Decline in Current Tobacco Use and Socio-Economic Inequalities in 22 Sub-Saharan African Countries Between 2003 and 2018

Background: Tobacco companies have shifted their marketing and production to Sub-Saharan African countries which are in an early stage of tobacco epidemic. We report changes in current tobacco use and socio-economic inequalities between 2003 and 2019. Methods: We estimated country-level, sex-wise, age-standardised prevalence estimates of current tobacco use in 22 SSA countries using sequential Demographic and Health Survey data. On pooled baseline (2003-11) and most recent survey (2011-19) data, prevalence by education, wealth, and age groups; Slope index of inequality and relative index of inequality were estimated. Change in prevalence in each country and by socio-economic subgroups and change in socio-economic inequalities (pooled data) were calculated. Findings: Tobacco use among men ranging [6·1% (Ghana) to 38·3 (Lesotho)] at baseline and [4·5% (Ghana) to 46·0% (Lesotho)] most recent surveys. Decline in prevalence points ranged from 1·5% (Ghana) to 9·6% (Sierra Leone). For women countries where prevalence was <1% rose from nine to 15. In most countries prevalence of current tobacco use significantly declined. WHO target of 30% decline was achieved in 15 and 10 countries for women and men, respectively.  In both sexes, tobacco use rate and decline were higher among less educated and poor while magnitude and direction of inequalities were consistently declined. Absolute inequalities three-fold higher among men, while relative inequalities were nearly twice higher among women.  Interpretation: Tobacco use declined in a third of SSA countries. Persistence of socio-economic inequalities warrants stricter implementation of tobacco control measures to reach the vulnerable groups and continued monitoring of inequalities. Funding Statement: Authors did not receive any funding for this research. Declaration of Interests: Both authors have nothing to declare. Ethics Approval Statement: DHS survey protocols undergo ethical review in the United States with ICF’s (Inner City Fund) institutional review board. In each country, institutional review boards of the implementing agency approved the DHS survey. Permissions were sought from the governmental agencies in each country. Each eligible participant was explained about the survey procedures and verbal consent was sought before the interview.