Tobacco use and associated risk factors in Burkina Faso: results from a population-based cross-sectional survey

Despite considerable efforts, tobacco use remains a leading cause of preventable deaths worldwide, according to the World Health Organization (WHO) [1]. Tobacco use, including smoking and the use of smokeless tobacco products (SLT), kills nearly 7 million people each year, including approximately 600,000 deaths from second-hand smoke [2‐5]. If current trends persist, it is projected that tobacco use will kill over 8 million people per year by 2030, with 80% of these deaths occurring in low- or middle-income countries [6]. Characterizing tobacco use and associated factors is especially important for public health policy and intervention in low- and middle-income countries.

While the prevalence of tobacco use has been low in Africa compared to other regions, future projections show rapid increases in smoking, particularly among men, and an increase in the burden of non-communicable disease in the region, accentuating the need for country-level data on the prevalence of smoking and SLT use [7]. According to analyses of Demographic and Health Surveys (DHS), the prevalence of adult tobacco use smoking is highly heterogeneous across African countries, ranging from 7.6% in Ghana, 14.8% in Senegal, and 15.8% in Mali to 37.6% in Sierra Leone among men in Western Africa. The prevalence of smoking in all countries was higher in men than women, although studies have shown an increase in the marketing of tobacco products to women in sub-Saharan Africa (SSA) [8]. In most SSA countries, SLT consumption among women is higher than cigarette use [9].

In response to concerns about morbidity and mortality associated with tobacco consumption, the WHO created the Framework Convention on Tobacco Control (FCTC) in 2005 and “MPOWER” measures in 2008 as a set of low-cost, high-effective measures to control tobacco use [5, 10]. The use of population-based surveys, under the first pillar of the MPOWER strategy, helps countries and public health audiences to understand patterns of tobacco use and its associated factors, as well as to track the impact of tobacco control measures and policy changes [9].

According to 2011 Demographic and Health Survey data, the prevalence of smoking among a representative sample of adult men in Burkina Faso was 21.2% and among adult women, was 0.09%, with 3.86% reported SLT use among women. No SLT data was collected from men in this survey [10]. The only other nationally representative dataset that includes information about tobacco consumption in Burkina Faso is the 2013 WHO STEPwise approach to surveillance (STEPS) survey of non-communicable disease (NCD) risk factors. The present analysis uses these data to describe prevalence estimates for tobacco consumption in Burkina Faso and assess associated demographic and behavioral factors, in order to inform future prevention and control initiatives. In the context of the rapid increase in tobacco consumption predicted in SSA countries, it is particularly important to have accurate results on tobacco consumption in order to ensure an epidemiological surveillance program.

Our study analyzed the most recent national representative survey data on tobacco consumption among adults in Burkina Faso and our findings suggest that tobacco consumption is higher than what was reported from the 2011 DHS survey [9]. It is not possible to compare our findings with others, such as the age-standardized prevalence of daily smoking from 2015, which considers daily smoking instead of any current smoking and found the age-standardized prevalence of daily smoking for 2015 women to be 4.2% and for men, to be 12.5% [4].

From 2006 to 2013, the government of Burkina Faso carried out national tobacco control programs. Laws regulate tobacco consumption health care facilities, educational facilities, government facilities, and indoor offices. Additionally, Burkina Faso has national bans on the direct advertising of tobacco products on billboards and outdoor advertising, as well as on national television or radio [5]. In addition, an addiction center was recently opened in the largest hospital in the country. Despite national action to decrease tobacco use since the WHO FCTC took effect on October 2006, Burkina Faso continues to have higher tobacco consumption than other countries in the region [5, 9, 15]. The results from our analyses of STEPS data, as well as the 2011 DHS data, show that Burkina Faso’s smoking prevalence in men is higher than seven of nine other countries in West Africa and the prevalence of SLT in Burkina Faso is higher than nine of 10 other countries in West Africa [9]. The adoption and implementation of tobacco control measures has been slow and faced major challenges in Burkina Faso compared to some countries where vigorous measures have been adopted. The adoption of strict regulatory texts and measures against smoking has been recorded in recent years. The last of these texts is the decree No. 2015–366/MS/MICA fixing the modalities of packaging and labeling of tobacco products in Burkina Faso. This text recommends that importers and manufacturers of tobacco affix graphic health markings on tobacco packets. The government must strive for effective communication in the fight against tobacco within the population and the strict application of current regulations to address the prevalence of smoking. Young people are the main consumers of tobacco in Burkina Faso. Our findings show that nearly one of third of young people aged 25–34 years-old reported smoking tobacco and that prevalence decreases with age. In pooled data from 30 SSA countries, age is associated with tobacco consumption; however, both smoking and SLT use increase with age [9]. However, analyses of STEPS data from Kenya also found that the majority of smokers were in younger age groups [16]. Earlier smoking initiation is a major public health concern. The average age of smoking initiation among adults in Burkina Faso was 20.9 years of age, highlighting the importance of tobacco prevention policies to address people in younger age groups [12]. The Global Youth Tobacco Survey carried out in two cities in Burkina Faso in 2009 found that about 11.9% of boys from 13 to 15 years old in Ouagadougou and 6.0% in Bobo-Dioulasso were currently tobacco smokers [17, 18]. While youth smoking has decreased between 2001 and 2009 in both of these cities, the prevalence of the use of other tobacco products increased, as did youth reports of exposure to second-hand smoke at home in Bobo-Dioulasso [17].

In our study, smoking was also significantly associated with gender and alcohol consumption, but not to location of residence. In various other SSA countries, tobacco use is higher in men than in women [9], likely related to differing social norms about gender and tobacco use. Alcohol consumption and tobacco use were also linked in Kenya’s STEPS survey [16], among other studies. The combination of those two risk factors may contribute to future increases of NCDs in Burkina Faso. Our study did not find any association between smoking, education, or employment status, while other studies from SSA found that men and women from rural areas, or those with lower educational levels, smoke more than those from urban areas [9].

According to our findings, SLT is more frequently used by women and among those living in rural areas of Burkina Faso. Although SLT is less prevalent than smoking, it presents an important public health problem due to its association with many diseases, such as cancer (i.e., mouth, pharynx, and esophagus cancer) and ischemic heart disease. Health effects of SLT vary by region, related to the types of tobacco that are used in those regions [19]. In Sub-Saharan Africa, few studies have focused on the health effects of SLT [20, 21]. In general, women SLT users are exposed to multiple health risks, such as pregnancy complications (e.g., placenta praevia, placental abruption, and pre-eclampsia) [22]. In this study we did not estimate SLT consumption during pregnancy. A study published in 2017, however, found that the prevalence of SLT during pregnancy in Burkina Faso was 2.8%. This prevalence is higher compared to other African regions (1.7%), but lower than in Sierra Leone (4.6%) [22]. Even at a national level, as shown in Fig. 2, important differences were observed between the regions. Therefore, further and more advanced spatial analysis of tobacco consumption is needed to better guide health care prevention programs.

Concerning the limitations of this study, we report here the results of the first nationally representative survey on the prevalence and risk factors for tobacco consumption in Burkina Faso. The first limitation stems from the cross-sectional nature of the data, which limits the possibility of deriving causal inferences. The second limitation is that tobacco and alcohol consumption were obtained during interviews and are therefore dependent on the faith of the participants. There is thus both a risk of memory bias and social desirability. It can therefore be estimated that the numbers and prevalence obtained in this survey underestimate the actual consumption. The last point is that some well-known risk factors for tobacco consumption were not included in the study because data on these variables have not been collected during the STEPS survey. One of these variables is the socio-economic status. Given the study design (cluster sampling design) and the sample size, the results of this study can be extended to the whole of Burkina Faso.

Based on the results of this study, important preventive measures need to be taken to reduce tobacco consumption in Burkina Faso, with targeted approaches to sections of the population most affected by different types of tobacco use. In general, efforts should target tobacco use in youth, smoking among men, and SLT consumption among women and in rural areas.

Two important aspects should be taken into consideration when organizing tobacco prevention campaigns in Burkina Faso. The first is the necessity to integrate tobacco and alcohol campaign programs, since we have seen that both consumptions are highly correlated for both smoked and SLT consumption. The second is to pay more attention to SLT use in tobacco control programs as it constitutes a significant part of the tobacco use in Burkina Faso and is the principal type found in women.

The prevalence of tobacco consumption remains high in Burkina Faso, despite restrictive measures and control plans adopted in recent years. Since tobacco consumption is an important risk factor for cardiovascular diseases and other NCDs, it is important to promote and accelerate the implementation of various measures to decrease consumption, especially SLT consumption, in future years. Further spatial analyses could be useful to identify areas of high tobacco consumption in order to focus more on these areas in tobacco control and prevention program planning.