Anti-Tobacco Media Exposure and Cessation Behaviors Among Tobacco Users in South Asia: Evidence from a Multi-Country Analysis of GATS Data

Abstract

Introduction: Tobacco use is among the leading causes of preventable death and disability globally, with South Asia ranking first for oral cavity cancer burden since 1990, a burden that has grown by 13% and reached an age-standardized DALY rate of 197 per 100,000 in 2023 (4). Anti-tobacco media and health warning labels represent a key FCTC-mandated intervention for driving cessation, yet quit rates remain low and evidence on their effectiveness across both smokers and SLT users in South Asia remains limited. This study examines the association between exposure to anti-tobacco media and health warnings and quit attempts and quit intentions among smokers and smokeless tobacco (SLT) users across four South Asian countries: Pakistan, India, Bangladesh, and Sri Lanka. Methods: Using data from the Global Adult Tobacco Survey (GATS), we included adult smoking and smokeless tobacco users from Pakistan (2014), India (2016-2017), Bangladesh (2017), and Sri Lanka (2019). Quit attempts and quit intentions were the outcomes of interest, defined as whether participants attempted to quit or intended to quit smoking or smokeless tobacco (SLT) use in the past 12 months. Survey-weighted multivariable logistic regression models estimated the odds of quit attempts and quit intentions associated with anti-tobacco media exposure, adjusting for age, sex education, residence, employment, and country. Results: The final pooled sample included 29,694 tobacco users across four countries, with 14,664 smokers and 20,139 SLT users. Anti-cigarette media exposure varied modestly across countries (71.2% in Pakistan to 84.3% in Sri Lanka), while anti-SLT exposure showed fourfold variation (17.8% in Pakistan to 84.3% in India). Among smokers, anti-cigarette media exposure was associated with 56% higher odds of quit attempts (aOR=1.56, 95% CI: 1.27-1.92) and 27% higher odds of quit intentions (aOR=1.27, 95% CI: 1.01-1.60). Among SLT users, anti-SLT media exposure was associated with 50% higher odds of quit attempts (aOR=1.50, 95% CI: 1.29-1.73) but not with quit intentions (aOR=1.09, 95% CI: 0.92-1.29). Country-stratified analyses revealed meaningful heterogeneity in these associations: in Pakistan, anti-tobacco media exposure was significantly associated with quit attempts among both smokers and SLT users; in India, anti-tobacco media exposure was significantly associated with quit attempts and quit intentions among smokers only; whereas no significant associations were observed in Bangladesh or Sri Lanka for either outcome. Conclusions: Anti-tobacco media exposure is associated with quit attempts among smokers and SLT users across South Asia, though this effect is concentrated in Pakistan and India and is not evident in Bangladesh or Sri Lanka. The pronounced cross-country variation underscores the importance of context-specific tobacco control strategies and highlights opportunities to strengthen media-based interventions in settings where their impact remains limited.