Associations between disability and tobacco use in 31 low-income and middle-income countries: a secondary analysis of cross-sectional data from Multiple Indicator Cluster Surveys.

Background: Globally, individuals with disabilities may experience disproportionate tobacco use burden, though evidence comes predominantly from high-income settings. A substantial knowledge gap persists regarding tobacco consumption patterns among populations with disability in low- and middle-income countries (LMICs). This study aimed to examine associations between disability and tobacco use across diverse LMIC contexts. Methods: We conducted secondary analysis of cross-sectional data from the sixth round of UNICEF-supported Multiple Indicator Cluster Surveys (MICS), spanning 2017-2023 across 31 LMICs. Participants were adults aged 18-49 years in the MICS Adult Functioning module with valid survey weights (weight >0); we excluded respondents with non-positive weights. For pooled meta-analyses, we applied a prespecified minimum sample-size criterion (<25 smokers with disability), which did not exclude any country. Disability status was measured using the validated Washington Group Short Set criteria (WG-SS). Self-reported tobacco use behaviours constituted primary outcomes. Modified Poisson regression models estimated risk ratios (RR) adjusted for age, marital status, residence, education level, number of children, and wealth status with 95% confidence intervals (95% CI), stratified by country. Main analyses were stratified by sex to account for differential sampling frames between male and female respondents. Meta-analysis pooled country-specific estimates for an overall estimate. Findings: The analytical sample comprised 637,123 adults aged 18-49 living in 31 LMICs, of whom 29,368 (4.61%) reported disability. Pooled meta-analysis revealed a significant positive association between smoking and disability in both sexes. The association was stronger among females (RR = 1.45, 95% CI: 1.25-1.68) compared to males (RR = 1.08, 95% CI: 1.02-1.14). Considerable heterogeneity was observed across countries, with the most pronounced disparities observed in Yemen (RR = 4.70, 95% CI: 2.6-8.51), Gambia (RR = 4.46, 95% CI: 1.0-19.9), and Chad (RR = 2.62, 95% CI: 1.43-4.78) for women with disabilities. Analysis of tobacco product types revealed sex-specific patterns: females with disabilities showed significantly elevated risks for tobacco products (RR = 1.79, 95% CI: 1.29-2.50), smokeless tobacco (RR = 1.64, 95% CI: 1.25-2.17), mixed smoking products (RR = 1.52, 95% CI: 1.09-2.10), and cigarettes (RR = 1.39, 95% CI: 1.10-1.77), while males demonstrated more modest but significant associations for smokeless tobacco (RR = 1.42, 95% CI: 1.05-1.91), mixed smoking products (RR = 1.26, 95% CI: 1.12-1.43), tobacco products (RR = 1.22, 95% CI: 1.08-1.38), and cigarettes (RR = 1.06, 95% CI: 1.00-1.12). In contrast, smoking frequency among current smokers showed no significant association with disability status in female (RR = 1.00, 95% CI: 0.96-1.04) and male (RR = 0.99, 95% CI: 0.98-1.00). Interpretation: This multi-country analysis reveals heterogeneous associations between disability and tobacco use across LMICs, with particularly pronounced sex disparities demonstrating increased smoking risk among women with disabilities in some settings. These findings highlight marked sex and geographic variations in smoking disparities among people with disabilities in LMICs. They underscore the imperative for disability-inclusive, sex-responsive tobacco control strategies that acknowledge regional contextual variations. Such evidence-informed approaches are essential to achieve equitable tobacco control outcomes and prevent the perpetuation of health inequities among vulnerable populations. These conclusions should be interpreted in light of key limitations, including the cross-sectional design (precluding causal inference), self-reported tobacco use, and the WG-SS/MICS measurement scope (higher-severity cut-off, adults aged 18-49 years, household-based sampling), which may underestimate disability prevalence and limit generalisability. Funding: This study itself received no specific external grant from any funding agency.