Behavioral Interventions for Tobacco Cessation in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Abstract

Introduction: An estimated 78% of the total deaths attributable to smoking tobacco use occurred in low- and middle-income countries (LMICs) in 2019. In addition, smokeless tobacco increases the risk of all-cause mortality, all cancers, including upper aero-digestive tract cancer, stomach cancer, ischemic heart disease and stroke, with 88% of the mortality burden being borne by the South-East Asian region. Evidence-based interventions from high-income countries (HICs) are not easily transferable to LMICs, as patterns of tobacco use, health beliefs associated with tobacco use, and awareness of specific health risks vary substantially.

Methods: We synthesized the effectiveness of behavioral interventions for tobacco cessation in LMICs through a systematic review and meta-analysis. Interventional studies which delivered individual behavioral intervention and assessed abstinence from tobacco use were included. We examined the pooled intervention effect at 6 months postintervention follow-up.

Results: For continuous abstinence at 6 months, the intervention was superior to the active comparator (RR 2.32; 95% CI 1.78 to 3.02) and usual care (RR 4.39; 95% CI 2.38 to 8.11). For point prevalence abstinence at six months, the intervention was superior to the active comparator (RR 1.76; 95% CI 1.28 to 2.44), and usual care (RR 2.37; 95% CI 1.47 to 3.81). The statistical heterogeneity was substantial to considerable for all comparisons. Only six studies had an overall low risk of bias. Publication bias was observed for all comparisons except for 6-month continuous outcomes.

Conclusions: Implementation research is needed to understand factors for programme sustainability and equity of the impact of behavioral interventions in reducing tobacco use in LMICs.

Implications: Our review is an important step towards understanding the effectiveness of behavior interventions for tobacco cessation suited for LMICs and which are responsive to the contextual needs of such countries.

Figure 1.

PRISMA 2020 flow diagram for study selection.

Figure 2.

Behavioral intervention versus active intervention*. Outcome: 6-month continuous abstinence. *Active intervention included other behavioral intervention or pharmacological intervention.

Figure 3.

Behavioral intervention versus usual care*. Outcome: continuous abstinence. *Usual care included printed self-help materials or unspecified usual care for tobacco cessation. Dogar 2013a: participants smoking cigarettes exclusively; Dogar 2013b: participants smoking both cigarettes and hookas, Dogar 2013c: participants smoking hookah exclusively.

Figure 4.

Behavioral intervention versus active intervention*. Outcome: Point prevalence abstinence at 6 months. *Active intervention included other behavioral intervention or pharmacological intervention.

Figure 5.

Behavioral intervention versus usual care*. Outcome: Point prevalence abstinence at 6 months. *Usual care included printed self-help materials or unspecified usual care for tobacco cessation.

Figure 6.

Quality of studies included in the review.