Current tobacco use and susceptibility to using tobacco among non-users of tobacco: a cross-sectional study among school-going adolescents in Sierra Leone.

doi:10.21203/rs.3.rs-798614/v2

Introduction

Tobacco use is a global health threat associated with a high disease burden and deaths. Studies concerning current tobacco use and susceptibility to using tobacco products among adolescents who are potential adult tobacco users in Sierra Leone have not been explored. We aimed to estimate the prevalence and correlates of current tobacco use and tobacco non-users susceptibility to using tobacco amongst Sierra Leonean high-school students.

Method

We used data obtained from the 2017 Sierra Leone Global Youth Tobacco Survey (GYTS), which presented information collected from 6680 students aged 11-17years nationwide. Gender-based correlates of current use and susceptibility to using tobacco among non-tobacco users were determined by complex sample logistic regression analyses. Adjusted odds ratios (AOR) and respective 95% confidence intervals (CIs) were reported. p-values less than 0.005 were considered significant.

Results

The prevalence of current tobacco use among high school adolescents in Sierra Leone was 24.6% and was higher in males (27.9%) than in females (18.6%). Male [AOR=1.50 (95%CI: 1.18-1.91)], parental smoking [AOR=1.73(95%CI:1.32-2.26)] exposure to household secondhand smoke [AOR=1.82(95%CI:1.27-2.62)], having peers who smoke [AOR=2.24(1.51-3.31)] were more likely to be currently using tobacco. On the other hand, adolescents exposed to antismoking media messages were less likely to be current tobacco users [AOR=0.67(95%CI: 0.52-0.85)]. The overall tobacco non-users susceptibility to using tobacco among adolescents in Sierra Leone was 18.2% [male (18.0%), female (18.5%)]. Exposure to tobacco promotion [AOR =1.50(95%CI:1.06-2.10)] and non-exposure to antismoking education [AOR =1.39(95%CI:1.05-1.86)] were significantly associated with tobacco non-users’ susceptibility to using tobacco.

Conclusion

Our study suggests that one-in-four school-going adolescents currently use tobacco, with nearly one in five non-users susceptible to using tobacco. Given the high prevalence of tobacco product use among Sierra Leonean adults, our findings highlight the need for policies and interventions to prevent tobacco use behaviour among adolescents aimed at averting tobacco use in adulthood.

Health Economics & Outcomes Research

Infectious Diseases

Health Policy

Tobacco use

Susceptible to using tobacco

Adolescents

Sierra Leone

Low- and middle-income countries

Africa

Tobacco use is considered a global public health threat. Currently, there are 1.3 billion people using tobacco, and 80% of them resides in low to middle-income countries, where tobacco-related morbidity and mortality are the highest¹, and this figure is expected to rise to 1.7 billion by 2025². It is estimated that eight million people die every year from health conditions for which tobacco use is considered the major cause, and more than three-quarters of deaths are due to direct tobacco use¹. Chronic tobacco use is a leading risk factor for many preventable chronic diseases in children and young adults with short term (nicotine addiction, sudden infant death syndrome, respiratory and atopic conditions) and long term (stroke, chronic respiratory diseases, and cancers) repercussions³. Aside from its health impact, a high economic cost is associated with tobacco use, and this includes the health cost linked with managing diseases due to tobacco use and the loss in productivity due to tobacco-related morbidity and mortality¹.

In sub-Saharan Africa, the prevalence of tobacco use is relatively low but increasing. Such characteristics make sub-Saharan Africa a potential market for multinational tobacco companies to sell their products. The increasing use of tobacco in the region is further exacerbated by globalisation, increased youth population and high illiteracy levels in the region⁴. Sierra Leone is one country that shares similar characteristics. A study conducted by Samai et al. in 2009 reported that 26% and 8% of adults use tobacco and smokeless tobacco products in Sierra Leone⁵. The same study reported that more than two-thirds of non-smokers were exposed to secondhand smoke at home or at their workplace. Another study conducted by Lisk et al. in Freetown and three villages in the northern province of Sierra Leone reported that the prevalence of tobacco smoke (cigarette) and smokeless tobacco use were 21.7% and 17.7%, respectively⁶. A recent UNDP report estimated that more than 3,300 deaths are linked to tobacco-related diseases every year and that a quarter of those deaths are among the poor. The same report estimated that tobacco use cost 1.5% of the Sierra Leone GDP in 2017, and this cost includes healthcare cost (SLL 108.4 billion), lost productivity due to morbidity, mortality, and workplace smoking (SLL 295.5 billion). Such statistics create a challenge to public health, which is augmented by the fact that non-communicable diseases are on the rise⁷. Also, despite a national non-communicable disease(NCD) policy and strategic plan was developed in 2013, the country’s capacity to prevent, control, and manage the growing NCD burden is limited⁷. This has been associated with limited funding from government and donor partners, structural and financial barriers for users, maldistribution, limited training of the health workforce, and limited access to quality-assured medicines⁸.

Sierra Leone is a signatory to the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO FCTC). The WHO FCTC provides measures to protect the public from social, environmental, and economic consequences of tobacco use. These measures include reducing demand (taxation, bans on smoking in all public places, public education) and supply (illegal trade in tobacco products and sales to and by minors) of tobacco. As of 2018, Sierra Leone has only imposed a 30 percent excise tax on tobacco products, below the 70 percent excise tax recommended by WHO⁹. Also, anti-tobacco media campaigns have been implemented, although they have not been aired on mass media outlets. Measures such as bans on smoking in all public places, mandate tobacco products carry health warnings that cover 50% of the packaging products and ban on all forms of tobacco advertising, promotion, and sponsorship have not yet been implemented⁹.

Along with strong tobacco control measures targeting tobacco users, it is critical to implement interventions targeting non-tobacco users susceptible to tobacco use or initiating tobacco use behaviour. Previous research has indicated that susceptibility to using tobacco is strongly associated with experimenting with a tobacco product compared to family history of using tobacco products ^10,11, with youths being more likely to be established users¹². A previous global study found that 1 in 8 never-smoking youths was susceptible to smoking, of which 7.2% and 5.3% were males and females, respectively¹³. Currently, few studies have been conducted in low-income countries^14-17 on this subject, but none has so far been conducted in Africa and Sierra Leone in particular.

Given that the burden of tobacco use in Sierra Leone is increasing^5,18,19, and many young people start smoking during adolescence [20], call for the need to investigate the tobacco use behaviour among adolescents to inform policy, public health interventions and advocacy. Currently, studies on tobacco use among adolescents are scarce. A study by Bangura et al reported that the prevalence of cigarette use was 3.2% among school-going pupils in Bo southern Sierra Leone²⁰. However, this study has certain key limitations. Firstly, it was conducted more than two decades ago, and therefore, its findings may not hold true given the demographic transitions and increased urbanisation that have occurred in Sierra Leone over the years. Secondly, the study findings are not representative of the whole country, given that it was only conducted in Bo, the second city of Sierra Leone. Also, other nationwide studies have only explored tobacco use among the adult population^5,18. Using data from the 2017 Sierra Leone Global Youth Tobacco Survey (GYTS), we estimated the prevalence and correlates of current tobacco use and never-smoking youth susceptibility to using tobacco among high school students in Sierra Leone.

Study setting, design, and population

We obtained our data from the Sierra Leone GYTS conducted in 2017 publicly available at WHO- Global Tobacco Surveillance System (WHO - GTSS) Data portal²¹. GYTS is a nationwide cross-sectional survey among high school students to assess behaviours and risk factors associated with tobacco use among adolescents. The survey was conducted among 6,680 eligible students in Junior Secondary school (JSS) 2, 3 and Senior Secondary School (SSS) 1. The Sierra Leone GYTS uses a standard questionnaire that explores the following topics: tobacco use (smoking and smokeless), cessation, secondhand smoke (SHS), pro-and anti-tobacco media and advertising, access to and availability of tobacco products, and knowledge and attitudes regarding tobacco use. The research design employed in this study has been described in previous studies^13,22.In summary, a two-stage cluster sampling method was used to collect the nationally representative data. In the first stage, schools were selected based on their enrolment size, and in the second phase, classes were randomly selected in of the selected schools. The overall response rate was 79.6%.

Measures: Our outcome measures include current tobacco use and susceptibility to using tobacco among non-users of tobacco. The current tobacco use was defined as using cigarettes, smoked tobacco products other than cigarettes and smokeless tobacco products in the last 30 days. Current use of cigarettes was determined by respondents’ self-reported response of one or more days to the question, ‘‘During the past 30 days, on how many days did you smoke cigarettes?’’, and the current use of tobacco products other than cigarette was determined by respondents’ saying “yes” to any of the following questions – ‘‘During the past 30 days, did you use any form of smoked tobacco products other than cigarettes (such as cigar, pipe water pipe and shisha)?’’ and ‘‘During the past 30 days, did you use any form of smokeless tobacco products (e.g. chewing tobacco, snuff, dip)?’’, respectively.

We accessed susceptibility to using tobacco among non-tobacco users using the algorithm developed by Pierce et al.^23,24. Non-tobacco users were defined as those who have never used cigarettes, smoked tobacco products other than cigarettes and smokeless tobacco products. Non-tobacco users were identified as those respondents who responded “no” to the any of the following questions- “Have you ever tried or experimented with cigarette smoking, even one or two puffs?”, “Have you ever tried or experimented with any form of smoked tobacco products other than cigarettes (such as cigar, pipe, shisha or water pipe)?” and “Have you ever tried or experimented with any form of smokeless tobacco products (such as snuff, chewing tobacco)?” We defined susceptibility to using tobacco by participants’ responses to the following four-point ordinal scale: (1) definitely not; (2) probably not; (3) probably yes; and (4) definitely yes, as based on the following questions 1) “If one of your best friends offered you a cigarette, would you smoke it?” and 2) “At any time during the next 12 months do you think you will smoke a cigarette?” Based on the current scholarship^13,22,25,26, we developed 13 factors from 27 questions that could likely be linked with current tobacco use and susceptibility to using tobacco among non-tobacco users in the adolescent population in Sierra Leone. These factors include age, sex, grade, money to be spent on an average week, parental, peer smoking, exposure to secondhand smoke (SHS) inside or outside the home, exposure to antismoking media messages, exposure to tobacco industry promotions, support for the smoke-free policy, knowledge about harmful effects of smoking and SHS, the family discussed the harmful effects of smoking tobacco and antismoking school education. We dichotomized all variables based on previously described methods^27,28 Please see Table 1

Table 1: Study measures, survey items with responses, Sierra Leone Global Youth Tobacco Survey (GYTS)

Study measure

GYTS survey items

GYTS item responses

Dichotomized measure

GYTS question used to obtain never-non-tobacco users’ status

Have you ever tried or experimented with cigarette smoking, even one or two puffs?”,

Yes

No

Yes- Ever smoker

No-Never smoker

No- no for all three dichotomized items

Yes - for all three dichotomized items

Have you ever tried or experimented with any form of smoked tobacco products other than cigarettes

Yes

No

Yes- Ever smoker

No-Never smoker

Have you ever tried or experimented with any form of smokeless tobacco products (such as snuff, chewing tobacco)?”

Yes

No

Yes- Ever use smokeless tobacco

No - Never used smokeless tobacco

Dependent variable

Tobacco use susceptibility

If one of your friends offered you a cigarette,

would you smoke it?

Definitely not

Probably not

Probably yes

Definitely yes

No “Definitely not” for

all three items

Yes any other responses

for any of the three item

At anytime during the next 12 months do you think you will use any form of tobacco?

Definitely not

Probably not

Probably yes

Definitely yes

No “Definitely not” for

all three items

Yes any other responses

for any of the three item

Dependent variable: current tobacco use

During the past 30 days, on how many days did you smoke cigarettes?

0 days

1 or 2 days

3 to 5 days

6 to 9 days

10 to 19 days

20 to 29 days

All 30 days

No- 0 days

Yes- 1 or more days

No- no for all three dichotomized items

Yes - for all three dichotomized items

During the past 30 days, did you use any form of smoked tobacco products other than cigarettes (such as cigar, pipe water pipe and shisha)?

Yes

No

Yes

No

During the past 30 days, did you use any form of smokeless tobacco products (e.g. chewing tobacco, snuff, dip)?

Yes

No

Yes

No

Independent variables

Age

How old are you?

11 years old or younger

12 years old

13 years old

14 years old

15 years old

16 years old

17 years old or older

≤13 years old

≥14years old

Sex

What is your sex?

Male

female

Male

female

Grade / form

In what grade/form are you?

JSS2

JSS3

SSS1

JSS2

JSS3

SSS1

Money to be spent on average week

During an average week, how much money do you have that you can spend on yourself, however you want?

I usually don't have any spending money

Less than Le 20,000

Le 20,000 - Le 40,000

Le 41,000 - Le 60,000

Le 61,000 - Le 80,000

Le 81,000 - Le 100,000

Le 101,000 -Le 500,000

No Money- I usually don't have any spending money

Have money- any other responses for any of the remaining six items

Parental smoking

How often do you see your father (stepfather or mother's partner) smoking in your home?

Don't have/Don't see this person

About every day

Sometimes

Never

No- Don't have/Don't see this person and Never

Yes- About every day and Sometimes

No- no for both dichotomized items

Yes - for both dichotomized items

How often do you see your mother (stepmother or father's partner) smoking in your home

Don't have/Don't see this person

About every day

Sometimes

Never

No- Don't have/Don't see this person and Never

Yes- About every day and Sometimes

Peer smoking

Do any of your closest friends smoke tobacco?

None of them

Some of them

Most of them

All of them

No- None of them

Yes- Some of them

Most of them

All of them

SHSb exposure in your home

During the past 7 days, on how many days has anyone smoked inside your home, in your presence?

0 days

1 to 2 days

3 to 4 days

5 to 6 days

7 days

No- 0 days

Yes-1 to 2 days

3 to 4 days

5 to 6 days

7 days

SHSb exposure outside home

During the past 7 days, on how many days has anyone smoked in your presence, inside any enclosed public

place, other than your home (such as office, school, shops, restaurants, cinemas, night club)?

0 days

1 to 2 days

3 to 4 days

5 to 6 days

7 days

No- 0 days

Yes-1 to 2 days

3 to 4 days

5 to 6 days

7 days

No- no for all three dichotomized items

Yes - for all three dichotomized items

During the past 7 days, on how many days has anyone smoked in your presence, inside any public

transportation vehicles, such as trains, buses, or taxicabs?

I did not use public transportation during the past 7 days

I used public transportation, but no one smoked in my presence

1 to 2 days

3 to 4 days

5 to 6 days

7 days

No-“ I did not use public transportation during the past 7 days” and “I used public transportation, but no one smoked in my presence”

Yes-1 to 2 days

3 to 4 days

5 to 6 days

7 days

During the past 7 days, on how many days has anyone smoked in your presence, at any outdoor public place

(such as playgrounds, sidewalks, entrances to buildings, parks, beaches, vehicle)?

0 days

1 to 2 days

3 to 4 days

5 to 6 days

7 days

No- 0 days

Yes-1 to 2 days

3 to 4 days

5 to 6 days

7 days

Exposure to antismoking

media messages

During the past 30 days, how many

antismoking media messages (e.g., television,

radio, billboards, posters, newspapers, magazines,

movies) have you seen?

Yes

No

Yes

No

No- no for both dichotomized items

Yes - for both dichotomized items

Support for smoke-free

policy

Are you in favour of banning smoking in public

places (such as in restaurants, in buses, streetcars,

and trains, in schools, on playgrounds, in gyms

and sports arenas, in discos)?

No

Yes

No

Yes

No- no for all three dichotomized items

Yes - for all three dichotomized items

Do you think the sale of tobacco products to minors should be banned?

No

Yes

No

Yes

Do you think tobacco advertising should be banned?

No

Yes

No

Yes

Knowledge about harmful effects of smoking and SHS

Do you think cigarette smoking is harmful to

your health?

Definitely not

Probably not

Probably yes

Definitely yes

No “Definitely not” for both

items

Yes - any other responses

for either item

No- no for both dichotomized items

Yes - for both dichotomized items

Do you think the smoke from other people’s

cigarettes is harmful to you?

Definitely not

Probably not

Probably yes

Definitely yes

No “Definitely not” for both

items

Yes - any other responses

for either item

Tobacco industry promotion

Do you have something (t-shirt, pen, backpack, etc.)

with a cigarette brand logo on it?

No

Yes

No

Yes

No- no for both dichotomized items

Yes - for both dichotomized items

Has a (cigarette representative) ever offered

you a free cigarette?

No

Yes

No

Yes

Family discussed the harmful effects of smoking tobacco

Has anyone in your family discussed the harmful effects of smoking tobacco with you?

No

Yes

No

Yes

Antismoking school education

During the past 12 months, were you taught in any of your classes about the dangers of tobacco use?

No

I don’t know

Yes

No- No

I don’t know

Yes- Yes

Data Analysis

We used SPSS v27 to analyse our data. The sample data were weighted to adjust for sampling design effect, non-responses at school, class and student levels, and post-stratification of the sample relative to sex and grade distribution in the population like earlier studies^13,25,29 using complex sample design. We represent variables using weighted percentages Given the established gender difference regarding tobacco use, we conducted separate analyses for male and female adolescents. Complex sample logistic regression analyses were used to determine the correlates of the current tobacco use and susceptibility to using tobacco among never-smokers for males and females. The adjusted odds ratios (AOR) and respective 95% confidence intervals (CIs) were reported. A p-value less than 0.005 was considered significant for all inferential statistics. Hosmer and Lemeshow was employed test to test the fitness of our models and all models were found to be fit. The variance inflation factor (VIF) was used to test for multicollinearity among independent variables and all VIFs were below 1.30.

Ethics review

Ethics approval was not required for this study given that the GYTS data are deidentified and publicly available. The 2017 Sierra Leone GYTS received ethics approval from the Ministry of Health and Sanitation. A written informed consent was obtained from the parent and guardians of the students who participated in the survey.

Study population

Table 2 gives a detail of the study population. The study included 6680 school-going adolescents. Majority (85.6%) were aged 14years and older, and half of them (50.7%) were males. Close to a quarter of were exposed to parental (24.5%) and peer smoking behaviour (24.0%). Majority of males (94.1%) and females (95.7%) were in favour of a smoke-free policy.

Table 2: Population characteristics of Sierra Leone Global Youth tobacco survey 2017

Characteristics	Total (%)	Male (%)	Female (%)
Sex Male Female
	50.7
	49.3
Age ≤12yrs 13-15yrs ≥16yrs
	5.4	3.7	4.7
	52.2	50.8	54.9
	42.5	45.5	40.3
Grade JSS2 JSS3 SSS1
	41.3	41.0	42.1
	39.7	40.8	39.5
	19.0	18.1	18.4
Money on average week
Have Money	61.1	60.3	63.4
No Money	38.9	39.7	36.6
Parental smoking
Yes	24.5	27.8	21.1
No	75.5	72.2	78.9
SHSb exposure in your home
Yes	27.7	30.9	24.6
No	72.3	69.1	75.4
SHSb exposure outside home
Yes	58.7	60.9	56.1
No	41.3	39.1	43.9
Peer smoking
Yes	24.0	31.4	15.1
No	76.0	68.6	84.9
Exposure to antismoking media messages
Yes	54.7	56.7	52.7
No	45.3	43.3	47.3
Support for smoke-free policy
Yes	94.8	94.1	95.7
No	5.2	5.9	4.3
Knowledge about harmful effects of smoking and SHS
Yes	91.6	90.7	92.8
No	8.4	9.3	7.2
Tobacco industry promotion
Yes	28.0	33.5	22.5
No	72.0	66.5	77.5
Family discussed the harmful effects of smoking tobacco
Yes	58.0	59.3	56.3
No	42.0	40.7	43.7
Antismoking school education
Yes	52.0	53.3	50.8
No	48.0	46.7	49.2

Current Tobacco-use and its correlates

Table 3 gives a summary of the current tobacco use. The overall prevalence of current tobacco use among high school adolescents in Sierra Leone was 24.6%, and it was higher in males (27.9%) than in females (18.6%). Interestingly, the highest current prevalence of tobacco use was among adolescents who support a smoke free policy (96.1%) and this was the case for both sexes [ males (95.2%) and females (97.0%). Equally, majority high school adolescents who said they were knowledgeable about harmful effects of smoking and SHS were current user of tobacco product (93.8%) and no significant gender difference was observed [ males (95.1%) and females (91.7%).]

Table 4 summarised the factors significantly associated with current tobacco use among school-going adolescents in Sierra Leone. Males [AOR=1.50 (95%CI: 1.18-1.91)] are more likely to be current tobacco users than females. Adolescents exposed to parental smoking [AOR=1.73(95%CI:1.32-2.26)], exposure to household secondhand smoke [AOR=1.82(95%CI:1.27-2.62)], having peers who smoke [AOR=2.24(1.51-3.31)] were more likely to be currently using tobacco. Similar associations between exposure to secondhand smoke at homes and the current use of tobacco were observed among males [AOR= 2.85(95%CI: 1.68- 4.84)] and females [AOR=2.54(95%CI: 1.36- 4.74)]. Also, adolescents who had peers who smoke [AOR=2.24(1.51-3.31)] were more likely to be current users of tobacco than those who do not have peers who smoke. A similar relationship between having friends who smoke and being a current tobacco user was observed among males [AOR=, 2.19(95%CI:1.42- 3.37)] and females [AOR= 2.21 (95%CI:1.40-3.50)]. Adolescents who were not exposed to antismoking media messages were less likely to be current tobacco users [AOR=0.67(95%CI:0.52-0.85)] although the such association was observed among females [AOR=0.51(95%CI:0.34- 0.77)] but not males [AOR=0.80(95%CI :0.63- 1.03)]. Interestingly, although no overall significant association was observed between not being knowledgeable about the harmful effects of smoking and SHS and being a current user of tobacco, a gender difference was observed with a more likely association seen among females [AOR=1.79(95%CI:1.14- 2.81)] and less likely association among males [AOR=0.39(95%CI :0.17- 0.88)]. Among females, those not exposed to antitobacco education in school were more likely to be current tobacco user than those exposed to antitobacco education in school [AOR=.2.20(95%CI:1.19- 4.08)].

Table 3: Bivariate analysis of factors associated with current tobacco use and susceptibility to using tobacco among non-users of tobacco in school going adolescents in Sierra Leone, Global Youth tobacco survey 2017

Characteristics	Current user tobacco product (N=5658)			Susceptibility to using tobacco among non-tobacco users (N=5537)
	Total n (%)	Male n (%)	Female n (%)	Total n (%)	Male (%)	Female (%)
	1613(24.6)	800(27.9)	658(18.6)	984(18.2)	418(18.0)	545(18.5)
Age ≤12yrs 13-15yrs ≥16yrs
	238(11.8)	41(5.1)	108(12.3)	24(2.2)	9(1.8)	11(1.9)
	719(49.1)	367(48.4)	321(55.4)	477(50.0)	194(48.1)	279(53.0)
	586(39.0)	358(46.5)	206(32.4)	455(47.8)	202(50.1)	243(45.1)
Grade JSS2 JSS3 SSS1
	590(41.2)	311(39.1)	251(48.8)	358(17.9)	175(18.2)	183(17.6)
	556(36.6)	313(40.3)	212(33.0)	445(19.1)	183(18.5)	262(19.7)
	420(22.2)	165(20.6)	175(18.2)	151(17.1)	55(16.1)	96(18.1)
Money on average week
Have Money	873 (58.1)	445(58.7)	381(61.8)	586(18.5)	229(17.0)	357(19.8)
No Money	710(41.9)	340(41.3)	271(38.2)	361(17.6)	186(19.8)	175(15.2)
Parental smoking
Yes	534(36.0)	307(40.7)	194(30.8)	230(19.9)	101(17.5)	129(23.1)
No	1011(64.0)	457(59.3)	441(69.2)	710(17.6)	311(18.2)	399(17.0)
SHSb exposure in your home
Yes	643(41.8)	372(48.1)	237(35.8)	281(19.9)	111(15.9)	170(24.8)
No	924(58.2)	405(51.9)	405(64.2)	666(17.5)	302(18.8)	364(16.4)
SHSb exposure outside home
Yes	1049(69.5)	533(73.3)	396(61.1)	578(18.9)	251(17.7)	327(20.1)
No	443(30.5)	195(26.7)	216(38.9)	355(17.1)	159(18.8)	196(15.7)
Peer smoking
Yes	746(44.9)	408(50.7)	239(32.5)	230(20.7)	127(17.9)	103(27.1)
No	842(55.1)	378(49.3)	412(67.5)	729(17.6)	290(18.0)	439(17.2)
Exposure to antismoking media messages
Yes	995(63.4)	498(64.0)	402(62.7)	567(17.5)	250(16.9)	317(18.1)
No	550(36.6)	277(36.0)	228(37.3)	369(19.7)	151(20.0)	218(19.4)
Support for smoke-free policy
Yes	1333(96.1)	682(95.2)	539(97.0)	670(18.1)	296(18.8)	374(17.5)
No	50(3.9)	31(4.8)	18(3.0)	286(18.6)	118(16.6)	168(20.8)
Knowledge about harmful effects of smoking and SHS
Yes	1411(93.8)	704(95.1)	572(91.7)	880(18.8)	376(18.4)	504(19.1)
No	91(6.2)	37(4.9)	48(8.3)	58(14.3)	30(14.2)	28(14.5)
Tobacco industry promotion
Yes	512(38.6)	325(45.9)	165(30.8)	284(21.6)	136(19.3)	148(25.1)
No	858(61.4)	389(54.1)	358(69.2)	638(17.3)	265(17.5)	373(17.2)
Family discussed the harmful effects of smoking tobacco
Yes	975(63.9)	492(64.9)	383(59.8)	522(17.3)	244(17.8)	278(16.8)
No	530(36.1)	263(35.1)	242(40.2)	412(19.3)	156(17.7)	256(20.8)
Antismoking school education
Yes	786(47.7)	391(49.2)	303(42.8)	465(16.5)	210(16.1)	255(16.9)
No	723(52.3)	363(50.8)	309(57.2)	491(20.8)	207(21.0)	284(20.7)

Adolescents susceptible to smoking tobacco and its predictors

The overall tobacco non-users susceptibility to using tobacco among adolescents in Sierra Leone was 18.2% [male (18.0%), female (18.5%)] (Table 3). The highest prevalence of susceptibility to using tobacco among non-users of tobacco was among who were 13-15 years(50.0%) and 16years and above (47.8%) followed by those exposed to tobacco promotion (21.6%) and those who had peers that smoke ((20.7%). Among males, the highest prevalence of the susceptibility to using tobacco among non-users of tobacco was among those who were not exposed to anti-smoking education in school (21.0%), followed by those not exposed to anti-smoking media messages (20.0%). Among females, the highest prevalence of susceptibility to using tobacco among non-users of tobacco was among those exposed to tobacco industry promotion (25.1%) followed by those exposed to secondhand smoke in their homes (24.8%).

Table 4 shows the factors that were associated with susceptibility to using tobacco among non-users of tobacco. Two factors were significant determinant of susceptibility to using tobacco among non-tobacco users. Adolescents who were exposed to tobacco promotion [AOR =1.50(95%CI: 1.06-2.10)] and those who were not exposed to antismoking education in school [AOR =1.39(95%CI: 1.05-1.86)] were more likely than their reference groups to be susceptible to using tobacco. Among males, those not exposed to anti-smoking education in school were more likely to be susceptible to using tobacco [AOR=1.45(95%CI:1.05-2.00)] compared to those who were exposed to anti-smoking education in school. Among females, those exposed to tobacco industry promotion [AOR=1.88(95% CI:1.20-2.94)] and those not in support for smoke-free policy [AOR=1.94(95%CI:1.10-3.45)] were more likely to be susceptible to tobacco use among non-users compared to their reference groups. On the other hand, adolescents who were not knowledgeable about the harmful effects of smoking and secondhand smoke were less likely to be susceptible to tobacco use among non-users [AOR=0.55(95%CI:0.33-0.92)] compared to those who were knowledgeable about the harmful effects of smoking and secondhand smoke. A similar association between not being knowledgeable about harmful effects of smoking and secondhand smoke and susceptibility to tobacco use among non-users was observed among females [AOR=0.46(95%CI:0.24-0.89)] but not males [AOR=0.57(95%CI:0.27-1.18)].

Table 4: Determinants of the current tobacco use and susceptibility to using tobacco among non-users of tobacco in school going adolescents in Sierra Leone, Global Youth tobacco survey 2017 (N= 6680)

Determinants	Current use of tobacco			Susceptibility to using tobacco among non -tobacco users
	Total	Male	Female	Total	Male	Female
	AOR (95%CI	AOR (95%CI)	AOR (95%CI)	AOR (95%CI	AOR (95%CI)	AOR (95%CI)
Sex
Male	1.50(1.18-1.91)^⁎			0.96(0.75-1.23)
Female	1			1
Age ≤12yrs 13-15yrs ≥16yrs
	1	1	1	1	1	1
	0.59(0.39-0.90)	0.50(0.30-0.84)	0.67(0.30-1.55)	1.46(0.82-2.59)	1.61(0.71-3.64)	1.27(0.62-2.63)
	0.59(0.37-0.94)	0.54(0.32- 0.94)	0.55(0 .22- 1.36)	1.64(0.89-3.01)	1.97(0.84-4.61)	1.36(0.63-2.89)
Grade JSS2 JSS3 SSS1
	1	1	1	1	1	1
	0.98(0.61-1.56)	1.16(0.68- 1.99)	0.80(0.48- 1.34)	1.13(0.72-1.77)	0.94(0 .60- 1.47)	1.33(0.72-2.44)
	1.05(0.59-1.88)	1.46(0.70- 3.04)	0.58(0.37- 0.93)	0.84(0.45-1.54)	0 .67(0.35- 1.29)	1.02(0.44-2.32)
Money to be spent on average week
Have Money	0.92(0.73-1.16)	0.80(0.58- 1.11)	1.12(0.74- 1.70)	1.10(0.79-1.52)	0 .83(0 .61- 1.14)	1.45(0.96-2.19)
No Money	1	1	1	1	1	1
Parental smoking
Yes	1.73(1.32-2.26)^⁎	1.64(1.25- 2.17)^⁎	2.00(1 .35- 2.95)	0.87(0.62-1.21)	0.88(0 .55- 1.40)	0.85(0.60-1.21)
No	1	1	1	1	1	1
SHSb exposure in your home
Yes	1.82(1.27-2.62)^⁎⁎	1.94(1.31- 2.86)^⁎⁎	1.64(1.03- 2.61)^⁎	1.12(0.69-1.84)	0.80(0.46-1.41)	1.57(0.92-2.70)
No	1	1	1	1	1	1
SHSb exposure outside home
Yes	1.00(0.62-1.61)	1.21(0.72- 2.01)	0.80(0.47- 1.37)	1.08 (0.77-1.53)	0.96(0.59- 1.56)	1.25(0.86-1.82)
No	1	1	1	1	1
Peer smoking
Yes	2.24(1.51-3.31)^⁎	2.19(1.42- 3.37)^⁎	2.21 (1.40- 3.50) ⁎	1.10(0.79-1.54)	1.01(0.71-1.45)	1.46(0.87-2.43)
No	1	1	1	1	1	1
Exposure to antismoking media messages
Yes	1	1	1	1	1	1
No	0.67(0.52-0.85)^⁎	0.80(0.63- 1.03)	0.51(0.34- 0.77)^⁎	1.19(0.88-1.60)	1.15(0.79-1.63)	1.26(0.89-1.78)
Support for smoke-free policy
Yes	1	1	1	1	1	1
No	0.69(0.41-1.15)	0.82 (0 .43- 1.57)	0.43(0.21- 0.90)	1.15(0.66-2.01)	0.70(0.33-1.51)	1.94(1.10-3.45)^⁎
Knowledge about harmful effects of smoking and SHS
Yes	1	1	1	1	1	1
No	0.70(0.41-1.18)	0.39(0.17- 0.88)	1.79(1.14- 2.81)^⁎	0.55(0.33-0.92)^⁎	0.57(0.27-1.18)	0.46(0.24-0.89)^⁎
Tobacco industry promotion
Yes	1.31(0.98-1.75)	1.28(0.94- 1.75)	1.26(0 .75- 2.10)	1.50(1.06-2.10)^⁎	1.28(0.84-1.96)	1.88(1.20-2.94)^⁎
No	1	1	1	1	1	1
Family discussed the harmful effects of smoking tobacco
Yes	1	1	1	1	1	1
No	0.95(0.63-1.44)	0.91(0 .58- 1.42)	1.00(0 .61- 1.63)	1.01(0.71-1.43)	0.86(0.58-1.28)	1.12(0.77-1.62)
Antismoking school education
Yes	1	1	1	1	1	1
No	1.66(0.98-2.78)	1.40(0.60- 3.28)	2.20(1.19- 4.08)^⁎	1.39(1.05-1.86)^⁎	1.45(1.05-2.00)^⁎	1.39(0.99-1.96)

⁎ = p< 0.05

⁎⁎= p< 0.001

SHS= Second-hand Smoke

Tobacco use is a significant risk factor to the increasing burden of non-communicable disease burden in sub-Saharan Africa. Given that non-communicable diseases are on the rise among the adult population in Sierra Leone, most of these adults start to smoke when they are teenagers. Such tobacco use pattern call for the need to explore adolescents’ current tobacco use and susceptibility to using tobacco among non-users to inform policy, public health interventions and advocacy. Our study indicates that one in four high school adolescents aged 11-17 years in Sierra Leone was a current tobacco user 30 days preceding the conduct of this survey.

The current prevalence of current tobacco use among males and females is higher than what was reported in similar studies in Ghana²⁹, Gambia³⁰ and Sudan³¹ but was lower than those reported in Madagascar²⁵ and the Republic of Congo³². Differences in prevalence maybe attributed to variations in how tobacco use was measured, and the age group considered. As reported among Sierra Leonean adults³³, the relatively high use of tobacco products among school-going adolescents is a public health concern, and it indicates the need for youth-centred tobacco policies and interventions designed to address their needs. As reported in other studies^29,31, we also observed a gender gap regarding tobacco use behaviour among school-going adolescents in Sierra Leone. Such difference in the tobacco use prevalence between males and females warrants the need to include gender when designing and implementing a tobacco policy targeting youths in Sierra Leone. Interventions such as age verification and a ban on tobacco products to minors could serve as deterrents that could restrict youth access to and demand for tobacco products.

Results from the regression analysis indicate that adolescents whose parents were smokers and were exposed to secondhand smoke in the home were more likely to be current tobacco users, and this was observed for both sexes. This suggests that family relation is a strong influencing factor associated with tobacco use behaviour. This is in line with studies from Ghana and Sudan, and South Africa in which familial relationship was a significant factor associated with youth tobacco use^29,31,34. Consistent with other studies^25,29,35, peer smoking behaviour was a significant predictor of current users of tobacco in our study, and such association was observed in both sexes. Our findings suggest that interventions need to be developed to target familial relations of adolescents and their peers. Family and peer education will be useful interventions to help curb the family and peer influence on youth smoking behaviour in Sierra Leone. We did not observe any significant association regarding youth exposure to promotion from the tobacco industry and current tobacco use as it has been reported in other studies^29,36. This further suggests that tobacco promotion and advertisement might not be significantly influencing school-going adolescent tobacco use behaviour. Notwithstanding that it is essential that the government implement a ban on tobacco promotion and advertisement along with other MPOWER strategies to help protect citizens from the harmful effects of tobacco use³⁷. Also, gender disparity was noted regarding exposure to anti-smoking education in school in our study. We found that non-exposure to anti-smoking education in school was a significant determinant of current tobacco use status among females, but not males, which implies the need for an education policy that allows teaching about the harmful effects of tobacco use mandatory in schools.

Our study also showed that close to one in five non-users of tobacco in Sierra Leone aged 11-17 years were susceptible to using tobacco products, although there was no significant gender difference. Our prevalence is higher than the global prevalence of 12.5%¹³ and among youths in three southeast Asian countries(Cambodia, Laos and Vietnam)³⁸, Pakistan³⁹ and Malaysia⁴⁰. Such a result suggests the need to develop interventions that prevent non-tobacco users from using tobacco and eventually become regular users by targeting them at the pre-experimental stage. In line with previous studies ^13,41-43, tobacco industry promotion is a significant factor influencing susceptibility to using tobacco products among non-users in our study. The strong influence of the tobacco industry on the intention to use tobacco among adolescent has been recognised by the World Health Organisation in 2012 World No Tobacco Day themed “Tobacco industry interference”, which exposes and advocate a ban to tobacco industry attempts to undermine global tobacco policy initiatives as enshrined in the WHO FCTC treaties^44,45. To reduce the tobacco industry's influence on the intention to use tobacco among non-tobacco users, it is important that the Sierra Leonean government take steps to impose a total ban on tobacco advertisement and promotion in line with the WHO Framework Convention on Tobacco Control (FCTC)⁴⁵. Also, non-exposure to anti-smoking education in school was a significant factor influencing susceptible to using tobacco products among non-users of tobacco, which is consistent with a study in Malaysia in which students exposed to educational programmes on the health effects of smoking were less likely to be susceptible to smoking⁴⁰. Our finding suggests that teaching about the adverse effects of tobacco use should be part of the national school curriculum in Sierra Leone. Also, female adolescents who are not in favour of a smoke-free policy/ban or ban on the use on tobacco in public places/ sale of tobacco products to minors/ tobacco advertising were likely to be susceptible to using tobacco products among non-users in our study. This maybe because of the significant strong influence of tobacco industry promotion observed in this study which would have influence their perception regarding the use of tobacco products.

Readers need to take the following limitations when interpreting our findings. First, our results are not representative of all adolescents given that only school-going adolescents were targeted and those that were present on the day that this survey was administered. Second, our study employed a cross-sectional study design, which limits any causal relationship to be inferred. Third, we used 27 questions to construct 14 predictors based on the available scholarship on tobacco use among school-going adolescents. Country specific measures such as national tobacco control programs or policies were not included. Future studies on this topic in Sierra Leone should include country-specific variables that might potentially influence youth tobacco use. Fourth, our study is also prone to recall bias as the data collected was based on self-report. Finally, we reported our finding as current even though the data was collected in 2017 since this study provides the latest picture regarding adolescent tobacco use. However, future GYTS surveys are needed to follow the trends in adolescent tobacco use and understand the impact of national tobacco policies and interventions on adolescent tobacco use patterns. Notwithstanding these limitations, our study is the first to estimate the prevalence and factors associated with current tobacco use and susceptibility to using tobacco products among non-users among 11-17 years of school-going adolescents using national representative data.

Our study suggests that one in four school-going adolescents are current users of tobacco. Also, close to one in five non-users of tobacco aged 11-17 years were susceptible to using tobacco products. There is gender disparity among current tobacco users but not among non-users of tobacco susceptible to using tobacco products. Irrespective of gender, exposure to secondhand smoke at home and peer smoking were significant determinants of current tobacco use. Exposure to tobacco industry promotion and non-exposure to antismoking education in school were significant factors associated with susceptibility to using tobacco products among non-users in our study. Given the high use of tobacco products among Sierra Leonean adults, our findings have provided evidence that showcases the need for government and other stakeholders to implement policy and interventions to prevent and protect tobacco use behaviour among adolescents in Sierra Leone with the aim of preventing them from becoming tobacco users in their adult life.

CI: Confidential Intervals

FCTC: Framework Convention on Tobacco Control

GYTS: Global Youth Tobacco Survey

GTS: Global Tobacco Surveillance

OR: odds ratio

SHS: second-hand smoke

SPSS: Statistical Package for The Social Sciences

WHO: World Health Organisation

Data Sharing Statement

The dataset informing the findings of this study is and publicly available. It can be freely available via the WHO NCD Microdata Repository https://extranet.who.int/ncdsmicrodata/index.php/catalog/783/study-description .

Ethics approval and Informed Consent: Ethics approval was not required for this study given that the GYTS data are deidentified and publicly available. The 2017 Sierra Leone GYTS received ethics approval from the Ministry of Health and Sanitation. A written informed consent was obtained from the parent and guardians of the students who participated in the survey. We confirm that methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: Not Applicable

Competing interests: The authors declared no conflict of interest

Funding: No funding was obtained for this study.

Authors' contributions: PBJ designed the data analysis plan, conducted the analysis, interpreted the results, and wrote the first draft of the manuscript. JAK participated in the interpretation of the results and contributed to writing the manuscript. ABJ, AI, CK, EBC, ML and PAD participated in the interpretation of the results and edited the manuscript. All authors read and approved the final manuscript.

Acknowledgements: We want to thank the high school students who participated in the 2017 Sierra Leone Global Youth Tobacco Survey. This paper uses data from the Global Youth Tobacco Survey (GYTS). GYTS is supported by the World Health Organization and the US Centers for Disease Control and Prevention.

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No competing interests reported.

Current tobacco use and susceptibility to using tobacco among non-users of tobacco: a cross-sectional study among school-going adolescents in Sierra Leone.

Status:

Version 2

Abstract

Introduction

Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 2