as for socioeconomic position) involves making judgments
about absolute versus relative inequality, whether to weight
social groups by population size, and reference points for
measuring departures from equality, among other issues
[25, 26]. For this study we summarized the magnitude of
health inequality using the concentration index [27], which
may be measured on the absolute or relative scale, and
measures differences between each individual and the
average prevalence of smoking among the total population.
Because measures of relative inequality may reach extreme
values when baseline values are very low (e.g., prevalence
of smoking among women in some LMICs), and because
measures of absolute effect are typically of more interest
from a population health perspective, we focus on mea-
suring absolute inequality.
The absolute concentration index (ACI) is derived from
an absolute concentration curve, which plots the cumula-
tive percentage of the population, ranked by socioeconomic
position, against their cumulative contribution to the
prevalence of smoking among the total population.
The ACI is calculated as ACI 1
m
n
P
n
i1
y
i
1 R
i

m1
,
where n is the sample size, i indexes individuals, y is the
tobacco variable, R represents each individuals relative
rank in the cumulative socioeconomic distribution (i.e.,
from 0 to 1), and m is a weighting factor that decreases with
increasing socioeconomic rank. We used the traditional
value of 2 for m, which assigns weights of 2.0, 1.5. 1.0, 0.5,
and 0 to the health of individuals at the 0th, 25th, 50th,
75th, and 100th percentiles of the cumulative distribution
of increasing socioeconomic position [28]. When the
outcome is negative (i.e., something to be avoided, as with
current smoking prevalence or accumulated exposure),
negative values of the ACI indicate greater concentration of
tobacco use among poorer individuals, and positive values
indicate greater concentration among richer individuals.
To facilitate comparison with more traditional estimates,
we also calculated prevalence differences and ratios.
We summarized estimates across the 50 country surveys
by using the meta-analysis commands in Stata [29]. Because
we take the particular countries included in the WHS as a
potentially random sample from a larger population of
studies across all countries, we used a random-effects meta-
analysis, which does not assume there is a single, common
estimate of socioeconomic differences in smoking across all
countries [30]. Heterogeneity across studies was assessed
using the I
2
statistic, which quanties the amount of variation
in results across studies beyond that expected by chance and
is calculated as 100% 9 (Q - df)/Q, where Q is Cochrans
heterogeneity statistic and df the number of degrees of
freedom[31]. We also investigated whether heterogeneity in
the magnitude of socioeconomic differences across studies
was related to country income, by using random-effects
meta-regression and each countrys gross domestic product
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per capita (GDPpc) in 2002 (in 2005 purchasing power
parity-adjusted international dollars), obtained from the
World Banks World Development Indicators database [32].
GDPpc was not available for Zimbabwe, and meta-regres-
sion estimates were weighted by the inverse of the standard
error of the estimated ACI in each country [29].
Results
Table 1 shows descriptive information for the WHS
sample. Among the WHS countries the overall prevalence
of smoking was highest in Bangladesh (45.8%) and lowest
in Ethiopia (3.9%). Table 1 also includes estimates of
global permanent income, which is measured on a con-
tinuous (latent) scale, and each countrys rank for the
average of the income variable. Although our analysis
focuses on country-specic estimates of permanent income,
the estimates of global permanent income accord reasonably
well with external estimates of national income, with the
richest countries being largely European and the poorest
being African. The correlation coefcient between the esti-
mates of global permanent income and GDPpc was 0.6.
For descriptive purposes, and to provide an indication
of exposure to tobacco among different socioeconomic
groups, Table 2 presents (unweighted) average estimates of
current smoking and pack-years among current smokers by
WHO region, gender, and permanent income quintile,
along with measures of inequality. We present two tradi-
tional measures of inequality, the rate difference between
the poorest and richest quintiles (Q1Q5) and their ratio
(Q1/Q5), and our summary estimates of the absolute (ACI)
and relative (RCI) concentration index, which is the ACI
divided by average prevalence. Not surprisingly, in all
regions men were both more likely to be current smokers
and to have accumulated greater numbers of pack-years of
smoking. Regionally, prevalence of current smoking ten-
ded to be highest for men in Southeast Asia, the Western
Pacic, and European regions, and lowest in the African
region. This pattern was generally true for women also,
with the notable difference being particularly low levels of
reported current smoking among women in the Eastern
Mediterranean region.
In general, simple comparison of the poorest and richest
quintiles paralleled the magnitude and direction of the
summary measures of inequality. The Spearman correlations
comparing summary measures with extreme quintile com-
parisons for absolute and relative inequality were greater
than -0.9 for current smoking for both genders (the corre-
lations are negative because more negative values of the
concentration index corresponded with higher quintile dif-
ferences/ratios). For accumulated exposure, the correlations
for absolute and relative measures were -0.68 and -0.71
for men, and -0.54 and -0.61 for women (all p \0.0001).
Despite this general concordance, there were important
discrepancies. For example, among women in the Eastern
Mediterranean region both the average risk difference and
the average risk ratio comparing pack-years for the lowest
quintile (7.3 years) with those for the highest quintile (4.9)
would suggest that accumulated tobacco exposure is greater
among the poor (Q1/Q5 = 1.44). However, if one looks
systematically across all levels of permanent income, pack-
years of exposure generally increases with increasing
permanent income, leading to a positive average absolute
concentration index (ACI = 0.15). Similarly, comparing
only extremes of the socioeconomic distribution for current
smoking among women in Africa versus Southeast Asia
suggests both have similar levels of relative inequality,
because women in the poorest quintile were approximately
2.5 times more likely than those in the richest quintile to be
current smokers (Q1/Q5 * 2.5). However, the average RCI
is more than three times as high for Southeast Asia (-0.19) as
for Africa (-0.05), because in the latter current smoking
does not vary much across the middle income quintiles
whereas in the former smoking prevalence declines steadily
as one moves up the socioeconomic ladder.
Overall we found, for both men and women, substantial
heterogeneity in the magnitude of socioeconomic inequali-
ties in tobacco exposure. The overall random-effects esti-
mate of the ACI for current smoking among men was -2.50
(95% CI = -3.2, -1.8) and for women was -0.45 (95%
CI = -0.86, -0.04). The negative value of the ACI indi-
cates that, for both men and women, current smoking is more
concentrated among individuals with lower permanent
income (though for women this estimate was not distin-
guishable from zero). However, for both men and women
the I
2
statistic suggested high heterogeneity [33] across
estimates (men I
2
= 92%, 95% CI = 9093%; women
I
2
= 96%, 95% CI = 9597%), with both statistics sug-
gesting that virtually all of the overall variation in inequality
estimates across the WHS is because of between-country
rather than within-country variation. To determine whether
similar heterogeneity was seen within regions, we conducted
WHO region-specic meta-analyses.
Figure 1a, b provides estimates of the magnitude of the
socioeconomic gradient in current smoking for men and
women derived from region-specic meta-analysis, with
estimates of the ACI for each country. Overall, absolute
socioeconomic differences in current smoking are larger
for men than for women in each region. For men, socio-
economic inequalities favored wealthier individuals in all
regions and most countries, and were largest in Southeast
Asia (ACI = -5.20, 95% CI = -6.7, -3.7) and the
Western Pacic (ACI = -4.82, 95% CI = -6.3, -3.4)
and much smaller in Africa (ACI = -1.59, 95% CI =
-2.4, -0.7). However, in all regions there was substantial
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Table 1 Descriptive characteristics, World Health Survey
Country Obs Mean
age (SD)
Male (%) Current
smoking (%)
Urban
residence (%)
Global permanent
income (rank)
Africa
Burkina Faso 4,821 37.0 47.4 18.0 16.1 -2.71 (50)
Chad 4,652 36.5 50.0 11.4 21.8 -0.53 (39)
Comoros 1,758 40.7 49.1 22.5 30.6 -0.75 (44)
Congo 2,488 35.3 47.7 10.0 94.4 -0.44 (34)
Cote dIvoire 3,178 34.7 57.8 13.5 71.1 -0.3 (30)
Ethiopia 4,937 35.6 50.3 4.0 12.9 -1.94 (49)
Ghana 3,932 40.1 45.5 6.0 42.4 -0.71 (42)
Kenya 4,346 35.3 49.6 14.3 17.9 -0.59 (41)
Malawi 5,300 35.5 44.0 14.8 9.5 -0.28 (29)
Mali 4,262 40.1 65.9 17.8 22.0 -1.56 (47)
Mauritania 3,772 37.5 44.0 14.4 49.5 -1.15 (46)
Mauritius 3,888 41.2 49.6 22.6 43.8 0.56 (18)
Namibia 4,250 37.4 42.6 19.6 38.2 -0.72 (43)
Senegal 3,021 37.9 55.5 14.3 48.1 -0.39 (32)
South Africa 2,352 37.6 47.6 25.2 60.1 0.61 (17)
Swaziland 3,069 38.9 47.0 12.0 26.7 0.52 (19)
Zambia 3,811 35.4 47.3 14.2 34.7 -1.68 (48)
Zimbabwe 4,065 37.1 39.9 12.9 40.8 -0.45 (35)
Americas
Brazil 5,000 41.1 45.5 22.2 84.6 0.68 (15)
Dominican Republic 4,534 40.0 46.5 15.1 63.0 0.36 (20)
Ecuador 4,614 40.7 41.8 18.0 82.5 0.25 (22)
Guatemala 4,767 40.0 38.4 11.7 42.2 0.24 (23)
Mexico 38,618 40.6 42.5 24.5 78.4 0.35 (21)
Paraguay 5,132 39.0 46.4 26.9 53.0 0.14 (26)
Uruguay 2,976 44.5 46.6 33.5 77.3 0.74 (10)
Eastern Mediterranean
Morocco 4,472 40.1 50.9 15.9 62.5 0.20 (25)
Pakistan 6,106 37.6 62.0 27.6 30.9 -0.41 (33)
Tunisia 5,069 40.1 48.7 26.9 64.2 0.21 (24)
Europe
Bosnia and Herzegovina 1,028 43.5 48.9 44.2 42.4 0.92 (7)
Croatia 990 49.5 41.9 26.6 67.2 1.23 (1)
Czech Republic 935 46.5 47.6 30.5 79.7 1.14 (2)
Estonia 1,012 49.7 35.8 35.7 68.7 1.04 (4)
Georgia 2,749 45.9 43.7 29.0 51.7 0.71 (12)
Hungary 1,419 49.8 40.6 34.0 67.2 0.84 (8)
Kazakhstan 4,496 42.6 34.1 25.9 80.9 0.92 (6)
Latvia 856 50.5 32.4 34.8 67.2 0.64 (16)
Russian Federation 4,422 51.4 35.6 27.6 87.6 0.75 (9)
Slovakia 2,518 34.3 40.7 36.7 87.2 0.93 (5)
Turkey 11,220 41.3 43.6 32.9 61.9 1.11 (3)
Ukraine 2,503 46.3 35.7 25.6 71.3 0.71 (13)
Southeast Asia
Bangladesh 5,552 38.9 49.0 45.8 19.7 -0.75 (45)
India 9,723 38.4 52.8 36.1 10.2 -0.48 (37)
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Table 2 Average prevalence of current smoking and pack-years among current smokers according to permanent income quintile, and measures
of inequality, by WHO region, and gender
Permanent income quintile (1st = poorest) Measures of inequality
1st 2nd 3rd 4th 5th ACI RCI Q1Q5 Q1/Q5
Current smoking (%)
Women
Africa 6.5 6.0 5.9 5.4 5.2 -0.30 -0.05 1.32 2.34
Americas 16.5 14.8 13.3 13.9 15.2 -0.31 0.02 1.30 1.29
Eastern Mediterranean 3.3 3.1 3.1 3.5 3.3 0.05 0.08 0.01 0.97
Europe 18.0 20.6 21.5 21.0 23.6 1.10 0.09 -5.64 0.72
Southeast Asia 25.7 19.4 20.3 16.5 9.6 -3.43 -0.19 16.11 2.77
Western Pacic 11.3 6.8 8.1 5.5 3.4 -1.77 -0.20 7.94 4.03
Men
Africa 27.8 24.1 23.2 22.7 20.7 -1.59 -0.07 7.17 1.56
Americas 36.6 30.4 30.2 28.4 27.1 -2.22 -0.08 9.52 1.46
Eastern Mediterranean 46.3 39.6 47.3 35.7 29.7 -3.19 -0.09 16.63 1.72
Europe 55.5 47.6 50.4 46.3 48.0 -1.71 -0.04 7.47 1.22
Southeast Asia 63.8 51.3 51.0 48.3 39.2 -5.19 -0.10 24.61 1.66
Western Pacic 67.6 55.8 58.2 53.3 45.6 -4.79 -0.08 21.97 1.50
Pack-years among current smokers
Women
Africa 5.3 5.8 6.1 6.2 5.6 0.37 0.06 -0.38 1.25
Americas 9.2 9.4 9.7 11.8 8.8 0.23 0.02 0.35 1.04
Eastern Mediterranean 7.3 10.1 20.8 12.5 4.9 0.15 -0.01 2.39 1.44
Europe 12.5 12.6 9.8 10.6 9.5 -0.19 -0.02 2.98 1.40
Southeast Asia 6.9 8.3 7.1 7.2 6.1 -0.45 -0.05 0.88 1.18
Western Pacic 12.9 11.6 13.6 11.0 10.9 -0.58 -0.06 2.07 1.28
Men
Africa 7.6 7.6 6.9 6.3 6.3 -0.04 0.00 1.26 1.24
Americas 12.7 12.8 13.6 15.4 12.5 0.17 0.01 0.21 1.05
Eastern Mediterranean 13.5 13.4 14.4 14.5 13.4 -0.01 -0.01 0.06 1.08
Europe 24.7 20.2 19.7 18.3 15.3 -0.92 -0.04 9.39 1.84
Southeast Asia 13.5 11.9 11.0 9.2 8.3 -1.10 -0.09 5.18 1.53
Western Pacic 14.3 14.1 14.0 13.1 12.6 -0.52 -0.04 1.63 1.12
ACI absolute concentration index (for current smoking ACI is multiplied by 100 for ease of interpretation); RCI relative concentration index;
Q1, permanent income quintile 1; Q5, permanent income quintile 5
Table 1 continued
Country Obs Mean
age (SD)
Male (%) Current
smoking (%)
Urban
residence (%)
Global permanent
income (rank)
Myanmar 5,886 40.6 44.6 30.8 26.2 -0.53 (38)
Nepal 8,688 38.8 46.1 40.7 15.2 -0.58 (40)
Sri Lanka 6,698 41.4 48.3 21.3 14.5 -0.47 (36)
Western Pacic
China 3,993 45.1 49.0 30.0 30.8 0.70 (14)
Lao PDR 4,889 38.2 47.5 39.3 26.6 -0.39 (31)
Malaysia 6,038 39.9 45.3 25.6 62.8 0.72 (11)
Philippines 10,078 38.9 47.5 34.7 51.3 -0.27 (28)
Vietnam 3,491 39.2 47.2 25.8 15.4 -0.25 (27)
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Fig. 1 Random effects meta-analysis of absolute socioeconomic inequality in current smoking among a men, b women, World Health Surveys,
20022003
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Fig. 1 continued
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evidence of heterogeneity, with the exception of the East-
ern Mediterranean region (I
2
= 65.5%, 95% CI = 0, 90%)
which is likely to be underpowered given that only three
countries in this region participated in the WHS. Notably,
although the overall estimate of inequality for European
men favored the rich, positive socioeconomic gradients in
current smoking (more smoking among the rich) were
observed for the Ukraine, Slovakia, and Georgia, for
Mauritania in Africa, and for Mexico in the Americas
region.
Absolute socioeconomic inequalities in current smoking
were generally smaller for women than for men, although
just as variable (Fig. 1b). Overall estimates suggested
higher smoking prevalence among the poor in Southeast
Asia (ACI = -3.43, 95% CI = -5.5, -1.3), the Western
Pacic (ACI = -1.75, 95% CI = -3.3, -0.2) and, mar-
ginally, in Africa (ACI = -0.24, 95% CI = -0.5, 0.0). In
Europe, however, positive associations between permanent
income and current smoking were observed for many
countries, leading to an overall positive ACI of 1.44 (95%
CI = 0.8, 2.1). As for men, however, in every region
except the Eastern Mediterranean, there was substantial
statistical evidence of heterogeneity, particularly in the
Americas, where ACI estimates ranged from -3.4 in the
Dominican Republic to 3.05 in Mexico.
In contrast with the pattern of greater smoking
prevalence among poorer men in all regions, among current
smokers there were generally weaker associations between
socioeconomic position and pack-years of smoking
(Fig. 2a). In Africa, the Americas, and the Eastern Medi-
terranean regions the ACI estimates were near zero,
whereas poorer individuals had more pack-years of expo-
sure in Europe, Southeast Asia, and the Western Pacic.
The largest ACI was for the Southeast Asian region at
-1.03 (95% CI = -1.7, -0.4). However, it should still be
noted that in Europe, Southeast Asia, and the Western
Pacic regions the I
2
statistics were close to 50% or higher,
and generally different from zero, suggesting there is
substantial heterogeneity within regions in the relationship
between income and pack-years of smoking. For women
(Fig. 2b), given their lower prevalence of smoking,
estimates of socioeconomic differences in pack-years of
exposure were less precise than for men, and few countries
had ACIs different from zero. The overall relationship
between income and pack-years of smoking was positive
among women in the African region (ACI = 0.28, 95%
CI = 0.0, 0.6) and negative in Europe (ACI = -0.25, 95%
CI = -0.5, -0.1) but both effects were small in magni-
tude. Estimates in other regions were not statistically dis-
tinguishable from zero.
With regard to the relationship between socioeconomic
differences and average prevalence, among women there
was little correlation between average smoking prevalence
and the magnitude of absolute inequality in current
smoking (Pearsons r = -0.09, p = 0.50); among men,
however, countries with higher smoking prevalence were
somewhat more likely to have greater socioeconomic dif-
ferences in current smoking, i.e., more negative ACIs
(r = -0.29, p = 0.04).
Finally, we attempted to explain heterogeneity in
estimates of socioeconomic inequality across countries by
using country GDPpc (in $10,000 units, logged). With the
exception of a weak positive relationship between log
GDPpc and socioeconomic inequality in current smoking
among women (b = 0.90, 95% CI = 0.3, 1.5), suggesting
slightly larger gradients in poorer countries, we could not
detect any other association between national income and
the extent of socioeconomic inequalities in tobacco use
(results not shown). Meta-regressions that included region
xed effects produced similar results. Figure 4, in the
Appendix, shows scatter plots of the four separate meta-
regressions.
Discussion
The primary objective of this study was to estimate
cross-nationally comparable measures of socioeconomic
inequalities for two important aspects of smokingcurrent
smoking prevalence and accumulated pack-years of expo-
sure among current smokers. Using similar measures of
socioeconomic position we found that poorer men were
more likely to be current smokers in most WHO regions,
especially in Southeast Asia and the Western Pacic, but
that there was substantial heterogeneity in the extent of the
social gradient in smoking in all regions. However, similar
estimates in the accumulated amount of smoking (pack-
years) among currently smoking men did not reveal a
similar inverse gradient. This suggests that estimates of
socioeconomic differences based solely on smoking prev-
alence may not reect intensity of smoking among income
groups. Gradients among women were generally weaker,
though no less heterogeneous within and across regions.
Although the lack of previous comparable systematic
surveys across LMICs largely limits our ability to compare
our estimates with previous studies, our results neverthe-
less have some bearing on previous efforts. Our results are
in some respects consistent with the summary of evidence
on poverty and smoking presented in the review by Bobak
et al. [13]. They also found substantial heterogeneity in
socioeconomic gradients across countries, and in most
countries more disadvantaged men were more likely to
smoke. In other respects, however, our results are less
consistent with previous research. Bobak et al. found
that relative differences in smoking prevalence in poorly
and highly educated males were largest in low-income
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Fig. 2 Random effects meta-analysis of absolute socioeconomic inequality in accumulated pack-years of smoking among a men who are current
smokers, b women who are current smokers, World Health Surveys, 20022003
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Fig. 2 continued
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countries. We found limited evidence of this pattern among
women, but virtually no relationship between country
income and socioeconomic inequalities in either smoking
prevalence or accumulated exposure among men. The fact
that the estimates of Bobak et al. used a different indicator
of socioeconomic position, were from (largely) different
countries, and were from the mid-1990s could potentially
explain the differences between their conclusions and the
WHS estimates.
In addition to estimating the magnitude of socio-
economic inequalities in current smoking, we also found
substantially smaller inequalities in accumulated tobacco
exposure in all regions, and virtually no inequality among
men in Africa and the Americas. There have been far fewer
studies looking at socioeconomic inequalities in measures
of accumulated smoking in LMIC, although some have
looked beyond simply current or daily smoking [34]. Hu
and Tsai found more highly educated rural Chinese less
likely to smoke overall, but no educational differences in
the amount of daily consumption. A systematic review of
smoking surveys in sub-Saharan Africa by Townsend et al.
[14] also considered measures of smoking intensity, but
concluded that the use of inconsistent measures of socio-
economic position made cross-country comparisons dif-
cult. We hope our estimates may provide useful reference
values for future assessment of socioeconomic differences
in multiple measures of tobacco consumption.
Limitations
Our estimates of socioeconomic inequalities in tobacco use
are subject to some limitations. First, the objective of the
WHS was to provide a broad survey of several aspects of
individual health and health system interactions. As such,
the measures of smoking we describe are both self-reported
and unable to capture potentially important socioeconomic
differences in other tobacco-related phenomena, for
example quitting behavior and exposure to passive smoke.
Second, we focused primarily on estimating absolute
inequalities using the concentration index. It is well known
that the use of different measures of inequality may lead to
different conclusions [3537]. Third, we only studied the
sample of countries that participated in the WHS and
grouped countries according to WHO regions. We used
WHO geographic regions because they correspond to
WHO program ofces. However, although they are geo-
graphically based, they are not synonymous with geo-
graphic areas. Thus, regional estimates using different
denitions such as those of the World Bank or the United
Nations may differ from ours. While this survey was
designed to be broadly representative of all global regions
and levels of economic development, estimates from other
countries may show different patterns. Given the extent
of heterogeneity in our estimates, this seems a likely
possibility.
We also note that our estimates of pack-years of
smoking among current smokers are subject to uncertainty
with regard to calculating tobacco equivalents. We could
not separate cigars from other types of tobacco, and did not
have information on the amount of loose tobacco used for
hand-rolled cigarettes, which may vary widely. The current
literature on tobacco equivalents in poorer countries is
diverse, with some studies equating hand-rolled cigarettes
and pipes with manufactured cigarettes [38] whereas others
equate one manufactured cigarette with up to one hand-
rolled cigarettes [39, 40]. Given that the use of non-man-
ufactured cigarettes is greater in poorer countries, we may
have underestimated accumulated smoking in these areas.
Similarly, if poorer individuals are less likely to use
manufactured cigarettes, we may have underestimated
socioeconomic gradients in accumulated tobacco exposure.
A more important limitation is the fact that the WHS
surveys are now almost 10 years old, and may not accu-
rately reect the current state of the tobacco epidemic in
LMICs. However, we looked at the most recent data on
smoking prevalence from the WHOs Global Public Health
Observatory, which generally date from 2006 for the
countries we studied. In most cases our estimates were
similar to WHOs 2006 estimates, but in some cases, par-
ticularly for some European countries, for example the
Russian Federation and Ukraine, our prevalence estimates
are much lower. On the other hand, our estimates are
higher than recent surveys from WHOs 20092010 Global
Adult Tobacco Surveys (e.g., for Bangladesh, China,
Brazil, and Mexico) [41]. Whether this is a consequence of
different survey designs or actual secular changes requires
additional investigation. As a nal point, the main advan-
tage of the WHS surveys, despite being somewhat dated, is
their ability to provide comparable estimates of socioeco-
nomic differences in smoking across countries, which is
currently not possible with the GATS data. Understanding
whether socioeconomic differences in LMICs are increas-
ing or decreasing over time more rapidly in some regions
will require new sources of harmonized data.
Conclusions
Our ndings suggest there is substantial heterogeneity
within geographic regions in the association between
socioeconomic position and tobacco exposure. Both posi-
tive and negative socioeconomic gradients in smoking are
evident for both men and women, suggesting there is
unlikely to be any universal relationship between socio-
economic factors and smoking behavior. The extent to
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which the heterogeneity in socioeconomic gradients we
observed may be explained by other individual-level
characteristics or the extant tobacco policy environment
and more general determinants of socioeconomic inequal-
ity should be the subjects of future research.
Acknowledgments We thank the Institute for Health Metrics and
Evaluation (http://www.healthmetricsandevaluation.org) for provid-
ing us with the estimates of permanent income that were used in these
analyses. This work was supported by the Canadian Institutes
for Health Research (191612). Sam Harper was supported by a
Chercheur-boursier from the Fonds de la Recherche en Sante du
Quebec (FRSQ). The funders had no role in the study design, data
gathering and analysis, interpretation of data, decision to publish, or
preparation of the manuscript. The corresponding author had full
access to all data that were analyzed and had nal responsibility for
the decision to submit the report for publication.
Appendix
See Figs. 3,4 and Tables 3, 4.
Regional offices and regions of the WHO
Africa
Americas
Eastern
Europe
South East Asia
Western Pacific
:
Mediterranean
Fig. 3 World Health Organization regional ofces (source: http://commons.wikimedia.org/wiki/File:World_Health_Organisation_regional_
ofces.png, accessed 15 July 2011)
Fig. 4 Estimated effect of log
GDP per capita ($10,000s) on
absolute socioeconomic
inequalities in tobacco
exposure. Note: size of bubble
based on study precision
(inverse of within-study
variance)
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Table 3 Countries involved in
the World Health Surveys
classied by World Health
Organization and 2003
World Bank lending regions
Upper middle income Lower middle income Low income
Africa Mauritius
South Africa
Congo
Namibia
Swaziland
Burkina
Faso
Chad
Comoros
Cote dIvoire
Ethiopia
Ghana
Kenya
Malawi
Mali
Mauritania
Senegal
Zambia
Zimbabwe
Western Pacic Malaysia China
Philippines
Laos
Vietnam
Eastern Mediterranean Morocco
Tunisia
Pakistan
Southeast Asia India
Sri Lanka
Bangladesh
Myanmar
Nepal
Europe Croatia
Czech Republic
Estonia
Hungary
Kazakhstan
Latvia
Russian Federation
Slovakia
Turkey
Bosnia and Herzegovina
Georgia
Ukraine
Americas Brazil
Mexico
Uruguay
Dominican Republic
Ecuador
Guatemala
Paraguay
Table 4 List of shared and country-specic assets used in the asset-based index of permanent income, World Health Survey (20022003)
Shared assets Low-income specic assets High-income specic assets
1. Bike
2. Washer
3. Dishwasher
4. Fridge
5. Phone
6. Cellular phone
7. Computer
8. TV
9. Medium space (C0.5 rooms/person)
10. High space (C1 rooms/person)
11. Highest space ([1 room/person)
12. 1 or more cars
13. 2 or more cars
14. Piped water
15. Electricity
16. Bucket
17. Clock
18. 1 or more chairs/person
19. 2 or more tables
20. Country-specic assets
21. VCR
22. Stereo
23. DVD player
24. Video camera
25. Vacuum cleaner
26. Internet
27. Magazine or newspaper subscription
28. Security system
29. Hired worker
30. 2nd home
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