Owusu-Dabo, Ellis
(2011)
Smoking in Ghana: a study of the history of tobacco industry activity, current prevalence and risk factors for smoking, and implementation of tobacco control policy.
PhD thesis, University of Nottingham.
Abstract
Background
There has been relatively little research on the prevalence and use of tobacco products in developing countries, where the majority of morbidity and mortality from tobacco use in this century is expected to occur. This is particularly true of countries in Africa. I conducted this study in the Ashanti region of Ghana, primarily to measure prevalence and risk factors for smoking, and secondarily to develop a template for national surveys in similar settings in developing countries. I also investigated the history of tobacco use in Ghana and looked into current implementation of tobacco control policy, in particular the Framework Convention on Tobacco Control (FCTC). The FCTC Is the World Health Organization's first public health treaty, established to counter the tobacco pandemic internationally
Methods
First, using electronic literature searches of the tobacco document archives and local library, I searched for all documents with information on the tobacco industry in Ghana and all studies of the prevalence of smoking in Ghana. Secondly, using a two-stage cluster randomized sampling design, I collected data from adults aged 14 and over in a representative household sample of approximately 720 households in the Ashanti Region of Ghana. Finally, I conducted interviews with 20 key policy makers involved with Ghana's implementation of the Framework Convention on Tobacco Control (FCTC) and other tobacco control policies to assess Ghana's progress of implementation.
Results
Searches of the literature and tobacco document archives established that British American Tobacco (BAT), and latterly the International Tobacco Company Ghana (ITG) and its successor, the Meridian Tobacco Company (MTC), have been manufacturing cigarettes In Ghana since 1954. After an initial sales booming the two decades after independence in 1957, further increases in consumption typical of the tobacco epidemic in most countries did not occur. Possible key reasons include the taking of tobacco companies into state ownership, and a lack of foreign exchange to fund tobacco leaf importation in the 1970s, both of which may have inhibited growth at a key stage of development; and the introduction of an advertising ban in 1982. BAT ceased manufacturing cigarettes in Ghana in 2006.
My survey involved 7096 eligible individuals resident in the sampled households, of whom 6258 (88%; median age 31 (range 14-105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%), and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking prevalence was strongly related to increasing age, being highest in the 60-69 age-group (Odds Ratio relative to 14-19 year olds 6.36 (95% Confidence Interval 3.26 to 12.38, Ptrend<0.001), and varied significantly in relation to religion (overall p<0.001), being particularly high in those of Traditionalist belief relative to the Christian majority (adjusted OR 7.50, 95% CI 4.43-12.69);in relation to education level (overall p=0.03, adjusted OR for those with no or only primary education compared with those of tertiary education OR 1.49, 95% CI 0.81-2.73); and in relation to occupation (overall p=0.003, adjusted OR for skilled workers relative to the unemployed 0.66, 95% CI 0.41-1.06). Smokers were more likely to drink alcohol (adjusted OR 7.70, 95% CI 4.63-12.93, p<0.001) and to have friends who smoke (adjusted OR 4.24, 95% CI 3.52-5.11 p<0.001), and significantly less likely to take exercise (adjusted OR 0.82, 95% CI 0.72-0.93, p<0.05). Among smokers, over three quarters (76%) had attempted to quit in the last six months, with the main sources of advice being friends and spouses. Use of smoking cessation medications, such as nicotine replacement therapy, was very rare. About 10% of cigarettes smoked were smuggled brands. About a third (38%) of smokers were highly or very highly dependent. Overall the proportion of ever-smokers who had quit smoking was high (61%) in all age groups. The median number and Interquartile range of cigarettes smoked per day by male and female current smokers on weekdays were respectively 6(1- 40) and 5 (4-10), and at weekends 19 (2-70) and 11 (8-20) respectively. The commonest brands smoked were London Brown (42%) and King Size (22%), both manufactured by BAT. Smokeless tobacco had been used ever by 3.2% of men and had been used more by older than younger people (adjusted OR for over 50's relative to 14-19 year olds 2.09 (95% 1.38-3.18, p<0.05, Ptrend =0.006).
Knowledge of the health risks of smoking, including passive smoking and its impact on children and non-smokers, was high; radio (74%) and television (28%) were the main sources of such information and advice. Levels of health awareness were typically but not invariably higher in older people, in men, among the more highly educated and in those living in rural areas. There were few restrictions on smoking in public, and most people (38%) therefore worked and/or spent time in places where smoking was permitted. There was very strong support (97%) for comprehensive smoke-free legislation, mainly among Christians and Muslims. Despite the advertising ban, around a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products. Again radio was the main source of exposure (72%) but some had also noticed advertising on television (28%).
The interviews with policy makers showed that they had good knowledge of the content of the FCTC, and reported that although Ghana had no explicit written policy strategy on tobacco control, the Ministry of Health had issued several tobacco control directives both before and after ratification of the FCTC. A national tobacco control bill had been drafted but had not yet been implemented, something which the policy makers needed to happen urgently. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritization of tobacco control efforts.
Conclusions
Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence In Ghana was low, particularly among younger people. This suggests that In contrast to many other developing countries, progression of an epidemic increase in smoking has been avoided. Awareness of health risks and support for smoke-free policies were high in Ghana. Exposure to tobacco advertising or promotion was limited, and most smokers reported having tried to quit. Whether these findings are cause or effect of the current low smoking prevalence is uncertain. The likely reasons that I have identified for the low smoking prevalence include an early advertising ban, substantial state intervention in the tobacco industry at a crucial point of growth, socio-cultural factors (particularly religion), the harsh economic environment at a time when the industry was experiencing growth and other public health interventions such as health education by stakeholders involved in tobacco control. Although policy makers were aware of the FCTC, implementation of the World Health Organization (WHO) treaty has been slow, requiring an urgent need for the passage of the national tobacco control bill into law to enable the country to sustain its tobacco control efforts.
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