The Burden and Factors Associated With Smokeless Tobacco Use Among Adults in Nikki, Benin

Abstract

Objective

This study aimed to determine the prevalence and factors associated with consumption of smokeless tobacco (SLT) at Nikki, northern Benin.

Methods

This was a cross-sectional interview study carried out from November 2023 to September 2024 among adults aged≥18 years, after a process of two-stage random sampling.

Results

Overall, 688 participants were interviewed. Their mean age was 32.2 ± 13.3 years with a male-female ratio of 4.5:1. The prevalence of current SLT use (defined as currently consumption or consumption in the last 12 months) was 26.9% (95% CI = 23.7-30.3) while that of daily use was 15.1% (95% CI = 12.6-18.0). Factors associated with SLT consumption were age ≥30 years (aPR = 3.7; P < 0.001), male gender (aPR = 10.8; P < 0.001), not attending school (aPR = 4.1; P = 0.035), alcohol consumption (aPR = 4.0; P < 0.001), lack of awareness of the harm caused by SLT (aPR = 2.2; P < 0.001), a impression of SLT being less harmful compared with smoking tobacco (aPR = 5.2; P < 0.001), peer pressure and influence (aPR = 2.9; P = 0.001) and exposure to marketing (aPR = 3.5; P < 0.001). The possible association of SLT with harmful health risks was known by 399 (58%) participants.

Conclusion

The prevalence of SLT use was high among adults in Nikki, northern Benin. Raising awareness and regulating the sale of SLT products would help to mitigate this scourge; and further qualitative research are needed to determine the socio-cultural determinants of SLT consumption.

Introduction

As one of the most important public health threats globally, tobacco use is responsible for up to 8 million deaths annually. ¹ Tobacco use also places a heavy burden on healthcare systems and the economy, particularly in low-and-middle-income countries, where more than 80% of tobacco users and tobacco-associated deaths are concentrated.^1-3 While the harmful effects of smoking are generally well known to the general population, smokeless tobacco (SLT), a hidden and often neglected form of tobacco use, is mistakenly thought to be less harmful, particularly in many settings in sub-Saharan Africa. ⁴

Whether snuffed or chewed, SLT is consumed by approximately 352 million people worldwide, 67% of whom are men and 33% are women. ⁵ Previous studies have reported a link between SLT consumption and high dependency, metabolic diseases, myocardial infarction, oral cancers and chronic inflammation of the respiratory tract.^5-10 This type of tobacco consumption is estimated to cause more than 650,000 deaths worldwide each year.^5-10

In sub-Saharan Africa, SLT is deeply rooted in traditional practices. In some rural settings, this way of consuming tobacco is used, in association with other substances, as a medicinal remedy or for mystical protection.^4,11,12

In Benin, according to the latest national survey on risk factors for non-communicable diseases, which was conducted in 2015, the prevalence of SLT use was 8.2% among men and 3.2% among women. ¹³ In the north of the country, for reasons that are not yet fully understood, SLT consumption seemed to be particularly common. ¹³ This finding highlights the need to understand the potential factors associated with this practice in order to contextualize preventive strategies that take into account the local realities. This study aimed therefore to determine the prevalence and factors associated with consumption of SLT at Nikki, northern Benin.

Method

Study Design

This was a cross-sectional study that was carried out between November 2023 and September 2024.

Setting

Nikki is a semi-urban commune located in the north of the country, 533 kms from Cotonou, the economic capital of Benin. With a population estimated at 66,109 according to the latest general census of population and housing, including 28181 individuals aged 18 years and over, Nikki is made up of several ethnolinguistic groups. ¹⁴ Economic activities of the region largely revolve around agriculture.

Study Population

The source population was all adults living in Nikki district in 2024.

Inclusion Criteria

Participants were eligible for inclusion if they resided for at least 6 months in the selected villages or urban neighborhoods of the Nikki district, were aged 18 years or older, provided informed and voluntary consent to participate, and demonstrated the ability to complete the questionnaire.

Exclusion Criteria

Individuals who refused to participate or who discontinued the interview before completing the questionnaire were excluded.

Sampling

Sample Size

The sample size was calculated using Schwartz’s formula:

The $n\ge \frac{U{\alpha }^{2}x p x q}{i^2 }\times g$ ; with n being the minimum sample size; α, the risk error equal to 5%; Uα the reduced deviation corresponding to the risk error α, equal to 1.96; P the prevalence of smokeless tobacco consumption in the general adult population in Benin equal to 5.7% ¹³ ; q = 1-p; g, the cluster effect equal to 1.5; i the desired precision of 3%. A minimum sample size of 344 inhabitants was required.

Sampling Technique

A two-stage random sample was taken, the first stage being a random selection of eight villages and neighbourhoods out of the sixteen in Nikki district. The number of adults who were surveyed in each village or neighbourhood was determined on the basis of one’s demographic weight among those selected. In each village or neighbourhood, the investigator stood up in the center and drew lots in one direction, using the spin-the-bottle method. With the bottle turned in this direction, each house was visited; and any person in the same household who met the inclusion criteria was approached. When the expected number of participants was not reached in this direction, the investigator returned to the center of the village or neighbourhood and took the opposite direction to the initial one to continue the selection process. In order to reduce the risk of missing workers, the preferred time for visits was in the morning before 10 a.m. or in the evening after 4 - 5 p.m.

Data Variables

The dependent variable of the study was a current consumption of SLT. This was defined as the use of SLT every day or at least once a week in the last 12 months.

Independent variables included socio-demographic and occupational characteristics, current consumption of smoked tobacco or alcohol (i.e., daily consumption of beer or wine or local alcoholic beverages commonly known as “sodabi” or “tchoukoutou”), regular physical activity (defined as activity of 30 minutes with moderate intensity at least 3 times per week), the reasons and motivation for consuming SLT and knowledge about any harmful health related-effects. Details on the main questions related to tobacco product use in the questionnaire are provided in the Box.

Data Collection

Data were collected during a face-to-face interview using a semi-structured individual and electronic questionnaire adapted from the Global Adult Tobacco Survey 2020 version, via the KoBoCollect v1.30.1 application. ¹⁵ Smartphones were used to collect the data. Prior to data collection, the questionnaire was pre-tested in an unselected neighbourhood and then amended. Main changes were related to the reformulation of certain items in order to facilitate their understanding by both the investigator and the translators into the local language.

The data collection team consisted of four senior epidemiology technicians. They received one week’s training before going to the field. To prevent information bias, the pre-established questionnaire was translated into the local language, and the investigators were selected on the basis of their proficiency in the local language.

Data Analysis

Data which were stored on the KoBoToolbox server during collection were exported in XLS (Excel) file format for analysis with R software version 4.4.1. For descriptive analysis, central tendency and dispersion parameters were estimated for quantitative variables, and numbers, proportions and 95% confidence intervals (CIs) were determined for categorical variables. Comparison between two categorical variables were made using chi-square or Fisher Exact (if applicable) tests. A top-down stepwise multiple logistic regression was then performed to identify factors associated with SLT consumption. The prevalence ratio (PR) was used as the measure of association in bivariate (crude PR, cPR) and multivariate (adjusted PR, aPR) analysis. The level of significance was set at P < 0.05.

Ethics Statements

The research protocol received prior approval from the Local Ethics Committee for Biomedical Research at the University of Parakou (REF: CLERB-UP 676/2024). Authorizations were also obtained from the Nikki town Hall and each village or district chief. Free and informed consent was obtained from participants. Anonymity and confidentiality of data that were collected were respected.

Results

Overall, a total of 763 inhabitants were selected for interview in the eight villages and neighbourhood in the Nikki region, of whom 688 (90.2%) consented to be interviewed.

Socio-Demographic and Occupational Characteristics

The mean age of the 688 participants was 32.2 ± 13.3 years, ranging from 18 to 90 years and their male: female ratio was 4.5 :1. Nearly two thirds were married with 39.1% having received no education and 28.2% having reached primary level education only. The commonest occupation in 37.4% was being a farmer. The monthly income was less than the guaranteed interprofessional minimum wage in 82.6%. Characteristics are shown in Table 1.

Table 1.

Smokeless Consumption Status in Relation to Socio-Demographic and Occupational Characteristics, Nikki, Northern Benin, November 2023-September 2024

	Smokeless tobacco consumption			P-value
	All n (%)	No n (%)	Yes n (%)
Age group (Years)				<0.001
[18-29]	349 (50.7)	292 (58.1)	57 (30.8)
[30-90]	339 (49.3)	211 (41.9)	128 (69.2)
Gender				<0.001
Female	125 (18.2)	120 (23.9)	5 (2.7)
Male	563 (81.8)	383 (76.1)	180 (97.3)
Martial status				0.003
Married	416 (60.5)	287 (57.1)	129 (69.7)
Single	225 (32.7)	185 (36.8)	40 (21.6)	0.001
Cohabitation	27 (3.9)	17 (3.4)	10 (5.4)
Divorced	11 (1.6)	8 (1.6)	3 (1.6)
Widowed	9 (1.3)	6 (1.1)	3 (1.6)
Education level				<0.001
Not attending school	269 (39.1)	178 (35.4)	91 (49.2)	0.012
Primary level	194 (28.2)	147 (29.2)	47 (25.4)
Secondary level	173 (25.1)	130 (25.8)	43 (23.2)
High level	52 (7.6)	48 (9.6)	4 (2.2)	<0.001
Residence				0.15
Urban	366 (53.2)	276 (54.9)	90 (48.6)
Rural	322 (46.8)	227 (45.1)	95 (51.4)
Occupation				<0.001
Farmer	257 (37.4)	165 (32.8)	92 (49.7)	0.002
Craftsman	204 (29.7)	150 (29.8)	54 (29.2)
Trader	70 (10.2)	59 (11.7)	11 (5.9)	0.029
Student	56 (8.1)	54 (10.7)	2 (1.1)	<0.001
Taxi driver	37 (5.4)	25 (5.0)	12 (6.5)
Housewife	24 (3.5)	22 (4.4)	2 (1.1)	0.040
Others*	40 (5.7)	28 (5.6)	12 (6.5)
Monthly income				0.130
< GIMW**	568 (82.6)	422 (83.9)	146 (78.9)
≥ GIMW	120 (17.4)	81 (16.1)	39 (21.1)
Total	688	503	185

Others*: civil servant (16), thatcher (15), traditional practitioner (7), soccer (2); GIMW** : Guaranteed Interprofessional Minimum Wage is 79.3 euros in Benin.

Prevalence and Characteristics of Smokeless Tobacco use

Of the 688 participants, 225 had either consumed SLT at least once at the time of the survey or were current users, giving an overall SLT ever use of 32.7% (95% CI = 29.2-36.2). There were 40 (5.81%) former and 185 current users. The prevalence of current SLT use was therefore 26.9% (95% CI = 23.7-30.3). SLT was taken on a daily basis by 104 participants (15.1%, 95% CI = 12.6-18.0), and was used 5.6 ± 3 times per day on average, ranging from 1 to 15 intakes. Daily consumers comprised 56.2% of all current users. Occasional SLT use was reported in 81 participants (11.8%, 95% CI = 9.6-14.4), with a weekly intake of 2.5 ± 1.9, ranging from 1 and 12 intakes per week.

The mean age at start of SLT consumption was 23.8 ± 7.4 and the duration of consumption was 12.9 ± 12.5 years. SLT was taken nasally by 177 (95.7%) current users, orally by 6 (3.2%) and both nasally and orally by 2 (1.1%). In 16 (8.6%) users, there was an association with cigarette smoking. In 111 (60%) users, SLT was consumed at home and in 93 (50.3%) in the morning, immediately on waking (Not shown).

Characteristics amongst current SLT users and others are shown in Table 1. Key findings were that compared to those who do not use SLT, current SLT users had a profile characterized by an age ≥30 years (69.2% vs 41.9%, P < 0.001), male gender (97.3% vs 76.1%, P = 0.007), no schooling (49.2% vs 35.4%, P = 0.012) and the profession of farmer (49.7% vs 32.8%, P = 0.002).

Reasons for Initiating Smokeless Tobacco and Knowledge of Health-Related Risks

Mystical protection, lifestyle habits and pleasure were the main reasons for initiating SLT according to 84 (45.4%), 28 (15.1%) and 25 (13.5%) of current SLT users respectively (Table 2).

Table 2.

Reasons and Motivation for Initiating Smokeless Tobacco as Reported by Current Users in Nikki, Northern Benin, November 2023 - September 2024 (N = 185)

	n	%
Mystical protection	84	(45.4)
Lifestyle habits	28	(15.1)
Pleasure	26	(14.1)
The common cold	22	(11.9)
Stress	15	(8.1)
Others*	10	(5,4)
Total	185

⁕: Anti-asthenic, tooth decay treatment and headaches.

Overall, 399 (58%) participants reported that SLT could be harmful to health, with the main perceived health risks being dysphonia in 259 (64.9%), cancer in 239 (59.9%) and rhinorrhea in 197 (49.4%) respectively (Table 3).

Table 3.

Health Risks Associated With Smokeless Tobacco Consumption as Reported by Participants in Nikki, Northern Benin, November 2023 - September 2024

	N	(%)
Dysphonia	259	(64.9)
Cancers	239	(59.9)
Rhinorrhea	197	(49.4)
Bad breath	96	(24.1)
Tooth discoloration	75	(18.8)
Tooth decay	71	(17.8)
Tooth loss	46	(11.5)
Eye disorders	25	(6.3)
Dyspnea	16	(4.0)
Others⁕	67	(16.8)
Reports of possible harmful effects with smokeless tobacco	399

⁕: Sexual weakness, mental disorders, cough, hypertension, dizziness, dependence, abdominal or back pain.

Factors Associated with a High Prevalence of Smokeless Tobacco Consumption

Factors associated with a high risk of SLT consumption were: being aged ≥30 years (aPR = 3.7, 95% CI = 2.2-6.2, P < 0.001), male gender (aPR = 10.8, 95% CI = 3.6-47.0, P < 0.001), no attending school (aPR = 4.1, 95% CI = 1.2-17.4, P = 0.035); alcohol consumption (aPR = 4.0, 95% CI = 2.5-6.3, P < 0.001), lack of knowledge on SLT harmful health associated effects (aPR = 2.2, 95% CI = 1.4-3.4, P < 0.001), impression that SLT is less harmful compared to smoking (aPR = 5.2, 95% CI = 2.6-11.4, P < 0.001), peer pressure or influence (aPR = 2.9, 95% CI = 1.6-5.7, P = 0.001) and exposure to marketing (aPR = 3.5, 95% CI = 2.0-6.1, P < 0.001) (Table 4).

Table 4.

Factors Associated With Smokeless Tobacco Consumption in Nikki, Northern Benin, November 2023 - September 2024

	Bivariate analysis			Multivariate analysis
	cPR	95%CI	P-value	aPR	95%CI	P-value
Age group (Years)
18-29	1			1
30-90	3.1	2.2-4.5	<0.001	3.7	2.2-6.2	<0.001
Gender
Female	1			1
Male	11.3	5.0-32.3	<0.001	10.8	3.6-47	<0.001
Marital status
Single/Divorce/Widowed	1			1
Married/Cohabitation	2.0	1.4-2.9	<0.001	0.9	0.6-1.6	0.9
Education level
High level	1			1
Not attending school	6.1	2.4-20.8	<0.001	4.1	1.2-17.4	0.035
Primary level	3.8	1.5-13.2	0.014	3.0	0.8-13.0	0.11
Secondary level	4.0	1.5-13.7	0.012	2.6	0.8-10.8	0.2
Monthly income
< GIMW*	1			1
≥ GIMW	1.4	0.9-2.12	0.13	0.9	0.5-1.7	0.8
Alcohol consumption
No	1			1
Yes	5.5	3.9-8.0	<0.001	4.0	2.5-6.3	<0.001
Regular physical activity
No	1			1
Yes	1.8	1.2-2.9	0.008	1.3	0.7-2.3	0.4
Knowledge of the harmful effects of smokeless tobacco
Yes	1			1
No	1.5	1.1-2.2	0.013	2.2	1.4-3.4	<0.001
Perception of smokeless tobacco less harmful than smoking
No	1			1
Yes	7.6	4.2-15.2	<0.001	5.2	2.6-11.4	<0.001
Peer pressure / influence
No	1			1
Yes	7.4	4.4-13.2	<0.001	2.9	1.6-5.7	0.001
Exposure to smokeless tobacco marketing
No	1			1
Yes	4.7	3.0-7.4	<0.001	3.5	2.0-6.1	<0.001

cPR = Crude Prevalence Ratio, aPR = Adjusted Prevalence Ratio, 95%CI : 95% Confidence Interval, GIMW* : Guaranteed Interprofessional Minimum Wage.

Discussion

This population-based study focused on an issue that has received little attention in sub-Saharan Africa, including Benin. The size of the sample, the random nature of the sampling and the measures that were taken to correct the questionnaire before its administration to participants represent some of the strengths of the study and contribute to the reliability of the findings. The main limitation, however, remains the declarative nature of the answers to the different questions, which might introduce some bias. Limiting ourselves to questioning study participants might lead to under-reporting of SLT use, with consequently an underestimation of the real prevalence of SLT consumption. In practice, it was difficult for logistic reasons to control for this bias by measuring nicotine derivatives or by interviewing the respondent’s family and friends. Another limitation relates to the spin-the-bottle approach for sampling. Such a strategy may lead to the exclusion of those who were shy, disengaged or marginalized, or be influenced by friendship or social dynamics. Moreover, selection bias remained possible, and might be due to the non-inclusion of less active people or of those who were outside during the investigator’s visit.

Findings from the study allowed a better estimate of the prevalence of SLT in this community. Based on the criterion applied in this study for current SLT use, i.e., SLT use every week within the 12 last months, just over a quarter of participants (26.9%) were considered current users. SLT was taken on a daily basis by 15.1%, and was used more than 5 times per day on average. Compared to those who do not use SLT, current SLT users were significantly more often aged 30 years-old or above, males, not educated, and were farmers. The main reason for initiating SLT reported by current users was for mystical protection; and just over half of participants (58%) knew that SLT could be harmful to health. Factors that were significantly associated with a high risk of SLT consumption were: being aged ≥30 years, male gender, no education, alcohol consumption, lack of knowledge on SLT harmful health associated effects, impression of less harmfulness of SLT compared to smoking, peer pressure or influence and exposure to marketing.

In the published literature, the prevalence of SLT consumption varies depending on the definition criteria. For instance, Zhao et al ¹⁶ and Onoh et al ¹⁷ in their studies considered current users to be those using SLT at the time of the survey. Thus, Zhao et al ¹⁶ in a multicenter study found a prevalence of current SLT use of 21.4% in India, 20.6% in Bangladesh and 7.7% in Pakistan. Onoh et al ¹⁷ in Nigeria, based on national statistics, reported a prevalence of 1.9% among adults aged 15 years and over. Among Asian Indians in California, the prevalence of current SLT use, defined as consumption of SLT every day or on some days, was 13%. ¹¹

Contrary to our expectation that the majority of those who were SLT users would also be cigarette smokers, only 8.3% declared concomitant use of cigarettes. This finding could be linked to cultural habits or to a misperception that SLT is less harmful than smoked tobacco.

One of the main risks of consuming SLT products is the development of a nicotine addiction. We believe that many users have developed a strong addiction to SLT. This statement is supported by the daily consumption of these products by more than half of the users, with an average intake of at least 5 doses per day and a mean duration of use of approximately 13 years. Additionally, the unbridled desire for mystical self-protection may also explain the high number of daily intakes.

This study highlights some characteristics of the SLT use in our setting. Being aged 30 years or above, being male and uneducated are associated with a high risk of consuming SLT. Similar findings were reported by Zhao et al ¹⁶ and Jones et al. ¹⁸ For various reasons, including stress and the perceived responsibility for providing for the family, men may be more attracted and exposed to psychoactive substances. Poor levels of education, with lack of knowledge about harmful health risks, may also lead to SLT use. The association with alcohol consumption, as is the case with cigarette smoking, was common and this further increases the risk of complications, including cardiovascular disease.^4,6,19 In sub-Saharan Africa, especially in Benin, along with SLT consumption for healing purposes, the use of alcohol, notably palm wine commonly called “Sodabi”, in association with plants, is a common practice for traditional treatment of various ailments.

For many years, in line with the WHO Framework Convention on Tobacco Control, tobacco control has been an important priority in countries’ national health policies, including Benin. The MPOWER strategy has been put in place to monitor tobacco use in all its forms, strengthen prevention policies by raising public awareness, and ensure protection against this scourge. Unfortunately, most activities have largely focused on smoking cessation. These include, for instance, regulating marketing, sales, and raising awareness of the harmfulness and negative impact of tobacco on health. This could partly explain the reason why a large proportion of participants were unaware of the harmfulness of SLT. The situation is aggravated by marketing practices and peer pressure and influence. Promotion of the apparent benefits of SLT products, their display by street vendors or at points of sale, and their regular use during group meetings or social events, encourage people to adopt them.

Other factors associated with SLT use have been identified in the literature, although we did not find these in the current study. These include, for instance, loneliness along with celibacy, stress,^19,20 rural residence and an occupation associated with a poor monthly income.^18,21-23

As in some countries with a high prevalence of SLT use, such as Bangladesh, the introduction of certain measures could help improve the situation. These include for instance regulating the trade in SLT, increasing taxes, disseminating awareness messages on the harmfulness of this form of tobacco consumption via telephones or radios, and eliminating advertising.^16,24

This study represents a step towards a better understanding of the extent and characteristics of SLT consumption in the region. Further qualitative research should focus on the socio-cultural determinants of SLT consumption, which also appear to play a significant role in its use.

Finally, findings from this study cannot be generalized to all semi-urban regions worldwide. Implementing such investigation in other semi-urban settings would help to better understand all global and setting-dependent smokeless tobacco related issues for more effective actions.

Conclusion

The prevalence of SLT use among inhabitants in Nikki, Benin, was high, involving more than one person in four; with more than one person in seven consuming the products on a daily basis. The typical demographic profile of the SLT consumer was a male, aged at least 30 years, uneducated and a farmer. This SLT user also consumed alcohol, was unaware of harmful health effects and was exposed to marketing or peer pressure and influence. Effective awareness-raising measures are needed to reduce the scale of this scourge in the region.

ORCID iDs

Mariano Efio https://orcid.org/0009-0005-4242-6442

Serge ADE https://orcid.org/0000-0001-6504-7625

Ethical Considerations

The research protocol received prior approval from the Local Ethics Committee for Biomedical Research at the University of Parakou (REF: CLERB-UP 676/2024). Authorizations were also obtained from the Nikki town Hall and each village or district chief. The procedures followed were in accordance with the ethical standards of the Helsinki Declaration (1964, amended most recently in 2008) of the World Medical Association.

Consent to Participate

Free and informed consent was obtained from participants. The patient’s written consent was obtained. Anonymity and confidentiality of data that were collected were respected.

Data Availability Statement

Data are kept confidential with the first author and can be made available upon request. *