Our finding that khat users are seven times more likely to smoke some type of tobacco is consistent with Kassim and colleague’s observation . This finding supports the hypothesis that khat use serves as a gateway to tobacco use. Our findings about sex, age, economic status, as measured by the wealth index, and religion are consistent with other studies that show that these factors are statistically significantly associated with tobacco smoking [26, 33].
Significant sex differences in tobacco smoking, with males six times more likely to smoke than females, could be explained by the low social acceptability and cultural norms towards females, where khat chewing and smoking practices are frown upon.
The finding that individuals from the bottom wealth quintile are 1.5 times more likely to smoke tobacco than those from the richest quintile (the reference category) raises concern about the most vulnerable economic groups. Several hypotheses may explain wealth-related inequalities in tobacco smoking. These include, but are not limited to, a lack of awareness of health risks among the poor and their inability to deal with the stress of their economic conditions . In their study of the economic impact of tobacco consumption on the poor in Bangladesh, Efroymson et al. (2001) suggest that poor people may choose to purchase cigarettes over meeting basic needs such as food, clothing, health care, and education, which further aggravates poverty .Footnote 16
It is not surprising that we find that the likelihood of smoking increased by 11 times if a household member smokes inside the house. In many rural parts of Ethiopia, while men smoke in both public places and in their homes, women mainly smoke in their homes, which often consist of small and poorly ventilated rooms . The combined DHS data (2011 and 2016 survey) suggests that 52% of female respondents reported to smoke inside the house. One expects that imitation and emulation of behaviors of the family members to take place. Being exposed to smoking on a regular basis would entice other family members to smoke themselves. As a result, more household members are exposed to smoking-related diseases.
The existing studies on Sub-Saharan Africa provide mixed evidence on urban/rural tobacco smoking. While our result that urban dwellers are more likely to smoke tobacco than rural residents, is consistent with Pampel (2008) , Sreeramareddy et al. (2014) found that rural residents are more likely to smoke than urban residents . However, as discussed before, the size-based categorization of urban/rural communities in the sample can produce misleading results, which should be interpreted with caution.
Consistent with the findings of Lakew and Haile (2015), we found significant variations in tobacco smoking across administrative regions . In addition, we found significant geographic variations in the neighboring communities and between lowlanders and highlanders. There are a number of factors that could be attributed to the geographical variations in tobacco smoking in the administrative regions, the higher likelihood of smoking in neighboring SSN community clusters bordering Gambela and a higher likelihood of smoking in lowlanders. These factors include differences in regional availability and accessibility of tobacco products; differences in regional tobacco control policies and regulations; differences in demographics; and differences in religious and cultural practices. For example, Gambela is a lowland where people are culturally unique. Unlike the rest of Ethiopia, smoking is not a taboo for women in this region. Tigray, on the other hand, has a long-standing ban on consumption of khat, banned its cultivation in 2009 and prohibited smoking in public places in 2015. The lowest smoking prevalence rate in Tigray could partly be attributed to stringent regulatory measures, along with the social acceptance toward these measures, which together makes them fairly effective in deterring smoking.
Finally, the results on the time variable suggest that the probability of smoking decreased by 37% in the 2016 survey year, when compared to the 2011 survey year. It is our assertion that the lower reported incidence of smoking in 2016 should be viewed with some caution and not be interpreted as if the prevalence of smoking has declined over time. There are a number of reasons for our concern. First, each survey year consists of a randomly selected sample of households and it does not track the smoking behavior within a household. Second, the sample size is higher in the 2011 survey and the participation rate for males, who are six times more likely to smoke than females, is also higher at 43.7%, compared to 42.4% in the 2016 survey. Third, other data sources indicate a higher prevalence rate of smoking in Ethiopia than reflected in these samples, separately or combined.Footnote 17 Fourth, although the Ethiopian parliament ratified the WHO framework on tobacco control in 2014 and eventually passed the anti-tobacco bill in 2015 prohibiting smoking in public places, it could be overreaching to attribute the results on time effects to these regulations. More specifically, while WHO framework prohibits tobacco advertising and promotion, sales of single cigarettes and sales to minors, and controlling of illicit trade of tobacco products, in Ethiopia all these banned practices continue to be widespread not only due to lack of awareness among users about their banning, but also the lack of any enforcement measures . Similarly, smoking in public places was widely observed in the capital city.
Model 2: interaction of region with khat
The result that khat chewers residing in the various regions differ considerably in their likelihood of smoking tobacco, provides some important insights regarding the local social osmosis of smoking behavior. For instance, individuals who live in the Eastern region and chew khat are almost 21 times more likely to smoke tobacco than Tigray residents. In addition, obtaining a statistically insignificant estimate for the main effect of the likelihood of smoking for Eastern residents (in reference to Tigray residents) when including the (Khat- regional) interaction term, suggests that the regional difference in smoking between the Eastern region and Tigray is primarily driven by the different prevalence of khat use in these regions.
Social osmosis is quite different in Gambela, the region with the highest incidence of smoking. As the results show, khat chewers in Gambela are only 56% more likely to smoke tobacco than Tigray residents. At the same time, with the inclusion of the regional interaction term, we see that the residents of Gambela are seven times (up from six times in Model 1) more likely to smoke than Tigray residents. This suggests that smoking behavior in Gambela is driven more by other factors such as those mentioned above in the discussion of the baseline results, rather than by khat chewing practices. Lastly, in Model 2, we obtained a slight decrease in the estimated likelihood of smoking by other religious groups compared to Islam (the reference category). One possible explanation is that percentage of those that smoke and chew khat is highest among Muslims at 57% (1146 out of 2009 respondents) and the overwhelming majority (86%) of Muslim khat chewers live in the Eastern region.
Model 3: interaction of religion with khat
The main highlights of Model 3 results are as follows. First, overall, individuals from Orthodox and Protestant religious groups become less likely to smoke than the individuals who practice Islam, by 70 and 63%, respectively. Furthermore, the results for Catholics and Traditional religious groups become statistically insignificant. This qualitative change in the results, namely less (from more) likely to smoke than Muslim individuals, is in line with the descriptive statistics that show an overall higher prevalence of smoking among Muslim followers.
Second, despite the overall lower likelihood to smoke among Orthodox and Protestant individuals, those who chew khat among these groups are six times more likely to smoke tobacco compared to Muslim khat chewers. A possible explanation for these results is that smoking and khat chewing can be considered as “sinful” practices within the Orthodox and Protestant communities. However, those that engage in one sinful practice are considerably more likely to practice the other “sin” as they have already broken some moral expectations.
Third, we find that individuals working in agriculture are 35% more likely to smoke tobacco than the unemployed (the reference category), at 1% statistical significance. As mentioned earlier, it is a common practice in the rural areas to grow tobacco in home gardens for their own consumption, making the product easily available and accessible. While this could explain the results in the agriculture occupation in all models, it is not obvious as to why the statistically significant result is only obtained when including the religion-khat interaction variable in the analysis.
Finally, we turn attention to the results regarding two Oromia regional variables that are only statistically significant in Model 3. Specifically, Oromia residents are almost 128% more likely to smoke than Tigray residents. Once controlling for the khat chewing differences among various religious groups, the statistically significant result is in line with the descriptive statistics. The distance variable of Oromia community clusters from Harari also becomes significant at 10% confidence level and indicates that Oromia’s bordering communities with the Eastern region are 8% more likely to smoke than those located at farther distances from Harari. It seems that the cultural and religious similarities of these neighboring communities do matter for the prevalence of smoking.
Implications for tobacco control policy
The findings of our study provide a number of policy implications for controlling tobacco consumption in Ethiopia. First, given the wide geographical variation in the prevalence of smoking, a “one size fits all” tobacco control policy that is national in scope and ignores geographical variation, may not be very effective. Instead, policies and regulations that take into account local and social contexts, would be more effective in reducing tobacco consumption.
One important consideration within local and social contexts is the prevailing practices of chewing khat. Currently, with the exception of Tigray, that has banned khat production since 2009 and also has a long-standing ban on consumption, other regions in Ethiopia have not regulated khat production or consumption at all. Since the use of khat can be considered a gateway to more tobacco smoking, an effective tobacco control policy could utilize the complementarity nature of these practices. Given that khat is a cash crop and one of the highest value export crops in the country, a production ban would affect the livelihood of many in the region. As a result, a production ban would be an unpopular policy that could drive the production into the unofficial economy. Its enforcement will be very costly and/or very lax and it is unrealistic to expect that it will be effective.
Instead, any measure that directly deters the consumption of khat could also lead to reducing tobacco smoking. Such policy can be particularly effective in regions with high incidence of both smoking and chewing khat, such as the Eastern region where khat users are 21 times more likely to smoke than Tigray residents who chew khat. In contrast, in a region like Gambela, where the incidence of smoking is the highest in the country but the khat chewing is not nearly as prevalent, measures that directly target smoking behavior could prove more effective than indirect policies for reducing khat consumption. Given the widespread culture of smoking, the high social acceptability of the practice, as well as the ease of accessing the locally grown tobacco in this region, regulatory measures based on price incentives such as taxation, or banning smoking in public spaces, may be difficult to change behavior in their own. Instead, to be more successful, they should be paired with educational campaigns about the adverse health and economic effects of tobacco smoking. Following the 2015 regulation, there was a lack of a nationwide awareness campaign on the dangers of smoking . Hence there continues to be a need for awareness campaigns. These public campaigns can utilize various media sources such as radio, TV, cell text messages, or social media campaign where available. They may be run in partnership with community organizations that engage youth, agricultural development extensions activities, rural health posts, and be part of broader health education added to the school curriculum.
Our analysis also shows that although the use of khat is a more prevalent practice among Muslims than other religious groups, khat users among these latter groups are several times more likely to smoke tobacco than Muslim khat users. The implication of this finding is that policy measures (such as banning consumption) that deter the use of khat, may indirectly lead to deterring smoking behavior among Protestant and Orthodox individuals. Given that Muslims chew khat more as a customary practice,Footnote 18 it could be more difficult to deter consumption of khat by an outright consumption ban. Instead, educational campaigns that raise awareness about the health hazard of both smoking and khat chewing may prove more effective. However, it is important that these educational campaigns avoid any perceived stigma toward a specific community, but instead are administered in partnership with religious community leaders.
Although educational campaigns about the adverse health risks of smoking are considered as soft touch policy tools, they provide broad benefits and could prove more effective in the long term, particularly when targeting youth. Youth with awareness about the health hazards of smoking are more likely to avoid starting smoking at a young age. One would expect that individuals, who have not engaged in smoking practices at a young age, are less likely to smoke later in life. A number of findings in our study provide support for a youth-targeted educational approach. For instance, since people are more likely to smoke if other household members smoke, educational efforts aggressively targeting youth could provide a resistance mechanism for imitating the harmful practice of smoking. Similarly, we find that older age groups are more likely to smoke and it is desirable to reduce the incidence of smoking within this group. It would be difficult, however, to deter smoking behavior using educational campaigns among those who have been engaging in the practice for a long time. Price incentives policy measures such as tobacco excise taxation may work more effectively for them instead of educational campaigns.
Other groups expected to respond more to tobacco tax/price increases are the urban dwellers and the professional workers who primarily use cigarettes. Currently, the tobacco tax rate in Ethiopia is 13.9%, while the WHO benchmark for tax rate is at 70% . It appears that further increases in the tobacco excise tax rate in Ethiopia are feasible were Ethiopia attempting to be in line with the WHO benchmark.
Overall, the various policy examples above suggest a need for a multipronged policy approach in line with the WHO FCTC framework. These include taxation, smoking bans in public places, advertising and packaging requirements for tobacco products, along with educational campaigns targeting youth and other communities to raise awareness about the harmful health effects of tobacco smoking. In addition, undertaking educational campaigns that raise awareness about khat’s hazardous health effect should be considered and implemented first and foremost on the basis of their own merits in reducing the harmful effects of khat use with the potential complementarity of indirect effects in deterring smoking as an added benefit.
There are a few limitations of this study, which are primarily driven by the quality of data. First, the data on smoking any type of tobacco was self-reported and may be subject to recall errors. Additionally, social norms or stigma may prevent the young and women from reporting, thereby leading to an under-reporting of the rates . Second, the DHS wealth index has been criticized for not being able to distinguish extremely poor households from poor households and being too focused on urban indicators in its construction . Third, DHS are cross-sectional surveys and the pooled survey data used in this study do not allow us to track the smoking behavior of individuals over time. Finally, factors that affect the frequency of smoking may differ from those affecting its use, but these factors are not analyzed in our study.