Trends and determinants of tobacco use among women of reproductive age in East Africa: a trend and multilevel analysis using demographic and health survey data.

backgroundTobacco use remains a leading preventable risk factor for morbidity and mortality worldwide. Although global evidence indicates a general decline in tobacco use among women, it is unclear to what extent these trends and associated determinants apply to populations in East Africa. Therefore, this study aimed to examine the trends in tobacco use and its associated factors among women aged 15-49 across East African countries.

objectiveTo examine trends in tobacco use and identify individual- and community-level factors associated with current tobacco use among women of reproductive age (15-49 years) in East Africa.

methodsWe analysed data from Demographic and Health Surveys (DHS) across multiple East African countries. Prevalence trends were assessed over four survey periods (1999-2005, 2006-2010, 2011-2015 and 2016-2022). A cross-sectional analysis of the most recent survey wave was used for the multilevel logistic regression models to identify individual-level and community-level factors associated with current tobacco use, including sociodemographic and socioeconomic characteristics (such as age, education, wealth status and marital status) and community-level factors (such as place of residence and contextual community characteristics). Country-specific trends were also assessed.

resultsA total of 543 013 women of reproductive age from 11 East African countries were included in this analysis. In each DHS survey, most respondents resided in rural areas. Of the pooled sample years, the overall prevalence of current tobacco use was 2.84% (95% CI 2.7% to 2.9%). After a slight increase from 3.74% (1999-2005) to 4.04% (2006-2010), the prevalence declined markedly to 1.35% (2011-2015) and then rose to 2.74% (2016-2022). Compared with cigarette smoking, the use of other tobacco products has consistently greater fluctuations. Country-specific trends showed a declining prevalence in most countries, although increases or fluctuations were observed in Madagascar and Zambia. In the multilevel analysis, age and education showed the strongest association with tobacco use. Women aged 35-49 years had significantly higher odds of tobacco use (adjusted OR (AOR) 2.86, 95% CI 2.44 to 3.36), and those aged 25-34 years (AOR 1.86, 95% CI 1.62 to 2.15) compared with women aged 15-24 years. Women with no formal education were substantially more likely to use tobacco (AOR 4.30, 95% CI 3.01 to 6.15) than those with higher education levels. Additional factors associated with increased odds included experience of child death (AOR 1.39, 95% CI 1.27 to 1.52) and abortion history (AOR 1.21, 95% CI 1.09 to 1.33). At the community level, urban residence (AOR 1.60, 95% CI 1.40 to 1.84) and lower altitudes of <1000 m (AOR 1.40, 95% CI 1.03 to 1.91) were also significantly associated with tobacco use.

conclusionTobacco use among women of reproductive age in East Africa remains relatively low but varies substantially across countries and over time. Older age, lack of formal education, reproductive factors and contextual community characteristics were important determinants. Targeted and context-specific tobacco control interventions are therefore required to reduce tobacco use among vulnerable populations in the region.