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<0.05, Ptrend =0.006). Knowledge of the health risks of smoking, including passive smoking and its impact on children and non-smokers, was high; radio (74%) and television (28%) were the main sources of such information and advice. Levels of health awareness were typically but not invariably higher in older people, in men, among the more highly educated and in those living in rural areas. There were few restrictions on smoking in public, and most people (38%) therefore worked and/or spent time in places where smoking was permitted. There was very strong support (97%) for comprehensive smoke-free legislation, mainly among Christians and Muslims. Despite the advertising ban, around a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products. Again radio was the main source of exposure (72%) but some had also noticed advertising on television (28%). The interviews with policy makers showed that they had good knowledge of the content of the FCTC, and reported that although Ghana had no explicit written policy strategy on tobacco control, the Ministry of Health had issued several tobacco control directives both before and after ratification of the FCTC. A national tobacco control bill had been drafted but had not yet been implemented, something which the policy makers needed to happen urgently. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritization of tobacco control efforts. Conclusions Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence In Ghana was low, particularly among younger people. This suggests that In contrast to many other developing countries, progression of an epidemic increase in smoking has been avoided. Awareness of health risks and support for smoke-free policies were high in Ghana. Exposure to tobacco advertising or promotion was limited, and most smokers reported having tried to quit. Whether these findings are cause or effect of the current low smoking prevalence is uncertain. The likely reasons that I have identified for the low smoking prevalence include an early advertising ban, substantial state intervention in the tobacco industry at a crucial point of growth, socio-cultural factors (particularly religion), the harsh economic environment at a time when the industry was experiencing growth and other public health interventions such as health education by stakeholders involved in tobacco control. Although policy makers were aware of the FCTC, implementation of the World Health Organization (WHO) treaty has been slow, requiring an urgent need for the passage of the national tobacco control bill into law to enable the country to sustain its tobacco control efforts

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<0.05, Ptrend =0.006). Knowledge of the health risks of smoking, including passive smoking and its impact on children and non-smokers, was high; radio (74%) and television (28%) were the main sources of such information and advice. Levels of health awareness were typically but not invariably higher in older people, in men, among the more highly educated and in those living in rural areas. There were few restrictions on smoking in public, and most people (38%) therefore worked and/or spent time in places where smoking was permitted. There was very strong support (97%) for comprehensive smoke-free legislation, mainly among Christians and Muslims. Despite the advertising ban, around a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products. Again radio was the main source of exposure (72%) but some had also noticed advertising on television (28%). The interviews with policy makers showed that they had good knowledge of the content of the FCTC, and reported that although Ghana had no explicit written policy strategy on tobacco control, the Ministry of Health had issued several tobacco control directives both before and after ratification of the FCTC. A national tobacco control bill had been drafted but had not yet been implemented, something which the policy makers needed to happen urgently. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritization of tobacco control efforts. Conclusions Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence In Ghana was low, particularly among younger people. This suggests that In contrast to many other developing countries, progression of an epidemic increase in smoking has been avoided. Awareness of health risks and support for smoke-free policies were high in Ghana. Exposure to tobacco advertising or promotion was limited, and most smokers reported having tried to quit. Whether these findings are cause or effect of the current low smoking prevalence is uncertain. The likely reasons that I have identified for the low smoking prevalence include an early advertising ban, substantial state intervention in the tobacco industry at a crucial point of growth, socio-cultural factors (particularly religion), the harsh economic environment at a time when the industry was experiencing growth and other public health interventions such as health education by stakeholders involved in tobacco control. Although policy makers were aware of the FCTC, implementation of the World Health Organization (WHO) treaty has been slow, requiring an urgent need for the passage of the national tobacco control bill into law to enable the country to sustain its tobacco control efforts

Cardiovascular disease risk assessment among patients attending two cardiac clinics in the Ashanti Region of Ghana

Background: Cardiovascular disease (CVD) is a major cause of morbidity and hypertension is the single most important modifiable risk. Assessment of an individual’s “total” predicted risk of developing a CVD event in 5- or 10-years using risk scores has been identified as an accurate measure of CVD risk. Using the latest Framingham risk score we assessed the risk among patients attending two cardiac clinics in Kumasi.Methods: We conducted a hospital-based cross-sectional study among 441 patients attending two cardiac clinics in Kumasi, the Ashanti region of Ghana. Hospital records were reviewed and information on demography, social history and laboratory results for the lipid profile tests were extracted.Results: The prevalence of low, medium and high risk were 41.5%, 28.1% and 30.4% respectively. More men were at high risk compared to females (36.0% vs 23.9%, p=0.003). The risk score showed good discrimination for cardiovascular risk stratification with an overall area under the curve of 0.95; 0.97 and 0.94 for males and females respectively. The sensitivity and specificity of the Framingham risk score were 89.5% and 86.3%, respectively.Conclusion: Majority of our study participants were at moderate to high risk with men being the most affected. The Framingham risk score proved to be a useful tool in predicting the 10-year total cardiovascular disease risk.Keywords: cardiovascular diseases, hypertension, Kumasi, total risk, Framingham risk scoreFunding: Not indicate

Status of implementation of Framework Convention on Tobacco Control (FCTC) in Ghana: a qualitative study

BACKGROUND: The Framework Convention on Tobacco Control (FCTC), a World Health Organization treaty, has now been ratified by over 165 countries. However there are concerns that implementing the Articles of the treaty may prove difficult, particularly in the developing world. In this study we have used qualitative methods to explore the extent to which the FCTC has been implemented in Ghana, a developing country that was 39th to ratify the FCTC, and identify barriers to effective FCTC implementation in low income countries. METHODS: Semi-structured interviews with 20 members of the national steering committee for tobacco control in Ghana, the official multi-disciplinary team with responsibility for tobacco control advocacy and policy formulation, were conducted. The Framework method for analysis and NVivo software were used to identify key issues relating to the awareness of the FCTC and the key challenges and achievements in Ghana to date. RESULTS: Interviewees had good knowledge of the content of the FCTC, and reported that although Ghana had no explicitly written policy on tobacco control, the Ministry of Health had issued several tobacco control directives before and since ratification. A national tobacco control bill has been drafted but has not been implemented. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritisation of tobacco control efforts, leading to slow implementation of the treaty. CONCLUSION: Whilst Ghana has ratified the FCTC, there is an urgent need for action to pass a national tobacco control bill into law to enable it to implement the treaty, sustain tobacco control efforts and prevent Ghana's further involvement in the global tobacco epidemic

A situational analysis of tobacco control in Ghana: progress, opportunities and challenges

Tobacco use is the leading cause of preventable deaths in the world, with most of these deaths now occurring in low and middle-income countries (LMICs). Sub-Saharan Africa (SSA) is at an early stage of a tobacco epidemic and is, therefore, particularly vulnerable to rapid growth in tobacco consumption. More than a decade into the implementation of the World Health Organization's Framework Convention on Tobacco Control (FCTC), State Parties in several countries in SSA, such as Ghana, have yet to fully fulfill their obligations. Despite early ratification of the FCTC in 2004, progress in implementing tobacco control measures in Ghana has been slow and much work remains to be done. The aim of this paper is to critically reflect on tobacco control implementation in Ghana, identify significant research priorities and make recommendations for future action to support tobacco control implementation. We emphasize the need for stronger implementation of the FCTC and its MPOWER policy package, particularly in the area of tobacco taxes, illicit trade and industry interference

MCP1 haplotypes associated with protection from pulmonary tuberculosis

<p>Abstract</p> <p>Background</p> <p>The monocyte chemoattractant protein 1 (MCP-1) is involved in the recruitment of lymphocytes and monocytes and their migration to sites of injury and cellular immune reactions. In a Ghanaian tuberculosis (TB) case-control study group, associations of the <it>MCP1 </it>-362C and the <it>MCP1 </it>-2581G alleles with resistance to TB were recently described. The latter association was in contrast to genetic effects previously described in study groups originating from Mexico, Korea, Peru and Zambia. This inconsistency prompted us to further investigate the <it>MCP1 </it>gene in order to determine causal variants or haplotypes genetically and functionally.</p> <p>Results</p> <p>A 14 base-pair deletion in the first <it>MCP1 </it>intron, int1del554-567, was strongly associated with protection against pulmonary TB (OR = 0.84, CI 0.77-0.92, P_corrected= 0.00098). Compared to the wildtype combination, a haplotype comprising the -2581G and -362C promoter variants and the intronic deletion conferred an even stronger protection than did the -362C variant alone (OR = 0.78, CI 0.69-0.87, P_nominal= 0.00002; adjusted P_global= 0.0028). In a luciferase reporter gene assay, a significant reduction of luciferase gene expression was observed in the two constructs carrying the <it>MCP1 </it>mutations -2581 A or G plus the combination -362C and int1del554-567 compared to the wildtype haplotype (P = 0.02 and P = 0.006). The associated variants, in particular the haplotypes composed of these latter variants, result in decreased MCP-1 expression and a decreased risk of pulmonary TB.</p> <p>Conclusions</p> <p>In addition to the results of the previous study of the Ghanaian TB case-control sample, we have now identified the haplotype combination -2581G/-362C/int1del554-567 that mediates considerably stronger protection than does the <it>MCP1 </it>-362C allele alone (OR = 0.78, CI 0.69-0.87 vs OR = 0.83, CI 0.76-0.91). Our findings in both the genetic analysis and the reporter gene study further indicate a largely negligible role of the variant at position -2581 in the Ghanaian population studied.</p

Public perceptions on the use of antibiotics at a market place in Kumasi, Ghana: A cross-sectional study

Background: Ghana launched its National Action Plan (NAP) to curb the spread of AMR in 2017. The current study was designed to gather data on the public perception concerning antibiotic use by surveying a population at Kejetia market in Kumasi with the aim of informing the design and implementation of public health campaigns linked to the NAP in Ghana. Method: A cross sectional study was conducted at the Kejetia market in Kumasi, Ghana between November 2017 and January 2018. Participants were adults over 18 years of age and data were gathered via a questionnaire regarding participants’ perceptions on the acquisition, use and disposal of antibiotics. Results: The number of participants was 302 of which nearly 60% were female. Statistically significant associations were identified between gender and level of education (p<0.05, Fisher’s exact test). Amoxicillin and metronidazole were the most commonly used antibiotics. Females were three times more likely to use these agents for diarrhoea than males and more likely to purchase them from non-pharmacy outlets and market pedlars. Conclusion: This study shows access to and the and misuse of antibiotics without prescriptions amongst this surveyed population. Antibiotics were also used more by females and by people with a lower level of education. This research highlights antibiotic misuse within a target population that needs addressing by implementation of the NAP

Public perceptions on the use of antibiotics at a market place in Kumasi, Ghana: A cross-sectional study

Background Ghana launched its National Action Plan (NAP) to curb the spread of antimicrobial resistance (AMR) in 2017. The current study was designed to gather data on public perception concerning antibiotic use by surveying a population at Kejetia market in Kumasi with the aim of informing the design and implementation of public health campaigns linked to the NAP in Ghana. Methods A cross-sectional study was conducted at the Kejetia market in Kumasi, Ghana between November 2017 and January 2018. Participants were adults over 18 years of age and data were gathered via a questionnaire regarding participants’ perceptions on the acquisition, use and disposal of antibiotics. Results The number of participants was 302, of which nearly 60% were female. Statistically significant associations were identified between gender and level of education (p<0.05, Fisher’s exact test). Amoxicillin and metronidazole were the most commonly used antibiotics. Females were three times more likely to use these agents for diarrhoea than males, and more likely to purchase them from non-pharmacy outlets and market pedlars. Conclusion This study shows access to, and the misuse of, antibiotics without prescriptions amongst the surveyed population. Antibiotics were used more by females and by people with a lower level of education. This research highlights antibiotic misuse within a target population that needs addressing by implementation of the NAP