title: Poly-tobacco use among adults in 44 countries during 2008-2012: evidence for an integrative and comprehensive approach in tobacco control.
abstract: BACKGROUND
  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.
authors.affiliation: Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA. Electronic address: iagaku@cdc.gov.
authors.forename: Israel T
authors.initials: IT
authors.lastname: Agaku
authors.affiliation: Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.
authors.forename: Filippos T
authors.initials: FT
authors.lastname: Filippidis
authors.affiliation: Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.
authors.forename: Constantine I
authors.initials: CI
authors.lastname: Vardavas
authors.affiliation: Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos State, Nigeria.
authors.forename: Oluwakemi O
authors.initials: OO
authors.lastname: Odukoya
authors.affiliation: Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, USA.
authors.forename: Ayodeji J
authors.initials: AJ
authors.lastname: Awopegba
authors.affiliation: Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA; Office of the Dean/Director, School of Oral Health Sciences, University of Limpopo, MEDUNSA campus, Pretoria, South Africa.
authors.forename: Olalekan A
authors.initials: OA
authors.lastname: Ayo-Yusuf
authors.affiliation: Center for Global Tobacco Control, Department of Social and Behavioral Sciences, Harvard School of Public Health, USA.
authors.forename: Gregory N
authors.initials: GN
authors.lastname: Connolly
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003625:Data Collection; D005260:Female; D014943:Global Health / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012737:Sex Factors; D012907:Smoking / Q000453:epidemiology; D000074606:Smoking Prevention; D012959:Socioeconomic Factors; D064424:Tobacco Use / Q000453:epidemiology* / Q000517:prevention & control; D055815:Young Adult
keywords: Alternative tobacco products; Cigarettes; Policy; Poly-tobacco; Smoking; Tobacco; Tobacco control