Assessment of sex inequalities in current tobacco smoking across 165 countries: a WHO Health Equity Assessment Toolkit analysis
Abstract
Abstract Background Tobacco smoking remains a leading cause of preventable morbidity and mortality, responsible for more than 7 million deaths annually. Although global prevalence has declined, substantial disparities persist across countries and between sexes. This study examined global sex differences in current tobacco smoking prevalence using standardised WHO measures. Methods A cross-sectional analysis of 2022 WHO Global Health Observatory data was undertaken, accessed via the WHO Health Inequality Data Repository and analysed using the Health Equity Assessment Toolkit. Two inequality metrics were applied, including absolute difference and prevalence ratio between female and male prevalence. Results were stratified by World Bank income classifications and patterns were described across and within income groups. Results Current tobacco smoking prevalence varied considerably across countries. The lowest prevalence estimates were observed in sub-Saharan Africa, including Ghana (2.1%, 95% CI 1.5% to 2.8%), Nigeria (2.9%, 95% CI 2.2% to 3.7%) and Ethiopia (3.1%, 95% CI 2.4% to 3.8%), whereas substantially higher prevalence was observed in Pacific Island nations, including Kiribati (38.0%, 95% CI 32.7% to 43.2%) and Solomon Islands (37.7%, 95% CI 31.9% to 43.4%). Across all income groups, males consistently reported higher prevalence than females. Pronounced disparities were identified in Lesotho (female 0.2%, male 36.6%; D=–36.4, R<0.01) and the Democratic People’s Republic of Korea (female 0.0%, male 30.2%; D=–30.2, R<0.01). Upper middle-income countries such as Mongolia (D=–41.1, R=0.1) and China (D=–45.5, R<0.01) also exhibited wide sex gaps. In contrast, high-income countries displayed narrowing or reversed differences; Sweden reported higher female prevalence (D=1.4, R=1.2). Conclusions Substantial sex inequalities in tobacco smoking remain, with women smoking far less than men in most countries. While convergence is evident in select high-income settings, extreme disparities in low- and middle-income countries underscore the urgency of gender-sensitive tobacco control interventions.