INTRODUCTION

Research has incontrovertibly established the association between tobacco use and the risk of development of several health effects^1-4. The World Health Organization (WHO) responded by developing the Framework Convention on Tobacco Control (FCTC)⁵ that emphasises the importance of informing the public of the health consequences, addictive nature and mortality risk from tobacco use and exposure to tobacco smoke. Warning about the dangers of tobacco smoke is also one of the six proven policies of the MPOWER package of the WHO⁶ aimed at reversing the tobacco epidemic. Possessing correct information is critical as it is an indispensable requirement in the accurate perception of risk in a context that can allow for behavioural change⁷. It has also been shown that behavioural change models that focus on changing beliefs about consequences can guide the development of behavioural change interventions⁸.

The most recent nationwide non-communicable risk factor cross-sectional survey carried out in Uganda found that 9.2% of the people in Uganda use tobacco products daily⁹, and yet research elsewhere has shown that tobacco users might preferentially opt for some tobacco products over others because of the false belief that they are safer^10,11. In 2013, the first Uganda Global Adult Tobacco Survey (GATS) was carried out to ‘establish baseline information on tobacco use and tobacco control measures in a nationally representative sample with regard to exposure to secondhand smoke, cessation, risk perceptions, knowledge and attitudes, exposure to media, price and taxation issues by using a global standard protocol adapted to country-specific context¹²’. We analysed data from this survey to assess the misconceptions about the harmfulness of tobacco and factors associated with it. With the passing of the Uganda Tobacco Control Act 2015¹³, findings from the analysis will provide country-specific data for evaluation of the impact of the legislation in the control of tobacco use. It will also provide valuable information for the development of the Tobacco Control Policy and the National Tobacco Control Strategic Plan.

METHODS

The data used in this analysis were obtained from the 2013 Uganda Global Adult Tobacco Survey (GATS) of persons in Uganda of age 15 years or older. GATS is a cross-sectional survey that uses a standardised methodology to collect tobacco-related information. Respondents are selected using a multi-stage sampling design that provides estimates that are representative of the country adult population. The sampling design and data collection tools and procedures have been described in detail elsewhere¹².

RESULTS

DISCUSSION

The analysis has revealed that across the three dependent variables, low level of education, smokeless tobacco use status and smoked tobacco use status were statistically significant predictors of unawareness about the harmfulness of tobacco. The fact that more educated people were less likely to be unaware of the harmfulness of tobacco could be that educated people are more likely to comprehend and appreciate anti-tobacco messages and the harmful effects of tobacco use. It could also be that going to school exposes people to more opportunities of acquiring knowledge about the harmful effects of tobacco use. In a worldwide survey of education on tobacco use in schools, it was noted that although 12% of the schools did not cover the topic of tobacco in the curriculum, 58% taught about it while teaching other subjects¹⁶. Higher education level has also been shown to be a significant predictor of knowledge that smoking causes heart disease, stroke, impotence and lung cancer¹⁷. Also, persons who attain low levels of education have been shown to smoke more, attempt to quit less, and have a lower likelihood of cessation¹⁸. This knowledge acquired from educational institutions might play a significant role in correcting any erroneous beliefs but also promoting abstinence. Low education attainment has also been shown to be a significant predictor of adult smoking¹⁹. In the Ugandan context, education institutions might play a significant role in the fight against tobacco use. In a comparative study of the efficacy of a comprehensive psychosocial smoking prevention program in schools in the US, it was found that students that received this program had better knowledge, personality and life coping skills²⁰. In addition to knowledge about the harmful effects of tobacco, schools provide a platform for inculcating other personality and life skills that are important in deterring the initiation of tobacco use.

The survey also established that users of smoked and smokeless tobacco products were significantly more likely to be unaware of the harmfulness of tobacco. Smokers have been shown to have significant gaps in their knowledge of the risks of smoking²¹. Our survey also showed that the unawareness about the harmfulness of tobacco was more pronounced about smokeless tobacco compared with smoked tobacco. For example, 19.6% of females did not believe that smokeless tobacco causes serious illness compared with 5.9% who did not believe that smoking causes serious illness. Research has shown that people perceive smokeless tobacco as more tolerable and less harmful compared with smoked tobacco²². One of the documented ways of educating tobacco users on the perils of tobacco use is through instituting graphic health warnings on smokeless and smoked tobacco products²³. The cross-sectional nature of the survey does not preclude the possibility that the perceptions that people hold about the harmfulness of tobacco might be because of their tobacco use status. The reasons why tobacco users are unaware about the harmfulness of tobacco might be attributed to an optimistic distortion in risk assessment called optimistic bias. Optimistic bias is an error in perception whereby people believe that they are less likely to experience negative events²⁴. The bias in judgment occurs in such a way that tobacco users do not believe that they will experience the negative health effects of using tobacco, even though they may be aware of these effects. It has been shown that smokers are more likely to doubt that they would die from smoking if they smoked for 40 years²⁵ or even till old age²⁶. Optimistic bias has been attributed to the false perception of being in control of the negative events that could happen to an individual²⁴. It has been demonstrated that the perception of control could originate from beliefs that the quantity of tobacco someone uses is too little for it to have harmful effects, or that the way someone smokes can protect them from any tobacco use related morbidity²⁷. The optimistic distortion in the perception of risk has also been attributed to ineffective warning labels on tobacco product packaging²⁸.

Uganda could draw from the practices and strategies that were used to combat the HIV/AIDS epidemic in the early 1990s that involved formalising the information, education and communication about HIV/AIDS²⁹. The National Tobacco Control Program could come up with formalised information, education and communication campaigns about the different forms of tobacco, dangers of tobacco use, assistance with quitting and the risks averted with abstinence from use. Also, these campaigns should contain messages that expose the craftiness of the tobacco industry, as this has been shown to be an important ingredient in effective tobacco control programs³⁰.

CONCLUSIONS

There is a high level of unawareness about the harmfulness of tobacco use among adults in Uganda. The unawareness is especially high among tobacco users. The National Tobacco Control Program should prioritise public awareness and education about the dangers of tobacco use in the Tobacco Control Policy and National Tobacco Control Strategic Plan.