LAUSR

Background Concurrently using two (dual users) or more than two (poly tobacco users) tobacco products is common in low-and middle-income countries, especially among men, and has been linked to increased health risks and nicotine addiction compared to single tobacco product use. While substantial inequalities persists with high tobacco use prevalence among disadvantaged groups, very little is known about the impact of health care support and migration status on tobacco use patterns among these population. This study aims to explore socioeconomic, health care and migration related risk factors of ploy tobacco users among men in 15 low-and middle-income countries. Methods Data from 15 countries around the world were obtained from the most recent wave of the Demographic and Health Survey (DHS), collected between 2015 and 2018. A total of 155,425 men aged 15–49 were surveyed. Outcomes included single, dual and poly use, examined by education, wealth, health system support and migration status. Migration defined as whether the respondent slept or reside away from home in the last 12 months. Multilevel models were used to estimate the effect of covariates on tobacco use with along with fixed and random parameters. Results In all studied countries, prevalence of dual and poly-tobacco use was highest in respondents with low socioeconomic status (SES). SES gradients in dual and poly use by education (RR=0.64; 95%CI: 0.55–0.67 for higher education vs illiterates) and wealth index (RR=0.15; 95%CI: 0.11–0.20 for richest vs poorest) were observed. Furthermore, results showed higher risks of being a poly user among migrant men (RR=1.70; 95%CI: 1.65–1.71) and a lower risk against dual use for those covered by health insurance (RR=0.82; 95%CI: 0.79–0.85). However, dual and poly tobacco use were not associated with a country’s purchasing power parity. Conclusion Positive associations were found between dual and poly tobacco use among male respondents with lower SES and migration backgrounds, whereas respondents protected by health care system were associated negatively. This is the first study to examine the impact of health system support and migration status among men in low and middle-income countries. Findings imply that policy makers should consider targeting populations with migration background and those with reduced access to health care to tackle with smoking inequality in tobacco control science.