Current smoking behaviour among rural South African children: Ellisras Longitudinal Study

Tobacco use is a major public health concern, not only because of its indisputable impact on the health of both smokers and non-smokers, but because it is one of the preventable causes of morbidity and mortality. Smoking is a lifestyle factor that is strongly associated with certain forms of cancer [1‐4] and cardiovascular diseases [2, 5, 6]. Internationally, public awareness and beliefs about the health risks of smoking have increased considerably, especially among adolescents and this was reflected in declining smoking rates in numerous developed countries [7]. However, in developing countries cigarette smoking is likely to increase tremendously in the next two decades as the tobacco industry concentrates its marketing on youth [8]. Indigenous knowledge, practice and traditional beliefs are sometimes also blamed for this escalating behaviour in the developing countries [9].

There is an increasing public awareness of health risks of tobacco products usage which is reflected in the declining rate of cigarette smoking in the developed countries, while in developing countries the rate is increasing [10‐12]. For example, tobacco consumption, amongst adolescents in South Africa, that began in the 1960s, has peaked up in the last decade of the twentieth century [13]. In 1992, Martin et al. [7] reported that 31.5% of South Africans, 18 years and older smoked. This figure increased to 34% in 1995 which includes younger children who start smoking earlier [14]. Subsequently, Reddy et al. [15] reported that about one in five learners (21.1%) of Grades 8 to 11 in public schools were classified as current smokers nationally while the South African Demographic Health Survey [16] reported 3.3 to 7.0% for females. About 1.0 to 23.7% male adolescents aged 15 to 19 years old were reported to have ever use tobacco product daily.

This trend is indeed worrying especially with an increase of incidents of smokers among younger children of which little is known about their behaviour, beliefs and practices of tobacco products given the fact that these communities are traditionally known to be conservative. This study therefore, was intended to investigate the current smoking behaviour among rural South African children aged 11 to 18 years who are part of the ongoing Ellisras Longitudinal Study cross-sectionally.

Table 1 presents prevalence of tobacco usage by age group and gender. The prevalence of cigarette smoking increased with increasing age (ranged from 4.9 to 17.1%) and was high among boys aged 11 to 18 years as compared to the usage of pipe (ranged from 1.4 to 3.9%) and snuff (1.0 to 3.9%) (Table 1). No Ellisras rural girls aged 11 to 18 years smoked cigarette. The prevalence of snuff usage ranged between 0.7 to 4.1% for girls aged 11 to 18 years. There was no significant difference between the prevalence of pipe and snuff usage between boys and girls through out the age range (Table 1).

Table 2 presents frequency and percentage frequency for positive responses on beliefs, habits and knowledge of home made usage of tobacco products for Ellisras rural children aged 11 to 18 years. The use of tobacco product among the Ellisras rural children family circle as reported by boys ranged from 5.7% to 24.9% and girls 0 to 27.8%. A considerable number of children (52% boys and 46% girls) were sent by somebody to buy smoking products in the local shop. Nine percent (9.0%) of boys and 5.8% girls believed they would use the tobacco product when they were adults.

There were relationships of various indicators of attitudes towards smoking with experimentation. For both boys and girls there was an effect on the perception of smoking when observing TV stars, men and women smoking. For example, almost similar number of boys and girls (20%) in Ellisras rural area admired TV stars and men who smoke cigarettes while women who used the tobacco products were less admired by many children (Table 3). Fifty point eight percent (50.8%) of boys and 50.9% of Ellisras rural girls watch Television actors in the movies using tobacco products (Table 2). There was no significant difference in the proportion of boys and girls who regarded men (19.7% vs 18.8% for cigarette, 15.2% vs 15.1% for snuff) and women (11.6% vs 13.4% for cigarette, 14.2 vs 15.6% for snuff) using tobacco products a symbols of being cool, rich and successful (Table 3).

Table 4 presents odd ratio, 95% confidence interval for the association of tobacco product usage and habits and attitudes towards the tobacco product among the Ellisras rural children. There was a significant (p < 0.001 to 0.05) association between the tobacco products use and the success of TV stars (OR 2.3 95% CI 1.3; 3.4) and smoking women (OR = 2.8 95% CI 1.5; 5.2; OR 2.9 95% CI 1.5; 5.4) even after adjusting for age and gender. The use of tobacco products and the rights of using tobacco products were significantly associated (OR 2.32 95% CI 1.4; 3.8 and OR 2.31 95% CI 1.4; 3.9) even after adjusting for age and gender (Table 4).

Figure 1 shows the estimated period during which rural boys first started to use tobacco products by age group. The majority of children started smoking around the age of seven years. Figure 2 presents the amount of tobacco products used by Ellisras rural boys aged 11 to 18 years. The majority of participants (cigarette = 34.6%; pipe = 16.2%; snuff = 16.9%) did not know the amount of tobacco they used per week as they relied on others or use home made tobacco product while few children (10%) reported to use less than seven packets of cigarettes or seven grams of BB or boxer a week. Figure 3 presents the influential people in the use of tobacco product among the Ellisras rural children by age group. The majority (almost 50%) of younger children (11-14 years) were influenced by their parents and grand parents whereas teachers and friends also contributed in influencing (20%) older children (15-18 years).

The aim of the study was to evaluate habits, beliefs and practices of Ellisras rural children regarding tobacco products usage. The overall results indicated an increase in the prevalence (about 17%) of cigarette smoking by boys with age. Similar results were reported in South Africa nationally [15, 16] on children of similar age groups. The usage of cigarette smoking by girls in this Ellisras population did not exist. This was different from the 14.9% girls grade 8 to 11 and 5.2 to 7.5% girls aged 15 to 19 years reported in South Africa nationally [15, 16]. However, the prevalence of smoking among the Ellisras boys was lower compared to that of the Zambian boys (9.3%) whereas smoking among the Zambian girls was high (12.1%) as compared to findings of both the current study and the national survey in South Africa [15, 16, 28].

The children further reported that they did not admire women who smoke cigarette. Smoking initiations in Ellisras rural boys starts between aged 11 to 12 and increases with increasing age. Similar results were reported in Hong Kong, Global Youth Tobacco Survey Project, Zambia and Cape Town for children between the age of 11 to 18 years or [28‐31]. However, Damas et al. [32] and Wen et al. [33] reported that most smokers had parents (n = 111, 57%), as well as friends who smoked (n = 187, 96.4%). Children who are surrounded by smoking friends and family members are more likely to be smokers [34, 35]. Similar discoveries were found among the Ellisras rural children since the use of tobacco product by family members and visitors is a normal practice (more that 80% reported less than ten people using tobacco product at their home) (Table 2). In addition, there was a significant (p < 0.001) association (OR = 2.33 95% CI 1.4; 4.0 and OR 2.08, 95% CI 1.2; 3.6 after adjusting for age and gender) between tobacco products use and the possibility of using tobacco products as an adult by the Ellisras rural children.

Tobacco advertising bans have been effective in reducing consumption in a number of countries including South Africa, Zambia, New Zealand, Canada where the ban has been associated with the rapid decline in tobacco consumptions [28, 36, 37]. Yang et al. [38] reported that children admire their doctors when they smoke. However, the overall impact of tobacco advertisement by TV stars and some role models who use tobacco products openly in the community was two-fold in this Ellisras rural community. Firstly, it starts as a stimulant to viewers to start smoking, thus supporting the impression that it is a socially desirable activity. For example, the children in the current study significantly (p < 0.05) view TV stars who smoke as rich and successful (OR 2.3 95% CI 1.3;4.1 and OR 2.3 95% CI 1.3;4.1) after adjusting for age and gender). Zulu et al. [28] also reported a positive association between seeing a TV star smoking and the smoking behaviour among Zambian adolescents (OR = 1.90; 95% CI 1.26, 2.88). Secondly, though tobacco products cost increases yearly in South Africa, it seems to have resulted in the underestimation of its impact on tobacco use relative to a range of other public health issues. For example, in the current study, over 70% of the Ellisras children view home made cigarette as not having the same effect on one's health as the bought ones. Ultimately adolescents opted for the home made ones so as to imitate the TV stars, men and women who use tobacco in the Ellisras community.

Habits and beliefs in this Ellisras rural community appear to be central to the escalating use of tobacco products. In this study grand parents and parents were the most influential (50%) people to the children who smoke especially that the majority of the participants used home made or indigenous tobacco products (Figure 2). The possible explanation of this behaviour might be that boys in these communities spent most of their time outside their homes (engaged in animal husbandry and cattle rearing) and thus were exposed to people who use indigenous tobacco products as compared to their female counterparts (i.e. girls), who spent most of their time at home engaged in house chores, such as cooking, cleaning, fetching water and washing their family clothes, etc. On the one hand it is still a cultural taboo for a woman to smoke, let alone girls in Ellisras rural area. Similar trends are observable in Global Youth Tobacco Survey (GYTS) in countries that are still conservative like India and other parts of developing countries [39].

The South African Tobacco Product Control Act of 1993 and its amendments in 1999 and 2007 provides a hopeful paradigm shift in the use of tobacco products in the quest for the improvement of health and provision of awareness in communities about mortality emanating from chronic diseases. The findings of this study suggest that to succeed in these efforts, eradication of illiteracy should be the first hurdle to jump by health professionals in terms of providing primary health to these sectors of the community [40, 41]. The South African population should make strides to shift from the traditional knowledge and medication, and seek new innovative ways of addressing issues facing the population with regard to health, climate, environment and lifestyle changes in line with the ongoing political transformation.

We acknowledge that we did not consider the socio-economic status of families of the participants in the analysis. Furthermore, our study is cross-sectional in nature. Many changes are taking place in South Africa today, which are of concern. These include the adoption of western diets, hence the changing of lifestyles which include among others, excessive use of contemporary tobacco products and an increase level of alcohol usage [42, 43]. Also, a follow up on the use of tobacco products may shed more light on how smoking is related to other biological parameters in this population. Furthermore, the role of schools in the teaching of health education, to curb the escalating drug abuse in the South African schools will be helpful.

The prevalence of tobacco use increase with increasing age among boys. Girls do not smoke but use snuff. Ellisras rural children do not admire women who smoke. The findings of this study have at least two implications for both public health and education authorities respectively. Firstly, for the public health sector, there is an urgent need to carry out intervention programmes that can boost primary health facilities to provide information regarding adverse effects in this community, something that includes the home made tobacco products usage. Secondly, for the education sector, there is also an urgent need to include health education in the curriculum to address the risk behaviour among children who smoke. For example, policy makers in education should begin to introduce life skills programmes that address this health hazard.