Guliani et al. BMC Public Health (2019) 19:938 https://doi.org/10.1186/s12889-019-7200-8 RESEARCHARTICLE Open Access Factors affecting tobacco smoking in Ethiopia: evidence from the demographic and health surveys Harminder Guliani*, Samuel Gamtessa and Monika Çule Abstract Background: Tobacco smoking is growing at an alarming rate in the developing world and sub-Saharan Africa. Although Ethiopia has a relatively low rate in the region, it is not immune to the tobacco epidemic. The government of Ethiopia passed an anti-tobacco bill in 2015 that includes measures governing tobacco consumption, advertising, packaging, and labeling. To effectively address the challenge of tobacco control, the government should consider a number of aspects of tobacco production and consumption, such as local production in rural areas, as well as the complementarity nature of tobacco and khat use. Methods: Using the World Bank’s Demographic and Health Surveys (2011 and 2016), this paper analyzes the key determinants of tobacco smoking in Ethiopia, emphasizing possible differences in various social contexts, across regions. More specifically, we assess the association between khat use and tobacco smoking while controlling for various observed individual-level, household-level, and community-level covariates. Using GPS data, we are able to capture the neighboring effects of smoking behavior in community clusters bordering other administrative regions as well as differences in smoking patterns between lowland and highland residents. We utilize a multilevel modeling framework and use a two-stage residual inclusion estimation method that accounts for the endogeneity of khat and tobacco use. Results: The results suggest that chewing khat and geographic regions are statistically significant determinants of tobacco smoking even after controlling for various socioeconomic and demographic factors. Altitude information analysis suggests that people living in lowlands are more likely to smoke compared to those living in highland areas. Additional analysis including interactions between regions and khat use indicate wide inter-regional variations in tobacco smoking by khat users. We also extend our analysis by interacting khat use with religious adherence. Results indicate a wide variation in tobacco smoking by khat chewers across different religious groups. Conclusions: To effectively control tobacco smoking of the diverse communities in Ethiopia, policymakers should consider a multi-pronged policy approach that combines various policy tools that account for regional variation, the local social contexts, as well as the complementary nature of smoking and khat chewing practices. Keywords: Tobacco smoking, Khat chewing, Two-stage residual inclusion, Multi-level analysis, Ethiopia * Correspondence: [email protected] Department of Economics, University of Regina, 3737 Wascana Parkway, Regina, SK, Canada © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Guliani et al. BMC Public Health (2019) 19:938 Page 2 of 17 Background the underlying behavior of tobacco consumers in those Despite decades of tobacco control policies, smoking markets. kills more than seven million people each year. It is esti- In addition, income disparity has resulted in a clear mated that over 86% of these deaths are from direct to- segmentation of tobacco retail markets in urban centers. bacco use, while around 13% are due to secondhand While local producers such as the Ethiopian National smoke [1]. The low and middle-income countries are es- Tobacco Enterprise cater to low-income smokers with pecially facing an increasing burden of tobacco related cheaper and lower quality brands (Gissila and Nyala diseases. Africa, particularly sub-Saharan Africa, is ex- among others), the imported and relatively more expen- periencing increasing tobacco use. The prevalence of sive brands are only consumed by high-income urban smoking varies considerably among African countries, residents. This market segmentation within the urban ranging from 4% in Ghana to 27.2% in Lesotho [2, 3]. centers, as well as the rural-urban differential smoking Some countries have seen a rapid and significant in- practices, suggests that policies that utilize consumption crease in consumption over the past 16 years. More spe- taxation as a means to moderate the prevalence of cifically, Mozambique and Nigeria have seen 220 and smoking, or banning smoking in certain areas, have dif- 60% growth in cigarette consumption, respectively [4]. ferential effects in reducing smoking and the external Rising population growth, increased consumer purchas- harms of secondhand smoke. To effectively control to- ing power due to economic growth, and lax enforcement bacco consumption in Ethiopia, it is important that pol- of tobacco control policies are among the contributing icymakers design policies that account for risk factors factors that make the African region more susceptible to affecting tobacco consumption within their proper the tobacco industry [4]. contexts. Ethiopia is one of the sub-Saharan countries that have relatively low rates of tobacco smoking in the region. Tobacco smoking and khat Nevertheless, it is not immune to the tobacco epidemic. Another consideration with relevance of tobacco con- According to the World Health Organization (WHO) sumption in the Ethiopian context is the rising con- (2015), 8.9% of Ethiopian men and 0.5% of Ethiopian sumption and production of khat (Catha edulis). Khat is women age 15 years and older smoke tobacco products a plant leaf that has been used as a stimulant for recre- [5]. Every year, more than 16,800 Ethiopians are killed ational purposes for centuries in the Horn of Africa and by tobacco-related diseases such as tuberculosis, lung the Arabian Peninsula [9]. In terms of production, khat cancer, cardiovascular and respiratory disorders. In has become a large export crop over the past two de- addition, the direct and indirect cost of smoking in cades, following coffee and oilseed. Khat trade is boom- Ethiopia is considerable and it is estimated to be 1391 ing, with many growers switching production from million Birr (about USD 50 million) [6]. In an attempt to coffee to khat [10].2 control tobacco consumption, the government of In terms of consumption, currently, 16% of the na- Ethiopia became a party to the WHO framework con- tion’s 100 million population is chewing khat, with wide vention on tobacco control on June 23, 2014, and then variation in consumption across the country. For in- followed with passing the anti-tobacco bill in 2015.1 stance, while in the Harari region in eastern Ethiopia the These regulations, based on Tobacco Control Directive prevalence rate is 53%, in the Tigray region in northern (no. 28/2015), include measures governing consumption, Ethiopia this rate is only 1.1% [11]. The DHS data (from tobacco advertising, packaging and labeling, and other both 2011 and 2016 survey years) used in this study sug- various product regulations [7]. gests that about 17% of Ethiopian respondents reported While these regulations are welcomed first steps in chewing khat in 30 days preceding the survey. In controlling tobacco consumption, it is important to addition, a meta-analysis on the prevalence of khat recognize that their effectiveness is blunted, in the Ethi- chewing among Ethiopian university students indicated opian context, due to rural-urban differences in smoking that more than one in five students have been engaged practices, the existence of the unregulated/illicit tobacco in khat chewing [12]. Furthermore, it appears that there economy and the income related market segmentation is an increase in local consumption. Before the begin- [8]. For instance, in the rural areas locally produced to- ning of the twenty-first century only limited amount of bacco products (e.g water pipes locally known as gaya) khat was chewed for socialization and at religious are sold and consumed in open markets. These products gatherings among Muslims, while currently, the number are not subject to taxation or other types of modern of khat chewers has increased among all socio- regulatory requirements with respect to labeling or ad- demographic characters [13]. The Economist (2017) also vertising. In other words, the tobacco control regulations reports that khat kiosks are spotted around all main have no enforceability in the unregulated/illicit tobacco towns along with young men chewing on street corners economy and as a result, they have little to no effect on or in university libraries [10]. Guliani et al. BMC Public Health (2019) 19:938 Page 3 of 17 Increasing khat consumption has become a growing pooled data, with Ethiopia being one of the observations, public health concern. Potentially due to its WHO status it is difficult to infer the significance of their findings for as a drug of abuse [14], khat has been banned in the US, the case of Ethiopia. Other studies with a specific focus Canada, Uganda, and some European countries.