**3. Determinants of cigarette smoking**

A substantial body of literature has emerged over the last few decades which examined the determinants of smoking behaviour in an economic framework of demand incorporating cigarette prices. Most studies in Nigeria were focused mainly on the determinants without much emphasis on the effect of cigarette pricing. Some of the determinants highlighted include the age of onset, peer group, parental influences, media influence etc. The Nigeria climate and weather favours the cultivation of tobacco in large commercial scale, especially in the South-western part of the country. This agricultural setting may influence tobacco smoking, but little is known about the influence of tobacco leave plantation (agricultural setting) on the incidence and prevalence of tobacco among children and adults in Nigeria.

#### **3.1 Age**

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

lung cancer in women and the most important cause of chronic bronchitis. The guided restrictions placed on the use of tobacco in Nigeria and other parts of the world were the results of the early steps taken by Luther L. Terry who insisted on warning labels on every cigarette pack [7] which forced tobacco industries to modifying their products by introducing filters and reducing the nicotine contents in their products. The warning labels transformed over years [7] and most developed countries made a stricter conditionality that forced many cigarette companies outside the shores of the US to the developing countries especially in Asia, Africa and South America where they found safe haven to establish their

consumption of this product worldwide [5].

that the sales of tobacco are illegal [8].

(NTCA) was signed into law [9, 11].

**2. Prevalence of smoking in Nigeria**

Virginia USA. Tobacco consumption gradually gained wide publicity through 1880s, through chewing, smoking pipes and hand rolled cigar or cigarettes. However, the invention of the first cigarette–making machine by James Bonsack capable of milling 120,000 sticks of cigarette per day revolutionised the trade, spread and

There was an astronomic growth in the industry across the globe and consumption was freely rising until 1964 when it witnessed its first set back. The Surgeon General of the USA, Luther L. Terry (MD) issued the first warning dangers on cigarette smoking on January 11th 1964, relating the tar and nicotine content as causes of cancer. His Advisory Committee made their observations and conclusions based on the findings of more than 7,000 articles relating to smoking and disease available at that time in the biomedical literature [6]. They concluded that cigarette smoking was responsible for lung and laryngeal cancers in men, probable cause of

Generally, the 19th Century was associated with improvement in health research which further revealed other adverse effects of smoking. Subsequently, its ban or reduction in use gained a global attention. Despite the known adverse consequences of tobacco consumption, it is only in the Kingdom of Bhutan (South Asian country)

Historically, the agenda for a national policy on tobacco control in Nigeria dates back to the pre independence era, it however was not until a decade after the 2005 signing of the World Health Organisation Framework Convention for Tobacco Control (WHO FCTC) [9, 10]. Economic challenge such as lack of fund and loss of employment by the citizens were some of the reasons cited for the delay in implementing the tobacco compliant policy. This is in difference to the observation by Egbe et al. in their 2017 report that focused on and implicated the tobacco industry as the major influence against the implementation of the WHO FCTC since 2005 when Nigeria ratified the FCTC, until 2015 when the National Tobacco Control Act

Globally, it is estimated that the number of smokers will increase from the present prevalence of 1.3 billion to 1.6 billion people in 2025. Its associated mortality is estimated to increase to 8.3 million persons in 2030 from 4.8 million persons in 2006 [12]. In 1990, Obot reported a prevalence of 26.8% of current smokers and 4.7% of past smokers among Nigerian adults [13]. According to the 2012 GATS conducted in Nigeria, the overall prevalence of adults who currently smoked was 3.7% [(3.1 million people): 7.2% - males; 0.3% - females)] [14]. The average age at initiation of daily smoking, according to the report showed that majority began after 16 years old [14]. More recent studies among medical, pharmacy and nursing students in Southwest Nigeria had life time prevalence of 17.9% and 5.04% for lifetime and current smokers [15]. The undergraduate university students study in Ilorin, North-central

**136**

industries.

One important determinant of cigarette smoking with perhaps the highest immediate and long term consequences is the age. Early age at debut implies that the smoker will not only have longer time over which his/her tolerance levels can increase but also that the period of exposure to cigarette smoking with subsequent complications will be high. On the average, at the turn of thirty years of age, the rate of decline in the functional capacities of human organ-system is at about 0.1% annually. This modest decline is lost and the downward trend as high as 1% annual decline is seen in those with one form of existing morbidities or harmful lifestyle practices such as cigarette smoking.

Age of smoking debut is around 15 years in Nigeria and by age 17, a persistent smoking pattern is already established and a significant 15% smoking prevalence among the adolescents [21, 22]. The male to female prevalence ratio among current smokers were 3.8:1, male 7.7% and female 2.0%. The mean age at initiation of smoking for males (15.5 ± 2.9, range 10–22 years) was not significantly different from that of females (15.6 ± 3.3, range 10–19 years) [16]. The driving force for the onset age of smoking among Nigerian children depends on the population being under study, whether out-of-school youths or in-school youths. For the out-of-school youths, psychosocial factors such as belonging to a polygamous home, low level of fathers' education, feeling loneliness in the face of weak family bonds and harsh survival realities plays an initial dominant factor, coupled with peer pressure with the attendant high prevalence of smoking among the group [20, 23]. Since these

psychosocial problems 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. And among the in-school youths, the onset age of smoking is influenced by peer pressure and media influences. Additional risk factors in both groups are family conditions, such as low parental education, polygamy, not living with parents, having a parent who smokes and having divorced or separated parents [20]. Older studies in Nigeria and other developing countries in Africa were in agreement with the findings regarding early initiation of the youths into the act of cigarette smoking. Early commencement of smoking in high schools within Nigeria was reported in several works in this field [24–26]. The path to addiction commonly commences from this stage (the initiation phase) and by the age of 21 (in the university), the cigarette uptake process is mostly completed [27]. This trend of early initiation into cigarette smoking has been related to the highly addictive nature of cigarette and tobacco related substances.

Studies suggest that age at smoking initiation is related to subsequent aspects of smoking behaviour, such as cigarette consumption, nicotine dependence and smoking cessation [28]. Breslau predicted that the probability of smoking cessation among adults is inversely related to age at initiation [29].

Reports have shown that initiation into smoking and other dangerous life styles majorly occurs at the adolescent age [24–26, 30]. The disease burden emanating from chronic cigarette smoking is quite enormous. A recent report placed the current cost of medical treatment and low productivity emanating from cigarette smoking in Nigeria at five hundred and ninety-one million dollars (\$591 M) per annum [31]. This is capable of significantly eroding the gains and advantages of a young population in growing economy like ours. Therefore the policy formulators must painstakingly exercise every right to inform and protect this group of individuals at all times.

#### **3.2 Parental factors**

Environmental factors also known as behavioural factors that are important in smoking prevalence can be found in the familiar (shared) or individual-specific (unshared) environment. The familiar environment is more likely to influence a smoker if anyone in his immediate environment is smoking such the parent(s). Parental influence could be direct (when the parent is a smoker) or indirectly (when parents are uninvolved in the affairs of their children).

A study in Port Harcourt Nigeria attributed 6.3% of the adolescent smokers, in their recent survey, to parental influence [32]. This factor ranked fourth behind Experimental exposition, Peer Influence and Advertisement. They reiterated the role of parents in moulding the characters of their children/wards against cigarette smoking, a factor though not as strong as peer influences and experimental expositions [32]. There is also some contribution by religiosity and the culture of the region which can influence the family/societal values and traditions and in the long run an individual's smoking habit.

A study among secondary school students in the Southwest Nigeria established a very strong relationship between the students smoking behaviour and those of their parents among other factors [24]. The study posited that parental influence (p = 0.002856) played significant role in the adoption of smoking behaviour by youths. They further advised that enlightenment and rehabilitation programmes targeted against cigarette smoking should also involve parent smokers to ensure effective outcome [24].

**139**

to quit.

another.

*Smoking and Non-Communicable Diseases in Sub-Saharan Africa: The Nigeria Scenario*

peer effects play a significant role in youth smoking decisions [35].

The peer influence has been observed to have a higher influence on smoking initiation and persistence [33, 34]. Powell et al., used the peer effect model in their study on tobacco control policies and youth smoking behaviour; to establish that

The numbers of hours people watch television have also been shown to influence the smoking habits and initiation [26]. Television programs depicting tobacco usage may encourage smoking among adolescents, however the converse was observed in an Iraq study [36]. Although bans have prevented direct tobacco advertising on television, studies have indicated the widespread portrayal of smoking on television on prime-time programming, movies, music videos, and sporting events. Rarely is smoking portrayed as a negative influence or unattractive, thus making television an indirect means of smoking

The presence of legislation against smoking also determines smoking habits. This will limit the availability and youth access to cigarettes, elevate the age of onset of smoking, ensure a smoke-free indoor air and thus reduce the adverse effects of tobacco on the smoker and passive smokers. Chaloupka studied the effects of limits on youth access on smoking rates controlling for their enforcement and compliance [38]. He found that most state and local tobacco control policies did not have statistically significant effects on youth smoking except when strong restrictions exist. However, the combined effect of all non-tax policies on smoking participation was significant [37, 38]. Studies have concluded that strong smoking restrictions significantly reduced both smoking prevalence and average daily cigarette consumption among young adults [39, 40]. In fact a strict enforcement against cigarette smoking for 20 years in Brazil resulted in a 50% cut in prevalence of smoking among the young adults [40]. This is probably why in developed countries, where there is strong political will against the act of smoking, a decreasing prevalence of smoking

Furthermore, individual-specific environmental factors include factors like mood and general state of health play significant role. Depressed individuals tend to smoke more and a history of major depressive disorder is associated with a lower chance to quit smoking [41]. Personal feeling of insecurity, insomnia, loneliness and feeling of grandeur all increase affiliation to cigarette smoking. On the other hand, sudden diagnosis of an ailment can encourage a current smoker

Some people may associate a particular status with smoking. They feel that smoking brings respect and is an acknowledgment of superiority. Finally, defiance to authority can be a factor that influences smoking. Some children tend to show disagreement/rebellion against parents, teachers or designated authorities through smoking [36]. These factors cannot be quantified and may confound with one

*DOI: http://dx.doi.org/10.5772/intechopen.96693*

**3.3 Peer influence**

**3.4 Media influences**

advertising [33].

is being documented [35].

**3.6 Health status**

**3.5 Legislation**

*Smoking and Non-Communicable Diseases in Sub-Saharan Africa: The Nigeria Scenario DOI: http://dx.doi.org/10.5772/intechopen.96693*

### **3.3 Peer influence**

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

psychosocial problems 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. And among the in-school youths, the onset age of smoking is influenced by peer pressure and media influences. Additional risk factors in both groups are family conditions, such as low parental education, polygamy, not living with parents, having a parent who smokes and having divorced or separated parents [20]. Older studies in Nigeria and other developing countries in Africa were in agreement with the findings regarding early initiation of the youths into the act of cigarette smoking. Early commencement of smoking in high schools within Nigeria was reported in several works in this field [24–26]. The path to addiction commonly commences from this stage (the initiation phase) and by the age of 21 (in the university), the cigarette uptake process is mostly completed [27]. This trend of early initiation into cigarette smoking has been related to the highly addictive nature of cigarette and tobacco related

Studies suggest that age at smoking initiation is related to subsequent aspects of smoking behaviour, such as cigarette consumption, nicotine dependence and smoking cessation [28]. Breslau predicted that the probability of smoking cessation

Reports have shown that initiation into smoking and other dangerous life styles majorly occurs at the adolescent age [24–26, 30]. The disease burden emanating from chronic cigarette smoking is quite enormous. A recent report placed the current cost of medical treatment and low productivity emanating from cigarette smoking in Nigeria at five hundred and ninety-one million dollars (\$591 M) per annum [31]. This is capable of significantly eroding the gains and advantages of a young population in growing economy like ours. Therefore the policy formulators must painstakingly exercise every right to inform and protect

Environmental factors also known as behavioural factors that are important in smoking prevalence can be found in the familiar (shared) or individual-specific (unshared) environment. The familiar environment is more likely to influence a smoker if anyone in his immediate environment is smoking such the parent(s). Parental influence could be direct (when the parent is a smoker) or indirectly (when

A study in Port Harcourt Nigeria attributed 6.3% of the adolescent smokers, in their recent survey, to parental influence [32]. This factor ranked fourth behind Experimental exposition, Peer Influence and Advertisement. They reiterated the role of parents in moulding the characters of their children/wards against cigarette smoking, a factor though not as strong as peer influences and experimental expositions [32]. There is also some contribution by religiosity and the culture of the region which can influence the family/societal values and traditions and in the long

A study among secondary school students in the Southwest Nigeria established a very strong relationship between the students smoking behaviour and those of their parents among other factors [24]. The study posited that parental influence (p = 0.002856) played significant role in the adoption of smoking behaviour by youths. They further advised that enlightenment and rehabilitation programmes targeted against cigarette smoking should also involve parent smokers to ensure

among adults is inversely related to age at initiation [29].

parents are uninvolved in the affairs of their children).

this group of individuals at all times.

run an individual's smoking habit.

effective outcome [24].

**3.2 Parental factors**

**138**

substances.

The peer influence has been observed to have a higher influence on smoking initiation and persistence [33, 34]. Powell et al., used the peer effect model in their study on tobacco control policies and youth smoking behaviour; to establish that peer effects play a significant role in youth smoking decisions [35].

#### **3.4 Media influences**

The numbers of hours people watch television have also been shown to influence the smoking habits and initiation [26]. Television programs depicting tobacco usage may encourage smoking among adolescents, however the converse was observed in an Iraq study [36]. Although bans have prevented direct tobacco advertising on television, studies have indicated the widespread portrayal of smoking on television on prime-time programming, movies, music videos, and sporting events. Rarely is smoking portrayed as a negative influence or unattractive, thus making television an indirect means of smoking advertising [33].

### **3.5 Legislation**

The presence of legislation against smoking also determines smoking habits. This will limit the availability and youth access to cigarettes, elevate the age of onset of smoking, ensure a smoke-free indoor air and thus reduce the adverse effects of tobacco on the smoker and passive smokers. Chaloupka studied the effects of limits on youth access on smoking rates controlling for their enforcement and compliance [38]. He found that most state and local tobacco control policies did not have statistically significant effects on youth smoking except when strong restrictions exist. However, the combined effect of all non-tax policies on smoking participation was significant [37, 38]. Studies have concluded that strong smoking restrictions significantly reduced both smoking prevalence and average daily cigarette consumption among young adults [39, 40]. In fact a strict enforcement against cigarette smoking for 20 years in Brazil resulted in a 50% cut in prevalence of smoking among the young adults [40]. This is probably why in developed countries, where there is strong political will against the act of smoking, a decreasing prevalence of smoking is being documented [35].

#### **3.6 Health status**

Furthermore, individual-specific environmental factors include factors like mood and general state of health play significant role. Depressed individuals tend to smoke more and a history of major depressive disorder is associated with a lower chance to quit smoking [41]. Personal feeling of insecurity, insomnia, loneliness and feeling of grandeur all increase affiliation to cigarette smoking. On the other hand, sudden diagnosis of an ailment can encourage a current smoker to quit.

Some people may associate a particular status with smoking. They feel that smoking brings respect and is an acknowledgment of superiority. Finally, defiance to authority can be a factor that influences smoking. Some children tend to show disagreement/rebellion against parents, teachers or designated authorities through smoking [36]. These factors cannot be quantified and may confound with one another.
