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Cigarette smoking and misperceived norms among adults in rural Uganda: a population-based study
  1. Jessica M Perkins1,2,
  2. Bernard Kakuhikire3,
  3. Charles Baguma3,
  4. Claire Q Evans1,
  5. Justin D Rasmussen4,
  6. Emily N Satinsky5,6,
  7. Viola Kyokunda3,
  8. Mercy Juliet3,
  9. Immaculate Ninsiima3,
  10. David R Bangsberg3,7,
  11. Alexander C Tsai3,5,8
  1. 1 Peabody College of Education and Human Development, Vanderbilt University, Nashville, Tennessee, USA
  2. 2 Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3 Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
  4. 4 Duke University, Durham, North Carolina, USA
  5. 5 Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
  6. 6 Department of Psychology, University of Southern California, Los Angeles, CA, USA
  7. 7 Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon, USA
  8. 8 Harvard Medical School, Boston, MA, USA
  1. Correspondence to Dr Jessica M Perkins, Vanderbilt University, Nashville, USA; jessica.m.perkins{at}


Background Little is known about perceived norms about cigarette smoking in Uganda or the extent to which perceptions drive personal cigarette smoking behaviour.

Methods We conducted a cross-sectional study in 2016–2018 that targeted all adults who resided within eight villages in Rwampara District, southwestern Uganda. Personal cigarette smoking frequency was elicited by self-report. We also asked participants what they believed to be the cigarette smoking frequency of most other adult men and women in their villages (i.e., perceived norms). Frequent cigarette smoking was defined as 4+ times/week. We compared perceived norms to cigarette smoking frequency reports aggregated at the village level. We used multivariable Poisson regression to estimate the association between perceived norms and personal cigarette smoking behaviour.

Results Among 1626 participants (91% response rate), 92 of 719 men (13%) and 6 of 907 women (0.7%) reported frequent smoking. However, 1030 (63%) incorrectly believed most men in their villages smoked cigarettes frequently. Additionally, 116 (7%) incorrectly believed that most women in their villages smoked cigarettes frequently. These misperceptions were pervasive across social strata. Men who misperceived frequent cigarette smoking as the norm among other men in their villages were more likely to smoke frequently themselves (adjusted relative risk=1.49; 95% CI, 1.13 to 1.97).

Conclusions Most adults overestimated cigarette smoking frequency among village peers. Men who incorrectly believed that frequent smoking was the norm were more likely to engage in frequent smoking themselves. Applying a ‘social norms approach’ intervention by promoting existing healthy norms may prevent smoking initiation or motivate reductions in smoking among men in rural Uganda.

  • low/middle income country
  • global health
  • prevention
  • social marketing
  • denormalisation

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  • Contributors JP conceived and designed the study. BK, VK, MJ and IN participated in the data collection. JP wrote the first draft. JP, BK, CB, CQE, JDR, ENS, VK, MJ, IN, DRB and ACT participated in interpretation of the data and provided critical revisions. ACT provided study oversight. All authors read and approved the final manuscript.

  • Funding This study was funded by Friends of a Healthy Uganda and US National Institutes of Health (NIH) R01MH113494. JP acknowledges salary support from NIH K01MH115811.

  • Competing interests Dr. Tsai receives a financial stipend from Elsevier, Inc. for his work as Co-Editor in Chief of the journal SSM-Mental Health. All other co-authors declare no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.