Age at Smoking Initiation and Prevalence of Cigarette Use Among Youths in Sub-Saharan Africa, 2014-2017 | Adolescent Medicine | JAMA Network Open | JAMA Network
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Table 1.  Exposure to Smoking-Related Risk Factors and Antismoking Advertisements Among Adolescents in Sub-Saharan Africa: Global Youth Tobacco Survey 2014 to 2017
Exposure to Smoking-Related Risk Factors and Antismoking Advertisements Among Adolescents in Sub-Saharan Africa: Global Youth Tobacco Survey 2014 to 2017
Table 2.  Cigarette Use–Related Characteristics of Adolescents in Sub-Saharan Africa: Global Youth Tobacco Survey 2014 to 2017
Cigarette Use–Related Characteristics of Adolescents in Sub-Saharan Africa: Global Youth Tobacco Survey 2014 to 2017
1.
World Health Organization (WHO). Stop tobacco industry exploitation of children and young people. Published May 29, 2020. Accessed March 27, 2021. https://www.who.int/news-room/detail/29-05-2020-stop-tobacco-industry-exploitation-of-children-and-young-people
2.
Thun  M, Peto  R, Boreham  J, Lopez  AD.  Stages of the cigarette epidemic on entering its second century.   Tob Control. 2012;21(2):96-101. doi:10.1136/tobaccocontrol-2011-050294PubMedGoogle ScholarCrossref
3.
Isip  U, Calvert  J.  Analyzing big tobacco’s global youth marketing strategies and factors influencing smoking initiation by Nigeria youths using the theory of triadic influence.   BMC Public Health. 2020;20(1):377. doi:10.1186/s12889-020-8451-0PubMedGoogle ScholarCrossref
4.
Chido-Amajuoyi  OG, Mantey  DS, Clendennen  SL, Pérez  A.  Association of tobacco advertising, promotion and sponsorship (TAPS) exposure and cigarette use among Nigerian adolescents: implications for current practices, products and policies.   BMJ Glob Health. 2017;2(3):e000357. doi:10.1136/bmjgh-2017-000357PubMedGoogle Scholar
5.
Warren  CW, Jones  NR, Peruga  A,  et al; Centers for Disease Control and Prevention (CDC).  Global youth tobacco surveillance, 2000-2007.   MMWR Surveill Summ. 2008;57(1):1-28.PubMedGoogle Scholar
6.
World Health Organization. WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use: executive summary. Published July 25, 2019. Accessed March 27, 2021. https://www.who.int/publications/i/item/WHO-NMH-PND-2019.5
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    Research Letter
    Global Health
    May 7, 2021

    Age at Smoking Initiation and Prevalence of Cigarette Use Among Youths in Sub-Saharan Africa, 2014-2017

    Author Affiliations
    • 1Division of Cancer Prevention and Population Sciences, Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston
    • 2Department of Pediatrics, Texas A&M University/Driscoll Children’s Hospital, Corpus Christi
    • 3Department of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Austin
    JAMA Netw Open. 2021;4(5):e218060. doi:10.1001/jamanetworkopen.2021.8060
    Introduction

    The 2020 World No Tobacco Day campaign was focused on promoting measures to protect children and young people from exploitation by the tobacco industry. This comes as more than 40 million adolescents aged 13 to 15 years are reported to have already initiated tobacco use.1

    The African continent has one of the lowest regional tobacco use rates and is generally considered to be at subepidemic levels, with lower smoking intensities compared with other parts of the world.2 However, evidence points to increasingly aggressive tobacco industry marketing in Africa, with a substantial proportion of these efforts targeted at youth.3,4 With increasing tobacco industry activity in this region, African countries are projected to progress to a tobacco epidemic by 2040.2 This study aimed to describe the prevalence of exposure to smoking-related risk factors, susceptibility to smoke, cigarette smoking, and age at smoking initiation among adolescents in 9 sub-Saharan African nations.

    Methods

    This cross-sectional study analyzed data from the Global Youth Tobacco Surveys (GYTS) from 2014 to 2017 for Cameroon, Gabon, Comoros, Seychelles, Mauritius, Tanzania, Gambia, Ghana, and Sierra Leone. GYTS is a school-based survey designed to monitor behaviors and risk factors associated with adolescent tobacco use. The GYTS uses a 2-stage cluster sample to derive nationally representative samples for each nation.5 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. GYTS data are deidentified and publicly available, hence institutional review board approval was not required in accordance with 45 CFR §46. Passive parental consent was used for the GYTS. Parents received a notification form or letter prior to the survey and were allowed to opt out.

    Weighted prevalence and 95% CIs were estimated for secondhand smoke exposure, parental and peer smoking (social exposure), and protobacco and antitobacco advertisement exposure. Prevalence of ever and current cigarette use and susceptibility to smoking initiation among never smokers was calculated, as well as the distribution of age at smoking initiation. A detailed description of measures is provided in an eAppendix in the Supplement. χ2 tests were used to examine for differences in cigarette use, as well as susceptibility to smoking initiation by sex. Statistical significance was determined at P < .05. Analyses were performed using Stata version 14.2 (StataCorp) from September 1 to September 28, 2021.

    Results

    The overall sample (N = 38 313) represented a weighted population of 5 488 250 youths. Of this sample, 50.5% (20 677, unweighted) were female youths, with mean (SD) age of 14.3 (1.4) years. Secondhand smoking exposure at home ranged from 16.0% (95% CI, 13.4%-19.0%) in Tanzania to 33.8% (95% CI, 31.1%-36.5%) in Gambia (Table 1). In Seychelles, 68.6% (95% CI, 63.7%-73.2%) of youths were exposed to smoking by school peers. Protobacco advertising was most prevalent on television and as high as 64.5% (95% CI, 55.2%-72.8%) in Cameroon. Antismoking advertisement exposure were mostly via mass media (69.3% [95% CI, 66.8%-71.7%] in Gabon) and cigarette packs (62.3% [57.4%-67.0%] in Cameroon).

    Weighted prevalence of ever cigarette use ranged from 5.4% (95% CI, 3.8%-7.6%) in Tanzania to 36.4% (95% CI, 32.3%-40.8%) in Seychelles (Table 2). Current cigarette use ranged from 1.0% (95% CI, 0.6%-1.8%) in Tanzania to 15.4% (95% CI, 13.1% 18.1%) in Seychelles. Susceptibility to smoking initiation ranged from 7.3% (95% CI, 5.3%-10.0%) in Tanzania to 28.9% (95% CI, 25.2%-33.0%) in Sierra Leone. In all countries, cigarette smoking prevalence was greater among male youths compared with female youths (eg, in Gabon: 40.8% [35.1%-46.7%] of male youths had ever smoked vs 17.1% [11.8%-24.0%] of female youths; P < .001). Among ever smokers, more than 20% of youths started smoking by age 8 years in Tanzania, Ghana, and Sierra Leone. In all study countries, more than 75% of youths who smoked initiated smoking before age 15 years (Table 2).

    Discussion

    In sub-Saharan African nations, ever and current cigarette smoking were as high as 36.4% and 15.4%, respectively, with use being significantly higher among boys. Equally concerning is the widespread early age of onset of smoking in this region; as well as the fact that despite lower smoking rates, girls seemed to be as susceptible to smoking initiation as boys.

    Findings call for stricter enforcement of the World Health Organization Framework Convention on Tobacco Control–compliant policies throughout the region and conscious efforts geared to protect children from tobacco industry exploitation. For example, despite comprehensive bans on tobacco advertising, promotion and sponsorship,6 Seychelles and Mauritius have the highest smoking rates reported in this study. Specific adolescent-targeted interventions include enforcing bans on sales of tobacco products to minors and adding smoking prevention courses to the curricula of schools throughout sub-Saharan Africa. Study limitations include the fact that study data are self-reported and prone to recall and social desirability bias.

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    Article Information

    Accepted for Publication: March 9, 2021.

    Published: May 7, 2021. doi:10.1001/jamanetworkopen.2021.8060

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Chido-Amajuoyi OG et al. JAMA Network Open.

    Corresponding Author: Onyema Greg Chido-Amajuoyi, MD, MPH, Division of Cancer Prevention and Population Sciences, Department of Epidemiology, The University of Texas MD Anderson Cancer Center, 1155 Pressler St, Dan L. Duncan Building, CPB 4.3278, Houston, TX 77030 (ougreg@mdanderson.org).

    Author Contributions: Dr Mantey had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Fueta, Mantey.

    Obtained funding: Mantey.

    Administrative, technical, or material support: Chido-Amajuoyi, Mantey.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Dr Mantey’s postdoctoral fellowship is supported by the University of Texas Health Science Center at Houston School of Public Health Cancer Education and Career Development Program – National Cancer Institute/NIH Grant – National Cancer Institute/NIH Grant T32/CA057712.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    World Health Organization (WHO). Stop tobacco industry exploitation of children and young people. Published May 29, 2020. Accessed March 27, 2021. https://www.who.int/news-room/detail/29-05-2020-stop-tobacco-industry-exploitation-of-children-and-young-people
    2.
    Thun  M, Peto  R, Boreham  J, Lopez  AD.  Stages of the cigarette epidemic on entering its second century.   Tob Control. 2012;21(2):96-101. doi:10.1136/tobaccocontrol-2011-050294PubMedGoogle ScholarCrossref
    3.
    Isip  U, Calvert  J.  Analyzing big tobacco’s global youth marketing strategies and factors influencing smoking initiation by Nigeria youths using the theory of triadic influence.   BMC Public Health. 2020;20(1):377. doi:10.1186/s12889-020-8451-0PubMedGoogle ScholarCrossref
    4.
    Chido-Amajuoyi  OG, Mantey  DS, Clendennen  SL, Pérez  A.  Association of tobacco advertising, promotion and sponsorship (TAPS) exposure and cigarette use among Nigerian adolescents: implications for current practices, products and policies.   BMJ Glob Health. 2017;2(3):e000357. doi:10.1136/bmjgh-2017-000357PubMedGoogle Scholar
    5.
    Warren  CW, Jones  NR, Peruga  A,  et al; Centers for Disease Control and Prevention (CDC).  Global youth tobacco surveillance, 2000-2007.   MMWR Surveill Summ. 2008;57(1):1-28.PubMedGoogle Scholar
    6.
    World Health Organization. WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use: executive summary. Published July 25, 2019. Accessed March 27, 2021. https://www.who.int/publications/i/item/WHO-NMH-PND-2019.5
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