Objective: To estimate changes in the prevalence of current tobacco use and socioeconomic inequalities among male and female participants from 22 sub-Saharan African countries from 2003 to 2019.

Design, Setting, and Participants: Secondary data analyses were conducted of sequential Demographic and Health Surveys in 22 sub-Saharan African countries including male and female participants aged 15 to 49 years. The baseline surveys (2003-2011) and the most recent surveys (2011-2019) were pooled.

Exposures: Household wealth index and highest educational level were the markers of inequality.

Main Outcomes and Measures: Sex-specific absolute and relative changes in age-standardized prevalence of current tobacco use in each country and absolute and relative measures of inequality using pooled data.

Results: The survey samples included 428 197 individuals (303 232 female participants [70.8%]; mean [SD] age, 28.6 [9.8] years) in the baseline surveys and 493 032 participants (348 490 female participants [70.7%]; mean [SD] age, 28.5 [9.4] years) in the most recent surveys. Both sexes were educated up to primary (35.7%) or secondary school (40.0%). The prevalence of current tobacco use among male participants ranged from 6.1% (95% CI, 5.2%-6.9%) in Ghana to 38.3% (95% CI, 35.8%-40.8%) in Lesotho in the baseline surveys and from 4.5% (95% CI, 3.7%-5.3%) in Ghana to 46.0% (95% CI, 43.2%-48.9%) in Lesotho during the most recent surveys. The decrease in prevalence ranged from 1.5% (Ghana) to 9.6% (Sierra Leone). The World Health Organization target of a 30% decrease in smoking was achieved among male participants in 8 countries: Rwanda, Nigeria, Ethiopia, Benin, Liberia, Tanzania, Burundi, and Cameroon. For female participants, the number of countries having a prevalence of smoking less than 1% increased from 9 in baseline surveys to 16 in the most recent surveys. The World Health Organization target of a 30% decrease in smoking was achieved among female participants in 15 countries: Cameroon, Namibia, Mozambique, Mali, Liberia, Nigeria, Burundi, Tanzania, Malawi, Kenya, Rwanda, Zimbabwe, Ethiopia, Burkina Faso, and Zambia. For both sexes, the prevalence of tobacco use and the decrease in prevalence of tobacco use were higher among less-educated individuals and individuals with low income. In both groups, the magnitude of inequalities consistently decreased, and its direction remained the same. Absolute inequalities were 3-fold higher among male participants, while relative inequalities were nearly 2-fold higher among female participants.

METHODS: This cross-sectional study was conducted in three Malaysian public hospitals namely Hospital Kuala Lumpur, Hospital Canselor Tuanku Muhriz and the National Cancer Institute using a multi-level sampling technique to recruit 630 respondents from February 2020 to February 2021. CHE was defined as incurring a monthly health expenditure of more than 10% of the total monthly household expenditure. A validated questionnaire was used to collect the relevant data.

RESULTS: The CHE level was 54.4%. CHE was higher among patients of Indian ethnicity (P = 0.015), lower level education (P = 0.001), those unemployed (P < 0.001), lower income (P < 0.001), those in poverty (P < 0.001), those staying far from the hospital (P < 0.001), living in rural areas (P = 0.003), small household size (P = 0.029), moderate cancer duration (P = 0.030), received radiotherapy  treatment (P < 0.001), had very frequent treatment (P < 0.001), and without a Guarantee Letter (GL) (P < 0.001). The regression analysis identified significant predictors of CHE as lower income aOR 18.63 (CI 5.71-60.78), middle income aOR 4.67 (CI 1.52-14.41), poverty income aOR 4.66 (CI 2.60-8.33), staying far from hospital aOR 2.62 (CI 1.58-4.34), chemotherapy aOR 3.70 (CI 2.01-6.82), radiotherapy aOR 2.99 (CI 1.37-6.57), combination chemo-radiotherapy aOR 4.99 (CI 1.48-16.87), health insurance aOR 3.99 (CI 2.31-6.90), without GL aOR 3.38 (CI 2.06-5.40), and without health financial aids aOR 2.94 (CI 1.24-6.96).