Background
Current rising trends in tobacco use in low- and middle-income countries suggest this will increase the burden of non-communicable diseases in these countries [
1]. Combined with demographic ageing in the same countries, the significance of chronic diseases among the ageing population and implications for quality of life of older adult population poses significant challenges [
2].Tobacco use, diet rich in saturated fat and high in calories, excessive alcohol use and physical inactivity, are some of the modifiable risk factors contributing to cardiovascular diseases, cancer, chronic respiratory diseases and diabetes [
3]. These non communicable disease (NCD) risks are strongly influenced by changing social and behavioural patterns and come at a high cost to health and economies, with lower income countries assuming an ever larger share of the economic burden of these factors and diseases [
4].
Smoking has long been identified to be of prime importance in the cardiovascular health of adult Ghanaians [
5] with more recent evidence suggesting it contributes more than 1% of total Disability Adjusted Life Years (DALYs) in Ghana [
6]. The prevalence of tobacco use among older adults in Ghana is relatively low compared to some middle and high income countries [
7‐
9]. Results from the 2003 Study on global AGEing and adult health (SAGE) in Ghana showed persistence of smoking into older ages; where 6.8% of the population 80-plus years were current daily smokers [
10]. With even more recent evidence of increasing prevalence in younger populations, the impact and control of tobacco use was legislated through Public Health Bill 2011 in July 2012 [
11]. This law is an important piece to help stem the impact of smoking on the population, with another key piece to address the risks posed by tobacco through evidence based research.
This research is based on the World Health Organization’s (WHO)2007/08 SAGE in Ghana and can be used as baseline data prior to implementation of the 2012 law. The goal is to describe the patterns of tobacco use among older adults (50 years and above) in Ghana by selected demographic, socioeconomic, health risk and life satisfaction indices and by location (administrative regions) to help identify high risk older adults in the population.
Results
Patterns of tobacco use in the older adults
Overall, 7.6% were current daily smokers, 2.6% were current smokers, but not daily while three-quarters of older Ghanaians had never smoked (75.5%). The proportion of respondents who were current daily smokers was higher among men (M:F ratio = 3.1), among rural residents, and increased with age (from 6.8% in 50-59 years to 8.2% in those 70 years and above). Respondents with secondary school (or equivalent) completed (11.9%) and those without formal education clearly showed higher proportions of current smokers (10.2%), compared to those with college/university or postgraduate education (1.6%). The proportion of current daily smokers decreased dramatically with income. Compared to the currently married/cohabiting, the widowed had lower proportions of current daily smokers (5.8% compared to 9.0%).
Amongst older women, 92.0% had never smoked, compared to 64.4% of older men (M:F ratio of 0.7). Higher proportions of respondents who had never smoked were urban residents, younger (50-59 years), and with higher education. Older adults who have previously smoked but are currently not smoking (shown as not current smoker in Table
1) was highest in the 70+ age group, was higher in women compared to men, was higher among urban residents and those with at least secondary education. Older adults who have quit smoking increased with income levels, was lowest (11.8% among the Q1 group) and highest (16.8% among the Q5 group).
Table 1
Prevalence of smoking and average daily tobacco consumption in older adults, by selected characteristics
Age group
| | | | | | |
50–59 | 6.8 | 2.9 | 14.0 | 76.4 | 5.7 | 1 694 |
60–69 | 7.6 | 3.0 | 13.1 | 76.3 | 5.1 | 1 172 |
70+ | 8.7 | 2.0 | 15.5 | 73.8 | 4.8 | 1 386 |
Sex
| | | | | | |
Male | 11.3 | 3.7 | 24.6 | 60.4 | 5.4 | 2 090 |
Female | 3.7 | 1.4 | 29.0 | 92.0 | 4.4 | 2 160 |
M : F Ratio | 3.1 | 2.6 | 0.8 | 0.7 | 1.2 | |
Residence
| | | | | | |
Urban | 4.1 | 2.2 | 15.6 | 78.2 | 4.8 | 1 753 |
Rural | 10.2 | 2.9 | 13.3 | 73.7 | 5.3 | 2 497 |
Education
| | | | | | |
No education | 10.2 | 1.8 | 10.7 | 77.2 | 5.0 | 2 310 |
Primary completed or less | 4.3 | 2.4 | 16.1 | 77.2 | 4.9 | 886 |
Secondary education(or equivalent) completed | 11.9 | 7.5 | 43.2 | 13.3 | 15.6 | 882 |
College/University/ Postgraduate | 1.6 | 0.9 | 31.8 | 16.7 | 3.5 | 149 |
Marital status
| | | | | | |
Never married | 12.2 | 4.3 | 21.6 | 61.9 | 3.3 | 61 |
Currently married/ Cohabited | 9.0 | 3.0 | 18.8 | 69.2 | 5.5 | 2441 |
Separated/divorced | 4.9 | 3.3 | 12.3 | 79.6 | 5.2 | 547 |
Widowed | 5.8 | 1.3 | 4.8 | 88.1 | 4.1 | 1 177 |
Income quintile
| | | | | | |
Q1 | 16 | 3.2 | 11.8 | 69.0 | 4.4 | 790 |
Q2 | 9.1 | 3.1 | 13.3 | 74.5 | 5.1 | 813 |
Q3 | 8.0 | 2.1 | 14.5 | 75.4 | 6.2 | 865 |
Q4 | 4.8 | 2.3 | 14.2 | 78.7 | 5.2 | 862 |
Q5 | 1.8 | 2.5 | 16.8 | 78.9 | 7.4 | 916 |
Total respondents (%)
| 325 (7.6) | 111(2.6) | 605 (14.2) | 3 211(75.5) | 325 (7.6) | 4252 |
The highest mean daily tobacco use decreased with age, however, the habit of tobacco use persisted into older age (70-plus age group still recorded a mean daily tobacco use of 4.8). Mean daily use of tobacco was higher for men (5.4) than women (4.4) and higher among rural residents (5.3) than urban residents (4.3). Respondents with at least secondary school (or equivalent) had the highest mean daily tobacco use (15.6) compared to those without formal education (5.0). The mean daily tobacco use was relatively higher among the currently married than the widowed.
Regional distribution of tobacco use in the older adults
Overall, the national prevalence of current daily smoking among older Ghanaians was 7.6%. Table
2 shows the relative percentage contribution of each region to the total number of older adults who use tobacco and indicates that, the three northern regions have the highest relative percentages of current daily smoking; 31.2% in Upper East, 22.5% in Northern and 7.9% in Upper West. The Ashanti and Greater Accra regions had the lowest relative percentage of current daily smoking, (2.6% and 3.1% respectively). The Brong Ahafo (being a transitional regional belt between the northern regions and the southern regions) had proportion of current daily smokers which was intermediate (7.2%).
Table 2
Patterns of overall tobacco use in older adults, by region
Ashanti | 2.6 | 15.3 | 18.7 | 670 |
Brong Ahafo | 7.2 | 13.6 | 11.2 | 409 |
Central | 5.8 | 8.5 | 9.8 | 452 |
Eastern | 6.2 | 8.5 | 13.1 | 557 |
Greater Accra | 3.1 | 13.6 | 12.8 | 493 |
Northern | 22.5 | 7.6 | 6.3 | 385 |
Upper East | 31.2 | 4.2 | 3.1 | 260 |
Upper West | 7.9 | 6.8 | 1.7 | 132 |
Volta | 5.8 | 8.5 | 9.1 | 411 |
Western | 7.7 | 13.6 | 14.2 | 511 |
Total | 100 | 100 | 100 | 4280 |
The Ashanti, Western and Greater Accra regions had relatively higher proportions of older persons who had smoked previously but were currently not smoking compared to the three northern regions. For example the Ashanti region had 18.7% of older persons who had smoked previously but were currently not smoking compared to 3.3% in the Upper East region (the region with the highest proportion of current daily smokers).
Demographic, socioeconomic, health risks and life satisfaction indices associated with tobacco use in older adults in Ghana
Results from logistic regression shown in Table
3 indicate that demographic, socioeconomic, chronic ill-health and life satisfaction indices have significant association with tobacco use in the older adults. Older males had a slightly higher risk of tobacco use (AOR = 1.10, CI 1.05-1.15), as well as older adults residing in rural location (AOR = 1.37, CI 1.083-1.724). Older adults without health insurance also had increased risk of tobacco use (AOR = 1.41, CI 1.111-1.787). Satisfaction with life was much lower for the older adults who use tobacco. There was increased self-reporting of dissatisfaction with life more for the older adults who use tobacco (AOR = 3.26, CI 1.190-5.928).
Table 3
Predictors of tobacco use in older adults in Ghana
Tobacco use
|
Sex
| | | |
Female |
Ref
| | |
Male | 0.001 | 1.100 | 1.046-1.148 |
Location
| | | |
Urban |
Ref
| | |
Rural | 0.009 | 1.366 | 1.083-1.724 |
Age group
| | | |
50-59 |
Ref
| | |
60-69 | 0.992 | 1.002 | 0.723-1.389 |
70 and above | 0.348 | 0.849 | 0.602-1.195 |
Educational level
| | | |
No formal education |
Ref
| | |
With education | 0.919 | 1.012 | 0.798-1.285 |
Marital status
| | | |
Never married |
Ref
| | |
Living with partner (currently married and cohabiting) | 0.088 | 0.277 | 0.063-1.211 |
Living without partner (separated/divorced and widowed) | 0.779 | 0.875 | 0.343-2.231 |
Income level
| | | |
| Lower income (Q1,Q2 and Q3) |
Ref
| | |
| Higher income (Q4 and Q5) | 0.460 | 1.408 | 0.567-3.495 |
|
Health insurance status
| | | |
Insured |
Ref
| | |
Uninsured | 0.005 | 1.409 | 1.111-1.787 |
Lifetime alcohol use
| | | |
Never |
Ref
| | |
Ever | 0.001 | 1.310 | 0.230-2.418 |
|
Self-reported angina
| | | |
| No |
Ref
| | |
| Yes | 0.323 | 1.532 | 0.658-3.566 |
|
Self-reported arthritis
| | | |
| No |
Ref
| | |
| Yes | 0.009 | 1.625 | 0.440-2.889 |
|
Self-reported asthma
| | | |
| No |
Ref
| | |
| Yes | 0.805 | 1.075 | 0.607-1.903 |
|
Self-reported chronic lung disease
| | | |
| No |
Ref
| | |
| Yes | 0.139 | 1.387 | 0.298-2.272 |
|
Self-reported depression
| | | |
| No |
Ref
| | |
| Yes | 0.291 | 1.613 | 0.247-2.520 |
|
Self-reported diabetes
| | | |
| No |
Ref
| | |
| Yes | 0.659 | 1.894 | 0.542-2.473 |
|
Self-reported hypertension
| | | |
| No |
Ref
| | |
| Yes | 0.809 | 1.024 | 0.731-1.435 |
|
Self-reported stroke
| | | |
| No |
Ref
| | |
| Yes | 0.914 | 1.035 | 0.555-1.930 |
|
Level of subjective well being/ life satisfaction
| | | |
| Satisfied |
Ref
| | |
| Indifferent | 0.006 | 4.115 | 1.505-8.252 |
| Not satisfied | 0.022 | 3.259 | 1.190-5.928 |
Although not statistically significant (per p-values in Table
3), there was increased associations (per adjusted odds ratios in Table
3) for self-reporting of chronic diseases among older adults who use tobacco for hypertension, stroke, diabetes, depression, chronic lung disease, asthma, arthritis and angina. Increased association with arthritis among older adults who use tobacco was statistically significant.
Discussion
Tobacco use has significant impact on mortality and morbidity from non-communicable diseases, based on recent estimates of mortality rates in the 50-54 age group of 34 per 100,000 population to 158 per 100,000 population in the 80+ age group and contributing up to 1% of DALYs in Ghana according to the 2010 Global Burden of Disease study [
6]; however, risk modification is possible through effective primary prevention and health promotion efforts [
2,
15].
Prevalence of current daily smokers in older Ghanaians was 7.6% and was higher among men (with M: F ratio of 3.1). This figure compares favourably to “ever smoking” rate but is much higher than current rate found in 2009 by Owusu-Dabo and colleagues in Ghana [
16]. The reported prevalence of smoking was relatively higher for both men and women in SAGE Wave 1, than in SAGE Wave 0 in 2003 among the population aged 50+ years [
10]. In SAGE Wave 1, prevalence of current daily was 11.3% in males and 3.7% in females compare to the SAGE Wave 0 where it was 7.5% in males and 0.7% in females [
10]. The prevalence of current daily smokers was also higher among rural residents (probably due to the use of smokeless tobacco among the rural Ghanaian population). The 2008 Ghana Demographic and Health Survey report also indicated higher use of tobacco among males than females and more in rural than urban locations [
9].
Prevalence of current daily smokers increased with age and decreased dramatically as income increased. Respondents without formal education clearly showed higher proportions of current smokers (10%), compared to those with College/University or Postgraduate education (2%). The older persons who were never married had the highest prevalence of current daily smokers (12%), while the widowed had lower proportions (6%) than those currently married/ cohabiting (9%). The mean daily tobacco use (number of cigarette/cigarette equivalent) generally followed the socio-demographic patterns described for the current daily smokers. A recent study by Blazer and Wu,2012 among older Americans showed similar sociodemographic correlates to tobacco use; prevalence of tobacco use was higher among males, those with less than high school education, those who were never married and among the unemployed and lower income groups [
17].
There were clear regional differences in the distribution of tobacco use in the older adults. The three northern regions had the highest proportion of current daily smoking; 31.2% in Upper East, 22.5% in Northern and 7.9% in Upper West. The two most populous and most developed regions (Greater Accra and Ashanti) had the lowest proportion of current daily smoking, (2.6%) in Ashanti and (3.1%) in Greater Accra. These regional differences are in conformity with findings in a 2012 analysis of the Ghana Demographic and Health Survey by Rijo and colleagues who found that tobacco use was significantly higher among those living in poverty stricken regions [
18]. These differences in tobacco use based on population sizes and level of development in different localities, are also similar to the study by Blazer and Wu. They found that, older adults residing in non-metropolitan areas had higher prevalence and those in large-metropolitan areas had the lowest prevalence [
17].
The increase prevalence of tobacco use with age poses major health challenges. Like cigarette smoking, smokeless tobacco use, cigar, and pipe smoking all contribute to addiction, cancers, heart disease, and respiratory conditions [
7,
8,
17‐
20]. Due to related changes in health status [
17,
21,
22], tobacco use affects older adults by exacerbating existing diseases, causing poorer physical functioning, prompting costly treatment use, and increasing mortality [
23,
24]. Cessation of tobacco use is critical for older adults because it reduces functional impairments and mortality associated with respiratory and cardiovascular diseases [
17,
24].
The prevalence of tobacco use among older adult Ghanaians is relatively low compared to many middle- and higher- income countries [
7‐
9]. However, the impact of tobacco use on older Ghanaians is sufficient to warrant national attention. These are mostly aged men residing in rural communities, with little or no education and in the lower income group for whom access to health care is a challenge. Low education, inadequate information, limited access to jobs or income and concomitant inadequate health screening, as well as age-related co-morbid conditions might be more prevalent in this identifiable older adult group.
Results from the logistic regression indicate that demographic, socioeconomic, chronic ill-health and life satisfaction indices have significant association with tobacco use in the older adults. Older males and older adults residing in rural locations had a higher association with tobacco use. The combined use of tobacco and alcohol in older adult pose significant health challenges [
3,
17,
19]. Importantly, SAGE can be used to further document impact and inform public health measures and also as a monitoring mechanism for the 2011 tobacco legislation [
11] with SAGE Ghana Wave 2 planned for 2013/14 and Wave 3 two years after this.
Associations were found between self-reported chronic diseases among older adults who use tobacco. Interestingly, older adults who use tobacco tended to be without health insurance and this is similar to findings from the 2008 Ghana Demographic and Health Survey [
9]. This observation is of major public health policy implications i.e. the older adults in Ghana who have increased risk for chronic health conditions as a result of tobacco use, tend not to be health insured. Add to this the reduced financial capacity in lower economic rungs of the population and poor coverage of social protection system (pension and health insurance), an active preventive health approach directed at older adults should be operationalized as part of Priority Direction II in the 2010 National Ageing Policy.
Self-reported satisfaction with life was much lower for the older adults who use tobacco. Dissatisfaction with activities of daily living or low social wellbeing has implications for the health of the individual and the social well being of dependants of these older adults.
The benefit of decreasing the risk for stroke for example among older adults appears particularly evident among non-heavy smokers [
25]. Unfortunately, research has suggested a low rate of smoking cessation among older adults [
26]. Interestingly, findings on older adults who have quit smoking revealed that the proportion of those who have quit smoking was higher in the 70+ age group, in women, among urban residents, those with at least secondary education and increased with income levels. In addition the more urbanized regions, Greater Accra, Ashanti and Western regions had higher proportions of older persons who have quit smoking compared to the least urbanized three northern regions. This may probably be due to increased exposure and awareness of harmful effects of tobacco in older adults living in these most urbanized regions of the country [
18,
27]. Also older persons may become more aware of the harmful effects of smoking, through life experiences by age, through formal education, and increased exposure to public education and media (in the urban areas). In our setting, other risk reduction measures such as improvement in access to health and social services might engender more health and social benefits when the most at risk population groups are targeted in national health risk reduction policies and programmes [
28].
The possibility that self-reported tobacco use data underreports the actual prevalence due to inhibitions in admitting to use is a limitation of this study, and may well result in higher estimates than obtained from the survey. Also the self-report of tobacco use as a health variable should be interpreted with caution due to potential measurement errors and also, the questions asked on the quantity or intensity of tobacco use depended on memory, therefore, there is the possibility of recall bias. In the survey however, the questions referred to very short time periods to minimize the potential recall bias [
12,
29].
Yawson AE, Mensah G, MinicuciN and Biritwum RB are members of the WHO Multi-country SAGE Team who conducted the SAGE Survey in Ghana. Naidoo N, Chatterji S and Kowal P are members of the WHO Multi-country SAGE Team and coordinators of the multi-country study at the WHO Headquarters in Geneva.
AN Baddoo, BNL Calys-Tagoe, and NA Hagan-Seneadza are Specialist Public Health Physicians, Dako-Gyeke P is a Social scientist and University lecturer. Hewlett S is a University lecturer and specialist Dental surgeon.
Acknowledgement
We are grateful to all respondents and interviewers who made the SAGE survey in Ghana possible. Financial support was provided by the US National Institute on Aging through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01) with the World Health Organization and a Research Project Grant (R01 AG034479- 64401A1). WHO contributed financial and human resources to SAGE. The Ministry of Health, Ghana, is supportive of SAGE.
The University of Ghana’s Department of Community Health contributed training facilities, data entry support, and storage of materials. The Ghana Statistical Office provided the sampling information for the sampling frame and updates.
Competing interests
The authors declare no competing interest. The views expressed in this paper are those of the authors. No official endorsement by the World Health Organization or Ministry of Health of Ghana/ Ghana Health Service is intended or should be inferred.
Authors' contributions
AEY, ANB and NAH-S developed the concept, AEY, GM, NM, NN N9, SC, PK and RBB are members of the WHO Multi-country SAGE Study Team involved in the conduct and analysis of the SAGE survey in Ghana. ANB, SH, BNLC-T, PD-G, NAH-S and AEY contributed to the writing and reviewing of the various sections of the manuscript. All the authors reviewed the final version of the manuscript before submission. All authors read and approved the final manuscript.