Tobacco use is a major public health concern, particularly in low- and middle-income countries where 80% of the world’s smokers reside. There is limited population-based data from rural Africa on patterns of tobacco smoking and smoker characteristics. We assessed trends in rates of smoking, characteristics of smokers, and factors associated with smoking using repeat population-based cross-sectional surveys in south-central Uganda.

Data accrued over five survey rounds (2010–2018) of the Rakai Community Cohort Study (RCCS) from consenting individuals aged 15– 49 years including sociodemographic and behavioral characteristics and smoking status. Proportions of smokers per survey were compared using χ2 test for trends, and factors associated with smoking were assessed by multivariable logistic regression.

The prevalence of tobacco smoking in the general population declined from 7.3% in 2010–2011 to 5.1% in 2016–2018, p<0.001. Smoking rates declined among males (13.9–9.2%) and females (2.2–1.8%) from 2010– 2011 to 2016–2018. Smoking prevalence was higher among previously married (11.8–11.7%) compared to currently (8.4–5.3%) and never married persons (3.1–1.8%) from 2010–2011 to 2016–2018. Older age (≥35 years) was associated with higher odds of smoking (AOR=8.72; 95% CI: 5.68– 13.39 in 2010–2011 and AOR=9.03; 95% CI: 5.42–15.06 in 2016–2018) compared to those aged <35 years (AOR=4.73; 95% CI: 3.15–7.12 in 2010–2011 and AOR=4.83; 95% CI: 2.95–7.91 in 2016–2018). Primary and secondary/higher education level was significantly associated with lower odds of smoking (AOR=0.20; 95% CI: 0.14–0.29 in 2010–2011 and AOR=0.26; 95% CI: 0.18–0.39 in 2016–2018) compared to no education (AOR=0.43; 95% CI: 0.31–0.59 in 2010–2011 and AOR=0.48; 95% CI: 0.34–0.68 in 2016–2018). Number of sexual partners and HIV status were not associated with smoking.

We observed declining trends in tobacco smoking in the Rakai region of rural Uganda. Smoking was more prevalent in men, older individuals, individuals who were previously married, and individuals with lower education. The decline in smoking may be due to tobacco control efforts, but there is a continued need to target sub-populations with higher smoking prevalence.

We thank the staff of Rakai Health Sciences Program, the RCCS study participants, the local community leadership, the Rakai and neighboring Districts’ Directorates of Health services and the Uganda Virus Research Institute for supporting this work.
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. F. Nalugoda and L.W. Chang report that since the initial planning of the work and in the past 36 months their institution received funding from the National Institutes of Health. C. Hoe reports that in the past 36 months she was funded by a grant from Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco Use. J. Kagaayi, D.M. Serwadda and G. Kigozi report that since the initial planning of the work they received funding from National Institutes of Health. M.J. Wawer reports that in the past 36 months is a paid consultant to the Rakai Health Sciences Program (outside of this work) and serves on its Board of Directors and that this arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. R.H. Gray reports that in the past 36 months he is a member of the Rakai Health Sciences Program Board.
This study was jointly supported by the National Institute of Allergy and Infectious Diseases, Division of Intramural Research (SJR and Grant numbers: R01AI110324, R01AI110324, and R01AI102939), the National Institute of Mental Health (Grant number R01MH107275), the Bill and Melinda Gates Foundation (Grant numbers 08113 and 22006.02), and the National Institutes of Health Fogarty International Center (Grant number D43TW010557).
Participants gave informed consent at baseline and at follow-up as needed depending on whether they are baseline or follow-up participants. Consent forms were translated in the local language of the region (Luganda) and back-translated to English before they were certified by the department of languages of Makerere University, Kampala, Uganda. They were then submitted for review and approval by the ethics review boards. The study was approved by the Uganda Virus Research Institute Research and Ethics Committee, Uganda National Council for Science and Technology, and the Western Institutional Review Board in the US (REC/UVRI, FWA 00001354, expiry 31 August, 2023).
The data supporting this research are available from the authors on reasonable request.
FN led conceptualization and design of the study. FN and DN analyzed and interpreted data and wrote the manuscript. JS, CH, RS, JK, NKS, DMS, MJW, MKG, SJR, GK, RHG, PTY and LWC supported concept development, data interpretation, and manuscript editing. All authors participated in data interpretation, manuscript revisions, and final manuscript approval.
Not commissioned; externally peer reviewed.
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