Sociodemographic factors associated with daily tobacco smoking and binge drinking among Zambians: evidence from the 2017 STEPS survey

Tobacco smoking and harmful alcohol consumption are major risk factors for non-communicable diseases (NCDs) [1, 2]. Tobacco smoking alone accounts for more than 8 million global deaths annually, with more than 85% of these deaths the result of direct use [3]. Over 80% of the 1.3 billion tobacco users worldwide live in low- and middle-income countries (LMICs) [4]. Further, harmful alcohol consumption contributes to 3 million deaths annually, and it is responsible for 5.1% of the global burden of disease and injury [5]. In 2016, the alcohol-attributable disease burden was highest in LMICs compared to high-income countries [6].

While considerable gains in reducing tobacco and harmful alcohol consumption have been made, progress has been slow in most LMICs, particularly sub-Saharan Africa (SSA) [7]. The majority of SSA countries remain off-track to meet the global target to cut tobacco use by 30% by 2025 [8]. In addition, SSA faces a growing burden of harmful alcohol consumption [9]. According to the World Health Organization (WHO), SSA is characterized by binge drinking or episodic excessive drinking [10, 11]. The prevalence of binge drinking among current drinkers in SSA is one of the highest in the world, at over 60% [5]. This is largely due to weak policy control measures and an increase in consumer purchasing power providing attractive markets to the tobacco and alcohol industries [12, 13].

This pattern is also reflected in Zambia. Some studies have shown that around 20% of men smoke tobacco, which is higher than most countries in the region [14, 15]. However, this figure is expected to increase because tobacco is a major cash crop prioritized by the government, with incentives provided to bolster its production. Taking advantage of these incentives, multinational companies are expected to produce 5 million cigarettes daily for the Zambian market [16]. Efforts to address tobacco smoking in Zambia have included awareness creation, introduction of tobacco levy, banning of tobacco sales to minors and advertising in the media. These efforts have nevertheless faded over the years. While Zambia signed in 2008 the WHO framework convention on tobacco control (FCTC) and passed the statutory instrument No. 39 which banned smoking in public places [17, 18], several studies have however highlighted the lack of enforcement of these legal frameworks [16, 19, 20]. For instance, in contrast with the FCTC recommended 75% tax share, in 2016 Zambia’s tax comprised only 37% of the retail price of cigarettes [21]. In addition, harmful alcohol consumption is becoming a major problem in the country. The WHO report of 2016 stated that the prevalence of alcohol use disorders among Zambians, including alcohol dependence and harmful use, was 9.8% for males and 1.2% for females, with an overall prevalence of 5.5%, which is above the average of 3.7% for the WHO African Region [22]. Although an alcohol policy was passed in 2018 to reduce harmful use of alcohol [23], it faces major implementation challenges. While the policy emphasises several restrictive measures along the marketing process, no legally binding regulations on alcohol production, distribution, advertising, sponsorship nor sales promotion have been established [22].

Any efforts to minimise the impact of tobacco smoking and harmful alcohol consumption, particularly binge drinking, in Zambia will require a better understanding of their sociodemographic distribution [14]. While some studies have previously explored the issue of tobacco smoking and binge drinking in Zambia, they were either not nationally representative or were conducted on selected subpopulations [24, 25].

This study aimed to determine the sociodemographic factors associated with daily tobacco smoking and binge drinking in a nationally representative sample of Zambian men and women.

This study investigated the sociodemographic factors associated with daily tobacco smoking and binge drinking among Zambians using a nationally representative sample from the 2017 WHO STEPS survey. The overall prevalence of daily tobacco smoking was 9.0%, while 11.6% of participants engaged in binge drinking, both of which were higher among men than women. Older age and having primary or no education were also significant factors related to daily tobacco smoking. Compared to employed participants, students and homemakers had a lower prevalence of daily tobacco smoking. Binge drinking was positively associated with being male and living in an urban area. Again, students and homemakers had a lower prevalence of binge drinking than employed participants.

Although tobacco smoking trends in Zambia have fluctuated over the years, they clearly indicate a major public health threat, particularly among men. The high prevalence of tobacco smoking amongst Zambian men (17.1%) has been reported in other studies, though slightly higher at 20% [14, 15]. This gender disparity was expected due to the differing social norms that promote tobacco use. Tobacco smoking is much more tolerated in men than women, owing to dominant internalised gender stereotypes of masculinity [30]. In similar lines, other studies have reported that Zambian men have some of the highest smoking rates in the southern African region [31, 32].

This study found that older age was positively associated with tobacco smoking. Similar findings were reported in a systematic review of smoking data from 30 SSA countries [33]. A possible explanation may be that in some SSA cultures, tobacco smoking is viewed as a practice reserved for elderly people [30]. However, other studies in countries such as Kenya and Burkina Faso have reported that tobacco smoking is more common in younger people [34, 35]. Our findings might suggest that tobacco smoking in Zambia may have been more popular among younger groups some years back, resulting in higher consumption among elderly individuals now.

A lower education level was significantly associated with daily tobacco smoking, which confirms the already established association reported in other studies [33, 36, 37]. Indeed, studies have pointed out that poor people and those with a lower education status tend to be missed by large public health prevention efforts [38]. Perhaps this could also be the case in the Zambian setting, where public health interventions such as anti-tobacco smoking awareness creation efforts might only be reaching those with some form of literacy. This calls for a reflection on how to ensure anti-tobacco messages are delivered in the most simple and effective way possible across a spectrum of media platforms.

Compared to the employed, students and homemakers had a lower prevalence of daily tobacco smoking. Similar findings have been reported in studies from other LMIC such as Ethiopia, Madagascar and Nepal [39‐41]. This group is, of course, comprised mainly of young people and women, but since we controlled for age and sex, this should not be the reason for the low prevalence. A possible explanation is that both students and homemakers may be subjected to a sociocultural environment that disapproves and frowns upon smoking in this category of tobacco users.

The prevalence of binge drinking was slightly lower than the overall WHO estimate among the Zambian population > 15 years old of 13.5%, again higher in men (23%) than in women (4.1%) [22]. This could be because of the different measurements of binge drinking [26, 27]. The higher level of binge drinking among men compared to women could be explained by the fact that culturally, binge drinking is encouraged among men as a representation of power and strength [42]. Similar patterns of drinking have been reported in studies from South Africa, where the overall prevalence of binge drinking was reported to be 18.3%, and again higher in men than women (22.8% vs. 6.4%) [10, 43]. It is not possible to compare our findings with other Zambian-based studies since these have been conducted on subpopulations such as HIV-positive people, those in psychiatric settings and college students [24, 44, 45]. These studies have found a much higher prevalence than in the general population [24, 44, 45]; for instance, 81.4% among people living with HIV [24].

The prevalence of binge drinking was significantly lower among rural residents compared to those from urban areas. This finding has also been reported in studies from neighbouring countries, such as South Africa [46]. According to Letsela et al., in urban areas, alcohol is easily accessible and highly marketed through advertising in the media which influence its consumption [47, 48]. In the Zambian context, the lack of legally binding regulations on alcohol distribution and advertising, may have also contributed to partly explain our findings [22].

Similar to tobacco use, students and homemakers were less likely to binge drink compared to those in employment. Similar findings have been reported in an Ethiopian study which found that the likelihood of heavy episodic drinking was lower among housewives compared to those employed [49]. One possible explanation could be limited control over money to spend on binge drinking among homemakers and students [50]. However, after stratifying by sex, unemployed women had a higher prevalence of binge drinking than employed women, which highlights the vulnerability of this specific group.

We found a high occurrence of tobacco smoking predominantly among men, elderly and those with a lower education level, while binge drinking was more prevalent in men and urban residents. Overall, rural residents smoked more, and urban residents drank more. Our findings emphasize the importance of local, tailored tobacco and alcohol control interventions to ensure relevance and utility in different Zambian at risk populations and communities. These interventions should be grounded in known family- and community-centred models to sustain efforts against the uptake of these risky social behaviours. Since Zambia has already committed to the FCTC, priority must be given to enforcing the FCTC recommendations such as mandatory tobacco health warnings, implementing plain packaging and enforcing tobacco advertising bans. There is also need for a more effective taxation regime to deter from both smoking and alcohol drinking. Further, multilevel interventions such as regulation of production, distribution, sale and consumption of alcohol in urban areas, including screening and referrals for treatment and counselling services for dependent individuals within primary healthcare facilities are required. Future research should focus on monitoring trends in tobacco smoking and harmful alcohol consumption among at-risk groups as well as exploring the bottlenecks stifling implementation of the existing legal and policy frameworks against tobacco and alcohol in Zambia.