Smoking Cessation and Utilization of Cessation Assistance in 13 low- and middle-income countries - changes between Two Survey Rounds of Global Adult Tobacco Surveys, 2009–2021

Abstract

Introduction

Monitoring changes in cessation behaviors and cessation assistance is critical for policymaking.

Methods

We analyzed two rounds (2009–2014 and 2015–2021) of Global Adult Tobacco Surveys in 13 countries. We estimated the quit ratio, quit attempt, and utilization of cessation assistance. The availability of cessation services was obtained from World Health Organization reports. We calculated absolute and relative changes in quit ratio, quit attempt, and cessation assistance. We assessed socio-economic determinants of cessation behaviors by binary logistic regression analyses on pooled data.

Results

In all countries during both rounds smoking prevalence was 7.6–33.8%, the quit ratio was 0.15–0.54%, and the quit attempt was 17.7–52.8%. Quit ratio improved in Indonesia by 100% but declined in Turkey by 56%. Quit attempts increased in Indonesia (31.9%), Mexico (16.9%) and China (15.9%) but decreased in Turkey (140.4%), Vietnam (43.1%), and Romania (62.4%). In both rounds, using at least one method was 12.5–99.8% while the WHO-recommended method was 4.1–88.4%. In both rounds “try to quit without any assistance” and “other methods” were the most frequently reported cessation assistance. Nicotine replacement therapy (0.2–25.3%) was frequently used as recommended cessation assistance. Nicotine replacement therapy was available in most countries but not quitline and support services.

Conclusion

Limited progress was made in smoking cessation behaviors and cessation assistance in most countries. Health education to improve demand for smoking cessation and availability of evidence-based, low-cost smoking cessation assistance including quit-smoking may improve quit ratios in the population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44197-024-00283-9.

Introduction

Tobacco use has declined but the burden of tobacco-induced diseases [1] has increased in the populous low- and middle-income countries (LMIC) where tobacco use is higher than in high-income countries (HIC) [2] where the implementation of tobacco control measures is weaker than HIC [3]. Prevention of smoking initiation and smoking cessation are needed to reduce smoking prevalence [4]. The World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) in Article 14 requires the signatory countries to provide adequate services for tobacco dependence treatment [5]. However, in most LMICs implementation of WHO-FCTC Article 14 was weak in in 2012 [6]. and 2015 [7]. Therefore, evidence-based tobacco dependence treatment services should be provided in LMIC [8].

Smoking cessation provides short-term and long-term health benefits at the individual level [9]. However, International Tobacco Control and Global Adult Tobacco Control Survey (GATS) data have shown that quit rates are usually < 10% in LMICs [10]. A weaker implementation of smoking cessation services [11] relative to other tobacco control interventions may be unethical [12]. Limited research from LMICs has reported that socioeconomic factors are associated with quitting behavior [13, 14], socioeconomic inequalities exist in quit attempts [10], and the cessation assistance used to quit [15]. Based on GATS (2008–2012) data from 16 LMICs, Wang et al. have reported that up to 20% of the individuals who currently smoke had made quit attempts and counseling, and pharmacotherapy was the commonly used cessation assistance [16]. Ahluwalia et al. have reported that in 31 GATS (2008–2018) countries, most individuals who smoke had attempted to quit without any assistance [15].

The emergence of newer tobacco products such as electronic cigarettes (e-cigarettes) and heated tobacco products marketed as harm reduction and smoking cessation assistance warrants examining if these products were used as cessation assistance [17]. For global tobacco control policy, the quit ratio informs the population-level impact of tobacco control interventions and quit attempts and the utilization of cessation assistance informs about demand for smoking cessation services. We examined the changes in quit ratio in the population quit attempts, and cessation assistance used by the adults who smoke between two rounds of GATS. We also provide sociodemographic factors associated with quit attempts and utilization of at least one cessation assistance. We report tobacco control policy scores and the availability of tobacco dependence treatment during the survey years for the 13 countries.

Methods

Design

We did a secondary data analysis of the two rounds of GATS in 13 countries between 2009 and 2014 and 2015–2021 respectively. (Table 1).

Table 1.

Survey characteristics, World Bank Group country classification, smoking prevalence, and tobacco control status during the two rounds in 13 Global Adult Tobacco Survey countries

Country	World Bank category	Sample surveyed	Response rate	Smoking prevalence (% and 95% CI)	MPOWER score	Status of cessation services
Bangladesh 2011	Low	9629	93.6	20.1 (19.8, 22.0) *	15	2
Bangladesh 2016	Low	12,783	90.8	16.4 (15.5, 17.4)	23	3
China 2011	Upper middle	13,354	96.0	24.1 (22.5, 25.6)	16	3
China 2016	Upper middle	19,376	91.5	23.2 (22.0, 24.5)	20	4
India 2009	Lower middle	69,296	91.8	10.7 (10.1, 11.2) *	25	4
India 2016	Lower middle	74,037	92.9	8.6 (8.2, 8.9)	26	4
Indonesia 2011	Lower middle	8305	94.3	29.2 (27.6, 30.9)*	18	3
Indonesia 2021	Lower middle	9,156	94.0	33.5 (32.1, 34.9)	23	4
Kazakhstan 2014	Upper middle	4,425	96.7	19.1 (17.5, 20.7) *	23	4
Kazakhstan 2019	Upper middle	10,677	95.5	21.6 (19.0, 24.2)	26	4
Mexico 2009	Upper middle	13 627	82.5	7.6 (6.8, 8.3)	18	4
Mexico 2015	Upper middle	14,664	82.7	7.6 (6.9, 8.3)	20	5
Philippines 2009	Lower middle	9,705	88.4	22.5 (21.3, 23.6) *	22	4
Philippines 2015	Lower middle	11,644	92.1	18.7 (17.7, 19.7)	24	4
Romania 2013	Upper middle	4517	88.5	24.3 (22.6, 26.0) *	23	4
Romania 2018	Upper middle	4,571	88.0	27.4 (25.3, 29.4)	27	5
Russia 2009	Upper middle	11,406	97.7	33.8 (32.5, 35.1)*	18	4
Russia 2016	Upper middle	11,458	98.2	26.1 (24.9, 27.3)	27	4
Turkey 2012	Upper middle	9,851	90.1	23.8 (22.6, 25.02)	27	5
Turkey 2016	Upper middle	8760	82.2	29.6 (28.6, 30.1)	29	5
Ukraine 2010	Lower middle	8,173	76.2	25.5 (24.4, 26.7) *	22	3
Ukraine 2017	Lower middle	8,298	64.4	20.1 (18.9, 21.2)	25	3
Uruguay 2009	Upper middle	5581	95.6	20.4 (19.1, 21.8) *	27	4
Uruguay 2017	High	4,966	89.4	18.3 (17.1, 19.5)	27	4
Vietnam 2010	Lower middle	9,925	95.7	19.5 (18.4, 20.5)	21	3
Vietnam 2015	Lower middle	8,996	-	19.2 (18.0, 20.4)	23	3

*The difference in prevalence between the two surveys was statistically significant

MPOWER-Monitor, Protect, Offer, Warn, Empower and Raise

Data Source

The GATS is a series of nationally representative, cross-sectional household surveys among civilian, noninstitutionalized individuals aged 15 years and above using a standardized questionnaire. Eligible individuals were sampled by a stratified, multistage, probability sampling technique. In each sampled geographic location, the households were randomly selected in which one adult aged ≥ 18 years responded to the household questionnaire and listed all household members aged ≥ 15 years. In each household one randomly selected member was interviewed with a handheld device. The core GATS questionnaire was adapted to suit the country context. Further details about the survey instrument, methodology, etc. are published elsewhere [18].

Ethics Approval

Since secondary data was used, ethical approval was not needed. All participants of the GATS survey provided voluntary consent.

Tobacco Control Policy and Availability of Smoking Cessation Services

Data about the extent of tobacco control policy [MPOWER: Monitor, Protect, Offer, Warn, Enforce and Raise)] score in each country was extracted from WHO reports on the global tobacco epidemic for the year nearest to the year of GATS to reflect the prevailing policy environment. The MPOWER indicators cover the following six evidence-based strategies:

1. Monitoring tobacco consumption and the effectiveness of preventive measures.

2. Protecting people from tobacco smoke.

3. Offering help to quit tobacco use.

4. Warning about the dangers of tobacco.

5. Enforcing bans on tobacco advertising, promotion, and sponsorship; and.

6. Raising taxes on tobacco.

For each of these measures, a score of 1 was assigned if data were lacking entirely, if no data from 2009 onward were available, or if available data were not both recent and representative of the national population. Scores of 2 to 4 (for M) and 2 to 5 (for P, O, W, E, and R) represent a scale from the weakest to the strongest level of tobacco control policy in the relevant country. The sum of scores assigned to each of the six dimensions MPOWER score for each country and the maximum score was 29 [19]. We used the WHO Global Health Observatory under the category of “offer help to quit tobacco use” (https://www.who.int/data/gho/data/indicators) to extract data about the availability of cessation assistance during the year of GATS. The index for scoring “offering help to quit tobacco use” was:

1. No data Available

2. No Services Available for Treatment of Tobacco Dependence

3. Nicotine Replacement Therapy and/or some Cessation Services (neither cost Covered)

4. Nicotine Replacement Therapy and/or some Cessation Services (at Least One of which the cost Covered)

5. National Quitline, and both Nicotine Replacement Therapy and some Cessation Services whose cost is Covered.

Operationalization of Cessation Methods and quit Ratios

Quit Ratio

We used the aggregate (country-level) weighted prevalence rates of smoking in the past and those who currently smoke (daily and non-daily) in the entire survey sample. The quit ratio was defined as the ratio of prevalence of past smoking to ever smoking (current and past) [20].

Quit Attempt

Quit attempt during the previous 12 months among the individuals who currently smoke was inquired by asking the question: “During the past 12 months, have you tried to stop smoking?” The response options were ‘yes’ or ‘no’. The options provided were counseling, nicotine replacement therapy, other prescription medications, alternative treatments, psychotherapy, quitline, replacing with smokeless tobacco, quitting without assistance, etc. The options provided slightly varied across successive rounds in each country and the countries.

Utilization of Smoking Cessation Assistance

The respondents who currently smoke and had attempted to quit during the previous 12 months were further asked the question: During the past 12 months, did you use any of the following to try to stop smoking tobacco? Utilization of at least one method of cessation assistance was defined as a response as ‘yes’ to any of the listed methods. Utilization of recommended methods was defined as a response as ‘yes’ to any one cessation assistance such as cessation counseling, quitline or quit line, nicotine replacement therapy, and other prescription medications [16].

Statistical Analyses

We estimated the weighted prevalence and their 95% CI of current smoking and past smoking in each country and survey round among the entire survey sample. We also estimated the weighted proportions and 95% CI of quit attempts (among respondents who currently smoke), utilization of at least one cessation assistance, and recommended cessation assistance (among the persons who currently smoke and made quit attempts during the previous 12 months). To assess the change in smoking cessation behaviors between two rounds, we estimated absolute and relative (percentage) differences in the indicators of smoking behaviors. The statistical significance of the change was tested by Wald statistics (difference/standard error). To determine the factors associated with quit attempts and use at least one cessation assistance with demographic factors binary logistic regression analyses were done on the pooled data. Adjusted odds ratios (AOR) and their 95% CI were estimated. All analyses were carried out in StataMP 11.2.

Results

Survey Characteristics, Smoking Prevalence, and Tobacco Control Policy in 13 GATS Countries

Among the 13 countries, Bangladesh was the only low income while the rest were upper (7) and lower (5) middle-income countries. Response rates ranged from 64.4 to 98.2%. The prevalence (%) of smoking ranged from 7.6 to 33.8 in the first round while it was 7.6 to 33.5 in the second round. Smoking prevalence had significantly declined in six while it increased in four countries (Table 1). Four countries had very high MPOWER scores (27–29). Four countries fared better than the rest in smoking cessation services having the highest score of five (Table 1). In pooled data, during both rounds, > 80% were aged 15–59 years, about 40% were educated up to primary, and women were slightly higher (appendix).

Changes in Smoking Cessation Behaviors

Quit Ratios and Quit Attempts

In all surveys, the quit ratios were < 0.5 (except in Uruguay). It ranged from 0.15 to 0.52 in the first round and 0.16 to 0.54 in the second round. A significant change between the two rounds was seen in two countries namely Indonesia (106.7% increase from 0.16 to 0.33) and Turkey (55.6% decline from 0.35 to 0.16) (Table 2). In most countries in all surveys, the quit attempts were around 33% but were around 50% in Mexico, the Philippines, and Vietnam. In the first round quit attempts ranged from 27.6 to 52.8 during the first rounds and 17.7 to 52.1 during the second round. Between two rounds, quit attempts significantly increased in three countries (by 32% in Indonesia to 16% in Mexico) and it significantly decreased in three countries (by 140% in Turkey to 43% in Vietnam) (Table 2).

Table 2.

Changes in quit ratios, quit attempts, and use of cessation methods among the persons who currently smoke between two rounds of global adult Tobacco surveys in 13 countries

Country (survey year)	Quit ratio	Quit attempt during the last 12 months (%)	Used at least one method (%)	who used. recommended methods (%)
Bangladesh 2011	0.23 (0.21, 0.24)	45.25 (41.85, 48.65)	27.74 (23.18, 32.30)	14.30 (10.99, 17.61)
Bangladesh 2016	0.23 (0.22, 0.24)	43.43 (39.86, 47.01)	12.51 (10.10, 14.93)	9.89 (7.64, 12.14)
Absolute change	0.01	-1.82	-15.23	-4.41
% change	3.32	-4.18	-121.67	-44.61
p-value	0.526	0.68	< 0.001	< 0.001
China 2011	0.18 (0.16, 0.19)	30.84 (26.62,35.06)	20.64 (13.46, 27.81)	5.27 (2.65, 7.89)
China 2016	0.21 (0.20, 0.22)	36.66 (33.97,39.34)	95.43 (93.66, 97.20)	6.86 (4.90, 8.82)
Absolute change	0.03	5.82	74.79	1.59
% change	18.62	15.87	74.38	23.17
p-value	< 0.001	< 0.001	< 0.001	< 0.001
India 2011	0.15 (0.15, 0.16)	36.22 (34.13, 38.31)	33.28 (30.29, 36.27)	10.98 (9.22, 12.75)
India 2018	0.19 (0.19, 0.20)	36.35 (34.44, 38.25)	79.56 (77.00, 82.11)	10.54 (8.62, 12.46)
Absolute change	0.04	0.13	46.27	-0.44
% change	25.9	0.35	58.16	-4.20
p-value	< 0.001	1.00	< 0.001	0.97
Indonesia 2011	0.16 (0.14, 0.17)	29.1 (25.4, 32.8)	90.8 (87.2, 94.3)	30.4 (24.6, 36.3)
Indonesia 2021	0.33 (0.31, 0.33)	42.7 (39.8, 45.5)	91.1 (88.1, 94.2)	32.3 (27.8, 36.8)
Absolute change	0.17	13.6	0.3	1.9
% change	106.7	31.85	0.33	5.9
p-value	< 0.001	< 0.001	0.999	0.89
Romania 2013	0.35 (0.34, 0.36)	35.32 (31.68, 38.95)	88.25 (83.79, 92.71)	10.74 (7.10, 14.38)
Romania 2018	0.31 (0.30, 0.32)	21.74 (19.18, 24.31)	79.91 (73.67, 86.15)	11.59 (5.69, 17.49)
Absolute change	-0.04	-13.57	-8.34	0.85
% change	-11.53	-62.42	-10.43	7.33
p-value	< 0.05	< 0.001	< 0.001	0.99
Kazakhstan 2014	0.17 (0.16, 0.18)	27.60 (23.58, 31.62)	87.36 (82.12, 92.60)	28.41 (20.20, 36.63)
Kazakhstan 2019	0.20 (0.17, 0.22)	31.81 (25.51, 38.12)	31.81 (25.51, 38.11)	88.43 (80.43, 96.43)
Absolute change	0.03	4.21	-55.55	60.02
% change	15.86	13.24	-174.62	67.87
p-value	0.003	0.27	< 0.001	< 0.001
Mexico 2011	0.44 (0.43, 0.44)	43.74 (40.36, 47.12)	93.59 (91.66, 95.53)	10.18 (7.72, 12.65)
Mexico 2015	0.48 (0.47, 0.48)	52.13 (49.07, 55.19)	94.43 (92.28, 96.57)	8.85 (6.18, 11.53)
Absolute change	0.04	8.39	0.84	-1.33
% change	25.9	16.09	0.88	-15.01
p-value	< 0.05	< 0.001	0.84	0.69
Philippines 2011	0.30 (0.29, 0.30)	45.41 (42.94, 47.89)	59.67 (55.77, 63.57)	83.16 (79.97, 86.35)
Philippines 2017	0.25 (0.24, 0.26)	49.94 (47.11, 52.77)	80.78 (77.61, 83.94)	20.14(16.74, 23.55)
Absolute change	-0.04	4.53	21.10	-63.02
% change	-14.43	9.07	26.13	-312.84
p-value	< 0.01	< 0.001	< 0.001	< 0.001
Russia 2013	0.35 (0.34, 0.36)	29.5 (27.5, 31.4)	54,6 (49.9, 59.3)	23.83(20.41, 27.25)
Russia 2018	0.31 (0.30, 0.32)	31.25 (20.53, 41.96)	85.0 (67.9, 102.1)	26.45 (5.53, 47.37)
Absolute change	0.11	1.78	30.39	2.62
% change	-37.36	5.68	35.76	9.89
p-value	< 0.05	0.98	< 0.001	0.99
Turkey 2014	0.35 (0.35, 0.36)	42.57 (39.98, 45.15)	84.79 (81.45, 88.13)	18.06 (15.04, 21.07)
Turkey 2018	0.16 (0.13, 0.18)	17.71 (14.50, 20.92)	67.47 (58.84, 76.11)	18.92(12.46, 25.39)
Absolute change	-0.20	-24.86	-17.32	0.87
% change	-55.66	-140.37	-25.67	4.58
p-value	< 0.001	< 0.001	< 0.001	0.99
Ukraine 2011	0.34 (0.34, 0.35)	36.12 (33.52, 38.72)	15.23 (12.09, 18.37)	4.38 (2.82, 5.93)
Ukraine 2017	0.40 (0.39, 0.40)	35.50 (32.60, 38.40)	90.2 (87.3, 93.0)	9.71 (6.59, 12.74)
Absolute change	0.06	-0.62	74.97	5.33
% change	16.22	-1.75	83.11	54.94
p-value	< 0.05	0.978	< 0.001	< 0.001
Uruguay 2011	0.52 (0.52, 0.52)	44.16 (40.46, 47.85)	99.79 (99.46, 100.11)	22.71(17.85, 27.57)
Uruguay 2017	0.54 (0.54, 0.54)	41.28 (37.75, 44.82)	97.22 (95.45, 99.00)	18.84(14.28, 23.39)
Absolute change	0.02	-2.87	-2.56	-3.87
% change	4.33	-6.96	-2.64	-20.54
p-value	0.52	0.27	< 0.001	0.24
Vietnam 2011	0.30 (0.29, 0.31)	52.80 (49.95, 55.65)	34.15 (30.57, 37.74)	26.49(23.10, 29.88)
Vietnam 2016	0.31 (0.30, 0.31)	36.90 (34.27, 39.53)	81.90 (77.94, 85.85)	4.09 (2.49, 5.68)
Absolute change	0.01	-15.90	47.74	-22.40
% change	2.16	-43.08	58.30	-548.29
p-value	0.180	< 0.001	< 0.001	< 0.001

Utilization of at Least One and Recommended Cessation Assistance

The utilization of at least one cessation assistance ranged from 15.23 to 99.8% during the first round and 12.5–97.2% during the second round. This indicator significantly increased between the two surveys in six countries, among these countries the largest increase was in Ukraine (83%) and the smallest increase was in the Philippines (26%). The use of at least one cessation method had significantly declined in four countries, the largest decline was in Kazakhstan (174%) and the smallest was in Romania (Table 2). In both rounds the indicator, use of recommended cessation assistance was < 30% in all except two surveys. The range recommended cessation assistance during the first round was 4.4–83.2% while it was 4.1 to 88.4 for the second round. Use of recommended cessation assistance significantly increased in Kazakhstan (68%), Ukraine (55%) and China (23%) but significantly decreased in Bangladesh (44%), the Philippines (310%), and Vietnam (548%) (Table 2).

Utilization of each Cessation Assistance Method

The use of ‘other prescription medications’ (0.2-10.7%) and quitline (0.1-6.1%) was much less than the nicotine replacement therapy (0.2-25.3%) and counseling (1.4-14.2%) among the recommended cessation assistance. In most surveys/countries, the highest proportion of respondents reported ‘attempt to quit without any assistance’ and/or ‘other methods’ (43.3%-83.7%). Notably, in Bangladesh (7.1%), India (8.0%), and Kazakhstan (8.1%) smokeless tobacco; in China (16.1), Russia (18.2%), and Romania (16.3%) e-cigarettes were used as cessation assistance (Table 3).

Table 3.

The types of cessation methods used by the persons who currently smoked during their quit attempts (in the last 12 months) in two rounds of global adult Tobacco surveys in 13 countries

Country (survey year)	D01#	Counselling	Nicotine replacement therapy	Other prescription medications	Alternative treatments	Psychotherapy	quitline	replace by smokeless tobacco	Quit without assistance	other	E-cigarettes	Heated tobacco products
Bangladesh 2011	1058	145 (14.2)	8 (0.9)	-	6 (0.3)		1 (0.1)	79 (7.1)	-	72 (6.9)
Bangladesh 2016	1069	127 (9.7)	5 (0.2)	-	3 (0.1)		1 (0.1)	31 (1.8)	756 (69.5)	23 (1.3)
China 2011	489	12 (2.0)	14 (2.5)	6 (1.1)	10 (1.6)		1 (0.1)	5 (1.1)	-	63 (1.1)
China 2016	837	29 (3.1)	41 (5.0)	2 (0.2)	5 (0.7)		3 (0.4)	11 (1.7)	745 (88.7)	25 (5.1)	93 (16.1)
India 2009	3499	389 (8.7)	97 (2.4)	91 (2.2)	144 (3.2)		50 (1.5)	248(8.0)	-	426(15.1)
India 2016	2939	264 (8.4)	74 (1.7)	94 (2.7)	66 (2.5)	*	18 (0.4)	124(4.0)	2300(72)	78 (2.2)
Kazakhstan 2014	207	21 (10.3)	38 (15)	31 (14.3)	5 (4.4)	7	-	20 (8.1)	208 (76.9)	24 (10.4)
Kazakhstan 2019	679	38 (5.6)	63 (9.3)	55 (8.1)	23 (3.4)	14 (2.1)	9 (1.3)	13 (1.9)	530 (78.1)		50 (7.4)	31 (4.6)
Mexico 2009	840	27 (3.1)	51 (6.6)	5 (0.1)	7 (0.7)		3 (0.5)	5 (0.5)	750# (89.5)	48 (6.4)
Mexico 2015	927	44 (6.0)	30 (2.8)	12 (0.9)	7 (1.3)	*	2 (0.1)	6 (1.0)	840 (90.7)	66 (6.7)
Philippines 2009	1288	160 (12.4)	69 (6.1)	7 (0.4)	12 (1.0)	-	-	22 (1.4)		492 (37.3)
Philippines 2015	1393	155 (10.0)	182 (11.7)	27 (1.9)	19 (1.5)	-	59 (4.4)	24 (1.5)	923 (67.9)	72 (5.4)	24 (2.3)
Romania 2011	375	6 (1.3)	36 (9.0)	6 (1.5)	8 (1.8)	-	1 (0.1)	-	301 (79.5)	19 (4.5)
Romania 2018	303	5 (1.6)	13 (7.5)	9 (5.4)	17 (7.4)	-	2 (1.4)	-	203 (64.2)		18 (16.3)	26 (11)
Russia 2009	1403	55 (3.5)	213 (15.7)	115 (8.0)	21 (1.5)	30 (2.7)		22 (1.6)		413 (31.9)
Russia 2016	1115	36 (2.1)	225 (20.0)	135 (10.7)	81 (7.3)		3 (0.2)	9 (1.0)	899 (82.3)	53 (4.8)	158 (18.2)
Turkey 2012	1208	67 (6.2)	87 (8.8)	74 (7.7)	55 (5.1)		46 (4.3)		716 (70.3)	4 (0.3)
Turkey 2016	616	60 (8.8)	50 (8.1)	46 (8.7)	23 (3.6)		43 (6.1)		269 (43.3)	1 (0.1)
Ukraine 2010	832	23 (2.8)	15 (1.9)	38 (4.9)		11 (1.3)	7	*		39 (6.2)
Ukraine 2017	635	15 (1.7)	38 (6.8)	13 (2.6)	20 (3.4)	7 (0.6)		*	528 (84.3)	20 (3.0)
Uruguay 2009	613	54 (11.5)	83 (16.8)	26 (3.8)	9 (1.8)		12 (3.3)		584 (93.7)	22 (4.4)
Uruguay 2017	432	52 (10.2)	57 (13.2)	28 (5.2)	11 (1.9)		4 (0.7)		395 (91.6)	6 (1.7)
Vietnam 2010	1168	27 (2.3)	276 (25.3)	5 (0.4)	3 (0.4)		11 (0.9)	7 (0.6)		111 (8.7)
Vietnam 2015	768	10 (1.4)	24 (3.0)	2 (0.3)	0		3 (0.9)	2 (0.2)	563 (72.9)	23 (2.8)	1 (0.2)

# Number of smokers who had attempted to quit during the last 12 months prior to the survey date

* China 2011- e-smoke − 4 (1.2); India 2016- m-cessation 10 (0.3); Romania 2018- Natural products 17 (7.4); Vietnam 2015- Gum without nicotine130 (18.2); Ukraine 2010- Internet/email 10 (1.6); Ukraine 2017- Internet email 28 (5.0); Mexico 2015–18 (1.8)

# Mexico 2009 will power 750 (89.3)

Philippines 2011- self-education materials such as posters, pamphlets, informational sheet etc.- 177 (13.9)

Philippines 2015- self education materials such as posters, pamphlets, informational sheet etc. 198 (14.2)

Romania 2011 Natural plant products 8 (1.8), acupuncture 2 (0.6)

Romania 2018 acupuncture 0

Russia acupuncture 9 (0.9)

Ukraine 2010 traditional medicine 7 (0.4)

Ukraine 2018 acupuncture 2 (0.3)

Sociodemographic Factors Associated with quit Attempts and use of at Least One Cessation Aid

Both quit attempts and use of at least one cessation assistance were higher respondents who are young, women, had higher education and participated in the recent round of GATS. All the comparisons were statistically significant (p < 0.05). Women who smoke had 1.2 times (AOR 1.2; 95% CI 1.1, 1.3) higher odds of making a quit attempt, 1.4 times (AOR 1.4, 95% CI 1.2, 1.7) higher odds of using at least cessation aid compared to men. Persons with higher education had 1.1 times (AOR 95% CI 1.0, 1.3) higher odds of quit attempt and 1.9 times (AOR 1.9, 95% CI 1.5, 2.3) higher odds of using at least one cessation aid compared to those with least/no education. Similarly, respondents who reported smoking tobacco during the recent GATS surveys had 1.2 times (AOR 95%CI 1.1, 1.3) higher odds of quit attempt and 4.5 times (AOR 95%CI 3.8, 5.4) higher odds of using at least one cessation aid compared respondents of previous survey (Table 4).

Table 4.

Sociodemographic factors associated with quit attempts and utilization of at least one cessation assistance among persons who currently smoke in two rounds of global adult Tobacco surveys in 13 countries

	Weighted proportions (95%CI)		Adjusted Odds Ratio (95%CI)
	Quit attempt	At least one cessation assistance used	Quit attempt	At least one cessation assistance used
Age group
15–29	43.46 (41.15, 45.76)	63.55 (58.67, 68.44)	1	1
30–44	35.75 (34.23, 37.26)	63.24 (60.63, 65.85)	0.73 (0.65, 0.81) *	0.98 (0.82, 1.19)
45–59	33.03 (31.55, 34.52)	60.75 (57.71, 63.79)	0.65 (0.57, 0.73) *	0.89 (0.73, 1.10)
≥ 60	32.94 (30.92, 34.96)	63.38 (59.15, 67.62)	0.64 (0.56, 0.73) *	0.97 (0.76, 1.24)
Sex
Men	36.22 (35.16, 37.28)	62.30 (59.72, 64.87)
Women	38.88 (36.88, 40.88)	66.68 (63.20, 70.17)	1.15 (1.05, 1.26) *	1.43 (1.22, 1.68) *
Educational attainment
Primary or less	34.48 (33.17, 35.79)	54.80 (52.09, 57.52)	1	1
Secondary	37.48 (35.55, 39.41)	59.35 (54.52, 64.17)	1.07 (0.97, 1.17)	1.18 (1.00, 1.40) *
High school	36.42 (34.66, 38.18)	71.80 (68.82, 74.77)	0.99 (0.90, 1.08)	1.81 (1.52, 2.15) *
Higher	40.13 (37.61, 42.65)	73.02 (69.09, 76.94)	1.14 (1.00, 1.30) *	1.90 (1.54, 2.31) *
Survey round
Previous	34.33 (32.90, 35.75)	45.77 (42.61, 48.93)	1	1
Most Recent	38.88 (37.55, 40.20)	79.64 (77.92, 81.36)	1.23 (1.13, 1.34) *	4.54 (3.83, 5.37) *

^* Statistically significant at p < 0.05

Availability of Services for Smoking Cessation Assistance during GATS Survey Years

Counseling and nicotine replacement therapy were available in 11 countries during both surveys (except Bangladesh and Viet Nam). Bupropion and Varenicline were available in most countries in both rounds but not cysteine. Quitline was unavailable during both rounds in Bangladesh, China, Kazakhstan, the Philippines, and Vietnam. In most other countries, quitline was available during recent GATS (except Uruguay) (Table 5).

Table 5.

Availability of recommended cessation assistance during the two rounds of global adult Tobacco surveys in 13 countries

Country	Nicotine replacement therapy	Bupropion	Cysteine	varenicline	Toll-free quitline	Support services in hospitals	Support services in clinics
Bangladesh 2011	No	No	-	No	No	Some	Most
Bangladesh 2016	No	No	-	No	No	Some	Some
China 2011	Yes	Yes	-	Yes	No	Some	Some
China 2016	No	Yes	-	yes	No	Some	Some
India 2009	Yes	Yes	-	Yes	No	Some	Some
India 2016	yes	Yes	-	Yes	Yes	Some	Some
Indonesia 2011	Yes	No	-	Yes	No	Some	Some
Indonesia 2021	yes	No	no	No	Yes	Some	Some
Kazakhstan 2014	Yes	Yes	-	Yes	No	Some	Some
Kazakhstan 2019	Yes	Yes	Yes	Yes	No	No	Some
Mexico 2009	Yes	Yes	-	Yes	Yes	Some	Most
Mexico 2015	Yes	Yes	-	Yes	Yes	Some	Most
Philippines 2009	Yes	No	-	Yes	No	Some	Some
Philippines 2015	Yes	No	-	Yes	No	Some	Some
Romania 2013	Yes	Yes	-	Yes	Yes	Some	Some
Romania 2018	Yes	Yes	-	Yes	Yes	Some	Some
Russia 2009	Yes	No	-	Yes	Yes	No	Some
Russia 2016	Yes	No	-	Yes	Yes	No	Some
Turkey 2012	Yes	Yes	-	Yes	Yes	Some	Some
Turkey 2016	Yes	Yes	-	Yes	Yes	Some	Some
Ukraine 2010	Yes	Yes	-	No	No	No	No
Ukraine 2017	Yes	No	Yes	Yes	Yes	No	Some
Uruguay 2009	Yes	Yes	-	Yes	Yes	Most	Most
Uruguay 2017	Yes	Yes	-	Yes	No	Most	Most
Vietnam 2010	No	Yes	-	Yes	No	Some	No
Vietnam 2015	No	No	-	No	No	Some	No

Discussion

Overall, on pooled data only about a third of individuals who smoked had attempted to quit during the last 12 months and about two-thirds of them had used at least one cessation aid. The quit attempts and use of cessation assistance were higher among the younger, women and higher educated, and during recent surveys. Low quit ratios had seldom improved between the two GATS rounds. Recommended cessation assistance was seldom used, rather ‘try to quit without any assistance’, and ‘other methods’ were commonly used during quit attempts. Among recommended cessation assistance, nicotine replacement therapy was more commonly used than counseling and other prescription medications.

Population-based assessment of smoking cessation behaviors informs about the impact of tobacco control measures and informs about utilization rates of cessation assistance [21]. We provide updated and comprehensive analyses of changes in quit ratio, quit attempts, cessation assistance; prevailing tobacco control policy environment, and cessation services in 13 countries. The inclusion of GATS during the year 2015 onwards was useful in reporting the utilization of newer cessation assistance methods such as m-cessation (mobile phone-based tool) and newer nicotine products claimed to assist smoking cessation. Studies based on GATS data have reported that cessation assistance was underutilized [16], and quitlines were not utilized [15]. We found that quit attempts and utilization of recommended cessation assistance have declined in some countries while the quit ratio had stalled in most countries. The association of quit attempts and use of cessation assistance with female sex and higher education was consistent with previous GATS report [16]. According to pooled data, current smoking had significantly declined between the first (6.4, 95% CI 5.7, 7.0) and second (3.5, 95% CI 3.1, 3.9) round. Research has shown that pregnancy encourages smoking cessation [22], GATS does not collect information about pregnancy.

Only about a third of respondents who currently smoke had attempted to quit ‘without any assistance’ signifies that the demand for smoking cessation exists. However, low utilization rates support that WHO FCTC Article 14 was not well implemented in LMICs [6, 7] despite most of them being WHO-FCTC signatory countries. WHO FCTC Article 14 emphasizes that evidence-based cessation strategies should be made accessible and affordable [5]. Limited availability of quitlines, and support services in 13 countries is similar to findings from Eastern Mediterranean Countries [23]. Mexico and Turkey scored the highest of five on offering help to quit among the MPOWER score components. However, a contrasting pattern of quit ratio, quit attempts, and utilization of cessation assistance between Mexico and Turkey suggest that the availability of cessation assistance may not ensure their utilization. Uruguay was the only HIC, that had the highest quit ratio, utilization of recommended cessation assistance, MPOWER score and availability of cessation services.

‘Try to quit without assistance’ was the most frequently reported cessation assistance and quitlines were not available in most countries. Population-based, evidence-based services such as national quitlines, should be made available to provide practical information and individualized support for persons who are trying to quit. Ensuring the availability of nicotine replacement therapy (nicotine patch, lozenge, gum, oral inhaler, and nasal spray) and other medications such as varenicline, bupropion, and cysteine would enable individuals who intend to quit to achieve successful quitting [24]. Some countries have implemented national quitlines in recent years. Reasons for low rates of utilization of any cessation assistance may be the lack of services the cost of nicotine replacement therapy and medications, or accessibility due to the need for prescriptions [11]. Licensing nicotine replacement therapy for harm reduction may increase successful quitting [21]. Nicotine replacement therapy should be easily accessible, available over the counter, and its cost covered/subsidized to improve their uptake. The use of cessation assistance such as traditional medicines, acupuncture, smokeless tobacco, and other methods is not evidence-based. However, quitting attempts with these methods suggest that people who are smoking have entered a contemplation stage. If these individuals receive treatment with recommended cessation assistance, they may successfully quit. To date, there is a limited evidence base about cessation interventions in LMICs [25] and if interventions and the best practices adopted in HIC apply to the contexts of LMICs [26]. Use of Smokeless tobacco to quit tobacco may result either in dual tobacco use or replacement with another tobacco product. E-cigarettes have been shown to assist smokers quit if they contain nicotine [27]. The role of heated tobacco products in smoking cessation is uncertain. However, use of both these nicotine-containing products should be discouraged [28].

The prevailing low quit ratio, low quit attempts, and utilization of cessation assistance in GATS countries and the lack of improvement between surveys highlight that the current pool of individuals who smoke has remained static. This hampers the efforts to lower smoking prevalence. Population-wide measures to increase the demand for smoking cessation and improve the supply side by making evidence-based low-cost cessation methods available and accessible to improve their utilization. By improving the quit ratio smoking prevalence in the population can be reduced. Hence effective implementation of WHO FCTC article 14 has a significant role to play in tobacco control, yet this is the most neglected component of MPOWER in developing countries [8]. Very low rates of utilization as well as the availability of recommended cessation assistance call for LMICs to implement comprehensive tobacco control measures. The availability of cessation services availability was based on the information provided by country-level nodal officers. Further research is needed into the availability and accessibility of cessation services in public and private facilities, socioeconomic inequalities and factors that determine their utilization, and barriers to non-utilization.

Self-reported behaviors are known to have reporting bias, yet population-level valid estimates are provided by GATS [18]. We compared the changes in smoking cessation and cessation assistance during the two rounds of GATS that were implemented during different years. As the GATS countries could adapt questions to suit the local context different options of cessation assistance were provided. The classification as any type of cessation assistance and recommended cessation assistance are subject to misclassification. Diverse options were provided for cessation assistance across the countries and some of the respondents may not be aware of all cessation assistance options listed in the questionnaire. The information about cessation services and MPOWER scores during the GATS survey years is limited by the time lag in the implementation of WHO FCTC article 14, and the availability of cessation services. Finally, any changes in smoking cessation behaviors observed in a few countries cannot be directly attributed to tobacco control measures due to the cross-sectional design of GATS. Nevertheless, some cohort effects are likely to have happened in the second rounds of GATS.

Conclusion

Smoking cessation and utilization of cessation services have not improved in most of the 13 GATS countries. A low demand for smoking cessation and utilization of cessation assistance methods highlights the limited implementation of the “offer help to quit tobacco use” component of the MPOWER strategy. Our findings support that population-wide implementation of low-cost evidence-based smoking cessation assistance and provision of quit-smoking medications may complement other tobacco control measures aimed at demand reduction.

Electronic Supplementary Material

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Abbreviations

WHO

World Health Organisation

LMIC

Low-and-Middle-Income Countries

HIC

High-Income Countries

WHO-FCTC

The World Health Organization Framework Convention on Tobacco Control

GATS

Global Adult Tobacco Survey

MPOWER

Monitor, Protect, Offer, Warn, Enforce and Raise

Author Contributions

CTS Conceptualization (lead); data curation (equal); formal analysis (lead); methodology (lead); writing—original draft (lead); writing—review and editing (equal).LPK Conceptualization (supporting); data curation (equal); formal analysis (equal); methodology (lead); writing—original draft (supporting); writing—review and editing (equal).

Funding

No funding was available for this study based on a secondary data analysis.

Data Availability

The data used for this manuscript are available for free download on the website of centers for disease control, Atlanta, United States of America at https://www.nccd.cdc.gov/GTSSDataSurveyResources/Ancillary/DataReports.aspx?Country=180&CAID=2&Survey=4&WHORegion=2&Site=3840002016. The analyses code can be provided from the authors on a reasonable request.

Declarations

Ethics Approval and Consent to Participate

Since secondary data was used, ethical approval was not needed. All participants of the GATS survey provided voluntary consent for participation in the survey.

Consent for Publication

Not applicable.

Competing Interests

The authors declare no competing interests.