A Systematic Review of Tobacco Smoking Prevalence and Description of Tobacco Control Strategies in Sub-Saharan African Countries; 2007 to 2014

The association between smoking and cervical human papillomavirus infection among women from indigenous communities in western Botswana

INTRODUCTION

Cervical cancer, a malignancy caused by infection with oncogenic human papillomavirus, disproportionally affects women from low resource settings. Persistence of human papillomavirus infection may mediate an association between tobacco use and cervical cancer. In limited resource settings, women from indigenous communities are often marginalized and do not benefit from evidence-based interventions to prevent tobacco use or cervical cancer due to the limited reach of mainstream healthcare services to these communities. This study determined the association between smoking and high-risk human papillomavirus infection among women from indigenous communities in western Botswana.

METHODS

A cross-sectional study of women in indigenous communities was conducted between June and October 2022. Demographic, clinical and self-reported smoking data were collected. Cervical cytology and HPV DNA testing for high-risk human papillomavirus genotypes were performed. Multilevel multivariable logistic regression models were fit to evaluate the association between smoking and high-risk human papillomavirus infection while adjusting for potential confounders.

RESULTS

A total of 171 participants with a median (interquartile range) age of 40 (31-50) years from three settlements and two villages were recruited for the study. Of these, 17% were current smokers, 32.8% were living with HIV and high-risk human papillomavirus DNA was detected in 32.8% of the cervical specimens. Women who were current smokers, were nearly twice as likely to have cervical high-risk human papillomavirus infection compared to non-smokers (Adjusted Odds Ratio (95% CI); 1.74(1.09, 2.79)) after controlling for confounders.

CONCLUSION

These data underscore the need for effective tobacco control to help mitigate cervical cancer risk in this setting. These findings can help inform decisions about targeted cervical cancer prevention and tobacco cessation interventions for women from indigenous communities.

Exposure to pro-tobacco and anti-tobacco media messages and events and smoking behaviour among adolescents in Gambia

BACKGROUND

Despite the widespread prevalence of adolescent smoking in Gambia, a West African country, there is limited research exploring the relationships between exposure to pro-tobacco and anti-tobacco media messages and events and smoking behaviour among young people. This study investigates the interplay of these exposures and smoking behaviour among 11-17-year-old adolescents in Gambia.

METHODS

Secondary data analysis was conducted using the 2017 Gambia Global Youth and Tobacco Survey (GYTS), which included a total of 9,127 respondents. Descriptive and inferential analyses, including proportions, Pearson's chi-squared tests, and multivariable logistic regression models, were employed to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

The final model revealed significant associations between exposure to anti-tobacco media messages and events and smoking behaviour. Adolescents exposed to anti-tobacco media messages had a 29% increased odds of smoking (aOR 1.29,CI = 1.08,1.53) compared to those unexposed, while exposure to anti-tobacco media events showed a 31% increased odds (aOR 1.31,CI = 1.09,1.59) compared to those unexposed. Exposure to pro-tobacco messages, such as witnessing tobacco use on TV (aOR 1.41, CI = 1.17,1.69) and owning objects with tobacco brand logos (aOR 1.49,CI = 1.19,1.86), was associated with higher odds of smoking. Covariates, including sex, age, and exposure to smoking behaviour by significant others, also demonstrated associations with smoking behaviour. Notably, male respondents showed significantly higher odds of smoking (aOR = 4.01,CI = 3.28,4.89) compared to females. Respondents aged 15 years and older had increased odds of smoking (aOR = 1.47,CI = 1.22,1.76) compared to those below 15 years old. Those whose fathers smoke displayed higher odds of smoking (aOR = 1.35, CI = 1.04,1.76) compared to individuals with non-smoking parents. Additionally, those whose closest friends smoke showed remarkably higher odds of smoking (aOR = 2.87,CI = 2.37, 3.48) compared to those without such influence.

CONCLUSION

This study underscores the significant impact of exposure to both anti-tobacco and pro-tobacco media messages and events on smoking behaviour among adolescents in Gambia. However, pro-tobacco messages had a greater influence on smoking prevalence than anti-tobacco messages and events. Understanding these associations is crucial for devising effective public health interventions aimed at reducing tobacco use in this population.

The global, regional, and national burden of stomach cancer attributed to smoking in 204 countries, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019

INTRODUCTION

Understanding the current burden of stomach cancer linked to smoking and the variations in trends across different locations, is crucial for developing effective prevention strategies. In this study, we present findings on the age-standardized death rate (ASDR) and age-standardized disability-adjusted life years (DALYs) rate attributed to smoking in 204 countries and territories spanning 21 regions from 1990 to 2019.

METHODS

The data for this study were obtained from the Global Burden of Disease Study (GBD) 2019, which assessed 369 diseases and injuries, as well as 87 risk factors in 204 countries and 21 regions. To assess the trend in ASDR and age-standardized DALYs rate, the estimated annual percentage change (EAPC) was utilized.

RESULTS

Between 1990 and 2019, smoking was found to be associated with a decrease in ASDR (EAPC = -2.20) and age-standardized DALYs (EAPC = -2.42) rates for gastric cancer. As the sociodemographic index (SDI) increased, the decline in rates also increased gradually. However, the decline was smallest in regions with low SDI (EAPCASDR = -1.34; EAPCage-standardized DALYs rate = -1.38). In 21 regions, both ASDR and DALYs rates experienced a decline. The smallest decline in ASDR was observed in Western Sub-Saharan Africa, with an EAPC of -0.80, while the smallest decline in DALYs rate was found in Oceania, with an EAPC of -0.81. Among the 204 countries analyzed, the Dominican Republic showed the highest increase in ASDR and age-standardized DALYs rate (EAPCASDR = 1.19; EAPCage-standardized DALYs rate = 1.21), followed by Afghanistan (EAPCASDR = 1.09; EAPCage-standardized DALYs rate = 1.09) and Sao Tome and Principe (EAPCASDR = 1.05; EAPCage-standardized DALYs rate = 1.03). In the year 2019, the highest ASDR and age-standardized DALYs rate was observed in East Asia, with the highest rates occurring in Mongolia.

CONCLUSIONS

The burden of stomach cancer worldwide, adjusted for age, and related to smoking, has shown a decline from 1990 to 2019. However, regional disparities have been identified, with some areas experiencing an increase in this burden. These regions with a higher burden emphasize the necessity for the implementation of strong tobacco control measures.

Gender differences in use of cigarette and non-cigarette tobacco products among adolescents aged 13-15 years in 20 African countries

INTRODUCTION

Examining gender differences in youth tobacco use is important as it aligns tobacco control within the context of broader human development goals seeking to eliminate gender inequalities. In this study, we examined gender differences in adolescent use of cigarettes, smokeless tobacco, shisha, and e-cigarettes in Africa.

METHODS

This was a cross-sectional study using data from the Global Youth Tobacco Survey. Our analytical sample comprised 56442 adolescents aged 13-15 years from 20 African countries. Weighted, country-specific prevalence estimates were computed overall and by gender. Adjusted prevalence ratios (APRs) were calculated in a multivariable Poisson regression model to examine whether correlates of tobacco use differed between boys and girls.

RESULTS

Ever cigarette smoking prevalence was significantly higher among boys than girls in 16 of the 20 countries, but a significantly higher percentage of girls reported earlier age of cigarette smoking initiation than boys within pooled analysis. Some of the largest gender differences in current cigarette smoking were seen in Algeria (12.2% vs 0.8%, boys and girls, respectively), Mauritius (21.2% vs 6.6%), and Madagascar (15.0% vs 4.1%). Current use of e-cigarettes, shisha, and smokeless tobacco was generally comparable between boys and girls where data existed. Among girls, higher levels of reported exposure to tobacco advertisement were positively associated with shisha smoking whereas perceived tobacco harm was inversely associated with current cigarette and shisha smoking. Among boys, perceived social acceptability of smoking at parties was associated with an increased likelihood of cigarette smoking (APR=2.27; 95% Cl: 1.20-4.30).

CONCLUSIONS

The prevalence of cigarette smoking among boys was higher than that of girls in many countries. However, girls who smoke tend to start at an earlier age than boys. Differential gender patterns of cigarette and non-cigarette tobacco product use among youth may have implications for future disease burden. As the tobacco control landscape evolves, tobacco prevention efforts should focus on all tobacco products, not just cigarettes.

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

The association between body weight indices, behavioral factors, and type 2 diabetes mellitus in Africa: A systematic review and meta-analysis of population-based epidemiological studies

BACKGROUND AND AIM

Type 2 diabetes mellitus (T2DM) is a significant public health concern in Africa. While the associations between modifiable risk factors and T2DM are likely to be Africa-specific, their overall estimations have not been published. This study aimed to use systematic and meta-analytic methods to examine the strength of associations between modifiable risk factors and T2DM in Africa.

METHODS AND RESULTS

A systematic search of literature published between January 2000 to March 2022 was conducted. The review included only population-based studies and data extracted from 57 studies. Of these, unadjusted data from 50 studies were included in meta-analysis. With considerable heterogeneity between studies, random-effect models were calculated to ascertain the odds ratios (OR) and 95% confidence intervals (CI) for the associations between obesity (OB) and overweight (OV), defined by BMI; central obesity (waist circumference (OB-WC), waist-to-hip-ratio (OB-WHR)), alcohol, fruit and vegetable consumption, smoking, physical activity (PA) and T2DM. Moderator effects of age, African regions, and urban/rural location were assessed. Risk factors associated with T2DM include BMI-OB [OR = 3.05, 95% CI: (2.58, 3.61)], BMI-OV [OR = 2.38, 95% CI: (1.51, 3.75)], and BMI-OV/OB [OR = 2.07, 95% CI: (1.82, 2.34)]; OB-WC [OR = 2.58, 95% CI: (2.09, 3.18)] and OB-WHR [OR = 2.22, 95% CI: (1.69, 2.92)]; PA [OR = 1.85, 95% CI: (1.50, 2.30)]. Significant moderator effects were not observed.

CONCLUSION

Obesity defined by BMI and central obesity, but not behavioral risk factors were most strongly associated with T2DM in African populations, emphasizing the need for obesity prevention to limit the rise of T2DM.

REGISTRATION

The PROSPERO registration number is CRD42016043027.

Association between urban-rural location and prevalence of type 2 diabetes and impaired fasting glucose in West Africa: a cross-sectional population-based epidemiological study

OBJECTIVES

We investigated the association between urban/rural location and both type 2 diabetes mellitus (T2DM) and pre-diabetes among populations of five West African countries.

DESIGN

Cross-sectional studies, using the WHO Stepwise (STEPs) survey data.

SETTING

National representative data of both urban and rural areas from Benin, Burkina Faso, Ghana, Liberia and Mali.

PARTICIPANTS

Adults comprising 15 468 participants (6774 men and 8746 women; 7663 urban and 7805 rural residents) aged between 25 and 64 years.

RESULTS

The age and sex-adjusted prevalence of T2DM was 6.2% for urban areas and 2.5% for rural areas. The prevalence of impaired fasting glucose (IFG) was 6.6% for urban areas, and 3.0% for rural areas. No differences by sex were observed. The crude relative risk (RR) and 95% CI of T2DM and IFG in urban compared with rural areas were 2.69 (1.85 to 3.91) and 2.37 (1.53 to 3.66), respectively. This reduced to RR: 2.03, 95% CI (1.34 to 3.08) and RR: 2.04, 95% CI (1.27 to 3.28), respectively, after adjusting for covariables.

CONCLUSION

The prevalence of both T2DM and IFG was more than two times as high in urban areas compared with rural areas in West Africa. Behavioural risk factors are common among urban populations, with ongoing urbanisation expected to drive increases in the prevalence of T2DM. These results could guide planning for T2DM screening, preventive strategies and resource allocation in West Africa.

Tobacco control research on the African continent: a 22-year literature review and network analysis

OBJECTIVE

Describe the landscape of tobacco-related topics, funders and institutional networks in Africa.

DATA SOURCES

We searched PubMed, Embase and African Index Medicus for published articles from January 1996 to August 2018 in any language.

STUDY SELECTION

Two researchers independently reviewed titles and abstracts for a focus on nicotine or tobacco product(s) and describe data or recommendations specific to Africa. Ultimately, 818 articles were identified.

DATA EXTRACTION

Three independent coders conducted qualitative analyses of articles and extracted funders, study populations, countries of research focus, research topics, tobacco products, study design and data source. A bibliometric analysis estimated coauthorship networks between the countries of authors' primary institutional affiliation.

DATA SYNTHESIS

All 54 African countries were represented in two or more articles. The coauthorship network included 2714 unique authors representing 90 countries. Most articles employed a cross-sectional study design with primary data collection, focused on cigarettes and studied use behaviour. Few articles examined tobacco farming or interventions for cessation or prevention. The most frequently cited funder was the US National Institutes of Health (27.2%). A range of coauthorship patterns existed between African institutions with some coauthoring with one institution while others coauthored with 761 institutions in other African countries.

CONCLUSIONS

The literature review identified the need for implementation research for tobacco control interventions and policies, economic and development impacts of tobacco use research, and tobacco industry and tobacco production and farming research. Numbers of research collaborations between institutions in Africa vary, suggesting the need for regional institutional capacity building.

COPD in Africa: risk factors, hospitalisation, readmission and associated outcomes-a systematic review and meta-analysis

BACKGROUND

This review aims to synthesise available evidence on the prevalence of chronic obstructive pulmonary disease (COPD), associated risk factors, hospitalisations and COPD readmissions in Africa.

METHOD

Using the Met-Analyses and Systematic Reviews of Observational Studies guideline, electronic databases were searched from inception to 1 October 2021. The quality of studies was assessed using the Newcastle-Ottawa Scale. Evidence from retrieved articles was synthesised, and a random-effect model meta-analysis was conducted. The protocol was registered on PROSPERO.

RESULTS

Thirty-nine studies met the inclusion criteria, with 13 included in the meta-analysis. The prevalence of COPD varied between the Global Initiative for Chronic Obstructive Lung Disease (2%-24%), American Thoracic Society/European Respiratory Society (1%-17%) and Medical Research Council chronic bronchitis (2%-11%) criteria, respectively. Increasing age, wheezing and asthma were consistent risk factors for COPD from studies included in the narrative synthesis. Our meta-analysis indicated that prior tuberculosis ((OR 5.98, 95% CI 4.18 to 8.56), smoking (OR 2.80, 95% CI: 2.19 to 3.59) and use of biomass fuel (OR 1.52, 95% CI: 1.39 to 1.67)) were significant risk factors for COPD. Long-term oxygen therapy (HR 4.97, 95% CI (1.04 to 23.74)) and frequent hospitalisation (≥3 per year) (HR 11.48, 95% CI (1.31 to 100.79)) were risk factors associated with 30-day COPD readmission.

CONCLUSION

This study not only highlights specific risk factors for COPD risk in Africa but also demonstrates the paucity and absence of research in several countries in a continent with substantial COPD-related mortality. Our findings contribute towards the development of evidence-based clinical guidelines for COPD in Africa.PROSPERO registration numberCRD42020210581.

Prevalence and correlates of tobacco use in Botswana: evidence from the 2014 Botswana STEPwise survey

BACKGROUND

Tobacco use is one of the notable risk factors for non-communicable diseases globally. The objective of this study was to assess the prevalence of tobacco use and identify its correlates in the general population of Botswana aged 15 to 69 years.

METHODS

This study used a nationally representative WHO STEPwise Approach to Non-Communicable Disease Risk Factor Surveillance (STEPS) risk factors conducted in 2014 to explore the prevalence of tobacco use and its correlates in Botswana. Using IBM SPSS version 27, data on 4062 people aged 15 to 69 years who had been selected using multistage cluster sampling and had successfully completed the individual questionnaire were analysed. The prevalence of current tobacco smoking and smokeless tobacco use was determined using descriptive statistics while multivariable logistic regression was employed to assess correlates of current tobacco smoking and smokeless tobacco use. All comparisons were statistically significant at 5% significance level.

RESULTS

From a total sample of 4062 participants the prevalence of current tobacco smoking was estimated to be 12.9% while smokeless tobacco use was 3.2%. Adjusted results indicate that the odds of current tobacco smoking were eight times (AOR = 8.57, C.I = 6.28-11.7) higher among males compared to their female counterparts; six(AOR = 6.52, C.I 3.64-11.6) and three (AOR = 3.27, C.I. =2.07-5.15) times higher among respondents with no education and primary level education respectively, compared to their counterparts with tertiary or higher education; while for alcohol users the odds of current tobacco smoking were four times (AOR = 4.28, C.I = 2.93-6.24) higher than among non-alcohol users. The odds of smokeless tobacco use were significantly higher among women compared to men (AOR = 7.34, C.I = 4.01-13.4); individuals aged 50-59 (AOR = 1.15, C.I = 1.06-3.37) and 60-69 years (AOR = 1.23, C.I. =1.08-3.63) compared to 15-29 years; individuals with no education (AOR = 2.07, C.I = 1.03-4.02) and primary education (AOR = 1.05, C.I = 1.01-2.23) compared to individuals with tertiary education. However, the odds of smokeless tobacco use were significantly lower among individuals who consume alcohol (AOR = 0.48, C.I. = 0.29-0.80) compared to non-alcohol consumers.

CONCLUSION

Findings of this study indicate the need to strengthen existing national policies to reduce harmful use of tobacco among men, women, older adults, no or primary education level individuals and alcohol users.

Prevalence of tobacco smoking between 2009 and 2015 among students and the general population in the Kingdom of Saudi Arabia

INTRODUCTION

Tobacco smoking is a major risk factor for morbidity and mortality. Studies on smoking in the Kingdom of Saudi Arabia (KSA) have shown inconsistent results. The purpose of this study was to provide a literature review on the prevalence of tobacco smoking among school students, university students, and the general population of KSA during 2009-2015, before the implementation of new tobacco control measures.

METHODS

We searched PubMed and Google for articles published in English from 2009 to 2015, focused on overall tobacco smoking and/or any form of tobacco smoking (e.g. tobacco, cigarette, and waterpipe) and conducted with a sample of ≥300 participants. Only the prevalence of current smoking was assessed. A narrative synthesis of the prevalence results was conducted.

RESULTS

Of the 360 studies found in the primary search, 91 were selected for further examination for eligibility, and 20 studies were included in the review. Among school students, the prevalence of smoking any form of tobacco (cigarettes, waterpipes, or both) ranged 10.0-21.7%. The prevalence of cigarette smoking ranged 8.9-19.5% and for waterpipe smoking it was 9.5%. Among university students, the prevalence of smoking any form of tobacco ranged 11.1-25.3%, cigarette smoking 7.8-17.5%, and waterpipe 4.3-18.0%. In the general population, the prevalence of cigarette smoking ranged 19.6-23.5% and for waterpipe smoking it was 4.3%.

CONCLUSIONS

Our study shows smoking levels were high in the KSA between 2009 and 2015. Studies utilizing standardized methodology with nationally representative samples are needed to better characterize the prevalence of different types of tobacco smoking. More research on national representative samples is needed, including studies on the same populations/groups/areas over time using standardized tools and definitions.

Cigarette smoking is associated with an increase in blood monocytes in people with tuberculosis: A cross-sectional study

The effect of smoking on immune responses in people with tuberculosis (TB) is not well elucidated. We aimed to compare peripheral blood counts of CD4+ and CD87 + T-lymphocytes, monocytes, and neutrophils and the CD4:CD8 ratio in TB patients with and without history of cigarette smoking. We further determined factors associated with current smoking. Participants with TB were consecutively enrolled in a cross-sectional study at a national TB treatment center in Uganda in 2018. We compared cell counts and the CD4:CD8 ratio using the median test among never smokers, past smokers (>6 months ago) and current smokers (≤6 months). Factors associated with current smoking were determined using logistic regression. A post hoc analysis for factors associated with an increase in the monocytes was also performed. Of 363 participants, there were 258 (71.1%) never smokers, 50 (13.8%) past smokers, and 55 (15.2%) current smokers. Most current smokers (49.1%) had a high sputum mycobacterial load. They also had the lowest body mass index and the highest axillary temperature. The median (interquartile range [IQR]) monocyte count among current smokers was 815 (540-1425) cells/mm3 and was significantly higher than that among past smokers (610 (350-900) cells/mm3, P = .017) and never smokers (560 [400-800] cells/mm3, P = .001). The monocyte counts positively correlated with the number of cigarettes smoked per day among current smokers (R = 0.43, P = .006). Current smokers also had higher neutrophil and CD4+ T-cell counts than never smokers. In a multivariable logistic regression model, an increase in the monocyte count was associated with current cigarette smoking (adjusted odds ratio [aOR] = 4.82, 95% confidence interval 1.61-14.39, P = .005). Similarly, current cigarette smoking was independently associated with an increase in the monocyte count (aOR = 1.80, 95% CI 1.39-2.32, P < .001). Cigarette smoking is associated with an increase in the blood monocytes in people with TB in a dose- and time-dependent manner. Further, current smoking is associated with an increase in neutrophils and CD4+ T-lymphocytes. The findings suggest that current smokers have systemic inflammation that is not necessarily beneficial to TB control in TB patients.

Effect of heavy cigarette and water pipe smoking on antioxidants and lipids in Sudanese male smokers: a case-control study

Background

Tobacco smoking is a source of many toxins such as free radicals, mutagenic substances as well as cause for developing cardiovascular diseases (CVD), particularly atherosclerosis. This study aims to assess the impact of smoking on antioxidants in Sudanese male smokers.

Methods

Cases were 85 and 48 men who smoke cigarettes (CS) and water pipe (WPS) respectively and they were compared with matching 50 non-smoking controls. Blood samples were collected and following parameters: Glutathione peroxidase, Superoxide dismutase, Total cholesterol, Triglyceride, LDL, HDL, Paraoxinase, and Malondialdehyde were measured.

Results

There were no significant differences in biochemical parameters between light CS and WPS compared to controls. In heavy smokers of both WPS and CS, the TC, TG, LDL, and MDA were higher than controls (p>0.05), GPx, SOD, HDL, and PON were lower in smokers than controls (p>0.05). In both groups of smokers; HDL, GPx, SOD, and PON were inversely correlated with duration of smoking (p>0.05), also, HDL was positively correlated with SOD and GPx (p>0.05). Moreover, GPx and SOD were correlated with each other in both groups of smokers (p>0.05).

Conclusion

In Sudanese male smokers' biochemical profile disturbances suggest that heavy smoking was leading to developing CVD, particularly WPS.

Global, regional, and national burden of cancers attributable to tobacco smoking in 204 countries and territories, 1990-2019

BACKGROUND

Cancers are leading causes of mortality and morbidity, with smoking being recognized as a significant risk factor for many types of cancer. We aimed to report the cancer burden attributable to tobacco smoking by sex, age, socio-demographic index (SDI), and cancer type in 204 countries and territories from 1990 to 2019.

METHODS

The burden of cancers attributable to smoking was reported between 1990 and 2019, based upon the Comparative Risk Assessment approach used in the Global Burden of Disease (GBD) study 2019.

RESULTS

Globally, in 2019 there were an estimated 2.5 million cancer-related deaths (95% UI: 2.3 to 2.7) and 56.4 million DALYs (51.3 to 61.7) attributable to smoking. The global age-standardized death and DALY rates of cancers attributable to smoking per 100,000 decreased by 23.0% (-29.5 to -15.8) and 28.6% (-35.1 to -21.5), respectively, over the period 1990-2019. Central Europe (50.4 [44.4 to 57.6]) and Western Sub-Saharan Africa (6.7 [5.7 to 8.0]) had the highest and lowest age-standardized death rates, respectively, for cancers attributable to smoking. In 2019, the age-standardized DALY rate of cancers attributable to smoking was highest in Greenland (2224.0 [1804.5 to 2678.8]) and lowest in Ethiopia (72.2 [51.2 to 98.0]). Also in 2019, the global number of DALYs was highest in the 65-69 age group and there was a positive association between SDI and the age-standardized DALY rate.

CONCLUSIONS

The results of this study clearly illustrate that renewed efforts are required to increase utilization of evidence-based smoking cessation support in order to reduce the burden of smoking-related diseases.

Prevalence of and factors associated with tobacco smoking in the Gambia: a national cross-sectional study

OBJECTIVES

To examine the prevalence of and risk factors associated with tobacco smoking in the Gambia.

DESIGN

A nationwide cross-sectional study.

SETTING

The Gambia.

PARTICIPANTS

The study participants were both women and men aged between 15 and 49 years old. We included 16,066 men and women in our final analysis.

DATA ANALYSIS

We analysed data from the Gambia Demographic and Health Survey (DHS), 2019-2020. DHS collected nationally stratified data from local government areas and rural-urban areas. The outcome variable was the prevalence of tobacco smoking. Descriptive analysis, prevalence and logistic regression methods were used to analyse data to identify the potential determinants of tobacco smoking.

RESULTS

The response rate was 93%. The prevalence of current tobacco smoking was 9.92% in the Gambia in 2019-2020, of which, 81% of the consumers smoked tobacco daily. Men (19.3%) smoked tobacco much higher than women (0.65%) (p<0.001). People aged 40-49 years, with lower education, and manual workers were the most prevalent group of smoking in the Gambia (p<0.001).Men were 33 times more likely to smoke tobacco than women. The chance of consuming smoked tobacco increased with the increase of age (adjusted OR (AOR) 9.08, 95% CI 5.08 to 16.22 among adults aged 40-49 years, p<0.001). The strength of association was the highest among primary educated individuals (AOR 5.35, 95% CI 3.35 to 8.54).Manual workers (AOR 2.73) and people from the poorest households (AOR 1.86) were the risk groups for smoking. However, place of residency and region were insignificantly associated with smoking in the Gambia.

CONCLUSIONS

Men, older people, manual workers, individuals with lower education and lower wealth status were the vulnerable groups to tobacco smoking in the Gambia. Government should intensify awareness programmes on the harmful effects of smoking, and introduce proper cessation support services among tobacco smoking users prioritising these risk groups.

A cross-sectional investigation of softening indicators among South African smokers: Results from the South African Social Attitudes Survey between 2007 and 2018

Recent studies have shown softening among smokers in different countries and in different population groups i.e., as smoking prevalence declined remaining smokers made more quit attempts and smoked fewer cigarettes per day (CPD), as opposed to hardening. We examined tobacco use-related cross-sectional data from five waves of the South African Social Attitudes Survey (SASAS 2007-2018, N = 14,822). Accounting for the SASAS's complex survey design, we ran logistic and linear regressions for smoking prevalence, and for the following indicators of softening: plans to quit smoking within a month, time to first cigarette (5 min, TTFC) and cigarettes smoked per day (CPD). We controlled for survey wave, age, sex, race, marital status, educational level and urban/rural residence. Smoking prevalence remained stable from 2007 (20.7%) to 2018 (22.2%) in the overall population of smokers (p = 0.197), and within sex and race group of smokers. In the adjusted model, there was a significant decline in CPD over time, 0.12 cigarettes per year. There was also a significant decrease in TTFC among males over time. Among women, CPD declined significantly by 0.32 cigarettes per year. The proportion of Asians/Indians planning to quit also decreased over time. South African smokers do not consistently show significant change in the softening indicators overall. Stronger tobacco control policies and better-tailored smoking cessation interventions are needed to achieve a significant decrease in smoking prevalence across sex and other subpopulations in South Africa.

[Individual and contextual factors associated with smoking among young Brazilian adults]

Young people receive special attention regarding smoking as it is a period of life in which the use of this and other substances generally starts and is consolidated. There are no studies on risk factors associated with young adults with a representative sample from Brazil that take into consideration individual and contextual aspects. The objective was to identify factors associated with smoking among young Brazilian adults aged 18 to 24 years, considering the combined influence of individual and contextual factors assessed through the Municipal Human Development Index (MHDI). It involved a cross-sectional, population-based study that used data from the 2019 National Health Survey. Using the Poisson multilevel model with robust variance for estimating the Prevalence Ratio, individual variables were analyzed, and the MHDI as a contextual variable in each Federative Unit. In addition to individual factors, the MHDI was also associated with smoking among young people, with an increase in the prevalence of tobacco consumption among young people as the state's MHDI increases (p<0.001), indicating that living in a state with better conditions according to the MHDI, socioeconomic status is associated with a higher probability of young people smoking when compared to those residing in other states.

Prevalence of cannabis use among tobacco smokers: a systematic review protocol

INTRODUCTION

Understanding the prevalence of cannabis use among tobacco smokers has important implications for research in terms of intervention effectiveness and measurement in smoking cessation trials. The co-use of these substances also has important implications for health service planning, specifically ensuring appropriate and adequate clinical treatment. To date, there have been no synthesis of the literature on the prevalence of tobacco and cannabis co-use in adult clinical populations. Improved understanding of the current prevalence, route of administration and specific subpopulations with the highest rates of tobacco and cannabis co-use will support future intervention development. We aim to provide a pooled estimate of the percentage of smokers who report using cannabis and to examine the prevalence of co-use by sociodemographic characteristics.

METHODS AND ANALYSIS

We will conduct a systematic review using six scientific databases with published articles from 2000 to 2022 inclusive (CENTRAL, CINAHL, EMBASE, Medline, PsycINFO, Psychology and Behavioural Sciences Collection, Scopus). Peer-reviewed journal articles published in English that report on tobacco and cannabis use will be included. Rates of co-use (simultaneous or sequentially) and routes of administration will be assessed. Use in populations groups will be described. Quality assessments will be conducted for all included studies. Data will be synthesised using a narrative approach. This study will be conducted from June 2022 to the end of August 2022.

ETHICS AND DISSEMINATION

This review is based on previously published data and, therefore, ethical approval or written informed consent will not be required. It is the intention of the research team to disseminate the results of the systematic review as a peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020194051.

The Magnitude of NCD Risk Factors in Ethiopia: Meta-Analysis and Systematic Review of Evidence

Background: Non-communicable Diseases (NCDs) and their risk factors are the leading contributors to morbidity and mortality globally, particularly in low- and middle-income countries including Ethiopia. To date, there has been no synthesis of the literature on the relative prevalence of NCD risk factors in Ethiopia. Methodology: We conducted a systematic review and meta-analysis of primary studies reporting on the prevalence of NCD risk factors in Ethiopia published in English from 2012 to July 2020. Pre-tested NCD search terms were applied to Medline, Embase, Scopus, CINAHL, and Global Health. Three reviewers screened and appraised the quality of the identified papers. Data extraction was conducted using a pilot tested proforma. Meta-analysis was conducted using Stata 16 and pooled prevalence estimated with associated 95% confidence intervals. Clinically heterogeneous studies that did not fulfil the eligibility criteria for meta-analysis were narratively synthesised. I² was used to assess statistical heterogeneity. Results: 47 studies fulfilled the inclusion criteria and contributed 68 NCD risk factor prevalence estimates. Hypertension was the most frequently examined NCD risk factor, with a pooled prevalence of 21% (n = 27 studies). The pooled prevalence percentages for overweight and obesity were 19.2% and 10.3%, respectively (n = 7 studies each), with a combined prevalence of 26.8% (n = 1 study). It was not possible to pool the prevalence of alcohol consumption, smoking, metabolic disorders, or fruit consumption because of heterogeneity across studies. The prevalence of alcohol use, as reported from the included individual studies, ranged from 12.4% to 13.5% (n = 7 studies). More than 90% of participants met the WHO-recommended level of physical activity (n = 5 studies). The prevalence of smoking was highly variable, ranging between 0.8% and 38.6%, as was the prevalence of heavy alcohol drinking (12.4% to 21.1%, n = 6 studies) and metabolic syndrome (4.8% to 9.6%, n = 5 studies). Fruit consumption ranged from 1.5% up to the recommended level, but varied across geographic areas (n = 3 studies). Conclusion and recommendations: The prevalence of NCD risk factors in Ethiopia is relatively high. National NCD risk factor surveillance is required to inform the prioritisation of policies and interventions to reduce the NCD burden in Ethiopia.

Tobacco Use among HIV-Positive and HIV-Negative Women and Men in Zambia-Demographic and Health Survey, 2018

Country-specific estimates of tobacco use among people living with HIV (PLWH) are lacking for much of sub-Saharan Africa. We aim to evaluate the association between the HIV status and tobacco product use status, frequency, and intensity, using nationally representative data from Zambia. We analyzed data from the 2018 Demographic and Health Survey conducted in Zambia among women aged 15–49 years and men aged 15–59 years. We performed logistic regression to assess the associations of HIV status, selected sociodemographic, and other characteristics with indicators of tobacco use (i.e., status, frequency, and intensity). Among women, 14.3% tested positive for HIV and 2.7% reported current smoking or tobacco use; women living with HIV were more likely to report currently smoking or using tobacco than women living without HIV (4.4% vs. 2.4%; aPR: 1.46). Among men, 8.4% tested positive for HIV and 19.5% reported current smoking; men living with HIV were more likely than men living without HIV to report current smoking (27.8% vs. 18.7%; aPR: 1.22). Several sociodemographic characteristics were associated with tobacco use, including age, residence (urban/rural), education level, employment status, and wealth index. The frequency and intensity of smoking among men who currently smoked did not differ by HIV status. Tobacco use was more likely in PLWH than those without HIV in Zambia. Our findings highlight the need to encourage and support tobacco cessation among PLWH, possibly by offering cessation services at existing intersections with health care or integrating cessation support into mHealth and other alternative models of care.

Spatial Distribution and Factors Associated With Risky Health Behavior Among Adult Males Aged 15-59 Years in Ethiopia: Generalized Structural Equation Modeling

Background

Alcohol drinking and tobacco smoking are the largest preventable causes of death and important risk factors for a number of non-communicable diseases and cause premature death and many socioeconomic consequences. Therefore, the present study is aimed to assess the spatial distribution of risky health behavior and its associated factors among adult males in Ethiopia.

Methods

All men (12,688) within the age range of 15-59 years were included in the final analysis. The distribution of risky health behavior across the country was observed by using ArcGIS software. In SaTScan software, the Bernoulli model was fitted by Kulldorff methods to identify the purely spatial clusters of risky health behavior. Generalized Structural Equation Model (GSEM) was used to determine factors associated with risky health behavior (regular alcohol drinking and tobacco smoking).

Results

Risky health behavior had spatial variation across the country. The primary clusters were located in Tigray, Amhara, and north-eastern Benishangul national regional states. Spatial scan statistics identified 118 primary clusters [Log-Likelihood ratio (LLR) = 524.8, p < 0.001]. Residence, frequency of listening to a radio, occupation, and frequency of watching television were significantly associated with drinking alcohol, whereas wealth index was associated with tobacco smoking. Age, region, educational status, marital status, and religion had association with both domains of risky health behavior.

Conclusion

Risky health behavior had spatial variation across the country. Bans on advertising and promotion of alcohol and tobacco on national press media should be strengthened. Aggressive health education efforts should be directed toward this high-risk population (Tigray, Amhara, and north-eastern Benishangul regional states). Improving risky health behavior is an important approach to reducing health disparities and promoting a more cost-effective utilization of scarce resources in the public health sector.

Beyond Educating the Masses: The Role of Public Health Communication in Addressing Socioeconomic- and Residence-based Disparities in Tobacco Risk Perception

Public health communication has long been a key component of tobacco control efforts. However, little is known whether and how such an effort could address disparities in tobacco risk perceptions among population subgroups. In this study, using data from the Global Adult Tobacco Survey of Ethiopia, we examined if tobacco risk perceptions varied across socioeconomic and urban vs. rural population subgroups, and whether and how exposure to anti-smoking message was associated with disparities in risk perceptions across socioeconomic and urban-rural subgroups. The results indicated that health risk perceptions of smoking and secondhand smoke exposure were significantly lower among rural, less educated and less affluent population subgroups. Controlling for age, gender, education, wealth, place of residence, and pro-smoking message exposure, anti-smoking message exposure was associated with greater risk perceptions of smoking. Moreover, anti-smoking message exposure moderated the associations of place of residence and education with risk perceptions of smoking and secondhand smoke exposure, respectively. The probability of risk perception of smoking associated with anti-smoking message exposure was higher among the rural populace compared to urbanites. Similarly, the probability of risk perception of secondhand smoke exposure associated with anti-smoking message exposure was the highest among individuals without formal education compared to those with primary, secondary, and college-level education. The findings suggest that efforts should be made to make sure adequate anti-smoking message exposure among less educated and rural audiences so as to reduce disparities in tobacco risk perceptions.

Sociodemographic factors associated with daily tobacco smoking and binge drinking among Zambians: evidence from the 2017 STEPS survey

BACKGROUND

The burden of disease attributable to tobacco smoking and harmful alcohol consumption poses a major threat to sustainable development in most low- and middle-income countries. However, evidence on tobacco use and harmful alcohol consumption to inform context-specific interventions addressing these harmful social behaviours is limited in the African context. This study aimed to determine the sociodemographic factors associated with daily tobacco smoking and binge drinking in Zambia.

METHODS

The study stems from nationwide population-based representative survey data collected using the World Health Organization's STEPwise approach for non-communicable disease risk factor surveillance in 2017 among 18-69-year-old Zambians. The main outcomes were daily tobacco smoking and binge drinking, and the demographic and socioeconomic variables included sex, marital status, age, residence, level of education and occupation. Prevalence ratios (PR) were calculated using log-binomial regression analysis.

RESULTS

Overall, 4302 individuals (weighted percentage 49.0% men and 51.0% women) participated in the survey. The prevalence of daily tobacco smoking was 9.0%, and 11.6% of participants engaged in binge drinking, both of which were higher among men than women (17.1% vs. 1.3% and 18.6% vs. 5.3%, respectively). The adjusted prevalence of daily tobacco smoking was 14.3 (95% CI: 9.74-21.01) times higher in men than women, and 1.44 (95% CI 1.03-1.99) times higher in the > 45-year-old group compared to the 18-29-year-old group. Significant positive associations with daily tobacco smoking were found among those with no education 2.70 (95% CI 1.79- 4.07) or primary education 1.86 (95% CI 1.22-2.83) compared to those with senior secondary or tertiary education. The adjusted prevalence of daily tobacco smoking was 0.37 times lower (95% CI 0.16-0.86) among students and homemakers compared to employed participants. The adjusted prevalence of binge drinking was 3.67 times higher (95% CI 2.83-4.76) in men than in women. Significantly lower adjusted prevalences of binge drinking were found in rural residents 0.59 (95% CI: 0.46-0.77) compared to urban residents and in students/homemakers 0.58 (95% CI: 0.35-0.94) compared to employed participants.

CONCLUSION

This study shows huge differences between men and women regarding tobacco smoking and binge drinking in Zambia. A high occurrence of tobacco smoking was observed among men, older members of society and those with lower levels of education, while binge drinking was more common in men and in those living in urban areas. There is a need to reshape and refine preventive and control interventions for tobacco smoking and binge drinking to target the most at-risk groups in the country.

Lung function and atherosclerosis: a cross-sectional study of multimorbidity in rural Uganda

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of global mortality. In high-income settings, the presence of cardiovascular disease among people with COPD increases mortality and complicates longitudinal disease management. An estimated 26 million people are living with COPD in sub-Saharan Africa, where risk factors for co-occurring pulmonary and cardiovascular disease may differ from high-income settings but remain uncharacterized. As non-communicable diseases have become the leading cause of death in sub-Saharan Africa, defining multimorbidity in this setting is critical to inform the required scale-up of existing healthcare infrastructure.

METHODS

We measured lung function and carotid intima media thickness (cIMT) among participants in the UGANDAC Study. Study participants were over 40 years old and equally divided into people living with HIV (PLWH) and an age- and sex-similar, HIV-uninfected control population. We fit multivariable linear regression models to characterize the relationship between lung function (forced expiratory volume in one second, FEV₁) and pre-clinical atherosclerosis (cIMT), and evaluated for effect modification by age, sex, smoking history, HIV, and socioeconomic status.

RESULTS

Of 265 participants, median age was 52 years, 125 (47%) were women, and 140 (53%) were PLWH. Most participants who met criteria for COPD were PLWH (13/17, 76%). Median cIMT was 0.67 mm (IQR: 0.60 to 0.74), which did not differ by HIV serostatus. In models adjusted for age, sex, socioeconomic status, smoking, and HIV, lower FEV₁ was associated with increased cIMT (β = 0.006 per 200 mL FEV₁ decrease; 95% CI 0.002 to 0.011, p = 0.01). There was no evidence that age, sex, HIV serostatus, smoking, or socioeconomic status modified the relationship between FEV₁ and cIMT.

CONCLUSIONS

Impaired lung function was associated with increased cIMT, a measure of pre-clinical atherosclerosis, among adults with and without HIV in rural Uganda. Future work should explore how co-occurring lung and cardiovascular disease might share risk factors and contribute to health outcomes in sub-Saharan Africa.

Prevalence and Associated Factors of Substance Use Male Population in East African Countries: A Multilevel Analysis of Recent Demographic and Health Surveys From 2015 to 2019

Background:

East Africa is still home to one of the world’s highest rates of substance user. Substance use is primarily associated with male behavior and is becoming one of the region’s most public health issues.

Methods:

The study included data from 11 East African countries’ Demographic and Health Surveys. About 55 307 men were enrolled in the study and multilevel logistic regression model was applied

Result:

East African countries had a 43.70% prevalence of substance abuse coverage. Education level, age, current working status, marital status, wealth index, media exposure, residence, and nation were all found to be statistically associated with substance use of males.

Conclusion:

In East African countries, the prevalence of substance abuse among men was high. As a result, substance control programs should focus on the poor, not (least) educated, rural people, and adult age groups, who are the region’s most vulnerable social groups.

Acute respiratory infections in an adult refugee population: an observational study

The presence of acute infectious respiratory diseases (ARD) is one of the main reasons why recently arrived refugees seek medical help. This paper investigates the incidence rates of acute respiratory diseases in an adult refugee population as well as associated sociodemographic factors and drug treatments. We conducted a retrospective observational study of deidentified medical records. The data were collected between 2015 and 2019 in the health care centers of two large German initial reception centers for refugees. Multivariable analyses controlling for sociodemographics were carried out using generalized estimating equations. Out of 10,431 eligible residents, 6965 medical encounters of 2840 adult patients were recorded over 30 months. Of all the adult patients, 34.4% sought medical help for a respiratory symptom or diagnosis at least once. Older patients and patients from Sub-Saharan Africa sought help less often. The occurrence of ARD showed a typical distribution over the course of the year. Facility occupancy was not associated with ARD occurrence. Acute respiratory symptoms are a leading cause for adult refugee patients to seek medical care. The doctor contact rates due to ARD were consistently two to three times higher among refugees than among German residents.

Trends in Prevalence of Tobacco Use by Sex and Socioeconomic Status in 22 Sub-Saharan African Countries, 2003-2019

IMPORTANCE

Tobacco companies have shifted their marketing and production to sub-Saharan African countries, which are in an early stage of the tobacco epidemic.

OBJECTIVE

To estimate changes in the prevalence of current tobacco use and socioeconomic inequalities among male and female participants from 22 sub-Saharan African countries from 2003 to 2019.

DESIGN, SETTING, AND PARTICIPANTS

Secondary data analyses were conducted of sequential Demographic and Health Surveys in 22 sub-Saharan African countries including male and female participants aged 15 to 49 years. The baseline surveys (2003-2011) and the most recent surveys (2011-2019) were pooled.

EXPOSURES

Household wealth index and highest educational level were the markers of inequality.

MAIN OUTCOMES AND MEASURES

Sex-specific absolute and relative changes in age-standardized prevalence of current tobacco use in each country and absolute and relative measures of inequality using pooled data.

RESULTS

The survey samples included 428 197 individuals (303 232 female participants [70.8%]; mean [SD] age, 28.6 [9.8] years) in the baseline surveys and 493 032 participants (348 490 female participants [70.7%]; mean [SD] age, 28.5 [9.4] years) in the most recent surveys. Both sexes were educated up to primary (35.7%) or secondary school (40.0%). The prevalence of current tobacco use among male participants ranged from 6.1% (95% CI, 5.2%-6.9%) in Ghana to 38.3% (95% CI, 35.8%-40.8%) in Lesotho in the baseline surveys and from 4.5% (95% CI, 3.7%-5.3%) in Ghana to 46.0% (95% CI, 43.2%-48.9%) in Lesotho during the most recent surveys. The decrease in prevalence ranged from 1.5% (Ghana) to 9.6% (Sierra Leone). The World Health Organization target of a 30% decrease in smoking was achieved among male participants in 8 countries: Rwanda, Nigeria, Ethiopia, Benin, Liberia, Tanzania, Burundi, and Cameroon. For female participants, the number of countries having a prevalence of smoking less than 1% increased from 9 in baseline surveys to 16 in the most recent surveys. The World Health Organization target of a 30% decrease in smoking was achieved among female participants in 15 countries: Cameroon, Namibia, Mozambique, Mali, Liberia, Nigeria, Burundi, Tanzania, Malawi, Kenya, Rwanda, Zimbabwe, Ethiopia, Burkina Faso, and Zambia. For both sexes, the prevalence of tobacco use and the decrease in prevalence of tobacco use were higher among less-educated individuals and individuals with low income. In both groups, the magnitude of inequalities consistently decreased, and its direction remained the same. Absolute inequalities were 3-fold higher among male participants, while relative inequalities were nearly 2-fold higher among female participants.

CONCLUSIONS AND RELEVANCE

Contrary to a projected increase, tobacco use decreased in most sub-Saharan African countries. Persisting socioeconomic inequalities warrant the stricter implementation of tobacco control measures to reach less-educated individuals and individuals with low income.

Social Norms Change and Tobacco Use: A Protocol for a Systematic Review and Meta-Analysis of Interventions

Tobacco use kills more than eight million individuals each year, and results in substantial economic and human capital loss across nations. While effective supply-side solutions to tobacco control exist, these approaches are less effective at promoting cessation among heavy smokers, and less feasible to implement in countries with weaker tobacco control policy environments. Thus, effective demand-side solutions are needed. Shifting social norms around tobacco use is one such promising approach. To this end, a systematic review and meta-analysis of social norms intervention studies to influence tobacco use will be conducted following PRISMA 2020 guidance. Tobacco intervention studies with at least two time points that explicitly mention social norms or social influence as part of an intervention or set of measured variables will be included. Literature sources will comprise PubMed, Scopus, PsycInfo, and the Cochrane Trial Registry, as well as several grey literature sources. Two reviewers will independently screen studies, and risk of bias will be assessed using the Cochrane Risk of Bias 2 and ROBINS-I tools. The primary outcomes will be change in tobacco use and change in social norms. A random-effects meta-analysis will be conducted for both outcomes. Sources of heterogeneity will be explored using meta-regression with key covariates. Non-reporting biases will be explored using funnel plots. PROSPERO: CRD42021251535.

Retrospective Policy Analysis of Tobacco Prevention and Control in Ethiopia

Background

The trend of non-communicable diseases is alarmingly increasing and tobacco consumption and exposure to its smoke have been playing the leading role. Thirty-seven Ethiopians deaths per day are attributable to tobacco. Unless appropriately mitigated, this has social, economic and political impacts. Implementation of the appropriate policy is a good remedy; however, the policy process has never been straight forward and always successful. The involvement of different actors makes policy process complex hence agenda setting, policy formulation, implementation, and evaluations have been full of chaos and even may fail at any of these levels. Thus the aim of this review was retrospectively analyzing tobacco-related policies in Ethiopia that are relevant to control tobacco use and mitigate its impacts.

Methods

Systematically, we searched in pub-med, Scopus, Web of Science and Embase. Additionally, we did hand search on Google scholar and national websites. The terms “tobacco”, “cigar”, “cigarette”, “control”, “prevention”, “policy” and “Ethiopia” were used. Eleven of 128 records met the inclusion criteria and then included. For data analysis, we applied the health policy analysis framework developed by Walt and Gilson.

Result

Lately, Ethiopia enacted and started to implement tobacco control policies and programs, but its implementation is problematic and consumption rate is increasing.

Conclusion

Despite the early involvement in tobacco control initiatives and enactment of legal frameworks, Ethiopia's journey and current stand to prevent and control the devastating consequences of tobacco is very limited and unsatisfactory. Therefore, we strongly call for further action, strong involvement of private sector and non-governmental organizations.

Examining the Relationship Between Occupational Physical Activity and Hypertension Status: Evidence from the Ghana WHO Study on Global Ageing and Adult Health

The employment landscape has changed significantly over the past few years in emerging economies including Ghana where many people are rapidly transitioning from livelihood activities that originally involved physical exertion to work environments where performance of duties are mostly non-physical. Working under non-active conditions could, however, exacerbate the risk of developing chronic diseases that are increasingly becoming problematic in many developing countries. Drawing on a cross-sectional nationally representative sample data of 4425 adult Ghanaian workers collected by the WHO Study on Global Ageing and Adult Health in developing countries, we examined the relationship between occupational physical activity and hypertensive status. We employed the complementary log-log analysis technique to build nested models with results presented in odds ratios. After controlling for several relevant variables, the results show that performing sedentary related work (AOR = 1.23, CI = 1.06-1.42) is significantly associated with a higher likelihood of being hypertensive compared with those whose work involved moderate physical activity. Other factors that were significantly associated with being hypertensive included tobacco use (AOR = 1.33, CI = 1.05-1.70), living in an urban environment (AOR = 1.15, CI = 1.01-1.32), and being a female (AOR = 1.18, CI = 1.01-1.37) and being an older person. Policies on reducing the risk of developing chronic conditions especially hypertension need to recognize the contributions of the work environment in emerging developing economies.

Tobacco Use and Risk Factors for Hypertensive Individuals in Kenya

This study aimed to examine the association between hypertension and tobacco use as well as other known hypertensive risk factors (BMI, waist–hip ratio, alcohol consumption, physical activity, and socio-economic factors among adults) in Kenya. The study utilized the 2015 Kenya STEPs survey (adults aged 18–69) and investigated the association between tobacco use and hypertension. Descriptive statistics, correlation, frequencies, and regression (linear and logistic) analyses were used to execute the statistical analysis. The study results indicate a high prevalence of hypertension in association with certain risk factors—body mass index (BMI), alcohol, waist–hip ratio (WHR), and tobacco use—that were higher in males than females among the hypertensive group. Moreover, the findings noted an exceptionally low awareness level of hypertension in the general population. BMI, age, WHR, and alcohol use were prevalent risks of all three outcomes: hypertension, systolic blood pressure, and diastolic blood pressure. Healthcare authorities and policymakers can employ these findings to lower the burden of hypertension by developing health promotion and intervention policies.

Socio-Economic and Demographic Correlates of Non-communicable Disease Risk Factors Among Adults in Saudi Arabia

Background: Over the past two decades, Saudi Arabia has made significant improvements in its population's health standards. These improvements have been coupled with an increase in risk factors related to non-communicable diseases (NCD) and a dramatic shift in the burden of disease profile. This study aims to provide empirical evidence on the socio-economic and demographic correlates of NCD risk factors among adults in Saudi Arabia.

Methods: The data used for this study is secondary data derived from the Saudi Health Interview Survey (SHIS) conducted in 2013. The SHIS used a cross-sectional survey design to derive a multistage representative sample of adults to estimate the prevalence of NCD risk factors. Risk factors considered for analyses in this study were; current tobacco use, low fruit and vegetable consumption, low physical activity, overweight/obesity and hypertension. The survey covered all regions in Saudi Arabia using probability proportional to size measures. A total of 10,735 adults aged 15 years and above completed the survey questionnaire. Logistic regression analysis was conducted to examine the socio-economic and demographic correlates of NCD risk factors among adults in Saudi Arabia.

Results: The prevalence of NCD risk factors were as follows: current tobacco use, 12.1%; low fruit and vegetable consumption, 87%; low physical activity, 94.9%; overweight/obesity 65.1%; and hypertension, 37.5%. The multivariate analysis results indicate that significant correlates of overweight/obesity and hypertension were being female, a government employee, income level, and education levels. On the other hand, current tobacco use and low fruit and vegetable consumption were generally associated with age, self-employment and being a student. For lifestyle factors, overweight/obesity was high among individuals who reported low fruit and vegetable consumption, while hypertension was high among current tobacco users and overweight/obese adults. All comparisons were statistically significant at p < 0.05.

Conclusions: This study's findings indicate a high prevalence of chronic NCD risk factors in Saudi Arabia's adult population. This study implied that there is a need for a reduction in life-damaging behaviors among the adults through the adoption of healthy lifestyles such as physical activity and nutritious diets. Moreover, a reduction in the prevalence of chronic NCD risk factors among different socio-economic groups in Saudi Arabia through healthy lifestyles will have far-reaching results.

An Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa

Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.

Tobacco use and associated factors among adults reside in Arba Minch health and demographic surveillance site, southern Ethiopia: a cross-sectional study

BACKGROUND

Tobacco use is one of the world-leading preventable killers. There was a varied prevalence of tobacco use and cigarette smoking across different areas. The aim of the study was to assess the prevalence and factors associated with current tobacco use among adults residing in Arba Minch health and demographic surveillance site (HDSS).

METHODS

A community-based cross-sectional study was conducted among adults residing in Arba Minch HDSS in 2017. The estimated sample size was 3368 individuals which were selected by simple random sampling techniques using Arba Minch HDSS dataset. Data collection tools were obtained from the WHO STEPwise. Current use of tobacco, which defined as the current use of smoked and/or smokeless tobacco, was considered as the dependent variable. A binary logistic regression model was used to identify candidate variables for the multivariable logistic regression model. An adjusted odds ratio (AOR) at a p-value of less than 0.05 was used to determine a statistically significant association between independent and dependent variables.

RESULT

The prevalence of tobacco use among adults was 20.2% (95% CI: 18.9-21.6%). The current use of smoked and smokeless tobacco were 17.1% (95%CI: 15.8-18.4%) and 9.7% (95%CI: 8.8-10.8%), respectively. The current use of tobacco was significantly associated with sex (female [AOR 0.54; 95%CI: 0.42-0.68] compared to men), age group (35-44 [AOR 1.57; 95%CI: 1.14-2.17], 45-54 [AOR 1.99; 95%CI: 1.45-2.74], and 55-64 [AOR 3.26; 95%CI: 2.37-4.48] years old compared to 25-35 years old), physical activity (moderate physical activity level [AOR 0.65; 95%CI: 0.44-0.96] compared with low) and residency (highland [AOR 4.39; 95% CI: 3.21-6.01] compared with at lowlander). Also, heavy alcohol consumption (AOR 3.97; 95% CI: 3.07-5.12), and Khat chewing (AOR 3.07(95%CI: 1.64-5.77) were also associated with the use of tobacco among the study participants.

CONCLUSION

Nearly one in five adults used tobacco currently in the study area, which is more than the national reports. Interventions for the reduction of tobacco use need to give due attention to men, older adults, uneducated, poor, and highlanders.

Tobacco smoking and meningococcal disease in adolescents and young adults: a systematic review and meta-analysis

OBJECTIVES

Systematically review the evidence on the association between active and passive tobacco smoking and invasive meningococcal disease (IMD) in adolescents and young adults aged 15-to-24-years.

METHODS

Electronic searches were conducted in Ovid MEDLINE, EMBASE, and Web of Science to June 2020. Reference lists were hand-searched. Two independent reviewers screened articles for eligibility. Risk of bias was assessed using an adapted Risk of Bias in Non-Randomised Studies - of Interventions tool. Meta-analyses were conducted using random-effects models.

RESULTS

Of 312 records identified, 13 studies were included. Five studies provided data on the association between active smoking and IMD in the target age group; pooled odds ratio (OR): 1.45 (95% CI: 0.93-2.26). The overall OR, including eight studies with a wider participant age range, was 1.45 (95% CI: 1.12-1.88). For passive smoking, the equivalent ORs were 1.56 (95% CI: 1.09-2.25) and 1.30 (95% CI: 1.06-1.59) respectively. All studies were at high risk of bias.

CONCLUSIONS

Active and passive smoking may be associated with IMD in adolescents and young adults. Since active smoking has also been linked to meningococcal carriage, and passive smoking to IMD in young children, smoking cessation should be encouraged to reduce transmission and IMD risk in all ages.

Mobile phone-based messaging for tobacco cessation in low and middle-income countries: A systematic review

INTRODUCTION

Mobile phone-based tobacco cessation (mCessation) interventions are effective in high-income countries but their effectiveness in low and middle-income countries (LMICs) is unclear. We aimed to assess the evidence-base for mCessation interventions in LMICs by synthesizing study characteristics and to describe intervention characteristics and content.

METHODS

Studies were included in this review if they evaluated an intervention that targeted tobacco users, were conducted in an LMIC, measured tobacco cessation as a primary or secondary outcome, and were primarily delivered using mobile phone (text or app-based) messaging. Data were extracted on fields pertaining to study and intervention characteristics and study quality was assessed using the Effective Public Health Practice Project tool. Screening, extraction and quality assessment were conducted by two independent reviewers.

RESULTS

Of 606 unique records, 12 articles were included. The majority of studies were methodologically weak. Methodological limitations included small sample sizes, short follow-up durations and use of self-reported outcomes. Most evaluations were conducted in upper middle-income countries with urban, adult smokers intending to quit smoking. Approximately half the interventions were bidirectional (enabled two-way messaging) and fully automated. Almost all interventions were delivered via SMS. Treatment offerings of the intervention and control groups varied widely.

CONCLUSIONS

More rigorous large-scale randomized controlled trials are needed to conclusively establish the efficacy of mCessation interventions in LMICs. Interventions also need to be tested across more diverse populations and settings. Future studies should test the relative effectiveness of different intervention characteristics.

Adherence to smoke-free policies in Ghana: Findings from a cross-sectional survey of hospitality venue owners and staff

INTRODUCTION

Implementation of and compliance with smoke-free policies (SFPs) can be problematic in many low- and middle-income countries (LMICs) due to limited resources. This study evaluated knowledge, opinions and compliance related to Ghana’s SFPs among owners and staff of hospitality venues by city, staff designation, and venue type.

METHODS

A cross-sectional study design was used in venue types including hotels, bars, pubs and restaurants in the three cities of Kumasi, Accra, and Tamale, in Ghana.

Data were collected between July and September 2019. Interviewer administered face-to-face surveys were conducted with owners and staff (n=142) recruited from randomly selected hospitality venues (n=154) in these three large cities of Ghana. The relationship between knowledge, opinions, and compliance items on SFPs, and city, venue type and staff designation was first studied using χ² or a Fisher’s exact test, and then with univariate logistic regression model analysis.

RESULTS

Of the 142 respondents, some had heard of Ghana’s 2012 Tobacco Control Act (27.5%), smoking restriction in public places (29%), smoke-free places (22%), and display of ‘no smoking’ signage (6.3%). Knowledge levels were higher in Accra compared to Tamale (OR=3.08; 95% CI: 1.10–8.60). Staff designation and type of venue did not have any relationship with knowledge levels. Support for SFPs was over 80%, but opinions in support of SFPs were lower in Accra than Tamale (OR=0.25; 95% CI: 0.08–0.71). Compliance with SFPs was similar in the three cities. Hotels were three times more compliant compared to bars and pubs (OR=3.16; 95% CI: 1.48–6.71).

CONCLUSIONS

The study highlights the strong support for restriction of smoking in public places including hospitality venues despite poor knowledge and low compliance levels with the current SFPs. A review of the current SFP in Ghana together with education of hospitality staff on the benefits and requirements of SFPs is recommended.

Tobacco cessation in low- to middle-income countries: A scoping review of randomized controlled trials

OBJECTIVE

The growing prevalence of tobacco use in low "to middle" income countries (LMICs) and the hurdles of conducting tobacco cessation in that context necessitates a focus on the scope of randomized controlled trials (RCTs) in LMICs to guide tobacco cessation in this environment. We conducted a scoping review to identify LMIC tobacco cessation RCTs.

METHODS

Consistent with PRISMA-ScR guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, PsycINFO, articles published since inception, latest searches in March 2020) and gray literature (clinical trials registries, searches between September and December 2019). We searched for data on RCT type, outcome significance and intervention description. Inclusion: research conducted in LMICs; tobacco cessation; RCT. Exclusion: research conducted in high income countries; non-RCT; studies involving only those aged <18. Data was extracted from published reports. We generated narrative summaries of each LMIC's tobacco cessation RCT research environment.

RESULTS

Of 8404 articles screened, we identified 92 studies. Tobacco cessation RCTs were recorded in 16 of 138 countries/territories in LMICs. Evidence was weak in quality and severely limited. Most RCTs were psychosocial, with limited behavioral and pharmacological variants.

CONCLUSIONS

Tobacco control within LMICs is essential to reduce the tobacco mortality burden. Researchers should be cognizant that tobacco cessation in LMICs is still not an environment where best practice has been established. We suggest that developing solutions specific for LMICs is key to effective tobacco control in LMICs.

Epidemiological Imaginaries of the Social: Epidemiologists and Pathologies of Modernization in Postcolonial Africa

There is a growing anthropological literature analyzing the place that epidemiological surveillance occupies in contemporary global health. In this article, I build on this literature and take it into new directions by exploring what I call the epidemiological imaginaries of the social. Drawing on science and technology studies, I suggest that epidemiologists help make up the world, articulating complex and normatively loaded visions of social life that both enable and constrain action. More specifically, I argue that epidemiologists tell stories about the type of societies and people that compose the world and that these stories often shape global health policies and programs in powerful ways. To substantiate this argument, I examine epidemiologists' efforts to map smoking in postcolonial Africa, documenting how they have imagined smokers and smoking through the lense of modernization theory and showing how these imaginaries have shaped tobacco control policies in the region up to this day.

Prevalence and Factors Associated with Current Cigarette Smoking among Ethiopian University Students: A Systematic Review and Meta-Analysis

Background

Although tobacco use is highest in high-income countries, most tobacco-related deaths occur in low- and middle-income countries with the highest number of deaths recorded in East Africa. The aim of this systematic review and meta-analysis is to determine the pooled prevalence and associated factors of current cigarette smoking among Ethiopian university students.

Methods

The authors searched databases from PubMed, PsycINFO, Google Scholar, EMBASE, and Web of Sciences. The publications included in the analysis were inclusive, the literature was searched from January 2011 to December 2018. The JBI-MAStARI critical appraisal tool was applied to 13 publications identified by the database search. I² statistics were used to indicate heterogeneity. Publication bias was evaluated using the visual funnel plot. A p value < 0.1 was considered as indicative of statistically significant publication bias. A random effect meta-analysis model was computed to estimate the pooled prevalence of cigarette smoking, and the variables associated with cigarette smoking were examined.

Results

The meta-analysis of 13 studies showed that the pooled prevalence of current cigarette smoking was found to be 12.55% (95% CI: 10.39–14.72; I² = 94.0%) with no publication bias according to Egger's test (p = 0.007) for cigarette smoking by 2.05 (95% CI: 1.52–2.75). Factors associated with cigarette smoking were peer influence 2.79 (95% CI: 1.62–4.82; I² = 35.7), khat chewing (95% CI: 2.81–15.26; I² = 82.5), and alcohol use 11.16 (95% CI: 7.46–16.71).

Conclusion

Our findings indicate a high prevalence of cigarette smoking among Ethiopian university students as compared to the general population. Gender, peer influence, khat chewing, and current alcohol use were significantly associated with cigarette smoking. The authors recommend promoting antismoking campaigns, emphasizing health hazard public service announcements about cigarettes, and integrating health education on smoking in youth-friendly services, especially targeting higher educational institutions.

The scope of tobacco cessation randomized controlled trials in low- to middle-income countries: protocol for a scoping review

BACKGROUND

Tobacco consumption is the leading cause of preventable death globally. The global mortality burden of tobacco use lies predominantly in low- to middle-income countries (LMICs). There is much evidence on the effectiveness of tobacco cessation RCTs in high-income nations. However, the evidence base in LMICs is far more limited. To effectively design randomized controlled trials (RCTs) that mitigate tobacco-related harms in LMICs, further understanding of RCTs in this environment will be helpful. We will provide quality evidence regarding the scope of tobacco cessation RCTs in LMICs.

METHODS

A scoping review of tobacco cessation RCTs will be conducted. MEDLINE, Embase, PsycINFO, Global Health, Web of Science and Sociological Abstracts will be searched to capture current literature. We will review RCTs that have already been done on tobacco cessation in the LMICs. The key outcome will be tobacco cessation in adults. Examples of the key outcome include smoking abstinence and reduction of tobacco use. Study selection will conform to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and study quality assessed with a modified version of the Cochrane Collaboration's instrument.

DISCUSSION

As researchers attempt to minimize the harms from tobacco in LMICs, they need to be aware of scientific evidence to develop RCTs to achieve their aim. The review will complement the evidence base on tobacco cessation in LMICs.

Smoking and HIV in Sub-Saharan Africa: A 25-Country Analysis of the Demographic Health Surveys

BACKGROUND

Having HIV/AIDS has been associated with a higher prevalence of smoking. Moreover, evidence suggests that people with HIV/AIDS who smoke have poorer treatment and survival outcomes. The HIV-smoking relationship is understudied in sub-Saharan Africa, where tobacco use patterns and HIV prevalence differ greatly from other world regions.

METHODS

Cross-sectional data from the Demographic Health Surveys and AIDS Indicator Surveys, representing 25 sub-Saharan African countries, were pooled for analysis (n = 286850). The association between cigarette smoking and HIV status was analyzed through hierarchical logistic regression models. This study also examined the relationship between smokeless tobacco (SLT) use and HIV status.

RESULTS

Smoking prevalence was significantly higher among men who had HIV/AIDS than among men who did not (25.90% vs 16.09%; p < .0001), as was smoking prevalence among women who had HIV/AIDS compared with women who did not (1.15% vs 0.73%; p < .001). Multivariate logistic regression revealed that the odds of smoking among people who had HIV/AIDS was 1.12 times greater than among people who did not when adjusting for socioeconomic, demographic, and sexual risk factors (adjusted OR = 1.12, 95% CI = 1.04% to 1.21%; p < .001). Similarly, multivariate logistic regression revealed that HIV-positive individuals were 34% more likely to use SLT than HIV-negative individuals (adjusted OR = 1.34, 95% CI = 1.17% to 1.53%).

CONCLUSION

Having HIV was associated with a greater likelihood of smoking cigarettes as well as with using SLT in sub-Saharan Africa. These tobacco use modalities were also associated with male sex and lower socioeconomic status.

IMPLICATIONS

This study shows that in sub-Saharan Africa, as in more studied world regions, having HIV/AIDS is associated with a higher likelihood of smoking cigarettes when adjusting for demographic, socioeconomic, and sexual risk factors. This study also supports the literature stating that cigarette smoking is inversely associated with socioeconomic status, as evidenced by higher smoking prevalence among poorer individuals, less educated individuals, and manual and agricultural laborers.

Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa

As longevity has increased for people living with HIV (PLWH) in the United States and Europe, there has been a concomitant increase in the prevalence of cardiovascular disease (CVD) risk factors and morbidity in this population. Whereas the availability of HIV antiretroviral therapy has resulted in dramatic increases in life expectancy in sub-Saharan Africa (SSA), where over two thirds of PLWH reside, if and how these trends impact the epidemiology of CVD is less clear. In this review, we describe the current state of the science on how both HIV and its treatment impact CVD risk factors and outcomes among PLWH in sub-Saharan Africa, including regional factors (unique to SSA) likely to differentiate these relationships from the global North. We then outline how current regional guidelines address CVD prevention among PLWH and which clinical and structural interventions are best poised to confront the co-epidemics of HIV and CVD in the region. We conclude with a discussion of key research gaps that need to be addressed to optimally develop an actionable public health response.

Prevalence and Epidemiological Pattern of Abdominal Aortic Aneurysms in Africa: A Systematic Review

Introduction

The incidence of abdominal aortic aneurysms (AAAs) in high-income countries has been declining in the last three decades. However, in most low-income and middle-income countries especially in Africa, little is known about its burden. The absence of screening services for AAA in African countries makes it difficult to detect and promptly manage AAA before rupture, which has significant implications for mortality. This study sought to systematically assess the prevalence of AAA amongst patients visiting hospitals in Africa and evaluate its epidemiological pattern.

Materials and Methods

A systematic review was performed on the EMBASE, GLOBAL HEALTH, MEDLINE, and PUBMED databases. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement standards and protocol registered with PROSPERO (CRD42020162214). A data extraction tool was used to get relevant information from these studies. Quality assessment and risk of bias were performed using the Newcastle Ottawa Scale for cross-sectional studies. Results were summarised in tables, figures, and a forest plot. A narrative synthesis approach of the articles was taken.

Results

Two hundred and sixty-one studies were identified and after the exclusion of 246, a final 15 were deemed suitable for analysis. A total of 4012 participants were screened for AAA and of these, 129 cases were identified. The prevalence of AAA in these studies ranged from 0.7 to 6.4%. Male participants accounted for 115 (89.1%) of the cases. There was a wide age range (31-72 years) reflective of both its possible infective and degenerative aetiology. AAA was reported to be associated with hypertension, smoking, advanced age, coronary artery disease, and HIV infection. There was no association between AAA and diabetes. Over 50% of cases were identified incidentally. About one-third (23-54%) of the participants presented aortic rupture with a mortality rate ranging between 65 and 72%.

Conclusions

AAA prevalence in Africa is probably higher than the current thinking as there is no baseline data to compare with. Aetiologically, AAA was shown to be associated with hypertension, smoking, coronary artery disease, and possibly infectious pathologies like HIV. Large epidemiological studies would help better characterise AAA in this setting. Lastly, efforts targeting the reduction of the risk factors for AAA would go a long way in reducing the burden of AAA.

Prevalence and Predictors of Smoking among Gambian Men: A Cross-Sectional National WHO STEP Survey

Background: Tobacco use is the leading cause of preventable death in the world, with a higher burden in low- and middle-income countries. The aim of this study was to quantify the prevalence and predictors of smoking among Gambian men using nationally representative data. Methods: Data was collected in 2010 from a random, nationally representative sample of 4111 adults aged 25–64 years (78% response rate) using the World Health Organization (WHO) STEPwise cross-sectional survey methods. Our analyses focused on men with valid information on smoking status (n = 1766) because of the low prevalence of smoking among women (1%). Results: The prevalence of current smoking among men was 31.4% (95% CI: 27.2–35.9). The median age of starting smoking was 19 years; 25% started before the age of 18 years and 10% started aged 8–10 years. Rural residence, underweight, and hypertension were significantly associated with smoking. Conclusion: The study reveals a high prevalence of smoking among Gambian men. It is evident that cigarettes are obtained by minors in The Gambia, as a high proportion of current smokers started at a young age. Advice and support to quit smoking should be extended to all smokers regardless of their age and whether or not they have any underlying health conditions.