Citation

Kaai, S.C., Sansone, G., Meng, G., Ong’ang’o, J., Goma, F., Ikamari, L., Quah, A.C.K., Fong, G. (2023). Quasi-experimental evaluation of Kenya’s pictorial health warnings versus Zambia’s single text-only warning: Findings from the International Tobacco Control (ITC) Project. Tobacco Control, 32(2), 139-145. doi: 10.1136/tobaccocontrol 2020 056396.

Abstract

Background: Population studies in mostly high-income countries have shown that pictorial health warnings (PHWs) are much more effective than text-only warnings. This is the first quasi-experimental evaluation of the introduction of PHWs in Africa, comparing the change from text-only to PHWs in Kenya to the unchanged text-only health warning in Zambia.

Methods: Data were from International Tobacco Control (ITC) Surveys in Kenya (n=1495), and Zambia (n=1628), cohort surveys of nationally representative samples of adult smokers in each country. The ITC Kenya Survey was conducted in 2012 and 2018 (2 years after the 2016 introduction of three PHWs). The ITC Zambia Survey was conducted in 2012 and 2014 with no change to the single text-only warning. Validated indicators of health warning effectiveness (HWIs) (salience: noticing, reading; cognitive reactions: thinking about health risks, thinking about quitting; and behavioural reactions: avoiding warnings; forgoing a cigarette because of the warnings), and a summary measure-the Labels Impact Index (LII)-measured changes in warning impact between the two countries.

Results: PHWs implemented in Kenya led to a significant increase in all HWIs and the LII, compared with the text-only warning in Zambia. The failure to implement PHWs in Zambia led to a substantial missed opportunity to increase warning effectiveness (eg, an estimated additional 168 392 smokers in Zambia would have noticed the warnings).

Conclusions: The introduction of PHWs in Kenya substantially increased the effectiveness of warnings. These results provide strong empirical support for 34 African countries that still have text-only warnings, of which 31 are Parties of the Framework Convention on Tobacco Control and are thus obligated to implement PHWs.

Citation

Kaai, S.C., Fong, G.T., Ong’ang’o, J.R., Goma, F., Meng, G., Craig, L.V., Ikamari, L., Quah, A.C.K., Elton-Marshall, T. (2022). Prevalence, perceptions, and factors associated with menthol cigarette smoking: Findings from the ITC Kenya and Zambia Surveys. Tobacco Control, [Published online April 22, doi: http://dx.doi.org/10.1136/tobaccocontrol-2021-057100].

Abstract

Background: Menthol masks the harshness of cigarette smoke, promotes youth smoking and encourages health-concerned smokers who incorrectly believe that menthols are less harmful to smoke menthols. This study of smokers in Kenya and Zambia is the first study in Africa to examine menthol use, smokers’ beliefs about its harmfulness and the factors associated with menthols.

Methods: Data were from the International Tobacco Control (ITC) Kenya Wave 2 (2018) and Zambia Wave 2 Survey (2014), involving nationally representative samples of smokers. This study focuses on 1246 adult smokers (644 in Kenya, 602 in Zambia) who reported smoking a usual brand of cigarettes (menthol or non-menthol).

Results: Overall, menthol use was significantly higher among smokers in Zambia than in Kenya (48.0% vs 19.0%), females (45.6% vs 31.2% males), non-daily smokers (43.8% vs 30.0% daily) and those who exclusively smoked factory-made (FM) cigarettes (43.0% vs 15.2%). The erroneous belief that menthols are less harmful was more likely among smokers in Zambia than in Kenya (53.4% vs 29.3%) and among female smokers (38.5% vs 28.2%). In Kenya, menthol smoking was associated with being female (adjusted odds ratios (AOR)=3.07; p=0.03), worrying about future health (AOR=2.28; p=0.02) and disagreeing with the statement that smoking was calming (AOR=2.05; p=0.04). In Zambia, menthol use was associated with being female (AOR=3.91; p=0.002), completing primary school (AOR=2.14; p=0.03), being a non-daily smoker (AOR=2.29; p=0.03), exclusively using FM cigarettes (AOR=14.7; p<0.001), having a past quit attempt (AOR=1.54; p=0.02), believing that menthols are less harmful (AOR=3.80; p<0.001) and choosing menthols because they believed it was less harmful (AOR=3.52; p<0.001).

Conclusions: Menthols are highly prevalent among females in both countries. There is a need in African countries to combat the myth that menthols are less harmful and to ban menthol and other flavourings.

Citation

Kaai, S.C., Fong, G.T., Goma, F., Meng, G., Ikamari, L., Ong’ang’o, J.R., Elton-Marshall, T. (2019). Identifying factors associated with quit intentions among smokers from two nationally representative samples in Africa: Findings from the ITC Kenya and Zambia Surveys. Preventive Medicine Reports, 15(2019), 100951.

Abstract

It is well established that intentions to quit smoking is the strongest predictor of future quit attempts. However, most studies on quit intentions have been conducted in high-income countries with very few in low- and middle-income countries particularly in Africa. This is the first population-based study to compare factors associated with quit intentions among smokers in two African countries. Data were from the International Tobacco Control (ITC) Kenya and Zambia Surveys (2012), face-to-face surveys of nationally representative samples of 2291 adult smokers (Kenya = 1103; Zambia = 1188). Multivariate logistic regression analyses were conducted to identify predictors of quit intentions. Most Kenyan (65.1%) and Zambian (69.1%) smokers had quit intentions of which 54.8% planned to quit within the next 6 months. Five factors were significantly associated with quit intentions in both countries: being younger, having tried to quit previously, perceiving that quitting is beneficial to health, worrying about future health consequences of smoking, and being low in nicotine dependence. The predictive strength of these factors did not differ in the two countries. Four additional factors were significant predictors in Zambia only: having a quit attempt lasting six months or more, lower smoking enjoyment, having a negative opinion about smoking, and concern about cigarette expenses. The factors predicting quit intentions were similar to those in other ITC countries including Canada, US, UK, China and Mauritius. These findings highlight the need for stronger tobacco control policies in Kenya and Zambia including increased taxation, greater access to cessation services, and anti-smoking campaigns denormalizing tobacco use.