Tobacco use in sub-Sahara Africa: Estimates from the demographic health surveys☆
Introduction
As use of cigarette and other tobacco products declines in high-income countries, increasing attention has turned to the growth of cigarette use in middle- and low-income countries (Jha and Chaloupka, 2000, World Bank, 1999). From 1970 to 2000, per capita cigarette consumption fell by 14% in developed countries and rose by 46% in developing counties (Guindon & Boisclair, 2003). The increase occurred primarily among men but, given marketing efforts of tobacco companies, use by women appears primed to move upward (Ernster et al., 2000, Mackay, 1998). Largely because of the growth in low- and middle-income nations, the number of smokers worldwide has now risen to 1.3 billion and may well reach 1.5 billion by 2025 (Mackay, Eriksen, & Shafey, 2006: 72).
Globalization of tobacco use represents a major threat to worldwide public health (Mackay, 1998, Yach and Bettcher, 2000). With premature smoking-related deaths currently numbering about 5 million per year worldwide (about 1 in 10 adult deaths), they may plausibly number 10 million (about 1 in 6 adult deaths) by 2020 (WHO, 2007a), of which 70% will occur in middle- and low-income nations (Warner, 2005). These changes will exacerbate worldwide health disparities and the divide between nations of the first and third worlds (Yach, 2005). On another level, the spread of tobacco use across large parts of the globe counters some success in high-income nations to combat cigarette use and restrict the power of the tobacco industry. The experience gained over recent decades by the tobacco industry in global marketing and the development of new markets has contributed to the worldwide expansion of tobacco consumption (Warner, 2000). In response, global public health efforts aim to provide consistent anti-smoking policies across the world (Satcher, 2001, Sugarman, 2001). One promising strategy, the creation of an international treaty, has moved forward with the WHO Framework Convention on Tobacco Control (WHO, 2005).
Other strategies to combat the globalization of tobacco include the goal of better describing the extent and social distribution of the problem (Corrao et al., 2000, Jha et al., 2002, World Bank, 1999). Surveillance of smoking prevalence can aid in developing locally grounded actions for tobacco control (Lando et al., 2005, World Health Organization, 1997). Thus, regional groups of researchers, policymakers, and anti-tobacco advocates have identified the lack of standardized and comparable data as a problem and called for regional surveillance of tobacco use by sex, age, and risk group (Baris et al., 2000). Improving the global knowledge base, an important first step in identifying targets for change, can come from better measures of the prevalence of tobacco use across developing nations and of the social groups within nations most at risk for tobacco use.
Such needs may be particularly important in sub-Sahara Africa (Sasco, 1994). Valuable efforts to compile information on tobacco use across the world offer much insight on global patterns (Guindon & Boisclair, 2003; Mackay et al., 2006, Shafey et al., 2003, World Health Organization, 1997). However, African nations, often among the world's poorest, have less complete and likely less accurate statistics than other regions of the world. Figures reported on cigarette use in the African region by the WHO (1997) for circa 1990 cover 33% of the population, and more recent data cover 68.3% of the African region population (Guindon & Boisclair, 2003). More problematic, the comparability of the figures is suspect. Reported prevalence figures for African nations (Mackay et al., 2006, Shafey et al., 2003) sometimes refer to any tobacco smoking, sometimes to cigarette smoking, and sometimes to regular or daily cigarette smoking. Moreover, the figures sometimes use non-representative samples such as hospital inpatients (Rwanda) or residents of major cities and suburbs (Tanzania). Figures on cigarettes consumed are better standardized (Guindon & Boisclair, 2003) but do not distinguish users by gender, residence, and SES. More comparable figures on tobacco use for even a small subset of sub-Sahara African nations would improve on what is now available.
Sub-Sahara Africa appears to differ from other regions of the world in having reached only the early stages of the cigarette epidemic. Estimates suggest that deaths from smoking-attributed causes reach only 5–7% for men and 1–2% for women (Ezzati & Lopez, 2004). By comparison, smoking deaths reach at least 15% for males in developing regions of the Americas, the Eastern Mediterranean, the Western Pacific, and Southeast Asia. The smoking deaths for females in other developing parts of the world seldom exceed 5% but still double or triple the percentage in Africa. The relatively low prevalence of smoking and high rates of deaths from AIDS, starvation, and violence that more immediately threaten the health of citizens in Africa (Zuberi, Sibanda, Bawah, & Noumbissi, 2003) may suggest that the consequences of cigarette use are not serious. Yet this could change quickly. Combined with weak government restrictions on tobacco use or sales, intensified advertising and promotions directed at young people in Africa (e.g., the “Taste the Adventure” campaign) has produced a fast rate of growth from the small base (Oluwafemi, 2003). Better knowledge about tobacco use at the early stages of the epidemic can help public health officials intervene before the problem peaks. Widespread tobacco use otherwise may block future improvements in longevity (Yach, McIntyre, & Saloojee, 1992).
Studies of smoking by socioeconomic status (SES) in developing nations have found that cigarette use is highest among urban men and women who are less educated and economically disadvantaged (Blakely et al., 2005, Bobak et al., 2000, Mackay and Mensah, 2004: 89–90; Pampel, 2005). In high-income nations, cigarette use began among high SES males, spread to females and lower SES males, abated among high SES males and females (Lopez, Collishaw, & Piha, 1994), and is now concentrated among low SES groups (Barbeau, Krieger, & Soobader, 2004). However, the adoption of cigarettes in low- and middle-income nations has emerged in a world context that has changed substantially. Diffusion across the world of scientific knowledge about the harm of smoking may lead high SES persons in low-income nations, particularly those with high education, to avoid tobacco. Tobacco companies are also more knowledgeable and sophisticated in their sales practices. Perhaps recognizing that low SES groups comprise their largest and most viable markets, transnational tobacco companies may target their ad campaigns to appeal to potential new smokers with lower income. Examining SES-based patterns in African nations with low national income and low tobacco usage can help in understanding the nature of cigarette diffusion today.
This study aims to describe the prevalence and distribution of tobacco use among men and women in 14 sub-Sahara African nations between 2000 and 2006. The data come from 16 Demographic Health Surveys (DHS), which use the same questions and cover representative samples of the nation's adult population. The DHS have been used to study tobacco use once before but only for two nations; Pampel (2005) found higher use of cigarettes by males than females, urban than rural residents, and low educated than high educated groups in Malawi and Zambia. An analysis of available data for other nations can provide new and more extensive information on this understudied region and, given the representative samples and comparable measures of tobacco from the DHS, improve on prevalence figures currently available for many African nations.
Section snippets
Data
The DHS aim to provide reliable and nationally representative data on fertility, family planning, health, and nutrition of populations in developing nations (Measure DHS, 2007). Since the mid-1980s, hundreds of surveys have been conducted in 79 countries across the world. The most recent surveys have been carried out by national statistical offices with funding from the U.S. Agency for International Development and with financial and technical assistance from ORC Macro of Calverton, Maryland,
Tobacco smoking prevalence
Table 1 presents the percent smokers of cigarettes and other tobacco (and confidence intervals) among all men and the number of cigarettes smoked in the last day (and confidence intervals) among male cigarette smokers. Nations are ordered from low to high cigarette prevalence. The two west central African nations of Nigeria and Ghana have low cigarette smoking of 8.0 and 8.8%, respectively, as does the eastern nation of Ethiopia (8.3%). The southern African nations of Mozambique (14.1%),
Discussion
Although based on only 14 sub-Sahara African nations (from a universe of more than 40), the results from the Demographic Health Surveys, nonetheless, reveal new and more accurate information on regional and social patterns of tobacco smoking. For cigarette prevalence among men, the range of national values from 8.0 to 27.3% demonstrates considerable diversity. Two west central African nations, Nigeria and Ghana, and one eastern nation, Ethiopia, have the lowest smoking. The southern African
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This research was supported by grant SES-0323896 from the National Science Foundation.