Edited by: Thomas Heffernan, Northumbria University, UK
Reviewed by: Janice Bartholomew, Teesside University, UK; Jonathan Ling, University of Sunderland, UK
Specialty section: This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry
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To determine whether screening, brief intervention, and referral for treatment can reduce the prevalence of tobacco use in rural and semi-rural settings.
At baseline, out of 1203 respondents, lifetime prevalence and current prevalence of any tobacco products were 405 (33.7%) and 248 (20.6%), respectively. Of the current users, on the ASSIST, 79 (31.9%) scored 0–3 (low health risk), 130 (52.4%) scored 4–26 (moderate risk), and 39 (15.7%) scored 27+ (high risk). At 3 months, out of 1199 respondents, prevalence of current users was 199 (16.5%) and out of 1195 respondents, was 169 (14.1%) at 6 months. Prevalence of tobacco use reduced significantly at 3 months
A one-time BI with a booster at 3 months had a significant effect on tobacco use in persons living in community settings. This finding suggests a need for promoting the adoption of this intervention for tobacco use in rural and semi-rural community settings.
While globalization of the use of cigarette and other products of tobacco is a major threat to public health worldwide (
The growth of cigarette use in developing countries might be linked to the marketing efforts of tobacco companies, loose restrictions of tobacco control policies (
In Nigeria, the infrastructure for tobacco control is poor despite the country’s ratification of the WHO Framework Convention on Tobacco Control (
Therefore, there is a need to find other strategies that might work while efforts are ongoing to firm up tobacco restrictions at the government level in Nigeria. Screening, brief intervention, and referral for treatment (SBIRT) is a public health model that is used to screen for substance abuse and also for the delivery of low-intensity substance abuse treatments in a primary health-care setting (
In the Western world, the provision of SBIRT as a form of smoking cessation intervention is generally toward treatment seeking smokers (
Therefore, in the developing countries, such as Nigeria, where it has not been evaluated before, there is a need for evaluative studies to guide policy and interventions. The current investigation was a single arm study designed to examine the prevalence of tobacco use and evaluate the effectiveness of SBIRT in semi-rural and rural communities. We hypothesized that participants who receive SBIRT intervention would demonstrate a decrease in cigarette consumption.
Nigeria is a developing country in West Africa. Nigeria was ranked 191st among 194 member states of the World Health Organization in terms of overall health attainment. The study site was in Ibadan, Oyo State. Ibadan is the capital of Oyo state, Nigeria, and it is the third largest city in Nigeria. The city is located in the southwestern part of the country. It has a population of over 3.5 million people and 11 local government areas (
Ethical approval for the study was obtained from the Ethical Review Committee of the Ministry of Health, Oyo State, Nigeria. Assent was obtained from participants between 15 and 18 years and informed consent from 18 years and above.
A systematic stratified sampling method was used to select two local governments in Ibadan between October 2010 and April 2011. In the first stage, all 11 LGA were classified into rural or semi-rural based on government fund allocation. In the second stage, one local government was randomly chosen from each group, and in the third stage, four enumeration areas were systematically selected as clusters. The fourth stage involved the mapping and numbering of all buildings in each of the selected enumeration areas. All households within each building were serially listed in the Form specifically designed for the purpose. After getting the list of the households, simple random sampling was used to identify the households that fell within the sample. Regular households were distinguished from institutional households. All eligible respondents, who were 15 years and above in each household, were selected and were interviewed using the questionnaires including alcohol, smoking, and substance involvement screening test (ASSIST) after they gave consent/assent. The inclusion criteria for the study were both male and female tobacco users of age ≥15 years and permanent residents of study areas. The exclusion criteria were non-users of tobacco of age <15 years, not willing to get tobacco cessation intervention, and not a permanent resident of the study areas.
To increase the possibility of an effect while observing a real-world feasibility in a resource poor setting, brief interventionists were recruited from community health-care extension workers (CHEWs) in participating primary health-care clinics (
A 3 days of debriefing and review of all protocols were carried out, after a pilot survey in each of the study local governments. Each interviewer had conducted two pilot interviews in the field. All questionnaires were reviewed for completeness by field coordinators. The pilot studies were carried out in a ward unit as enumerated during the National population census in each of the study local governments. This was to assess applicability of the instruments of data collection and research adherence.
A sociodemographic
The ASSIST was developed mainly to screen for drug use, but can be used for other substances, including alcohol and tobacco as well, particularly in high prevalence settings (
The lifetime prevalence of tobacco use was obtained from Q1: “In your life, which of the following substances have you ever used (non-medical use only)?” We obtained current prevalence of tobacco use from Q2: “In the past 3 months how often have you used the substances you mentioned?” Responses were “never,” “once or twice,” “monthly,” “weekly,” and “daily/almost daily.” For the purpose of this study, use in the past 3 months was considered to be current use.
For those who screened positive for unhealthy tobacco use, ASSIST-Linked SBIRT was conducted as appropriate.
The intervention for those who had a low risk of tobacco use (score of 0–3) was general health advice, for those with moderate risk (score of 4–26), was brief intervention and a leaflet containing information about tobacco use, and those with high risk tobacco use (score of 27+) had brief intervention, information leaflet on tobacco use and were offered referral to a specialist hospital for further assessment and treatment.
The information leaflet about tobacco use contained facts about the consequences of unhealthy tobacco use, tips for reducing the risk of tobacco-related harm, and sources of support for tobacco problems (e.g., contact details of services available in the local health district). Respondents, who had an unhealthy tobacco use, were followed up and reassessed at 3 and 6 months.
A booster brief intervention and referral to treatment was given at 3 months. Interviewers used eight anchor community members to maintain contact with members of the household, while interviewers maintained contact with these anchor persons in between interviews. Tobacco use in this study is defined as cigarette smoking.
The outcome of the intervention was assessed by evaluating changes in the mean number of cigarettes smoked/day at 3 and 6 months post-intervention and the mean ASSIST scores at 3 and 6 months. This is in accordance with the application of ASSIST instrument in following up clients over time. The use of mean ASSIST score has been specifically found to be highly valuable in assessing changes in ASSIST scores over time (
For our univariate analysis, the association between sociodemographic variables and current tobacco use was determined using the Pearson’s chi square statistics. Using the current prevalence rates at baseline, the Wilcoxon Signed-Rank test and paired
Multivariate analyses were carried out using variables that were significant during univariate analysis to determine the association with tobacco use. This was carried out using binary logistic regression. To facilitate the interpretation of odds ratio, a reference category was always chosen for the independent variables with which other independent variables could be compared with tobacco use. This was done for the data at baseline, at 3 and 6 months. Analysis of data was carried out using the Statistical Program for Social Studies SPSS version 13.0.
The interventionists identified a total of 1329 community dwellers as potentially eligible, of whom 1213 underwent screening. Of them, 10 were excluded because of the presence of severe general medical conditions, giving a response rate of 91.3%. The final analysis was carried out for 1203 questionnaires at baseline. At 3 months, analysis was carried out on 1199 respondents and on 1195 participants at 6 months.
The mean age of respondents at baseline was 24.45 ± 9.23 years, 51.8% were males, 66.2% were married, 47.4% had at least some secondary education, and 49.7% were of low-average socioeconomic group. Current tobacco use was more significant among males, χ2 = 55.2,
Variation | Total ( |
Current use ( |
% | χ2 | df | |
---|---|---|---|---|---|---|
<25 | 508 | 122 | 28.0 | 8.8 | (5) | 0.1 |
25–34 | 256 | 54 | 21.1 | |||
35–44 | 158 | 25 | 15.8 | |||
45–54 | 120 | 22 | 18.3 | |||
55–64 | 111 | 17 | 15.3 | |||
>64 | 50 | 8 | 16.0 | |||
<25 | 508 | 239 | 47.0 | 372.2 | <0.001 | |
>25 | 695 | 9 | 1.3 | |||
Male | 623 | 181 | 29.1 | 55.2 | (1) | <0.01 |
Female | 580 | 67 | 11.6 | |||
Urban | 487 | 78 | 16.0 | 10.1 | (1) | <0.01 |
Rural | 716 | 170 | 23.8 | |||
Married | 796 | 143 | 16.0 | 9.6 | (1) | 0.002 |
Not married | 407 | 105 | 26.0 | |||
0 | 119 | 26 | 21.8 | 1.2 | (3) | 0.7 |
1–6 | 431 | 91 | 21.1 | |||
7–12 | 570 | 111 | 19.5 | |||
>12 | 83 | 20 | 24.1 | |||
Low | 513 | 173 | 33.7 | 11.1 | (3) | <0.001BS |
Low average | 598 | 68 | 11.4 | |||
High average | 63 | 6 | 9.5 | |||
High | 29 | 1 | 3.4 |
At baseline, overall lifetime prevalence and current prevalence of any tobacco products was 33.7 and 20.6%, respectively. At 3 months, prevalence of current tobacco use was 16.5% and was 14.1% at 6 months. The prevalence of tobacco use reduced significantly at 3 months
Variables | Baseline ( |
3 months ( |
6 months ( |
Baseline vs. 3 months | Baseline vs. 6 months | 3 vs. 6 months |
---|---|---|---|---|---|---|
Statistics |
Statistics |
Statistics |
||||
Lifetime prevalence, |
405 (33.7) | 405 (33.7) | 405 (33.9) | |||
Current use, |
248 (20.6) | 199 (16.5) | 169 (14.1) | −3.1 |
−4.2 |
−2.1 |
Male, |
230 (19.1) | 192 (16.0) | 164 (13.7) | |||
Low risk tobacco use |
79 (31.9) | 114 (57.3) | 107 (63.4) | 7.4 |
6.6 |
1.3 |
Moderate risk tobacco use |
130 (52.4) | 64 (31.7) | 42 (24.9) | −8.9 |
−10.1 |
−3.5, |
High risk tobacco use |
39 (15.7) | 21 (10.6) | 20 (11.8) | −5.8 |
−5.7 |
1.1 |
High risk tobacco + moderate or high risk alcohol use |
36 (92.3) | 16 (76.2) | 13 (66.6) | −8.1 |
−8.8 |
1.2 |
Moderate risk tobacco + moderate or high risk alcohol |
65 (50.0) | 27 (42.2) | 16 (38.1) | −5.2 |
−5.5 |
1.3 |
Mean ASSIST score (SD) | 20.11 (5.56) | 16.12 (3.23) | 15.45 (3.1) | −5.0 |
−5.7 |
1.2 |
Mean (SD) daily cigarette smoking | 23.76 ± 13.53 | 18.56 ± 10.09 | 17.98 ± 9.76 | −7.85, |
−19.8, |
−0.8 |
Of the current users, 79 (31.9%) scored between 0 and 3 on the ASSIST (at low health risk), 130 (52.4%) scored between 4 and 26 on the ASSIST (at moderate health risk), and 39 (15.7%) scored 27+ on the ASSIST (at high health risk). The mean ASSIST score significantly reduced at 3 and 6 months, compared with baseline measure,
Thirty-nine (15.7%) participants had ASSIST scores ≥27 and were referred for treatment. At 3 months follow-up, 21 (10.6%) participants were referred for treatment and 20 (11.8%) at 6 months follow-up (Table
Of the 39 current users at high risk of health problems, 36 (92.3%) were also at either moderate or high risk of alcohol. Sixty-five (50.0%) of the 130 current users at moderate risk of health problems were either at high or moderate risk of health problems from alcohol (Table
There was a significant reduction in the mean number of cigarettes smoked per day at 3 months compared with baseline,
At 3 months, a significantly higher proportion of respondents whose age of initiation into tobacco use was <25 years were current users compared with those whose age at initiation into tobacco use was ≥25 years, χ2 = 309.4,
At 6 months, a significantly higher proportion of respondents whose age at initiation into tobacco use was <25 years were current users compared with those whose age at initiation into tobacco use was ≥25 years, χ2 = 265.1,
3 months |
6 months |
|||||||||
---|---|---|---|---|---|---|---|---|---|---|
Variation | Total ( |
User ( |
% | χ2 | Total ( |
User ( |
% | χ2 | ||
<25 | 507 | 110 | 21.7 | 2.9 | 0.09 | 506 | 102 | 20.2 | 3.0 | 0.08 |
25–34 | 255 | 44 | 17.3 | 254 | 39 | 15.4 | ||||
35–44 | 157 | 17 | 10.8 | 156 | 12 | 7.7 | ||||
45–54 | 119 | 14 | 11.8 | 118 | 9 | 7.6 | ||||
55–64 | 111 | 10 | 9.0 | 111 | 5 | 4.5 | ||||
>64 | 50 | 4 | 8.0 | 50 | 2 | 4.0 | ||||
<25 | 479 | 191 | 39.9 | 309.4 | <0.001 | 477 | 164 | 34.4 | 265.1 | <0.001 |
≥25 | 720 | 8 | 1.1 | 718 | 5 | 0.7 | ||||
Male | 604 | 192 | 29.0 | 200.0 | <0.001 | 602 | 164 | 27.2 | 160.0 | <0.001 |
Female | 595 | 7 | 4.0 | 593 | 5 | 0.8 | ||||
Semi-rural | 479 | 46 | 9.6 | 27.4 | <0.001 | 477 | 26 | 5.4 | 48.2 | <0.001 |
Rural | 720 | 153 | 21.2 | 718 | 143 | 19.9 | ||||
Married | 791 | 99 | 12.5 | 27.1 | <0.001 | 790 | 70 | 8.9 | 52.7 | <0.001 |
Not married | 408 | 100 | 24.5 | 405 | 99 | 24.4 | ||||
0 | 118 | 20 | 20.3 | 1.2 | 0.7 | 116 | 24 | 20.7 | 0.5 | 0.4 |
1–6 | 431 | 80 | 18.6 | 431 | 65 | 15.1 | ||||
7–12 | 567 | 95 | 16.8 | 566 | 68 | 12.0 | ||||
>12 | 83 | 10 | 12.0 | 82 | 9 | 11.0 | ||||
Low | 511 | 144 | 28.1 | 8.01 | 0.005BS | 511 | 134 | 26.2 | 8.2 | 0.004BS |
Low average | 596 | 51 | 8.6 | 596 | 33 | 5.5 | ||||
High average | 62 | 3 | 4.8 | 62 | 2 | 3.2 | ||||
High | 29 | 1 | 3.4 | 25 | 1 | 4.0 |
Multivariate analysis reveals that at baseline, significant factors that remained associated with current tobacco use were age at initiation into tobacco use OR = 0.03, 95% CI (0.001–0.05),
At 3 months, significant factors that remained associated with current tobacco use were age at initiation into tobacco use OR = 0.04, 95% CI (0.003–0.07),
At 6 months, significant factors that remained associated with current tobacco use were age at initiation into tobacco use OR = 0.02, 95% CI (0.003–0.04),
Baseline |
3 months |
6 months |
|||||||
---|---|---|---|---|---|---|---|---|---|
Variation | OR | 95% CI | OR | 95% CI | OR | 95% CI | |||
<25 | 1 | 1 | 1 | ||||||
>25 | 0.03 | 0.001–0.05 | <0.001 | 0.04 | 0.003–0.07 | <0.001 | 0.02 | 0.003–0.04 | <0.001 |
Male | 1 | 1 | 1 | ||||||
Female | 0.28 | 0.18–0.46 | <0.01 | 0.18 | 0.009–0.37 | <0.001 | 0.12 | 0.03–0.29 | <0.001 |
Married | 1 | 1 | 1 | ||||||
Not married | 2.96 | 1.12–5.23 | <0.01 | 2.07 | 1.28–4.22 | 0.01 | 3.54 | 2.02–7.42 | 0.001 |
Low | 1 | 1 | 1 | ||||||
Low average | 0.65 | 0.18–0.78 | 0.01 | 0.54 | 0.17–0.61 | 0.006 | 0.63 | 0.49–0.81 | 0.005 |
High average | 0.69 | 0.23–0.71 | 0.003 | 0.69 | 0.35–0.73 | 0.002 | 0.57 | 0.35–0.73 | 0.002 |
High | 0.32 | 0.19–0.59 | 0.001 | 0.31 | 0.002–0.37 | 0.001 | 0.32 | 0.002–0.57 | 0.001 |
Urban | 1 | 1 | 1 | ||||||
Rural | 3.05 | 2.00–4.14 | 0.001 | 2.83 | 1.54–4.02 | 0.002 | 2.99 | 1.03–8.23 | <0.001 |
This study is most probably the first in sub-Saharan Africa that aimed to determine in semi-rural and rural community settings, the prevalence and correlates of tobacco use, as well as the effectiveness of ASSIST-Linked SBIRT in unhealthy tobacco users among these communities dwellers.
The lifetime prevalence of tobacco use among our participants was 33.7% and this is not much lower than the 44% lifetime use among those 15 years and older in Canada (
Another key finding in our study is the group of correlates of tobacco use among current users. Those who used tobacco were more likely to have started around 17 years of age, to be males, unmarried, of low socioeconomic status and live in a rural setting. With respect to the age at initiation of tobacco use, this is similar to the age at smoking initiation that is before the age of 18 years in Western countries (
From the foregoing, one could justifiably ask “what could make youths especially in rural settings use tobacco at an earlier age?” Our data deductively serve to guide and stimulate additional research. In addition, priority needs to be given to the development of country specific tobacco control programs for adolescents and youths. Furthermore, given the public health importance of tobacco-related diseases such as CVD and other CVD risk factors (e.g., diabetes, hypertension) (
Concerning other correlates, our study aligns with prior research (
Our observation of an associated alcohol-related health risk among respondents with tobacco-related health risks is illustrative of the co-use of both tobacco and alcohol. Studies have found that smokers are much more likely to use alcohol and vice versa (
A major finding in this study is that it underscores the usefulness and applicability of SBIRT in the hands of CHEW and the positive impact of SBIRT delivered through CHEW on tobacco use as well as unhealthy use in a semi-rural community setting. This current study is important in three ways: (1) it focused on tobacco, and not alcohol, (2) SBIRT was deliverable by CHEW rather than by clinicians only, and (3) it enrolled people in the community with poor access to orthodox medicine and who might not seek treatment rather than those who went to the hospital or were admitted in emergency settings.
In rural and semi-rural community settings, we investigated the usefulness of a single session of brief intervention with a booster session in reducing tobacco use. A major finding in this assessment was that the rate of tobacco use reduced significantly between baseline and 3 and 6 months, respectively. There were significant shifts from high risk to moderate and low risk use of tobacco.
Our study was limited by a number of factors. First, we did not stratify the users into different stages of change. In other words, we could not assess the impact of different stages of change in unhealthy tobacco use in our study population. This is very relevant considering reports indicating that psychosocial interventions, that target behavioral change often do not yield a significant effect (
In conclusion, while tobacco use is reaching epidemic proportions in rural and semi-rural settings in Nigeria and is associated with male gender, early age at initiation into use, low socioeconomic status, and living in rural areas, SBIRT promises to have implementation potentials in delivering the intervention for the reduction of tobacco use and unhealthy tobacco use in semi-rural community in Nigeria.
VL conceived the idea and was responsible for study design, analysis, and manuscript writing. BO was responsible for data collection and was also involved in manuscript writing. Both authors gave a substantial contribution to the study.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgment is given to the Director of Planning, Research and Statistics, Oyo state Ministry of Health, Ibadan for granting ethical approval for this study. Acknowledge with thanks is also given to Dr. O. Aremu (RRSH), Dr. O. Amoran (OOUTH), and Christianah Alabi (NWPSH) for providing support during data collection. I thank the coordinating staff members of the two local governments where the study took place and all participants.
New World Specialists Hospitals, Ibadan, Nigeria.