Elsevier

Drug and Alcohol Dependence

Volume 119, Issue 3, 15 December 2011, Pages e58-e65
Drug and Alcohol Dependence

Manufactured and hand-rolled cigarettes and smokeless tobacco consumption in Mozambique: Regional differences at early stages of the tobacco epidemic

https://doi.org/10.1016/j.drugalcdep.2011.05.031Get rights and content

Abstract

Background

To describe the use of different types of tobacco (manufactured and hand-rolled cigarettes, and smokeless tobacco) in the adult Mozambican population, across regions.

Methods

A representative sample of 12,902 Mozambicans aged 25–64 years was evaluated in a national household survey conducted in 2003 using a structured questionnaire. The patterns of tobacco consumption were described to highlight the sex-specific differences by age and between urban and rural settings, and between the north, where most of the country's tobacco production is concentrated, and the south of the country, where the wealthiest provinces, closer to the city capital, are located.

Results

The prevalence of current tobacco consumption was 39.9% in men and 18.0% in women. Women consumed predominantly smokeless tobacco (prevalence: 10.1%), especially in the north. Hand-rolled and manufactured cigarettes were the most frequently consumed among men (prevalences: 18.7% and 17.2%, respectively). Additionally, hand-rolled cigarette consumption predominantly occurred in the northern provinces and rural settings, whereas manufactured cigarette consumption predominated in the south and urban areas.

Conclusions

The overall tobacco consumption was higher than expected for an African country with scarce economic resources, mostly due to traditional forms of consumption. The gender and regional specific patterns of consumption identified in Mozambique may contribute to the development of culturally adapted and locally grounded actions for tobacco control, and stress the need of locale-specific surveillance data and public health action in this field.

Introduction

While HIV/AIDS, malaria, and diarrhea are still the leading causes of death in sub-Saharan African countries (Yusuf et al., 2001), the burden of chronic, non-communicable diseases has increased in recent years. In particular, cardiovascular disease has been consistently placed among the five most frequent causes of death in the region (Jamison et al., 2006).

According to the epidemiologic transition theory (Omran, 1971), shifts in the causes of illness and death worldwide lead to and result from variations in the pattern and pace of population change. While in the classical or western model of transition a slow and gradual decline in mortality over 2 centuries led to morbidity overshadowing mortality as an index of health as chronic diseases prevailed, developing countries are currently undergoing a transition characterized by a decline in mortality that is not yet accompanied by decreasing fertility, with infant and childhood mortality remaining excessively high and women of reproductive age maintaining higher death rates than men of the same age (Omran, 1971). The concurrent increasing incidence and mortality by smoking-related diseases, mainly cardiovascular disease, cancer and chronic respiratory disease contributes to a “double burden” of disease in these countries (World Health Organization, 2005).

In 2008, 56% of new cancer cases and 63% of cancer deaths worldwide arose in developing countries. The estimates for the age-standardised rates (world reference population) in sub-Saharan Africa were 124.7 per 100,000 females and 115.9 per 100,000 males for cancer incidence and 92.8 per 100,000 females and 98.1 per 100,000 males for cancer mortality. According to the World Health Organization, the number of new cases of cancer diagnosed every year around the world is set to increase 69% to 21 million by 2030, and the burden will be greater in developing regions (Ferlay et al., 2010, Zarocostas, 2010).

Despite that studies on the prevalence of tobacco consumption in sub-Saharan Africa often rely on non-representative samples, national surveys are available for some countries (e.g., South Africa (van Walbeek, 2002), Tanzania (Pampel, 2005), Zambia (Pampel, 2005)) showing that smoking patterns are heterogeneous, between and within countries. Tobacco consumption prevalences vary greatly with ethnicity and gender (Townsend et al., 2006a, Townsend et al., 2006b, Townsend et al., 2006c), without a consistent relation with socioeconomic characteristics (Townsend et al., 2006a, Townsend et al., 2006b, Townsend et al., 2006c), although people with higher socioeconomic status tend to use more manufactured cigarettes, and the less educated traditional forms of tobacco (Pampel, 2008, Townsend et al., 2006a, Townsend et al., 2006b, Townsend et al., 2006c). However, a shift towards manufactured cigarettes smoking is expected in these settings, due to the lack of effective tobacco control policies and increasing urbanization (Pampel, 2008, Shafey et al., 2003, Townsend et al., 2006a, Townsend et al., 2006b, Townsend et al., 2006c, World Health Organization, 2009).

The increase in the burden of tobacco-related diseases, as well as within-country differences in this phenomenon, may also be expected in Mozambique, as the access to education, gender relationships and predominant religion vary considerably across the country. The proportion of illiterate adults is overall very high, especially among women (64.2% vs. 34.6% among men). The rural northern regions have higher prevalence of Muslims, illiterate women, and families under matrilineal systems, in which women have more social and economic power reinforcing their active role in decisions (Disney, 2008). Southern provinces have lower proportions of illiterate subjects and higher proportion of wealthier people, patrilineal systems and adherents to Pentecostal-type churches (Arnaldo, 2004, Instituto Nacional de Estatística, 2007, Instituto Nacional de Estatística e Ministério da Saúde, 2005). Tobacco production is concentrated in the north and increased from 1500 t, involving about 6000 producers, in 1997, to 60,000 t, involving about 150,000 producers, in 2006 (IAM (Instituto do Algodão de Moçambique), 2007). From 2008 to 2009 national tobacco production increased 10.8% (MINAG-CEPAGRI (Centro de Promoção da Agricultura Comercial), 2010), depicting the need for surveillance of tobacco consumption, namely taking into account the regional epidemiological (Damasceno et al., 2009, Gomes et al., 2010, Padrão et al., 2011, Silva-Matos et al., 2011), sociodemographic and cultural heterogeneity.

We aimed to describe the use of different types of tobacco (manufactured and hand-rolled cigarettes, and smokeless tobacco) in the adult Mozambican population, across regions at different stages of the epidemiological transition.

Section snippets

Sample and design

Between September and December 2003, 12,902 subjects aged 25–64 years were evaluated in a community-based cross-sectional study, using a sampling frame based on the 1997 census, which was designed to be representative at national and province levels and by place of residence (urban or rural). We selected 604 geographical clusters out of the 44,931 that cover the whole Mozambican territory. In each geographical cluster all the households were listed (mean number of households per cluster: 103;

Characteristics of the study sample

The population under study was predominantly rural (nearly three quarters). Most subjects were aged under 45 years (two thirds); about half of women and one quarter of men had no formal education and less than 5% of women and less than 10% of men had secondary or higher education (Table 1).

Overall tobacco consumption

The overall prevalence of ever and current tobacco consumption was 20.5% and 18.0%, respectively, in women, and 46.4% and 39.9%, respectively, in men.

The proportion of current tobacco consumers increased with

Discussion

In Mozambique the overall prevalence of tobacco consumption was high, with a large contribution of traditional forms of tobacco use. Smokeless tobacco was the predominant form of consumption among women and the use of hand-rolled cigarettes was more frequent than manufactured cigarette smoking as the main type of tobacco consumed. Gender differences were observed in the overall consumption, but also in the geographical distribution of the main types of tobacco used. Women mostly consumed

Role of funding source

Funding for this study was provided by the Mozambican Ministry of Health and by the World Health Organization; the Mozambican Ministry of Health and the World Health Organization had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Carla Araújo raised the hypotheses, analyzed and interpreted the data and drafted the first version of the manuscript. Carla Silva-Matos revised the final version of the manuscript. Albertino Damasceno analyzed the data and revised the final version of the manuscript. Lídia Gouveia revised the final version of the manuscript. Ana Azevedo analyzed and interpreted the data and participated in elaborating the first draft of the manuscript. Nuno Lunet raised the hypotheses, analyzed and interpreted

Conflict of interest

No conflict declared.

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