Background
The growing burden of chronic non-communicable diseases worldwide including the African continent is gaining attention [
1‐
3]. It is estimated that 41 million people die each year from non-communicable diseases, most of them in low- and middle-income countries [
4]. Heart diseases, stroke, cancers, chronic respiratory diseases, and diabetes by far constitute the leading cause of mortality in the world [
4,
5]. In 2030, such diseases are projected to claim the lives of 52 million people [
6].
As one of the modifiable risk factors for non-communicable diseases (NCDs), tobacco is responsible for almost 8 million deaths each year of these 7 million from direct tobacco use and 1.2 million due to secondhand smoke exposure [
7]. Smoking is attributed to high proportion of lung cancer (71%), chronic respiratory diseases (42%), and cardiovascular disease (10%) [
8]. Globally, tobacco use causes more than one and half trillion dollars of economic damage each year [
7]. If the current trend is not curbed, it will be responsible for 1 billion deaths at the end of this century [
9]. This NCDs epidemics is fueled by a combination of risk factors, including tobacco use, unhealthy diet, lack of physical activity, harmful alcohol use, overweight or obesity, and elevated blood pressure, blood sugar, and cholesterol [
10].
In contrary to the common perception that NCDs are only a problem of the richer world, but 80% of chronic disease deaths occur in low and middle-income countries, and affect younger populations and lead to premature mortality [
11]. This inequality of burden of NCD may be due to lack of prevention or effective management of the diseases in developing country [
12,
13]. Thus the low- and middle-income countries are affected by the double burden of the growing chronic diseases and communicable diseases, maternal and perinatal conditions, and nutritional problems [
14].
Ethiopia like other African countries experiences the challenges of a potential tobacco epidemic. According to the Global Burden of Disease 2016 report, annually about 16,800 people (259 males and 65 females per week) in Ethiopia die from tobacco-related death which is relatively higher compared to other African countries such as Kenya, Cameroon, and Botswana [
15].
Evidence around tobacco smoking in Ethiopia is meager. The Ethiopian Demographic and Health Survey (EDHS) and NCD STEPS survey generated the only nationally representative evidence on tobacco use with limited indicators [
16,
17]. Besides, Global Youth Tobacco Survey (GYTS,2005) conducted in Secondary Schools in Addis Ababa is the second organized data on youth tobacco use in Ethiopia [
18]. However, comprehensive, evidence-based population-level data on tobacco use was not available to show the magnitude, trends, and impact of the tobacco epidemic in the country. Hence, the Ethiopian Global Adult Tobacco Survey (GATS) 2016 measuring tobacco use, frequency of smoking, type of tobacco products and other tobacco control indicators at national level was conducted to address this major gap at national level. In addition, this paper was examined the association between key individual sociodemographic characteristics and current tobacco use. The present study also complements other government agency like Central Statistical Agency (CSA) efforts in periodically monitoring the tobacco epidemic and provides comprehensive evidence and information for tobacco control planning and policy development.
Methodology
Ethiopian GATS 2016 was conducted as nationally representative household survey targeting adults both men and women aged 15 years or older residing in any of the nine regional states and two city administrations in Ethiopia. The sample selection did not include institutionalized adults. The survey was conducted in the target population with a usual member of the sampled household who either (1) did not have any other residence, or (2) had multiple residences but had been living in the sampled household for at least six months during the year prior to the survey. The institutional population living in prisons, hospitals, military barracks, school dormitories, etc. were excluded from the universe defined for the household surveys [
19].
The GATS core questionnaire was adapted for Ethiopia to include some optional questions through a process of intensive consultations to reflect country-specific questions, meetings and proposed edits by the GATS Questionnaire Review Committee (QRC). Recognizing the high level of population diversity in Ethiopia—multiple nationalities and ethnicities, varying cultures, and 80 languages spoken—the Ethiopian GATS committee came to consensus to make use of three primary languages for interviewing: Amharic, Oromiffa, and Tigrigna. In addition, the English questionnaire was also included in the survey. To address language barriers, the committee recruited interviewers and supervisors who have skills in speaking and writing these languages. The QRC approved and incorporated the pretest experience into the questionnaire.
Survey design and sampling procedures
Researchers conducted a population-based descriptive cross-sectional study using the World Health Organization (WHO) and US Centers for Disease Control and Prevention (CDC) GATS globally standardized protocol to determine adult tobacco use and other tobacco control indicators in Ethiopia [
20]. The sampling frame was based on the population and housing census conducted in 2007 [
21]. A multi-stage geographically stratified cluster sampling and Population Proportion to size (PPS) designs were used to produce estimate for key tobacco control indicators for the country as a whole and by gender and residence (urban or rural). In addition, the sub-national prevalence was generated at the level of regions (9 regional states and two autonomous cities) without further disaggregation by age, gender, and place of residence. The GATS sampling procedure followed three stage approach and in the first stage 375 enumeration areas (EAs) — i.e., primary-sampling units (PSUs) — were selected from the master sample using probability proportion to size (PPS). An equal number of PSUs i.e. EAs were allocated to urban and rural domains before selection. Prior to selecting the household sample, a re-enumeration process (mapping and listing) of all 375 GATS EAs was conducted to update the household address information. The process of re-enumeration allowed for complete household coverage with precise sampling results for the survey. In the second stage, 10,875 households were chosen systematically from selected PSUs/EAs (secondary sampling unit). Twenty-nine households were selected per PSU/EA. In the last stage, one eligible member 15 years of age or older was selected randomly from the list (roster of 15+ eligible individuals) using handheld devices within each selected household.
A total of 10,875 households were sampled and of these 10,649 households completed the survey and 10,150 individuals were successfully interviewed (one individual was randomly chosen from each selected household to participate in the survey). The total response rate for Ethiopian GATS was 93.4%. The household response rate was 97.9% (98.1% urban, 97.9% rural), while the individual response rate was 95.4% (95.8% urban, 95.0% rural).
Study variables
The dependent variable “current tobacco use” is constructed based on the responses provided to the GATS individual questions in both sexes-male and female. The study population were asked if they were currently use both smoking and smokeless tobacco products. Smoking tobacco products including shisha, cigar, gaya (local traditional smoking tobacco leaves) and others. Current tobacco use in this manuscript includes daily and occasional (less than daily) smokers and smokeless tobacco users. We used demographic variables such as gender, age, educational level, marital status, occupation, wealth index (5 levels), and religion as smoking predicting factors. In this article, the wealth index is a measure of a family’s overall standard of living, measured by the size of assets, such as vehicles, television, radio, basic water and sanitation facilities, and land. Moreover, we used wealth index as equivalent of socio-economic status through this paper.
Data analysis
Complex survey data analysis adapted from GATS data analysis manual [
22,
23] was used to obtain prevalence and population estimates with 95% confidence intervals. To improve the representativeness of the sample in terms of the size, distribution, and characteristics of the study population, sample weights were calculated for each respondent before the analysis. SPSS version 19, SAS version 9.2, and SUDAAN version 10.1 software were used for data analysis. Standard errors were calculated using Taylor series linearization.
Multivariate analysis of risk factor for cigarette smoking was conducted to select predictors of any tobacco use in Ethiopia. Measures of associations (odds ratio) are also applied to determine the prevalence of cigarette smoking and factors associated with it. Additionally, bivariate and multivariate analyses were conducted to determine odds ratios and confidence intervals.
Statistical significance was measured by comparing the 95% confidence intervals of two estimates to determine whether they were statistically different. This report states two estimates are different, either higher or lower, only if their confidence intervals are non-overlapping.
Discussion
Ethiopian GATS was the very first of its kind in Ethiopia, and it provided critical information on key tobacco control indicators for policymakers and the tobacco control community. Before GATS, only DHS and NCD STEPS surveys reported the prevalence of tobacco use in Ethiopia at a national level. However, these surveys did not address tobacco use in full detail as GATS did. The present study provide estimates with confidence intervals on tobacco use prevalence and type of products smoked as well as predictors of any tobacco use (Table
6) among adults in Ethiopia.
Even though tobacco is one of the condemned products by most Ethiopian cultures [
26], it has been used as traditional medicine in some parts of the country [
27]. As growing evidence indicates, the practice of tobacco use by Ethiopian adult is increasing from time to time. For instance, Ayana and his colleagues found that the prevalence of current tobacco smoking was significantly higher in the years between 2014 and 2017 than in the year before 2014 [
28].
As Ethiopian GATS indicated, the overall current tobacco use prevalence of adults age 15 years and above was about 5.0% (men 8.1%, women 1.8%) in 2016 (Tables
3 and
7). This prevalence is relatively higher than other findings of DHS 2016 that reported 4.0% of men and 1.0% women smoked any type of tobacco products and STEPS 2015 that indicted 7.3% men and 0.4% women were used any form of tobacco [
17,
29]. On the other hand, the smoking prevalence in Ethiopia (3.7%) is lower than most African countries such as Kenya (13.5%), South Africa (9.6%), Uganda (9.2%), Nigeria (5.5%), and others [
30‐
33]. The tobacco industry may contribute to the observed difference in smoking prevalence, as the government-owned the National Tobacco Enterprise in Ethiopia at the time of study and the European industry operated manufacturing and cultivation of tobacco in the above-mentioned African countries such as Kenya, and Uganda. However, the absolute number indicated that 3.4 million Ethiopian adults currently use any form of tobacco and most of them smoked tobacco daily (Table
7). This indicated that tobacco use is a public health concern in the country.
Table 7
Distribution of current tobacco users ≥15 years old, by tobacco use pattern and gender – Ethiopian GATS, 2016
Current | Tobacco use | 3.4 million | 8.1% | 1.8% |
Tobacco smokers | 2.5 Million | 6.2% | 1.2% |
Cigarette smokers | 1.98 Million | 5.5% | 0.2% |
Smokeless tobacco users | 1.2 million | 2.6% | 0.8% |
Daily | Tobacco smokers | 2.2 million | 5.2% | 1.1% |
Occasionally | Tobacco smokers | 0.34 million | 0.9% | 0.1% |
Even though low smoking prevalence of female (1.2%) comparing with male (6.2%), the proportion of women smokers are in alarming trend in Ethiopia by comparing it with previously conducted studies of DHS that only deal on women of reproductive age groups. As DHS indicates, in 2011, there were only 35 women in number who were smoked tobacco products, but in 2016 about 0.8% of women were smoked any tobacco products higher than 2011 survey. However, the present study that includes all women 15+ years found that 1.2% female adults smoked any form of tobacco products in 2016. The increment of smokers particularly among woman will affect the low quality of life and challenge the health service, as most women are responsible for childcare in Ethiopia. Tobacco use itself is a source of health inequality and it may affect women’s survival advantage over men [
34].
Smoking initiation is one of the determinant of factor for long-term smoking [
35], tobacco dependency and overall risk of tobacco use [
36]. Early smoking initiation increases risks of experiencing smoking-related morbidities and all-cause mortality [
37]. The present study revealed that approximately 3 out of 5 cigarette smokers aged 20–34 had started smoking daily before the age of 20. Among the age group of 20–34, more females (55.4% (95% CI = 26.6, 81.0) than their counter (20.8% (95% CI = 10.5, 36.8) were started smoking daily before the age of 15. Most adults start smoking before the age of 20, for example above 70% of adults in Europe started smoking daily before the age of 18 [
38]. This calls to implement smoking initiation reduction among youths to protect this nicotine vulnerable groups and the overall adverse health effect of smoking [
39]. Among effective interventions of tobacco control, tailored education or youth focused tobacco education and counseling by health care providers are recommended [
40‐
42]. In our context, the term youth refers to members of society between the ages of 15–29, as defined by Ethiopian youth policy [
43].
The majority of adult tobacco users were used smoked tobacco products (3.7% or 2.5 million) than smokeless tobacco products (1.7% or 1.2 million). Overall, 1.98 million or 2.9% (95% CI = 2.2, 3.7) adults (5.5% of male and 0.2% of female) smoked cigarettes in 2016 (Table
7). Among smoked tobacco products, Gaya (traditionally smoked by burring tobacco leaf over a fire and sucking it using a bamboo stick) was common in Gambella, Southern Nations, Nationalities, and People’s Region (SNNPR), and Benshangul Gumz. This may be related to cultural believes that smoking tobacco can prevent communicable diseases like malaria [
17,
27]. Though Ethiopia prohibited the smoking of shisha products [
44,
45], water pipes were smoked more in the Eastern part of the country than in other regions. Besides geographical variations, the pattern of smoked tobacco products depended on the economic status of the smoker. High economic groups smoked relatively more manufactured cigarettes than the lowest economic groups. Contrarily high percentage of lowest economic group smoked Gaya (Table
4).
The majority of daily smokers smoked on average 10.4 cigarettes per day in 2016. The number of cigarettes smoked per day (including manufactured and hand-rolled cigarettes) is a key indicator in determining nicotine dependence [
46,
47] as well as consumption of a high number of cigarette per day could lead to different health concern such as Intracranial Aneurysm Rupture [
48] and low birthweight [
49]. As Hackshaw et al. (2018) and Pan et al. (2019) suggest even low cigarette consumption could lead to the risk of coronary heart diseases and stroke [
50,
51].
In addition to the descriptive analysis, we examined the factors related to tobacco use in adults by using Ethiopian GATS data to understand which socio-demographic variables (education, age group, wealth index, etc.) affect the tobacco use in the country (Table
6). Based on the bivariate analysis, gender, occupation, age, and marital status are significantly associated with the current tobacco use (
p-value< 0.05). Gender is one of the predicting factors of tobacco use as male is 7.63 times more likely to use any form of tobacco than female [COR = 7.63 95% CI (2.16–26.96). Our finding that males are seven times more likely to use any type of tobacco is consistent with other studies conducted in Ethiopia such as Guliani and colleagues’ observation [
52] and similarly, findings from Defar and his colleagues indicated that males are ten times more likely to smoke tobacco than female [
17]. This is also in agreement with other findings from Yemen [
53] and other East Africa countries and Madagascar [
54]. This finding supports the sex difference in tobacco use could be explained by some variables that contribute to psychological challenges like low social values and norms of the Ethiopia community to females [
52] and by biological factors such as nicotine sensitivity, nicotine metabolism, and distribution [
55].
Religion is one of the predicting factors for tobacco use and the present study found statistically significant among different religious groups (p- < 0.05). Nonbelievers (OR 101.8 CI (36.11, 287.04) and Islamic religion followers (OR 2.89 CI (0.95, 8.82) were more likely to use tobacco as compared to Christian religion followers (OR1.49 CI (0.57, 3.88). This may be related to the place of residence as most Muslim communities live in East part of the country [
56] where smoking prevalence was higher and they may have exposure to smuggling tobacco products as this part of the country have high rate of illicit tobacco market share [
57]. This result is consistent with other studies conducted in Ethiopia [
52,
58].
In addition, age group 45–64 years OR 4.54, 95% CI (2.25, 9.15); 65+ years OR 3.55, 95% CI (1.41, 8.91); 25–44 years OR 2.86, 95% CI (1.51, 5.41), were more likely to consume tobacco than the younger age group (15–24 years). The younger age groups [
15‐
24] are less likely to use tobacco products than all age groups above 25 years. This is consistent with other studies conducted across African countries as older age groups are more likely to smoke cigarette than younger age groups [
58,
59]. This could be explained by age of initiation of smoking for continued tobacco use as a result not try to quit because they have been smoking for a long time and think that it will not cause any health problems [
60,
61]. In addition, perceived risks of tobacco use and intention to quit between the younger and the adult smokers may contribute for this tobacco use differences [
62].
Occupationally, adults who were employed OR 8.86, 95% CI (3.11, 25.20); unemployed or retired OR 5.46 95% CI (1.69, 17.64) and homemaker OR 1.54, 95% CI (0.45, 5.30); are more likely to use tobacco products than a student, respectively. This finding is in agreement with a study conducted in India by Pramhakar et al. (2012) as being a student is less likely to use tobacco than unemployed and employed adults [
63]. Similarly, widowed is less risk factor for tobacco use than another marital status including married, separated, single, and divorced (Table
6). However, Cho and his colleagues found that unmarried adults are more likely to use tobacco products than other marital status including married one [
64].
Overall, the present study indicated that the prevalence of tobacco use among male adults is higher than female. Besides, the smoking prevalence of low wealth index adults is relatively higher. This is consistent with other studies conducted in Ethiopia [
28,
65] that shows increasing trends of tobacco use in both sexes. However, tobacco use has health burdens and economic impacts. As the evidence showed, tobacco use causes various health problems such as cancer [
66‐
70], cardiovascular disease [
71], and respiratory diseases [
72]. Globally, about 8 million people die each year from tobacco-related deaths with a high proportion in low and middle-income countries [
7]. Non-communicable diseases (NCD) contribute 44% of death in Ethiopia [
73] and tobacco-related deaths was estimated to 17 thousand in 2016 [
15]. Now, the government of Ethiopia shows it commitment by ratifying the strongest tobacco bill in line with the WHOFCTC provisions to reduce public health impact of tobacco. Therefore, the regulatory, tobacco control actors, and all concerned bodies should implement all tobacco control laws and regulation without exceptions in order to curb tobacco epidemics and its economic burden.
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