Tobacco use and associated factors among adults in Ghana: evidence from the 2022 Ghana Demographic and Health Survey

Abstract

Objective

To examine the prevalence and sociodemographic factors associated with tobacco smoking, smokeless tobacco and dual use among adults in Ghana using the 2022 Demographic and Health Survey (GDHS).

Setting

Ghana, nationwide sample of males and females aged ≥15 years.

Design

This was a cross-sectional secondary analysis of the 2022 GDHS.

Population

A representative sample of 22 058 individuals (females, 15 014 aged 15–49; males, 7044 aged 15–59)

Primary and secondary outcome measures

Current tobacco smoking, smokeless tobacco use and dual use.

Results

Prevalence for smoking, smokeless tobacco and dual use was 4.7 (4.1–5.4), 1.6 (1.3–2.0) and 0.6 (0.4–0.9) among males and 1.0 (0.8–1.3), 0.08 (0.05–0.1) and 0.1 (0.05–0.1) among females, respectively. Among males, smoking was associated with higher age (30–44 years: AOR: 2.3, 95% CI 1.7 to 3.1; 45–59 years: AOR: 2.6, 95% CI 1.8 to 3.7). Higher education was protective for both sexes [(males: AOR: 0.4, 95% CI 0.2 to 0.8) and (females: AOR: 0.4, 95% CI 0.2 to 0.8)] compared with their counterparts who had no education. Males in the Coastal zone had higher odds of use (AOR: 1.8, 95% CI 1.3 to 2.3) compared with males in the Middle zone, while females in the Northern/Savanna zone had lower odds of tobacco use (AOR: 0.5, 95% CI 0.3 to 0.8) compared with the Middle zone. Being Christian was associated with lower odds of smoking among males (AOR: 0.3, 95% CI 0.2 to 0.5) compared with others, while being Mole-Dagbani ethnic is associated with higher odds of smoking among females (AOR: 3.0, 95% CI 1.7 to 5.4).

Conclusion

The study provides the first national analysis across Ghana’s 16 regions and investigates patterns of smoking, smokeless tobacco and dual tobacco use. While tobacco use in Ghana remains predominantly smoked and male-driven, the divergent patterns of use across educational, regional and ethnic groups, especially the emerging risk among females, represent a significant public health shift that demands focused gender-sensitive tobacco control interventions.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study used the 2022 Ghana Demographic and Health Survey (GDHS), which provides the most recent and nationally representative data on tobacco use across Ghana’s 16 administrative regions.

• The large sample size (n=22 058) provides high statistical power to analyse low-prevalence behaviours, such as smoking among females and dual tobacco use.

• The application of sampling weights and complex survey design analysis ensures that the findings are representative of the national population, maximising the precision of the estimates.

• As a cross-sectional study, the analysis is limited in its ability to establish temporal sequences or to make causal inferences about the relationship between sociodemographic factors and tobacco use.

• Data were based on self-reports, which may be subject to social desirability bias, potentially leading to an underestimation of tobacco use, and recall bias regarding frequency of use.

Background

The harmful effects of tobacco use have been well-documented for decades, yet it remains the leading preventable cause of premature deaths and disability worldwide. In 2019, tobacco use claimed about 8.7 million lives, making it the second-leading cause of death globally after high systolic blood pressure.¹ Smoking and smokeless tobacco use are the major risk factors for cancers,² cardiovascular diseases^{3 4} and respiratory diseases.⁵ Additionally, using tobacco can also lead to periodontal problems and poorer dental treatment outcomes.⁶ Secondhand smoke also poses significant health risks to persons who do not smoke, particularly women, children and infants.⁷ Tobacco use is estimated to claim over one billion lives this century if the smoking rate continues unchanged.^{8 9} Low- and middle-income countries (LMICs) bear the brunt of tobacco use, accounting for smoking-related deaths worldwide.¹⁰ The tobacco industry is aggressively expanding its presence in sub-Saharan Africa through increased marketing and production largely due to the high drop in tobacco use in developed countries.¹¹ Consequently, tobacco use in sub-Saharan Africa is predicted to rise, with the number of persons who smoke estimated at 77 million in 2010, and expected to increase by nearly 40% by 2030, reflecting the region’s early stages of the tobacco epidemic.12,14

In Ghana, tobacco is a significant public health threat, claiming over 6700 individuals’ lives annually, within a national population of approximately 31 million people.¹⁵ Approximately two-thirds of these deaths occur prematurely.¹⁶ Tobacco use treatment costs Ghana approximately 668 million cedis ($65.9 million), equivalent to 0.2% of the country’s GDP in 2019.^{16 17} Additionally, implementing evidence-based tobacco prevention strategies can effectively prevent an estimated 20 000 deaths and save 3.1 billion Ghana cedis ($128.2 million) by 2037.¹⁶

Despite the enactment of the 2012 smoke-free law, which bans cigarette advertising, the sale of cigarettes to minors, the sale of single-stick cigarettes to consumers, and smoking in public places, its effectiveness has been hindered by factors such as socioeconomic differences and regional inequalities.¹⁸ While the law marks a significant stride in tobacco control, population-targeted interventions are needed to address the sociodemographic, economic and regional disparities. These include the design of focused, accessible cessation services, regional-level policies to promote awareness and education campaigns tailored to vulnerable groups.

A study by Brenya and colleagues¹⁹ revealed that socioeconomic factors, such as wealth, educational level, residential status, income and occupation, were associated with non-communicable disease risk factors, including tobacco use among Ghanaians.¹⁹ Studies in Ghana and other countries (eg, China, India and South Africa) reported a disproportionately high prevalence of tobacco use among low-income individuals, driven by factors like gender, geography, wealth status and other social and economic vulnerabilities.^{20 21}

A previous Demographic and Health Survey (DHS) conducted in 2014 examined tobacco use in Ghana, reporting a smoking prevalence among adult males of 4.8% and females of 0.1% in ten administrative regions.²² Earlier nationally representative estimates of smoking prevalence in Ghana were published within 2 years of the national smoke-free law, and updated estimates are needed to assess decadal progress in tobacco control. In 2019, Ghana created six new administrative regions from the existing 10, bringing the total to 16. Tobacco use prevalence by type of use (smoking, smokeless and dual use) and among males and females is not studied across the 16 regions.²³

Leveraging the 2022 Ghana Demographic and Health Survey (GDHS), this study aims to examine the prevalence and socio-demographic factors associated with tobacco use among Ghanaians (aged ≥15 years), providing the first national analysis of tobacco use across Ghana’s 16 administrative regions and examining the emerging threat of dual use. It addresses a critical gap in the literature by investigating female tobacco use patterns, informing gender-responsive tobacco control strategies in sub-Saharan Africa.

Findings from this study provide valuable insights to support Ghana’s tobacco control efforts by revealing tobacco use patterns and associated factors, thereby informing policies such as the National Tobacco Control Strategy²⁴ and the NCD Prevention and Control Policy.²⁵ Understanding these associated factors is essential for evaluating existing strategies and allocating limited resources for effective socioeconomic interventions.

Methods

Data source

This is a cross-sectional secondary data analysis of the 2022 Ghana Demographic and Health Survey (GDHS) data. The GDHS is a national survey that is conducted every 5 years, and the 2022 survey is the seventh since 1998.²⁶ The GDHS was conducted by the Ghana Statistical Service (GSS) with technical assistance from ICF International (formerly Inner-City Fund) and the Demographic and Health Surveys (DHS) Programme, and it was funded by the United States Agency for International Development (USAID). The goal of GDHS was to provide the latest estimates of demographic and health indicators, including tobacco use, and to inform policymakers and programme managers in designing and evaluating programme strategies to improve the population’s health status. Also, data from the GDHS surveys are used to measure the country’s progress towards the United Nations’ Sustainable Development Goals.

The GDHS collected household-level and individual-level data among males and females aged 15 years and above in Ghana. The sampling procedure included a two-stage cluster sample designed to yield representative results at the national level for urban and rural areas of Ghana. First, 618 clusters were selected using probability-proportional-to-size sampling in urban and rural areas within each region, followed by systematic random sampling. The second stage involved household listing and mapping, with 30 households selected randomly from each cluster. A total of 18 540 households were selected, of which 18 065 were occupied, and 17 933 interviews were successful, yielding a 99% response rate. In the interviewed households, 15 317 women aged 15–49 were identified as eligible for individual interviews, of which 15 014 completed the interview, yielding a response rate of 98%. In the subsample of households selected for men aged 15–59, 7263 were identified as eligible for individual interviews, and 7044 were successfully interviewed, yielding a response rate of 97%.²⁷ The DHS sampling method is inherently designed to sample a larger number of females of reproductive age (15–49 years) in selected households to capture maternal and child health indicators. The men aged 15–59 years are sub-samples from the selected households to capture a broader demographic profile.

This study used data from the 2022 Ghana Demographic and Health Survey (GDHS) conducted by the Ghana Statistical Service. The GDHS received ethical approval from the Ghana Health Service Ethics Review Committee and the ICF Institutional Review Board. Access to the anonymised dataset was granted following approval of a formal request to the DHS Programme. The details of the survey design, sampling methods, data collection, and quality assurance processes have been provided in the GDHS-2022 report.²⁶

Study variables

The dependent variables for this study included current smoking, smokeless tobacco use, and dual use among adult males and females in Ghana.²⁷ Place of residence, region, and respondent characteristics, including age, level of education, and health status, were independent variables. A full description of the study variables is provided in online supplemental table S1.

Current smoking was defined as self-reported daily or less-than-daily use of cigarettes, pipes, cigars, and other smoking tobacco products. Current smokeless tobacco use was defined as self-reported daily or less than daily use of snuff, chewing tobacco, and betel quid with tobacco. Current dual use refers to self-reported use of both smoking and smokeless tobacco products.

The dependent variables were developed from responses to survey items capturing various forms of tobacco use among respondents. In separate questions for tobacco smoking and smokeless tobacco, participants were asked, “Do you currently (smoke tobacco- (cigarette, pipes, cigars, and other smoking tobacco products)) / (use smokeless tobacco- (use of snuff, chewing tobacco, and betel quid with tobacco)) every day, some days, or not at all?” The options available to the respondents were ‘every day’, ‘some days’ and ‘not at all’. For this analysis, the ‘every day’ and ‘some days’ were grouped and coded as ‘1’ (indicating current use), and ‘not at all’ was coded as ‘0’ (indicating non-use). The current use of smoking products (ie, cigarettes, pipes, cigars and other smoking products) and the current use of smokeless tobacco products were developed as separate binary variables. Further, to compute the outcome variable for dual use, we combined current use of smoking products and current use of smokeless tobacco products.

The independent variables include place of residence (urban or rural), region of residence (across all 16 administrative regions in Ghana) and geographical zone. The 16 regions were categorised into three ecological zones. The Coastal zone, highly urbanised with the capital city Accra; the Middle/Forest zone, dominated by agricultural and mining activities; and the Northern/Savanna zone, known for its Sahel climate, were dominated by agriculture and animal husbandry activities, and diverse cultural practices, however, with the lowest socioeconomic indicators.²⁸ Additionally, the study considered demographic factors such as age (grouped into 15–29, 30–44, and 45 years or older), gender (male or female), marital status (married/formerly married or not married), and level of education (no education, primary, secondary, or tertiary). Other variables include ethnicity (grouped into Akan, Ewe, Mole-Dagbani, and others (Gan/Dangme, Guan, Grusi, Gurma, Mande)), self-reported health status (ranging from very good to very bad), and household wealth (ranging from poorest to richest wealth quintile as provided by DHS). Online supplemental table S1 provides an outline of the operationalisation of study variables.

Patient and public involvement

No patient was involved in this study. The findings will be disseminated to relevant stakeholders through publication and key stakeholder meetings.

Data cleaning and analysis

Sample weights were applied to address complex sample designs and ensure the representativeness of the study sample. Prior to analysis, the outcome and independent variables were screened for the presence of missing data using the code book and frequency tables, and no missing data were observed. To ensure representativeness of the findings, the respective sample weights provided by DHS surveys for male (MV005) and female (V005) samples account for complex samples.²⁹

We computed descriptive estimates (ie, unweighted frequencies and weighted proportions) to summarise the participant characteristics. Sex-stratified prevalence estimates for smoking tobacco, smokeless tobacco use and dual use were computed with their corresponding 95% CIs (using the Taylor Series linearisation method to estimate standard errors). Further, prevalence estimates were obtained across Ghana’s geographical regions and ethnic tribes. Cross-tabulations were developed and χ² tests were conducted to examine the association between tobacco use (smoking, smokeless and dual-use) and independent variables across sociodemographic characteristics and self-reported health status. The multivariable logistic regression analysis was conducted to identify the factors associated with smoking tobacco, smokeless tobacco use and dual use. Among females, the multivariable analysis was limited to identifying factors associated only with tobacco smoking, as the prevalence of smokeless tobacco use and dual use was negligible (~0.1%). All analyses were two-tailed, with p-values <0.05 set as the level of statistical significance. Analyses were conducted using the IBM SPSS Complex Sample module (IBM Corp., 2017, V 25) and Stata (V 18, StataCorp, College Station, TX).

Results

The 2022 Ghana DHS data analysed for this study comprised 7044 males and 15 014 females. Approximately 45% of males and 43% of females resided in rural areas. Most participants had formal education (primary to tertiary), with 11% of males and 16% of females having no formal education. Most participants were employed at the time of the survey (87% of males and 78% of females). Table 1 presents the socio-demographic characteristics of the participants.

Table 1. Sociodemographic characteristics of adult males and females, 2022 Ghana Demographic and Health Survey (GDHS).

Characteristics	Male (n=7044)		Female (n=15 014)
	N*	%†	N*	%†
Age Group
15-29 years	3335	47.5	7890	51.4
30-44	2416	33.7	5895	39.9
45 years and above‡	1293	18.8	1229	8.7
Marital Status
Unmarried	3810	57.4	8130	60.0
Married	3234	42.6	6884	40.0
Educational level
No education	1186	11.4	3357	16.1
Primary	923	11.7	2245	13.8
Secondary	4001	62.5	8111	59.9
Higher	934	14.4	1301	10.2
Religion
Christianity	4348	70.4	10 430	76.8
Islam	1993	20.7	3994	19.4
Traditional/spiritualist	348	3.9	305	1.8
Others	355	5.0	285	2.0
Region
Middle Zone	1764	29.2	3789	29.9
Northern Zone	2370	18.4	5076	18.6
Coastal Zone	2910	52.4	6149	51.5
Residence
Urban	3251	54.6	7362	57.0
Rural	3793	45.4	7652	43.0
Ethnicity
Akan	2412	46.0	5217	46.1
Ewe	765	11.2	1641	11.6
Mole-Dagbani	1811	18.0	4054	18.6
Others	2056	24.8	4132	23.7
Wealth Quintile
Richest	1089	23.2	2288	22.3
Richer	1235	23.0	2686	22.5
Middle	1318	18.2	3008	20.8
Poorer	1553	18.1	3366	18.1
Poorest	1849	17.6	3666	16.3
Occupation
Not working	859	13.0	3347	21.8
Working	6185	87.0	11 667	78.2
Health Status
Very good	1912	29.9	4879	31.2
Good	3432	45.9	6934	45.7
Moderate	1388	20.3	2648	19.7
Bad	284	3.4	480	3.0
Very bad	28	0.4	73	0.4

Ecological zones were categorised into coastal, middle and northern zones based on the Ghana Statistical Service (GSS) standard classification for the 2022 GDHS regional groupings.

Note: The total N for some variables may vary slightly due to missing data (<1%).

^*The frequencies are unweighted.

^†The percentages are weighted.

^‡Age range for the ‘45 years and above’ category is 45-59 for males, and 45-49 for females.

The bivariate analysis examined the relationship between socio-demographic characteristics and tobacco use prevalence among participants. Results from the Pearson’s χ² tests showed significant associations with tobacco use and age, educational attainment, wealth quintile and region of residence for males and females (p<0.05; table 2). Among the regions, Western North (9.7 (7.1–1.3)) and Northern (9.1 (6.8–12.0)) regions had the highest prevalence of smoking among males (figure 1a, online supplemental table S2) Table 1), while Northern (2.1 (1.4–3.1)) and Upper West (2.3 (1.3–4.0)) regions had a high smoking prevalence among females (figure 1b, online supplemental table S2).

Table 2. Sociodemographic characteristics and prevalence of tobacco use among males and females, 2022 GDHS.

Characteristics	Male (n=7044)			Female (n=15 014)
	Smoking %(95% CI)	Smokeless %(95% CI)	Dual use %(95% CI)	Smoking %(95% CI)	Smokeless %(95% CI)	Dual use %(95% CI)
Total	4.7 (4.1 to 5.4)	1.6 (1.3 to 2.0)	0.6 (0.4 to 0.9)	1.0 (0.8 to 1.3)	0.08 (0.05 to 0.1)	0.08 (0.05 to 0.1)
Age Group
15-29 years	3.1 (2.4 to 4.1)	1.1 (0.07 to 1.6)	0.4 (0.2 to 0.7)	1.0 (0.7 to 1.3)	0.01 (0.00 to 0.08)	0.01 (0.00 to 0.08)
30-44	5.8 (4.7 to 7.2)	2.1 (1.5 to 3.0)	0.8 (0.5 to 1.5)	1.1 (0.8 to 1.6)	0.08 (0.04 to 0.2)	0.08 (0.04 to 0.2)
45+years*	6.5 (5.2 to 8.1)	1.9 (1.2 to 2.9)	0.7 (0.4 to 1.2)	0.6 (0.4 to 1.2)	0.5 (0.2 to 1.0)	0.5 (0.2 to 1.0)
p-value†	<0.001	0.005	0.082	0.296	<0.001	<0.001
Marital Status
Unmarried	4.3 (3.5 to 5.3)	1.3 (0.9 to 1.8)	0.5 (0.3 to 0.7)	0.9 (0.7 to 1.3)	0.05 (0.02 to 0.1)	0.05 (0.02 to 0.1)
Married	5.2 (4.3 to 6.2)	2.0 (1.5 to 2.7)	0.8 (0.5 to 1.3)	1.1 (0.8 to 1.5)	0.1 (0.06 to 0.2)	0.1 (0.06 to 0.2)
p-value†	0.100	0.018	0.079	0.272	0.195	0.195
Education
No education	10.2 (8.3 to 12.5)	2.3 (1.9 to 4.3)	1.0 (0.5 to 1.9)	1.5 (1.1 to 2.2)	0.3 (0.1 to 0.6)	0.3 (0.1 to 0.6)
Primary	6.7 (5.0 to 9.0)	2.3 (1.4 to 3.7)	1.3 (0.7 to 2.4)	0.8 (0.5 to 1.4)	0.06 (0.02 to 0.2)	0.06 (0.02 to 0.2)
Secondary	3.9 (3.2 to 4.9)	1.5 (1.1 to 2.1)	0.5 (0.3 to 0.9)	0.9 (0.7 to 1.3)	0.03 (0.01 to 0.09)	0.03 (0.01 to 0.09)
Higher	1.9 (0.9 to 3.8)	0.3 (0.1 to 0.9)	0.1 (0.02 to 1.0)	0.8 (0.3 to 2.0)	–	–
p-value†	<0.001	<0.001	0.003	0.043	<0.001	<0.001
Religion
Christianity	2.8 (2.2 to 3.6)	1.4 (1.1 to 1.9)	0.5 (0.3 to 0.8)	0.9 (0.7 to 1.2)	0.07 (0.03 to 0.1)	0.07 (0.03 to 0.1)
Islam	7.4 (5.9 to 9.2)	1.8 (1.1 to 2.7)	0.9 (0.5 to 1.6)	1.3 (0.9 to 1.8)	0.1 (0.05 to 0.3)	0.1 (0.05 to 0.3)
Traditional	15.9 (11.5 to 21.8)	2.5 (1.2 to 5.5)	1.4 (0.5 to 4.1)	2.5 (1.1 to 5.3)	0.1 (0.02 to 0.9)	0.1 (0.02 to 0.9)
Others	10.1 (7.4 to 15.8)	2.6 (1.4 to 5.1)	0.5 (0.2 to 1.5)	0.3 (0.06 to 1.0)	0.1 (0.02 to 0.8)	0.1 (0.02 to 0.8)
p-value†	<0.001	0.162	0.092	0.013	0.849	0.849
Region
Middle Zone	3.7 (2.9 to 4.7)	1.6 (1.1 to 2.3)	0.7 (0.4 to 1.1)	1.1 (0.8 to 1.5)	0.05 (0.02 to 0.1)	0.05 (0.02 to 0.1)
Northern Zone	7.5 (6.3 to 8.9)	2.1 (1.5 to 3.0)	0.7 (0.4 to 1.2)	1.6 (1.2 to 2.1)	0.3 (0.2 to 0.6)	0.3 (0.2 to 0.6)
Coastal Zone	4.5 (3.4 to 5.8)	1.3 (0.9 to 1.9)	0.4 (0.2 to 1.0)	0.6 (0.4 to 1.0)	–	–
p-value†	<0.001	0.146	0.040	<0.001	<0.001	<0.001
Residence
Urban	3.8 (3.0 to 4.8)	0.9 (0.6 to 1.4)	0.05 (0.03 to 0.9)	1.1 (0.9 to 1.6)	0.05 (0.02 to 0.1)	0.05 (0.02 to 0.1)
Rural	5.8 (4.9 to 6.9)	2.4 (1.8 to 3.1)	0.7 (0.5 to 1.1)	0.8 (0.6 to 1.0)	0.1 (0.06 to 0.2)	0.1 (0.06 to 0.2)
p-value†	<0.001	<0.001	0.284	0.021	0.098	0.098
Ethnicity
Akan	3.1 (2.4 to 4.1)	1.5 (1.1 to 2.0)	0.5 (0.3 to 0.8)	0.9 (0.6 to 1.4)	–	–
Ewe	2.4 (1.6 to 3.7)	0.7 (0.3 to 1.3)	0.5 (0.2 to 1.0)	1.0 (0.5 to 2.0)	0.1 (0.05 to 0.5)	0.1 (0.05 to 0.5)
Mole-Dagbani	7.7 (6.2 to 9.5)	2.4 (1.6 to 3.5)	1.1 (0.6 to 2.0)	1.8 (0.9 to 1.8)	0.3 (0.2 to 0.6)	0.3 (0.2 to 0.6)
Others	6.4 (5.0 to 8.3)	1.6 (0.1 to 2.6)	0.5 (0.2 to 1.4)	0.6 (0.3 to 1.0)	0.02 (0.006 to 0.1)	0.02 (0.006 to 0.1)
p-value†	<0.001	0.021	0.103	<0.001	<0.001	<0.001
Wealth Quintile
Richest	1.9 (1.1 to 3.3)	0.4 (0.2 to 1.1)	0.2 (0.06 to 0.1)	1.2 (0.7 to 1.9)	0.3 (0.2 to 0.6)	0.3 (0.2 to 0.6)
Richer	4.8 (3.5 to 6.7)	1.2 (0.7 to 2.2)	0.5 (0.2 to 1.2)	0.9 (0.5 to 1.6)	0.1 (0.05 to 0.3)	0.1 (0.05 to 0.3)
Middle	5.3 (3.8 to 7.4)	2.1 (1.3 to 3.4)	0.8 (0.4 to 0.2)	0.9 (0.5 to 1.5)	–	–
Poorer	4.4 (3.3 to 5.9)	1.5 (1.0 to 2.4)	0.5 (0.3 to 0.9)	0.7 (0.5 to 1.0)	–	–
Poorest	7.8 (6.5 to 9.4)	3.2 (2.3 to 4.4)	1.2 (0.7 to 2.2)	1.4 (1.0 to 2.0)	0.01 (0.00 to 0.08)	0.01 (0.00 to 0.08)
p-value†	<0.001	<0.001	0.015	0.070	<0.001	<0.001
Occupation
Not working	1.7 (0.9 to 3.4)	0.3 (0.09 to 1.1)	0.2 (0.05 to 1.1)	0.9 (0.6 to 1.4)	0.05 (0.01 to 0.2)	0.05 (0.01 to 0.2)
Working	5.1 (4.4 to 5.9)	1.8 (1.4 to 2.2)	0.7 (0.5 to 9.0)	1.0 (0.8 to 1.3)	0.09 (0.05 to 0.5)	0.09 (0.05 to 0.5)
p-value†	<0.001	0.001	0.104	0.439	0.667	0.667
Health Status
Very good	4.4 (3.3 to 5.8)	1.5 (1.0 to 2.2)	0.7 (0.4 to 1.2)	1.2 (0.9 to 1.8)	0.02 (0.01 to 0.08)	0.02 (0.01 to 0.08)
Good	4.0 (3.2 to 5.0)	1.6 (1.2 to 2.2)	0.6 (0.3 to 1.0)	0.8 (0.6 to 1.2)	0.07 (0.03 to 0.2)	0.07 (0.03 to 0.2)
Moderate	5.6 (4.3 to 7.4)	1.9 (1.2 to 3.0)	0.7 (0.3 to 1.3)	1.0 (0.7 to 1.6)	0.1 (0.06 to 0.4)	0.1 (0.06 to 0.4)
Bad	10.7 (7.1 to 15.8)	0.7 (0.2 to 1.8)	0.5 (0.2 to 1.6)	0.7 (0.3 to 1.8)	0.3 (0.07 to 1.4)	0.3 (0.07 to 1.4)
Very bad	9.1 (2.0 to 3.2)	0.4 (0.05 to 3.0)	–	4.1 (1.0 to 15.8)	–	–
p-value†	0.008	0.702	0.966	0.008	0.320	0.320

Note: Participants with dual use overlap with smoking and smokeless tobacco use.

Note: ‘N’ is the unweighted frequency; % is the weighted proportion, weighted using GDHS sample weights for national representativeness. The 95% CI are weighted Wald CI using Taylor linearisation for SE.

^*Among men 45–59 years, women=45-49 years.

^†p-values were derived from Pearson’s χ2 tests comparing the distribution of tobacco use prevalence across sociodemographic characteristics.

GDHS, Ghana Demographic and Health Survey.

Figure 1. Geographic variations in smoking and smokeless tobacco use among adults in Ghana: A) Males; B) Females.

Tobacco use patterns

Males

Among adult males, 4.7% (95% CI 4.1 to 5.1) smoked tobacco, 1.6% (95% CI 1.3 to 1.9) used smokeless tobacco and 0.6% (95% CI 0.4 to 0.8) engaged in dual use. The prevalence of smoking was highest among males aged 45–59 years at 6.5%. Married men had a smoking prevalence of 5.2% and smokeless tobacco use of 2.0%. Males with higher education had a lower tobacco use prevalence of 1.9%, whereas those with no formal education had a smoking prevalence of 10.2% and 2.9% smokeless tobacco use. The Mole-Dagbani ethnic group reported the highest smoking prevalence at 7.6%. Traditionalists reported the highest smoking prevalence at 15.9% and 2.5% of smokeless tobacco use, while Christians reported the lowest prevalence at 2.8% and 1.4% prevalence of smoking smokeless tobacco, respectively. Regionally, the Western North region reported the highest prevalence of smoking at 9.7%, smokeless tobacco use at 9.4% and dual use at 4.7% (table 2, figure 1, online supplemental table S2).

Females

Among adult females, 1.0% (95% CI 0.9 to 1.2) smoked tobacco, 0.1% used smokeless tobacco and 0.1% engaged in dual use. The highest smoking prevalence was observed among females aged 30–44 years, at 1.1%. Married women had a smoking prevalence of 1.1% and smokeless tobacco use of 0.1%. Females with higher education had a lower smoking prevalence of 0.8%, while those with no formal education had a smoking prevalence of 1.5%. Traditionalists reported the highest smoking prevalence at 2.5%, while Christians reported the lowest prevalence at 0.9%. Regionally, the Upper West region reported the highest smoking prevalence at 2.3%, smokeless tobacco use at 1.7% and dual use at 1.7%, while the Oti region reported the lowest smoking prevalence at 0.3% (table 2, figure 1, online supplemental table S2).

Factors associated with tobacco use

The frequency of smokeless tobacco and dual use among females was minimal, negating the multivariable analysis for these specific outcomes in women. table 3 presents the multivariable logistic regression results for tobacco use reporting, including Adjusted ORs (AORs) and 95% CIs. The models were weighted for the 2022 GDHS complex survey design.

Table 3. Multivariable logistic regression analysis of sociodemographic determinants of tobacco use among males and females, 2022 GDHS.

Characteristics	Male (n=7044)			Female (n=15 014)*
	Smoking AOR (95% CI)	Smokeless AOR (95% CI)	Dual use AOR (95% CI)	Smoking AOR (95% CI)
Age group
15-29 years (reference)
30-44	2.3 (1.7 to 3.1)	2.0 (1.2 to 3.4)	2.2 (0.9 to 5.1)	1.1 (0.7 to 1.6)
45 years and above†	2.6 (1.8 to 3.7)	1.7 (0.9 to 3.1)	1.7 (0.6 to 4.7)	0.6 (0.3 to 1.3)
Marital status
Unmarried (reference)
Married	0.5 (0.4 to 0.7)	1.0 (0.6 to 1.6)	1.0 (0.5 to 2.3)	0.9 (0.6 to 1.4)
Educational level
No education (reference)
Primary	0.9 (0.6 to 1.4)	1.1 (0.6 to 2.1)	1.5 (0.6 to 4.0)	0.6 (0.3 to 1.1)
Secondary	0.7 (0.5 to 1.0)	1.0 (0.6 to 1.8)	0.9 (0.3 to 2.2)	0.6 (0.4 to 1.0)
Higher	0.4 (0.2 to 0.8)	0.3 (0.1 to 1.0)	0.3 (0.0 to 2.1)	0.4 (0.2 to 0.8)
Religion
Others (reference)
Christianity	0.3 (0.2 to 0.5)	0.7 (0.4 to 1.5)	1.4 (0.3 to 6.4)	3.8 (0.4 to 37.0)
Islam	0.7 (0.5 to 1.0)	0.7 (0.3 to 1.6)	2.5 (0.5 to 12.5)	3.8 (0.4 to 39.1)
Traditional/spiritualist	1.6 (0.9 to 2.7)	0.8 (0.3 to 2.2)	3.7 (0.6 to 23.6)	10.7 (1.0 to 116.8)
Region
Middle Zone (reference)
Northern Zone	1.0 (0.7 to 1.4)	0.8 (0.5 to 1.5)	0.6 (0.2 to 1.6)	1.0 (0.5 to 1.7)
Coastal Zone	1.8 (1.3 to 2.3)	1.2 (0.7 to 1.8)	3.9 (1.8 to 8.3)	0.5 (0.3 to 0.8)
Residence
Urban (reference)
Rural	1.2 (0.9 to 1.6)	1.6 (1.0 to 2.6)	0.8 (0.4 to 1.8)	0.5 (0.3 to 0.8)
Ethnicity
Others (reference)
Akan	0.7 (0.5 to 0.9)	1.3 (0.8 to 2.3)	1.2 (0.5 to 2.9)	2.3 (1.3 to 4.1)
Ewe	0.5 (0.3 to 0.7)	0.5 (0.2 to 1.2)	0.9 (0.2 to 3.1)	2.5 (1.2 to 4.9)
Mole-Dagbani	1.3 (0.9 to 1.7)	1.6 (0.9 to 2.7)	2.3 (0.9 to 5.5)	3.0 (1.7 to 5.4)
Wealth Quintile
Richest (reference)
Richer	2.2 (1.3 to 3.7)	2.1 (0.9 to 5.1)	1.7 (0.5 to 6.1)	0.7 (0.4 to 1.1)
Middle	2.1 (1.3 to 3.3)	3.6 (1.5 to 8.7)	3.4 (1.0 to 12.0)	0.6 (0.4 to 1.0)
Poorer	1.5 (0.9 to 2.5)	2.3 (0.9 to 6.1)	2.9 (0.7 to 12.4)	0.5 (0.3 to 1.0)
Poorest	2.0 (1.0 to 3.5)	4.4 (1.6 to 11.6)	8.0 (1.9 to 33.8)	1.1 (0.6 to 2.2)
Occupation
Not working (reference)
Working	2.2 (1.3 to 3.7)	3.7 (1.1 to 12.2)	1.7 (0.4 to 7.4)	1.2 (0.8 to 1.8)
Health Status
Very good (reference)
Good	0.9 (0.7 to 1.2)	0.9 (0.6 to 1.5)	0.7 (0.3 to 1.4)	0.7 (0.5 to 1.0)
Moderate	1.1 (0.8 to 1.5)	1.0 (0.6 to 1.7)	0.8 (0.3 to 1.8)	0.9 (0.6 to 1.4)
Bad	1.9 (1.2 to 3.1)	0.3 (0.1 to 1.3)	0.4 (0.1 to 2.9)	0.6 (0.2 to 2.0)
Very bad	1.4 (0.3 to 5.7)	0.3 (0.0 to 80.2)	N/A	3.1 (0.9 to 11.8)

Note: Participants with dual use overlap with smoking and smokeless tobacco use.

^*Due to the extremely low prevalence of the use of smokeless tobacco and dual use among females, these outcomes could not be modelled and, therefore, not reported.

^†Among men 45–59 years, women 45–49 years.

AOR, Adjusted Odds Ratio; N/A, the sample sizes were few due to which the odds ratios could not be modeled.

Males

The prevalence of smoking, smokeless tobacco use and dual use among males was associated with age, education, religion, ethnicity, zone and wealth quintile. Males aged 30–44 years had 2.3 times higher odds of tobacco use compared with those aged 15–29 years (AOR: 2.3, 95% CI 1.7 to 3.1). Males aged 45 years and above had 2.6 times higher odds of smoking tobacco compared with those in the youngest age group, 15–29 years (AOR: 2.6, 95% CI 1.8 to 3.7). Males with higher education had 60% lower odds of smoking tobacco compared with those with no education (AOR: 0.4, 95% CI 0.2 to 0.8). Being a Christian was associated with 70% lower odds of tobacco use compared with others (AOR: 0.3, 95% CI 0.2 to 0.5). Males of Akan (AOR: 0.7, 95% CI 0.5 to 0.9) and Ewe (AOR: 0.5, 95% CI 0.3 to 0.7) ethnicity had 30% and 50% lower odds of smoking compared with other ethnic groups. Males in the coastal zone had 1.8 times higher odds of smoking tobacco compared with those in the middle/forest zone (AOR: 1.8, 95% CI 1.3 to 2.3). Additionally, males in the poorest wealth quintile have higher odds of smokeless tobacco use and 8.0 times higher odds of engaging in dual use compared with those in the richest quintile (AOR: 8.0, 95% CI 1.9 to 33.8). Marital status was significantly associated with tobacco use; married males had 50% lower odds of smoking (AOR: 0.5, 95% CI 0.4 to 0.7) compared with their unmarried counterparts. Occupation and health status were not significantly associated with tobacco use among males in the multivariable model (p>0.05).

Females

The prevalence of smoking among females is associated with education, religion, ethnicity and zone. Among females, those with higher education had 60% lower odds of smoking tobacco compared with those with no education (AOR: 0.4, 95% CI 0.2 to 0.8). Being a traditional believer was associated with higher odds of tobacco smoking (AOR: 10.7, 95% CI 1.0 to 116.8) compared with other religious groups, although this finding was borderline significant given a wide CI. Females of Mole-Dagbani ethnicity had three times higher odds of smoking (AOR: 3.0, 95% CI 1.7 to 5.4) compared with other ethnic groups. Females in the Northern/Savanna zone had 50% lower odds of smoking tobacco compared with those in the Middle/Forest zone (AOR: 0.5, 95% CI 0.3 to 0.8). Marital status and occupation were not significantly associated with smoking among females; for instance, working women did not have significantly higher odds of smoking compared with those who were unemployed (AOR: 1.2, 95% CI 0.8 to 1.8). The associations between sociodemographic factors and both smokeless tobacco and dual use were not statistically significant due to the low prevalence of these outcomes.

Discussion

Our study examined the current tobacco use prevalence and associated factors among males and females in Ghana using evidence from the 2022 GDHS. The findings highlight significant gender disparity, with tobacco smoking, smokeless tobacco use and dual use being significantly more prevalent among males than females. Among males, being married, having a higher education and being Christian were found to be protective factors against smoking. Among females, higher education and being in the richest wealth quintile were identified as protective factors. Conversely, rural residence, lower wealth quintile and employment were associated with higher odds of tobacco use among males. Ethnicity and health status also emerged as significant predictors of tobacco use across both sexes. Tobacco smoking among men in Ghana decreased marginally, whereas female tobacco use prevalence increased when comparing the 2014 GDHS data to the current study.¹⁸

Our findings showed significant regional disparities in tobacco use across Ghana’s ecological zones. While previous data from 2014 identified different high-prevalence areas,³⁰ the current study finds that males in the Western North now exhibit the highest prevalence. Specifically, males in the Coastal zone had significantly higher odds of tobacco use compared with those in the Middle/Forest zone. This regional variation may be attributable to higher urbanisation and increased availability of diverse tobacco products in coastal areas. Conversely, the lower odds of tobacco use observed among females in the Northern/Savanna zone may reflect stronger cultural or religious prohibitions against female smoking in these regions.

Looking beyond Ghana’s borders, our results align with broader patterns observed in the Sub-Saharan African region, where tobacco smoking prevalence is generally low but marked by wide gender disparities.^{12 31} Similar to findings in Nigeria, Ethiopia and Kenya, our study confirms that male sex, older age and lower educational attainment remain primary drivers of tobacco use. While some studies previously predicted a rapid increase in tobacco use among African males,^{13 32} the marginal decline observed in Ghana mirrors the trend in Benin, Sierra Leone and Senegal.¹² This suggests that the implementation of the WHO Framework on Tobacco Control (WHO-FCTC) is yielding positive results across the sub-continent.

We observed an increase in female smoking prevalence that can be attributed to many factors, including the aggressive marketing strategies by tobacco companies targeting vulnerable populations, shifting cultural values and the emergence of new tobacco products.^{33 34} The findings also suggest that smoking is becoming increasingly normalised among women in certain contexts.³⁵ The lack of a strong upward trend in tobacco use in Ghana, particularly among men, can also be attributed to government interventions, including the implementation of the WHO Framework Convention on Tobacco Control Project 2030, which enhanced pictorial health warnings and led to the development of a national strategic plan.¹⁶ However, there is a need for further studies to identify gender-specific factors contributing to the rise in female tobacco use to develop more effective, focused interventions.

The Western North region, reporting the highest tobacco use prevalence among males in this study, requires immediate public health attention. This area has seen recent economic growth and interregional migration driven by the oil and gas and mining industries.^{36 37} The increase in manual labour in the region may contribute to the rise in tobacco use through increased product accessibility and affordability, and targeted marketing.³⁸ Consequently, community awareness campaigns should be initiated, involving religious and traditional leaders, to advocate for a smoke-free lifestyle. As religion was a significant predictor in our study, framing tobacco control as a moral and spiritual concern could positively influence communities.39,41

The study has several strengths, notably the use of a large, nationally representative dataset from the 2022 GDHS. Furthermore, disaggregating the analysis by sex and ecological zone provides a detailed understanding of tobacco use patterns. However, some limitations must be acknowledged. The cross-sectional nature of the data prevents causal inference regarding the relationship between sociodemographic factors and tobacco use. Additionally, because tobacco use was self-reported, the findings may be subject to social desirability bias. Finally, the low prevalence of smokeless tobacco products among females resulted in wide CIs for some predictors, limiting the statistical power of those specific models. Although we have adjusted for several confounders, unmeasured factors like genetic factors or specific health policies were not captured and may influence the outcomes.

The findings provide valuable evidence for the Ghana Ministry of Health to design accessible tobacco cessation support, including counselling and nicotine replacement therapies. Specifically, these findings inform Ghana’s 5 year National Tobacco Control Strategy²⁴ and national policies for the prevention and control of non-communicable diseases (NCDs)²⁵ by identifying the key sociodemographic factors driving tobacco use prevalence within the Ghanaian context.

Conclusion

This study identifies significant gender disparity in tobacco use in Ghana, showing relatively stable male prevalence and a concerning increase in female tobacco use prevalence. Key determinants, including educational attainment, religious affiliation, ethnicity and ecological zone, play a critical role in shaping these odds of tobacco use.

To mitigate these trends, Ghana must invest in focused public health interventions that address regional disparities in the Coastal and Western North zones and prioritise gender-sensitive cessation programmes. Addressing these specific determinants is essential for reducing the long-term public health and economic burden of tobacco use in Ghana.

Data availability statement

Data may be obtained from a third party and are not publicly available.