The role of tobacco promoting and restraining factors in smoking intentions among Ghanaian youth

Smoking continues to be a major but preventable cause of death and diseases worldwide [1]. Recent declines in smoking following a range of tobacco control measures have been limited to developed countries while a rise in smoking rates has been observed in several developing countries [2, 3]. It is suggested that if major preventive measures are not put in place, smoking-related death and diseases in many of these developing countries will increase rapidly as the number of smokers continues to rise [1]. Indeed, the WHO report estimates that with the steady increase in tobacco use, more than 8 million people worldwide will die each year by the year 2030, 80% of which will occur in developing countries.

The literature on smoking in many developing countries is scant and for Africa, the available literature suggests considerable variation across the different countries [4]. In Ghana, general rates of smoking are suggested to be low, with males smoking more than females [5, 6]. In a random sample of 30 regional census enumeration areas, comprising all individuals 14 years of age and above, [7] smoking rates of 8.9% and 0.3% were reported for males and females, respectively. However, the Global Youth Tobacco Survey (GYTS) reported higher rates among young people between ages 13 and 15. The 2006 GYTS revealed that 11.6% of boys and 10.9% of girls in Ghana used a tobacco product, while 9.4% boys and 8.0% girls have ever smoked cigarettes [8]. Higher rates of tobacco use among the youth may point to a rise in future use. Therefore even if the prevalence of tobacco use in African countries is generally low, it offers an opportunity for the control of the epidemic in these countries, the only region where the epidemic seems to be at its initial stages in many countries.

A large body of research has investigated factors that may determine smoking initiation as well as the relationship between smoking intentions and smoking behaviour among adolescents in Western countries [9–12]. It has been shown that intention to smoke in the future predicts both smoking initiation and subsequent smoking [10–12]. However, little is known about various factors behind youth smoking intentions in developing countries. Identifying factors that influence smoking intentions among young people in Ghana may thus be essential for preventing smoking among this vulnerable group.

Social cognition models have been extensively used to examine factors that tend to predict health behaviour, including smoking. In an integrated theoretical model, Fishbein and colleagues put together concepts from several major social cognition models that may promote or prevent the performance of health behaviour [13]. The social cognition models that constitute the integrative model are the theory of reasoned action [14], the social cognitive theory [15] and the health belief model [16]. In line with the integrative model, behavioural intention, skills and environmental constraints are directly related to behaviour. Thus, a strong intention to smoke, the necessary skills to engage in the behaviour and the ability to overcome environmental constraints could facilitate smoking. For intention to smoke, the model postulates three determining factors: attitudes, perceived norm and self-efficacy. Attitude towards smoking reflects the person’s favourable or unfavourable evaluation of smoking behaviour, while perceived norms reflect both the support from important referents to engage in the behaviour or not and the referents’ own engagement in the behaviour. Self-efficacy expresses the individual’s perception of being able to perform the behaviour under a variety of challenging circumstances.

Although, the social cognition models that constitute the integrative model were developed in Western countries and have mostly been studied in Western populations, the theoretical concepts of the model have been applicable also in non-Western countries. Attitudes, perceived norm and self-efficacy have each been found to predict a range of health behaviours such as oral health, food choices, condom use and smoking, among others in several African and Asian countries [17–19]. The predictive power of these theoretical concepts tends to be affected by the context, a finding which is consistent with the assumption of the integrative model that the relationship between the theoretical factors and behaviour may vary across different populations and behaviours. Smith and colleagues [20] found that differences in intentions between Western and non-Western countries may occur for variety of reasons, for example individuals’ attitudes, beliefs and knowledge, socio-environmental and cultural norms as well as several tobacco-related factors (factors that reflect several of the concepts of the integrative model).

From the public health viewpoint of developing countries, a better understanding of the factors influencing youth smoking intentions is essential to identifying the specific risk groups for smoking, allowing tailored preventive programs to be developed. In this paper, we explored smoking intentions among Ghanaian youth aged 12 to 20 years with regard to tobacco promoting and restraining factors, including several environmental, familial, attitudinal and knowledge measures. Because of the collective culture and the age of the participants, familial and environmental measures may be more strongly associated with smoking intentions than attitudes and knowledge.

A survey was conducted in 2008 on health behaviours and lifestyles of youth in Junior and Senior High schools in two out of the three zones in Ghana.

In this study, among both ever and never smokers, allowing smoking on school compound, exposure to tobacco advertisement and parental smoking were all significantly associated with an intention to smoke. In addition, compared to those who agreed that smoking is harmful to health, smoking is difficult to quit and that tobacco should not be sold to minors, those who disagreed or were not sure were more likely to have an intention to smoke in the future. In the multivariate analyses, these associations persisted, except that the attitude measures concerning the difficulty of quitting smoking, once started, and tobacco sales ban to minors were no longer significantly associated with smoking intentions.

On the whole, factors associated with youth smoking intentions in Ghana and Western countries are fairly similar. Previous studies have shown that strongly enforced smoking bans in schools have a protective effect on adolescents’ future smoking [21]. We found that if smoking was allowed on a school compound, youth had a higher intention to smoke than those whose schools banned smoking. An interesting finding in this study was also that among both ever and never smokers, the probability of future smoking intentions was higher among those who disagreed or were not sure regarding the statement that smoking is harmful to one’s health. This finding is consistent with the health belief model [16] which postulates that people’s engagement in behaviours is motivated by their perceived health consequences of the behaviour. Given that the association remained independent of the other tobacco promoting and restraining factors examined in this study suggests that among Ghanaian youth, the belief about the negative health consequences of tobacco use is an important predictor of tobacco use. In view of that, health promotion interventions that would focus on the health damaging effects of tobacco use will be likely to deter the youth from its use in the future.

The difficulty of quitting smoking once started was associated with smoking intentions in bivariate analyses, although not in multivariate analyses. This association to some extent may reflect the influence of self-efficacy in the uptake of the behaviour [13, 15], confirming that also among Ghanaian youth self-efficacy could be related to intentions to smoke. Previous studies have found that self-efficacy was associated with health behaviours and behavioural intentions such as intended contraception use among adolescents in Ethiopia [17] and sugar consumption among Ugandan adolescents [18]. Attitude towards a given behaviour has been documented to be an important predictor of intentions [22, 23]. In the present study, this finding was confirmed as a youth’s attitude concerning the harmful effects of tobacco use was associated with the probability of intentions to smoke. However, ban on the sale of tobacco products to minors and difficulty in quitting smoking, once started, were not associated with intentions to smoke in multivariate analyses. It is possible that other factors other than attitude also play role in predicting the future smoking intentions. Furthermore, among both ever and never smokers, exposure to tobacco advertisement was associated with smoking intentions, although at borderline level of significance. Advertisement exerts a normative influence on adolescents [13], enhances positive attitude towards smoking and intentions to smoke [24]. Among German adolescents exposure to cigarette ads, but not other adverts, was found to increase the chances of intentions to smoke [24].

Consistent with the social cognitive theory [15], parental smoking was found to be significantly predictive of intentions to smoke such that adolescents with at least one smoking parent were at higher risk of smoking in the future compared to those without smoking parents. This association was independent of the other predictive factors investigated in the present study. In the United Kingdom, parental smoking was related with youths’ smoking intentions [25]. The relationship between parental smoking and their children’s smoking uptake has been well documented [9, 26]. In addition to the role modelling plausibility of the impact of parental smoking on adolescent smoking, children with smoking parents may not only consider the behaviour as a norm but may also have access to cigarettes at home [26] and thus be more likely to initiate and maintain the behaviour compared to those with non-smoking parents. It is likely that the same mechanisms underline the relationship between parental smoking and the intention to smoke found in the present study.

A number of tobacco promoting and restraining factors including, allowing smoking on school compound, exposure to tobacco advertisement, parental smoking and perception that smoking is harmful to one’s health were associated to intentions to smoke among Ghanaian youth. Thus, to a large extent, the present study supports the integrated theoretical model, particularly, the associations of normative processes and attitude with intentions to smoke. The importance of school smoking policy, parental smoking behaviour and knowledge of the harmful effects of tobacco use in determining Ghanaian youths’ future smoking intentions is emphasised. Current smoking rates in Ghana may be low. Nevertheless, the present study indicates a probable increase in future rates as smoking intentions appear to be considerably high among smokers and non-smokers alike. Despite the ban on all cigarette advertisements on national television and radio, tobacco control measures in Ghana still fall short of several effective strategies recommended by the World Health Organization. “Raising taxes and prices, banning advertising, promotion and sponsorship, protecting people from second-hand smoke, warning everyone about the dangers of tobacco, offering help to people who want to quit, and carefully monitoring the epidemic and prevention policies” are six WHO tobacco control strategies that are not in place in Ghana yet, probably because of the low smoking rates. However, because the relatively high percentages in current smoking intentions may turn into high smoking rates in the future, a ban on cigarette advertisements may not be sufficient. The introduction of more effective tobacco control measures at all levels of society to prevent youth smoking may be essential.

The study was financially supported by the Finnish Cultural Foundation Central Fund, Tampere University research stipend and the Juho Vainio Foundation