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.

Automated summary

This study analyzed the changes in tobacco use prevalence and socioeconomic inequalities among male and female participants aged 15 to 49 from 22 sub-Saharan African countries from 2003 to 2019. Despite a decrease in smoking rates in most countries, persistent socioeconomic disparities highlight the need for stronger tobacco control measures to target less-educated individuals and those with low incomes.