Tobacco use in Nigerian youth: A systematic review
Tobacco use in Nigerian youth: A systematic review
Bankole K. Oyewole 0 1
Victor J. Animasahun 0 1
Helena J. Chapman 1
0 Faculty of Clinical Sciences, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University , Sagamu , Nigeria , 2 Lagos State University Teaching Hospital , Lagos , Nigeria , 3 Department of Environmental and Global Health, University of Florida , Gainesville, Florida , United States of America
1 Editor: Wei Wang, Edith Cowan University , AUSTRALIA
Tobacco use is the most important preventable cause of premature death and major risk factor for non-communicable diseases. Due to strict tobacco legislation in the western hemisphere, many African nations like Nigeria have shifted from being a tobacco-producing nation to a tobacco-consuming one. The purpose of this study was to systematically review existing literature on tobacco use among Nigerian adolescents and young people and identify the prevalence, distribution and factors influencing of tobacco smoking. These data are necessary to formulate and adapt control measures aimed at tobacco cessation among young people, and preventing long-term smoking behaviors. Three databases (African Journals Online, PsychInfo, PubMed) were searched for peerreviewed publications, published between January 2000 and March 2017. Additional searches were completed on Google Scholar, and other documents and reports of the Nigerian government and the Global Youth Tobacco Survey were consulted. Using the PRISMA guidelines to evaluate studies, we included studies that reported prevalence of tobacco use in adolescents or youths, aged 10 to 24, and excluded evaluations of tobacco-related medical conditions.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
A total of 30 studies with a total population of 26,709 were reviewed. Prevalence rates of
tobacco smoking ranged from 0.2% to 32.5%. Among the gender-specific studies, the
prevalence of smoking among females ranged between 2.2% to 10% while that of males ranged
from 1% to 32.5%. Gender distribution among these studies was mixed (80.0%), males only
(13.3%) and females only (6.7%). Smoking prevalence was higher among males than
females. The most common risk factors for tobacco use included peer influence, family
conditions, psychosocial factors and male gender. Additional risk factors included concomitant
substance abuse, media advertisements and increasing age.
Tobacco smoking poses a huge burden to Nigerian youths and various determinants were
highlighted in this review. It is imperative that all stakeholders engage in concerted efforts to
target both in-school and out-of-school youths in tobacco control strategies.
Tobacco smoking is the single most important cause of preventable and premature death
globally. The World Health Organization (WHO) estimates that tobacco kills nearly seven million
people annually and 100 million deaths were recorded over the course of the 20th century [
More than six million of those deaths are the result of direct tobacco use while close to 900,000
deaths are the result of non-smokers being exposed to second-hand smoke. Unless urgent
action is taken, the annual death toll could rise to more than eight million by 2030 [
to 80percent of world's one billion smokers live in low to middle income countries like Nigeria
Non-communicable diseases (NCDs) already account for more than 80 percent of
premature deaths in developing countries and the single largest preventable risk factor for NCDs is
tobacco smoking . While the global burden of NCDs is estimated to rise by 17 percent in
the next decade, it is expected that a sharp increase of 27 percent would be experienced in the
Africa region [
]. Nigeria is the most populous nation in Africa with a large population of
adolescents and young people, which affects health indices across the region. [3±5].
The transition of tobacco hubs from the West to the African continent is of paramount
importance, and Nigeria lies at the forefront of the shift from a tobacco-producing to a
tobacco-consuming nation [
]. Between 1990 and 2009, cigarette consumption decreased by
about 26 percent in western Europe while there was almost a 60 percent increase in tobacco
consumption in Africa and Middle Eastern countries [
]. As such, Africa has become a prime
target for tobacco companies [
]. Tobacco regulation has been tightened in North America
and Europe in contrast to the African region where some countries are either yet to implement
tobacco laws or are more susceptible to being influenced by the tobacco lobby groups that see
the continent as a vast area for growth [
]. The WHO Framework Convention on Tobacco
Control (FCTC), was adopted by the 56th World Health Assembly on May 21, 2003, and
implemented on February 27, 2005. In this treaty, WHO recommends a four-pronged strategy
for the control of smoking . The first prong advocates a ban on all forms of advertising and
an increase in public health information with special attention to youths [
]. The Nigeria
National Tobacco Control Act of 2015, was passed to domesticate the WHO FCTC; however,
implementation has been poor as most public places are yet to be smoke free, and no funds
have been dedicated for tobacco law enforcement [
Most smokers begin smoking during their adolescent years, and they grow into the habit
making nicotine addiction difficult to curb [
]. As these adolescents become adults, they
serve as role models to youths, reinforcing a vicious cycle [
]. The health consequences of
tobacco smoking depend on the duration and quantity of the smoking behavior. Starting to
smoke early in life increases the risk of NCDs, and adolescent smokers are at greatest risk of
future morbidity and mortality [
Half of adolescent smokers become regular smoking adults, and a further half of this
population is expected to die of tobacco-associated illnesses, further highlighting the great burden
smoking in young people poses and the need to end this habit [
]. The crucial role young
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people play in the perpetuation of smoking is not lost on the tobacco industry. Evidence shows
a large percentage of their advertising dollars is now spent to encourage young people to
smoke, with more than nine billion dollars directed towards this goal every year [
Approximately 40 percent of Hollywood movies and movies rated for young people depict
scenes of smoking, highlighting the shift from obvious tobacco advertisements to more
subliminal and harder to regulate spheres .
The purpose of this study was to systematically review existing literature on tobacco use
among Nigerian adolescents and young people to identify the prevalence, distribution and
factors influencing tobacco smoking. These data are necessary to formulate and adapt control
measures aimed at tobacco cessation among young people, and prevention of long-term
Search strategy and selection criteria
A systematic review was conducted, following the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines for assessments of intervention studies [
We aimed to identify studies that examined general tobacco use in Nigeria among ªyouthº,
using the WHO definition of youth as individuals between ages 10 and 24 years [
]. We also
consulted the Global Youth Tobacco Survey (GYTS), a school-based survey that examined
tobacco use in youth between 13 and 15 years of age, including academic curriculum on
tobacco use, exposure to secondhand smoking, media advertisement, tobacco cessation, and
availability of and access to tobacco, and guided the assessment of interventions [
defined ªcurrent smokerº as youth who had smoked at least once during the previous 30 days
]. Three researchers searched three databases (African Journals Online,
PsychInfo,PubMed), for peer-reviewed publications, published between January 2000 and March 2017. We
used key terms, ªNigeriaº and ªtobaccoº or ªsmoking or ªcigaretteº, and ªadolescentº or
ªyouthº or ªschoolº. References of eligible studies were searched for possible inclusion. We
limited our search to tobacco use prevalence in adolescents or youths, aged 10 to 24, excluding
the evaluation of tobacco-related medical conditions. We excluded studies that described case
reports, reviews, and qualitative or mixed method research designs. We did not include studies
published in languages other than English, reported findings from multiple countries, failure
to defied smoking behaviors, or conducted outside of Nigeria. Additional searches were
completed on Google Scholar and other documents and reports of the Nigerian government and
the GYTS were consulted. In initial search, two pairs of researchers (BKO and VJA or BKO
and HJC) reviewed all titles and abstracts and excluded studies that did not meet the inclusion
criteria. Full-text articles of eligible studies were obtained and evaluated independently by all
researchers, based on limits to the inclusion criteria. When full-text articles were unavailable
on library databases, we emailed authors and, if necessary, sent reminder emails over a period
of six months. Those full-text articles that were unable to be obtained by the respective authors
were excluded. Consensus was met by all researchers if there were discrepancies in this
evaluation process. Fig 1 presents the PRISMA flowchart of the search strategy. Since this review
evaluated the publicly available scientific literature, ethical authorization was not obligatory.
From the final included articles, authors extracted data in a spreadsheet, including year of data
collection period, study location (e.g., site, geopolitical zone, rural or urban setting), sample
size, gender (for single gender studies), smoking prevalence, definition of smoking status and
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Fig 1. PRISMA flowchart of the search strategy.
determinants or risk factors. A descriptive table was developed to organize the general
characteristics of selected studies.
Using the following study appraisal criteria, based on a previous systematic review [
evaluated the quality of the selected quantitative studies. First, the study population should be
representative, including the appropriate selection and size of the sample. Second, the
exposure variable, including sampling method and data collection strategy, should be described.
Third, the outcome variable should be defined along with the analytical plan to examine
associations and level of significance in order to determine tobacco risk factors. These criteria were
reviewed by two pairs of researchers (BKO and VJA or BKO and HJC), and consensus was
met to include or exclude each study.
This systematic review focused on studies that investigated the prevalence of tobacco smoking
among Nigerian youths between January 2000 and March 2017 (Table 1). Of the total 30 studies,
the sample sizes ranged from 128 to 2,408, and the cumulative sample total was 26,709. These
studies were conducted in rural (33.3%), urban (56.7%) and mixed settings (10.0%). A total of 3
(10.0%) studies were conducted in more than one region and could be said to be nationally
representative as respondents were from southern and northern Nigeria, while other studies (90.0%)
were city-specific. About three-quarters (76.7%) were conducted in southern Nigeria, and others
(13.3%) were conducted in northern Nigeria. The gender distribution among these studies was
mixed (80.0%), males only (13.3%) and females only (6.7%). A total of 13 (41.3%) did not include
the study date, but were published within the selected time frame for this review.
Of the total 30 studies, prevalence rates of tobacco smoking ranged between 0.2% and
32.5%. Studies showed that smoking prevalence was higher among males than females [20±
27]. Among the gender-specific studies, the prevalence of smoking among females ranged
between 2.2% [
] to 10% [
] while that of males ranged from 1% [
] to 32.5% [
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Although Atoyebi et al. (2013) did not outline risk factors in their study, all tobacco users in
that study were males [
]. In particular, two studies had striking prevalence rates of 19.1% in
] and 32.5% in males [
]. Three studies reported the prevalence among females as
], 4.7% [
] and 10% [
]. Over one-third (36.7%) of the studies reviewed did not
measure risk factors for tobacco smoking in young people. The most common risk factors
included peer influence; male gender; family conditions, such as low parental education,
polygamy, not living with parents, having a parent who smokes and having divorced or
separated parents; and psychosocial factors such as belonging to a polygamous home, low level of
father's education, feeling of loneliness and depressive symptoms, were found to contribute
significantly to the prevalence of smoking among these street children. Additional risk factors
were concomitant substance abuse, media advertisements and increasing age.
To the best of our knowledge, this is the first systematic review to investigate the prevalence,
distribution and influences of tobacco smoking among Nigerian adolescents and young
people. This is set against the backdrop of a nation experiencing significant demographic changes
with increased populations of young people [
]. The studies were predominantly from
southern Nigeria, reflecting the varying research productivity across geopolitical zones [
majority of the studies targeted males only, which is consistent with previous studies [35±37].
The gender difference may be attributed to societal perception as most African communities
see smoking as a sign of masculinity or even specific to manhood and vigor [
], while social
values discourages smoking among women [
]. Some studies reported prevalence values
above the latest WHO national prevalence of tobacco smoking among males (17.4%) and
females (1.1%) [
]. Most studies included in our review, that used the GYTS protocol,
targeted the in-school youth, demonstrating a lower prevalence of tobacco use when compared
to out-of-school (street).
Abdulmalik et al. (2009) conducted a study in Borno State, North East, Nigeria, among the
ªAlmajirisº, youth between 11 and 16 years of age, who lacked formal education, spent
minimal time in Arabic classes, and spent time involved in street begging [
]. Several psychosocial
factors, such as belonging to a polygamous home, low level of father's education, feeling of
loneliness and depressive symptoms, were found to contribute significantly to the prevalence
of smoking among these street children. Studies in India and Philippines documented that
street children, who are usually out-of-school youths, are more vulnerable to risky practices,
such as increased smoking and other forms of substance abuse especially in the face of weak
family bonds and harsh survival realities [
]. Adequate social support and efforts to
integrate youths with their families may serve as one strategy to reduce tobacco smoking .
Odukoya et al. (2016) reported the highest prevalence of tobacco smoking in this review,
focusing on out-of-school youths in motor parks around Lagos, South Western Nigeria [
Consistent among the general population and gender-specific groups, this high prevalence
highlights this vulnerable population of out-of-school youths in this geopolitical zone.
Out-ofSchool youths are usually least prioritized during tobacco smoking research and control
] and may lack opportunities to benefit from formal health education and
antismoking campaigns, when compared to in-school youths .
A noteworthy finding was that the lowest prevalence values of tobacco smoking in this
review was 0.2%, in a rural setting across Osun State, South West, Nigeria [
], and the highest
Prevalence was 32.5% in an urban population in Lagos, South West, Nigeria [
generally throughout the review, there were no clear-cut demarcations in the prevalence of
tobacco smoking within rural or urban communities apart from the one depicted by the range
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of prevalence. This finding, however, follows the systematic review conducted across
SubSaharan African countries [
], showing no consistent disparity in smoking prevalence
between rural and urban populations. For example, certain studies in rural settings reported
high prevalence of tobacco smoking among adolescents [
] and higher prevalence in
rural areas of the United States and India [44±46]. However, other studies in Poland and Peru
showed that the prevalence of tobacco smoking among adolescents was higher among the
urban population [
]. Hence, tobacco control policies should be strengthened across all
Nigerian societies regardless of geography or existing health or socioeconomic inequalities.
Peer influence was the most common risk factor described among the studies reviewed
[20,23,27,43,49±54]. This is consistent with one study among South African adolescents that
showed that peer smoking had the strongest influence on smoking lifestyle [
]. Also, family
conditions, such as low parental education, polygamy, not living with parents, having a parent
who smokes and having divorced or separated parents, were additional risk factors [24,25,27,
43,49,52±54,56]. One study among Australian youths documented that overt pressure from
older family members to initiate smoking was uncommon, but the majority were influenced
by the availability of tobacco owned by older relatives in their homes, smoking practices and
techniques of similarly aged family members [
Stress, loneliness and depressive symptoms were the most common psychosocial risk
factors for tobacco smoking [
], consistent in one study that focused on tobacco smoking
among adolescents in seven African countries [
]. This review identified that young people
who abuse other substances, such as alcohol and marijuana, or who consume other forms of
tobacco, Excluding smoking, were at risk of tobacco smoking [
]. Since psychosocial
problems among young people are usually due to physical, emotional and sexual abuse and
neglect, they usually resort to tobacco smoking or other forms of substance abuse as a coping
mechanism to ameliorate their condition . However, psychosocial problems among
adolescents are real and the access and availability of friendly supportive systems are needed to
limit the use of harmful coping behaviors like smoking. Since adolescents involved in cigarette
smoking are usually involved in alcohol or other forms of substance abuse, a widespread
multi-component control strategy may effectively reach this high-risk population [
Media advertisements and increasing age were identified as risk factors for tobacco
]. Similar findings among rural South African adolescents revealed
that Increasing age and seeing actors smoke on television had significant associations with
]. Television actors usually serve as role models for young people, and they may
subtly motivate adolescents to consider smoking as a socially desirable activity [
]. One study
among American adolescents revealed that the temptation to experiment with tobacco was
increased among those exposed to pro-tobacco advertisements [
]. Another study among
North African adolescents documented that 98% were exposed to at least one form of tobacco
advertisement, which was associated with increased susceptibility to smoking initiation and
current smoking [
]. The health hazards of smoking and the impact on quality of life should
be the primary focus on tobacco control initiatives for in-school and out-of-school youths.
This study has limitations. First, due to the heterogeneity of methodology and data, an
analysis of the trends of tobacco smoking among youths could not be implemented. Indeed, future
studies, which consider the adoption of the Nigerian National Tobacco Control Act of 2015,
can incorporate this control measure and assess its impact on tobacco prevalence.
Second, since no meta-analysis was performed in this study, no quantitative data analysis is
available for further interpretation.
Third, although this review exhausted the scientific literature, including three databases,
Google Scholar search, GYTS, government document review and direct communication with
authors, we cannot overlook the fact that some publications may have been missed. However,
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this review is a valuable addition to existing literature and necessary for policy formulation
and future monitoring of the impact of tobacco control measures. This also provides insight
into the common challenges that African researchers encounter, leading to a paucity of health
research productivity in Africa [
This systematic review on the prevalence and associated determinants of tobacco smoking
among Nigerian youths provides an adequate picture of this burden in the most populous
country in Africa. Hence, all stakeholders should engage in concerted efforts to target both
inschool and out-of-school youths in tobacco control strategies. Future research can explore the
implementation of existing tobacco laws and the associated effect on trends of tobacco
prevalence in Nigeria.
Conceptualization: Bankole K. Oyewole, Victor J. Animasahun, Helena J. Chapman.
Data curation: Bankole K. Oyewole, Victor J. Animasahun.
Formal analysis: Bankole K. Oyewole, Victor J. Animasahun.
Methodology: Bankole K. Oyewole, Victor J. Animasahun, Helena J. Chapman.
Supervision: Helena J. Chapman.
Writing ± original draft: Bankole K. Oyewole, Victor J. Animasahun, Helena J. Chapman.
Writing ± review & editing: Bankole K. Oyewole, Victor J. Animasahun, Helena J. Chapman.
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