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

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.