title: Market structures, socioeconomics, and tobacco usage patterns in Madagascar.
abstract: BACKGROUND
  The isolated island nation of Madagascar has substantial prevalence of both smoking and smokeless tobacco use, although not of dual use. Madagascar's tobacco market, much like its historical and cultural underpinnings, appears to have both Asian and African influences. Additionally, it has a unique market structure that plays an important role in influencing patterns of tobacco use. This study analyzes the determinants of smoking and smokeless tobacco use in Madagascar.
  
  
  METHODS
  We used the 2008 Madagascar Demographic and Health Survey to analyze both smoking tobacco and smokeless tobacco use, stratified by gender. Multivariate log binomial models were used to evaluate the relationship between tobacco use and age, residence (urban/rural), province, marital status, and education.
  
  
  RESULTS
  Our analysis indicates that two distinctly different groups of people use two distinctly different tobacco products. Smoking is almost exclusively used by men and does not appear to be related to socioeconomic status. Conversely, smokeless tobacco is consumed by large proportions of both men and women, who are less educated and live in rural areas of the country. This disparate pattern in consumption is a reflection of the different market structures for smokeless tobacco (a cottage industry) and smoking tobacco (a near monopoly).
  
  
  CONCLUSIONS
  Distinct market-based, geographic, and socioeconomic disparities in tobacco use are explored in order to begin the classification of Madagascar's tobacco epidemic as more African, more Asian, or as a distinctly different environment.
authors.affiliation: International Tobacco Control Research Program, American Cancer Society, Atlanta, GA;
authors.forename: Evan
authors.initials: E
authors.lastname: Blecher
authors.forename: Alex C
authors.initials: AC
authors.lastname: Liber
authors.forename: Martine
authors.initials: M
authors.lastname: Chaussard
authors.forename: Stacey
authors.initials: S
authors.lastname: Fedewa
mesh_terms: D000293:Adolescent; D000328:Adult; D000329:Advertising; D003430:Cross-Sectional Studies; D003625:Data Collection; D003710:Demography; D004522:Educational Status; D005260:Female; D006801:Humans; D008270:Madagascar / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D015995:Prevalence; D012424:Rural Population; D012737:Sex Factors; D012907:Smoking / Q000191:economics / Q000453:epidemiology*; D016540:Smoking Cessation / Q000191:economics / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D064424:Tobacco Use / Q000191:economics / Q000453:epidemiology*; D014030:Tobacco, Smokeless / Q000191:economics / Q000706:statistics & numerical data*; D014505:Urban Population; D055815:Young Adult