Tobacco use and the Risk of Non-communicable Diseases (NCDs) in Zimbabwe: A Comparative Study of the Smoking Characteristics of Urban (Bulawayo Province) and Rural settings (Mashonaland East Province)

1. INTRODUCTION

Developed countries, such as America, have higher smoking rates in rural areas than in urban areas [1]. The same pattern has also been witnessed in some developing countries such as India and China [2, 3]. However, a study conducted in Peru concluded that smoking rates are higher in urban areas than in rural areas [4]. Relationships between tobacco and demographic variables such as education, have also shown both positive and negative relationships [5-8]. Studies have also shown that tobacco smokers are at a higher risk of developing type 2 diabetes [9, 10]. A meta-analysis of the literature has revealed that tobacco smoking is also linked to increased blood pressure [11]. Evidence shows that tobacco smoking is a lifestyle risk factor for NCDs. The current tobacco prevalence rate in Zimbabwe is 18% [9]. The smoking rate for men is 17.5%, while for women is 1.3% [12]. Tobacco smoking in Zimbabwe has contributed to 11.5% of all deaths in men and 4.3% of all deaths in women [12]. The pattern shows that tobacco smoking affects more men in comparison to women, which is the reason this study only focuses on men. The Zimbabwe Demographic and Health survey reports that tobacco smoking rates are higher in rural areas (17.9%) than in urban areas (15.8%) [13]. This pattern is in contrast to studies in other low-income countries where smoking rates are higher in urban areas [4, 14]. The reported tobacco smoking rates for Mashonaland East province (which is largely rural) were comparable to that of Bulawayo province (urban setting) [13]. This study will contribute to the debates on the factors affecting smoking rates between rural and urban settings. The Zimbabwe Statistical Agency (ZimStat) report indicates that Bulawayo, an urban area, has the lowest prevalence rates of hypertension and diabetes combined. In contrast, Mashonaland East which is largely rural, has the highest rates [15]. This finding may be considered unexpected as studies have indicated that urbanisation is one of the underlying drivers associated with NCDs in developing countries [16]. This pattern is different from other studies in developing countries in Sub-Saharan Africa, namely Sierra Leone, Rwanda, Malawi, Ghana, and South Africa [17, 18]. There is a need to investigate this discrepancy in order to implement appropriate measures to reduce tobacco smoking and the associated risk of non-communicable diseases (NCDs) in both settings.To date, no studies have been conducted in Zimbabwe to determine the levels of smoking and their association with demographic characteristics. Existing studies on non-communicable diseases in Zimbabwe rely on data from other regions, which are then extrapolated to the Zimbabwean context [19]. Therefore, there is a pressing need for studies that provide actual statistics specific to Zimbabwe. The objectives of this study were to compare smoking rates between rural and urban settings, assess the relationship between tobacco smoking and demographic factors, and examine the association between tobacco smoking and the risk of high blood pressure and elevated glucose levels.

2. METHODOLOGY

Multi-stage probability-based sampling was employed to select 200 male respondents from Bulawayo Province (urban) and 200 male respondents from Mashonaland East Province (rural). The selection process began with the provinces, which were divided into districts, and then were further subdivided into wards. From these wards, households were randomly selected. The study utilized the enumeration areas (EAs) from the 2012 census, with wards being represented by these EAs. Each EA contains the locations of households, facilitating the sampling process. A total of 10 EAs were randomly selected, and 40 households were randomly chosen from each of these EAs.

Using the WHO STEP-wise approach, pictorial cards of tobacco were used to determine smokers, especially in the last 30 days. Daily smokers are defined as individuals who consumed at least one tobacco product (such as cigarettes, snuff, chewing tobacco, or pipe) every day or nearly every day for at least one month. The current rate of tobacco use was calculated as follows:

Number of current daily and less-than-daily tobacco users

Number of respondents (excluding Do not know respondents)

Current daily tobacco users: Number of current daily tobacco users

Number of respondents (excluding Do not know respondents)

Former Daily tobacco users: Number of daily users who no longer smoke

Number of respondents (excluding Do not know respondents)

The study employed a cross-sectional survey using the WHO step-wise questionnaire. A blood pressure monitor was used to measure blood pressure, and three readings (2 minutes apart) were taken for each participant. Normal blood pressure ranged from 120/80 to 139/89. Systolic and diastolic blood pressures were combined together, and those on treatment were put in the group with elevated blood pressure. For blood glucose, a glucose meter was used to take measurements, and each measurement was taken at least 2 hours after taking a meal. Blood glucose levels were determined from the measurements using a glucose meter. The meters were calibrated between strip batches and a code was used which had the correction factor. Measurements were done in the morning before participants had their breakfast. The advantage was that these readings were taken at night and are important for monitoring sugars related to diabetes control. Normal blood sugar level was between 4 mmol/l and 6.9 mmol/l. Respondents undergoing diabetes treatment were classified among those with elevated blood glucose.

3. DATA ANALYSIS

Using the WHO STEPwise approach, pictorial cards of tobacco were used to determine smokers, especially in the last 30 days. Exposure to secondhand smoke was analyzed by assessing the presence of smokers at home and in confined workplaces. A Logistic regression analysis was performed to estimate the influence of the demographic factors on smoking outcome (age, level of education, marital status, income per month, knowledge level, place of residence).

4. RESULTS

5. DISCUSSION

The current study has shown that rural respondents were 52% less likely to smoke than urban respondents. Rural smokers were 68% less likely to smoke daily. The tobacco smoking rates in urban areas (29%) are higher than the national average (18%), while the rates in rural areas (16.6%) are lower [13]. The rates are, however, lower than the findings in three provinces of Zimbabwe, with an average of 33.4% [20]. The differences may be due to differences in methodology i.e., the current study looked at age groups from 18 and above, while the ZDHS report included ages 15 to 17 years. The Ministry of Health study focused on individuals above 24 years, while the ZDHS examined those aged 15 to 49 years.This pattern confirms findings from other Sub-Saharan African countries where urban dwellers smoke more [17, 18]. The reasons given for higher smoking levels in urban areas are related to stress, fear of losing a job, commuting every day to work, and work pressure [17]. Smoking has been linked to stressful conditions, and the high costs of living in urban areas in Zimbabwe are creating stressful environments that can lead to high tobacco consumption levels [21-23]. In Zimbabwe, high-income earners live in towns, where the stressful urban lifestyle may contribute to higher smoking levels in urban areas compared to rural areas. Smoking has been seen as an activity to alleviate boredom [24]. The current study shows that respondents in urban areas exhibit negative attitudes that contribute to higher smoking rates, confirming findings in Pakistan where individuals with a positive attitude had lower smoking rates [25, 26]. The results have shown that urban respondents view smokers as people who are enjoying their leisure time. This might lead to higher smoking rates in urban areas. Another reason may be that urbanization has made tobacco products more readily available for consumption by urban residents. The cost of smoking products could also contribute to higher smoking levels in urban areas in the current study, as those with higher incomes are typically found in urban areas. The rural respondents were 49% less likely to smoke manufactured cigarettes than the urban respondents. This was due to the high costs involved as the results have shown that more people in rural areas had lower incomes than those in urban areas. These findings confirm patterns observed in South Africa and Finland [18, 27]. High-income individuals have the ability to purchase tobacco products, whereas low income generally prioritize basic commodities. However, the findings are different from the findings in the ZDHS (2015) report, where those with high income smoked less than those with low income [13]. The difference can be explained in terms of the differences in sample size where the sample for the current study was smaller, and the current study did not consider those below the age of 18 years. The observed pattern is also different from patterns in developed countries where those with low income consume more [26]. Some scholars have shown that people with high incomes smoke less than those with low incomes, as high-income earners tend to have a healthier lifestyle, a trend observed in countries at higher levels of economic transition [21, 28-30]. These same developed countries saw high-income earners consuming more during the early years of their transition. Zimbabwe, being in its early years of transition, affects high-income earners first. In urban settings, high-income earners smoke more than low-income earners, but the relationship is not significant in rural settings.

There is a negative association between smoking and education in both areas. This might be a result of the effects of education in changing people`s attitudes towards health management [6, 7]. These findings are similar to findings in the ZDHS (2015) report, which observed a decline in smoking with higher educational attainment [13]. This pattern confirms experiences in developed counties where those with higher education smoke less [28, 31]. Low education meant that people still had strong cultural ties, leading to higher tobacco consumption compared to the more educated population [29, 32].

The age group that smoked the most in urban areas was 35 years and above (67.2% to 22.8%), while in rural areas, it was 18 to 34 years (75.8% to 24.2%). These age groups are typically employed or seeking employment and often have family responsibilities that create stressful conditions associated with smoking [22, 23]. This pattern differs from that observed in 2005, when individuals aged above 65 years smoked more than other age groups [20]. The current statistics are similar to those in the WHO publication, where the difference between youth and adults was minimal, at 22.0% versus 22.9% [14]. These findings are similar to the statistics in the ZDHS report [13]. The differences may be attributed to variations in methodologies, particularly the composition of the samples. Individuals aged above 35 years smoke more because smoking is socially acceptable among adults, as observed in India [33]. However, this pattern differs from findings in countries like Ghana, where older generations smoke more than younger ones due to traditional beliefs [29]. In this research, individuals aged 30 to 44 were economically active and had means of earning. Therefore, they could purchase tobacco products, which signifies that income is an important factor for purchasing tobacco. In this study, it was found that urban respondents started smoking earlier than rural respondents. This pattern of early onset of tobacco smoking in urban areas is similar to findings in the urban areas of Ghana, where 87% started smoking before the age of 30 [29].

Married individuals were 10% more likely to smoke, while those who were divorced, separated, or widowed exhibited a 30% higher likelihood of smoking compared to the single group. This finding supports the notion that stress may act as a contributing factor to smoking behavior, particularly among individuals who are divorced, separated, or widowed, as they may lack a partner with whom to share responsibilities and navigate stressful situations [32]. Other studies have indicated that married individuals tend to smoke less, likely due to the support provided by a spouse [34]. The current study further supports the notion that marriage serves as a protective factor against unhealthy behaviors. The single group exhibited lower smoking rates compared to other marital status groups. This could be attributed to the fact that the single group primarily consists of younger individuals, who may refrain from smoking due to societal norms, as observed in countries such as India and Ghana [2, 29].

Tobacco smokers were found to be at a higher risk of elevated blood glucose, corroborating findings from studies conducted in China and Switzerland [35, 36]. This is supported by the CDC report of 2014, which reported that smokers have a 30% to 40% higher risk of diabetes than non-smokers and the risk increases with the number of cigarettes smoked. This may be attributed to the fact that smoking induces inflammation in body cells and causes oxidative stress, both of which are associated with elevated blood glucose levels. [37].

The current study found no significant relationship between tobacco smoking and blood pressure, although a higher proportion of individuals in the smoking group exhibited elevated blood pressure.This confirms the findings in England, where no significant relationship could be identified [38]. However, these findings differ from studies conducted in Sub-Saharan Africa (Uganda, Tanzania, South Africa, Nigeria), where significant relationships were observed, with smokers having higher odds of elevated blood pressure [39]. Our findings also differ from those of studies conducted in China and a meta-analysis of 23 population-based studies (CARTA consortium, including England, the Netherlands, and Scotland, among others), where current smokers exhibited lower blood pressure compared to non-smokers and former smokers [40, 41].

CONCLUSION

The current study revealed that urban respondents smoke more than their rural counterparts, and that individuals with higher incomes tend to smoke more than those with lower incomes. Additionally, economically active age groups were found to smoke more than other age groups. Those with higher levels of education smoked less than those with lower education, and individuals who were divorced, separated, or widowed smoked more than those in other marital status categories. Smokers were also found to be at a higher risk of elevated blood glucose. It is recommended that education on the health effects of smoking be incorporated into school curricula, similar to the approach taken by the government of Zimbabwe with HIV/AIDS. Further research is also recommended, focusing on both women and men, and encompassing a broader range of provinces.

REFERENCES