Tobacco Control in Ghana: Evidence from Qualitative and Cross-sectional Studies

Arti Singh

Research output: Book/ReportDoctoral thesisCollection of Articles


Introduction: Tobacco remains one of the leading causes of premature death and disease globally. The prevalence of smoking in the African region continues to increase due to aggressive marketing strategies and increasing affordability of tobacco products. Nevertheless, research on tobacco control policy and its implementation in several African countries including Ghana remains low. Local evidence in order to increase awareness and effectively formulate a tailored response to curb the rising smoking prevalence in the region is needed. Ghana has ratified World Health Organisation’s Framework Convention on Tobacco Control (WHO FCTC) and also has a national Tobacco Control Act. However, implementation and enforcement of tobacco control measures such as cigarette pack warnings, smokefree laws, and illicit cigarette market, remains a challenge.

Study aims: To assess the perception of smokers and non-smokers to pictorial and text-based warnings on cigarette packs; to evaluate the implementation of the smokefree policy (SFP) in hospitality venues, and to determine the extent and factors associated with the illicit cigarette market in Ghana.

Methods: Study I was a qualitative study with focus group discussions (n=12) among 50 smokers and 35 nonsmokers of age 15 years and above in Kumasi, Ghana. Studies II and III were cross-sectional studies using a structured observational checklist, air quality measurements, and face-to-face surveys among staff and owners within randomly selected hospitality venues (n=154) in three large cities in Ghana (Accra, Kumasi, and Tamale). Study IV was a cross-sectional study using empty cigarette packs from one day’s single stick cigarette sales collected from cigarette vendors in five large cities and three border towns in Ghana.

Results: According to the results of Study I, health warnings with both a picture and text were thought to convey health messages more effectively than those with just a picture or just text, by both smokers and non-smokers. Due to smokers' poor literacy rates, text-based warnings were thought to be only partially effective. Smoking behavior was thought to be most affected by warnings about lung cancer, blindness, stroke, and throat and mouth cancer.

In Study II, smoking was seen in one-third of the locations visited. The average level of PM2.5 (particulate matter 2.5) in indoor air was 14.6 μg/m3 (range: 5.2–349). The PM2.5 concentrations were higher (28.3 μg/m3) in hospitality venues where smoking was observed than in venues where smoking was not observed (12.3 μg/m3, p=0.001). Hospitality venues in Accra (Ghana’s capital city) had the lowest rate of compliance with the current SFP, and poorer air quality than hospitality venues in the other two cities. In Study III, of the 142 staff/owners in hospitality venues, 27.5% knew about Ghana's Tobacco Control Act, 29% about smoking bans in public places, 22% about smokefree zones, and 6.3% about signs prohibiting smoking being displayed. The knowledge levels of the respondents were greater in Accra than in Tamale (OR=3.08; 95% CI: 1.10-8.60). Despite having 80% support, opinions in favor of SFPs were less favorable in Accra than in Tamale (OR=0.25; 95% CI: 0.08-0.71). With regards to compliance to SFP by the type of venue; hotels were three times more compliant as compared to bars and pubs (OR=3.16; 95% CI: 1.48-6.71).

Finally, in Study IV, illicit packs made up 19.5% (95% CI: 18.34-20.66) of the entire sample of packs (n=4461) collected across the eight cities in Ghana. Aflao (Ghana-Togo border) and Tamale (Ghana-Burkina Faso border) had the highest percentage of illicit cigarette sales (99% and 46%, respectively, p<0.001). A large proportion of the illicit packs originated from border countries including Togo (51%), Nigeria (14.8%), and Cote d’Ivoire (10.3 %). Unadjusted and adjusted logistic regression models indicated that convenience stores, border towns, lower pack prices, and the northern zone of the country had higher odds of sale of illicit cigarettes in Ghana than the respective reference groups (drinking bars, non-border towns, higher price pack and, middle and southern zones).

Conclusions: According to study findings, warning labels with both text and pictures may have a positive impact on smoking behavior. In addition, despite widespread support for limiting smoking in public areas, such as hospitality venues, it was found that the hospitality venue staff had little knowledge of and compliance with the SFPs. Finally, to combat the illegal cigarette trade, market monitoring, and tighter regulation of the cigarette supply chain, particularly in border towns and the northern part of the nation, are required.
Original languageEnglish
Place of PublicationTampere
ISBN (Electronic)978-952-03-2762-0
Publication statusPublished - 2023
Publication typeG5 Doctoral dissertation (articles)

Publication series

NameTampere University Dissertations - Tampereen yliopiston väitöskirjat
ISSN (Print)2489-9860
ISSN (Electronic)2490-0028


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