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

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