Clara K. Chow, University of Sydney, Camperdown, New South Wales, Australia
Daniel J. Corsi, University of Sydney, Camperdown, New South Wales, Australia
Anna B. Gilmore, University of Bath, Bath, UK
Annamarie Kruger, West University Potchefstroom Campus, Potchefstroom, South Africa
Ehimario Igumbor, University of the Western Cape, Bellville, South Africa
Jephat Chifamba, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
Wang Yang, National Center for Cardiovascular Diseases, Beijing, China
Li Wei, National Center for Cardiovascular Diseases Cardiovascular Institute & Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
Romaina Iqbal, Aga Khan UniversityFollow
Prem Mony, St John's Medical College & Research Institute, Bangalore, Karnataka, India
Rajeev Gupta, Fortis Escorts Hospital, Jaipur, Rajasthan, India
Krishnapillai Vijayakumar, Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India
V Mohan, Madras Diabetes Research Foundation, Chennai, India
Rajesh Kumar, PGIMER School of Public Health, Chandigarh, India
Omar Rahman, Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
Khalid Yusoff, Malaysia UCSI University, Cheras, Malaysia
Noorhassim Ismail, University Kebangsaan Malaysia Medical Centre, Bangi, Malaysia
Katarzyna Zatonska, Wroclaw Medical University, Wroclaw, Poland
Yuksel Altuntas, Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
Annika Rosengren, University of Gothenburg, Goteborg, Sweden
Ahmad Bahonar, Hypertension Research Center Isfahan Cardiovascular Research Center Isfahan University of Medical Sciences, Isfahan, Iran
Afzal Hussein Yusufali, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
Gilles Dagenais, Université laval,Quebec, Quebec, Montreal, Canada
Scott Lear, Simon Fraser University, Burnaby, British Columbia, Canada
Rafael Diaz, Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina
Alvaro Avezum, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
Patricio Lopez-Jaramillo, Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca-Santander, Colombia
Fernando Lanas, Universidad de La Frontera, Temuco, Chile
Sumathy Rangarajan, Population Health Research Institute(PHRI), Hamilton, Ontario, Canada
Koon Teo, Population Health Research Institute(PHRI), Hamilton, Ontario, Canada
Martin McKee, London School of Hygiene and Tropical Medicine, London, UK
Salim Yusuf, Population Health Research Institute(PHRI), Hamilton, Ontario, Canada

Document Type



Community Health Sciences



This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.


545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.


Community audits and surveys of adults (35-70 years, n=12 953).


Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.


Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).


This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

Publication (Name of Journal)

BMJ Open

Creative Commons License

Creative Commons Attribution-NonCommercial 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License