Tobacco Cessation in Ethiopia
In 2016, 42.0% of smokers in Ethiopia aged 15 years and above attempted to quit smoking in the previous 12 months, while 23.5% of smokers planned to quit within the following 12 months.
Most primary healthcare providers in Ethiopia do not offer smoking cessation services. Furthermore, the majority of healthcare providers have limited knowledge of smoking cessation interventions.
Quitting smoking has extensive health benefits, of which the greatest is reduced risk of tobacco-related diseases.
There are 1.3 billion tobacco users around the world, many of whom want to quit. However, many people do not have access to the facilities/resources needed to quit smoking.
Currently, about 32% of the world’s population has adequate access to cessation services.In Ethiopia, 3.2 million adults (5% of the adult population) used tobacco products in 2016. About four out of ten adult smokers made an attempt to quit smoking in the same year. About five out of ten smokers who visited a healthcare provider received advice to quit smoking from the provider.
Smoking cessation is important from a public health standpoint as it improves health, saves lives, and reduces financial burdens.
However, most smokers usually fail to quit smoking because they do not receive sufficient support. Evidence suggests that the powerful addictive nature of nicotine makes it extremely difficult for users to quit. Moreover, users who have quit are more likely to relapse due to this acquired dependence on smoking (i.e., nicotine). Successful smoking cessation thus depends on a constructive and supportive relationship between a smoker and a cessation service provider. Smokers may be more likely to quit if they get access to holistic cessation services, including treatments with medication services and counseling sessions. Ethiopia is among the six countries that were advanced to best-practice level with their tobacco use cessation services.This page provides information on the levels of public awareness on the harms of tobacco use, the benefits of quitting, and the percentage of smokers who want to quit.
Levels of Public Awareness
on the Harms of Smoking in Ethiopia
Most members of the public are aware of the dangers associated with smoking tobacco.
Percentage of Adults (15 years and Older) Who Believe That Smoking Causes Serious Illness and Various Diseases, 2016
Source: GATS, 2016
Majority (88%) of respondents to the Ethiopia Global Adult Tobacco Survey (GATS), undertaken in 2016, believed that smoking causes serious illnesses. For instance, 81.7% of the respondents believed that smoking causes lung cancer, while 75.9% believed that secondhand smoke causes serious illness to non-smokers. Some 57.4% of adults believed that smokeless tobacco use causes serious illness.
Several studies indicate that people in higher wealth quintiles have a greater level of awareness about the harms of tobacco than people in lower wealth quintiles.
Attempts to Quit Tobacco Smoking in Ethiopia
About 23.5% of tobacco smokers aged 15 and above planned to quit within 12 months.
Percentage of Adults (15 years and Older) Who Plan to Quit Smoking, 2016
Source: GATS, 2016
According to the 2016 GATS, only 10.7% of smokers in Ethiopia planned to quit within 12 months while 45.1% of smokers planned to quit in future (but not within 12 months). Almost one third of smokers (31.3%) had no plans to quit at all.
Most healthcare providers do not help patients quit smoking due to a lack of knowledge, time, and referral sources.
In addition, they may not regard provision of smoking cessation services as their responsibility. Little attention has been paid to tobacco cessation interventions in Sub-Saharan Africa. There are very few programs designed to support individuals who wish to quit smoking. In addition, there are scant efforts to train healthcare practitioners in smoking cessation. Moreover, healthcare workers are not generally committed to ensuring that patients quit smoking.
Factors Driving Quitting Attempts in Ethiopia
According to the 2016 GATS, 42% of respondents had attempted to quit smoking in the previous 12 months.
About 80% of smokers who tried to quit in the previous 12 months did so without any assistance. On the other hand, 53% of smokers who visited a healthcare provider in the previous 12 months were advised to quit smoking by a health worker. According to GATS 2016 data, several factors played a role in the smoking cessation attempts, including gender, level of income/wealth, educational level, employment status, religion, and awareness about the harms of tobacco use.
More adult males than females attempted to quit smoking
The findings from the 2016 GATS align with the results of other studies that reveal individuals in lower wealth categories are less likely to quit smoking than individuals in higher wealth categories.
More than half (51.6%) of the smokers who made attempts to quit were aware of the health harms of tobacco use, while only 16.3% were unaware of the health dangers.
More employed adults than homemakers attempted to quit smoking.
Studies have revealed that an individual’s education and health literacy may influence how seriously advice is taken, impacting the success of subsequent smoking cessation efforts.
Tobacco Cessation
Services in Ethiopia
Delivery of tobacco cessation services in Ethiopia is generally hampered by a lack of knowledge, trained personnel, and medication.
The 2016 GATS also assessed whether smokers who had quit smoking for less than 12 months had received smoking cessation advice from the healthcare providers they visited in the previous year.
Approximately 23% of smokers who had quit for less than 12 months had visited a healthcare provider in the previous year. More than half (56%) of these smokers who visited a healthcare provider were asked about their tobacco smoking status, and a further half (53%)were advised to stop smoking tobacco by the healthcare provider.Research shows that brief advice offered by healthcare providers can increase quitting attempts by 40% and boost successful quit rates by 2-3%.
Evidence further shows that the intensity of counseling significantly increases long-term smoking abstinence rates. Minimal counseling (<3 minutes), moderate intensity counseling (3-10 minutes), and high intensity counseling (>10 minutes) increase abstinence rates for tobacco use by 13.4%, 16%, and 22.1%, respectively.According to health facility-based studies in Ethiopia, 70.4% of healthcare providers do not generally know how to provide smoking cessation advice. Some studies have indicated that 97.5% of healthcare providers in Ethiopia did not carry out smoking cessation interventions.
A facility-based study of pharmacy professionals also showed that there were clinical knowledge gaps on tobacco cessation services among healthcare workers in Ethiopia. There were no tobacco use cessation guidelines or strategies for healthcare workers in Ethiopia, and tobacco use cessation was not included among the indicators reporting list. Similarly, studies in Kenya and Jordan revealed that knowledge of tobacco use cessation services among healthcare workers was low.
Types of Interventions
There are several interventions to aid smoking cessation, but these interventions do not exist or are scarce in Ethiopia.
Smoking cessation is the process of quitting tobacco use.
There are numerous effective cessation interventions globally that can help smokers quit. There are two broad types of interventions, namely behavioral and pharmacological interventions.Behavioral interventions can be classified into two types, namely population-level approaches and individual specialist approaches. Population-level approaches include brief advice and quitlines, whereas individual specialist approaches include intensive behavioral support and cessation clinics.
Pharmacological interventions cover nicotine replacement therapies (NRTs) and non-nicotine pharmacotherapies.
Below are descriptions of the types of tobacco cessation interventions that are generally available in Ethiopia as well as the medications included in the list of essential medicines in the country. According to the WHO Tobacco epidemic report 2023, Ethiopia is among the three low-income countries that make cost covered NRTs available to those who want to quit tobacco and among the three African countries that established national toll-free quit lines.
Brief Advice
Quitlines
Quitlines
A national toll-free quitline is a telephone counseling service that can provide both proactive and reactive counseling sessions. A reactive quitline provides an immediate response to a call initiated by a tobacco user, but only responds to incoming calls. A proactive quitline schedules follow-up calls to tobacco users to provide ongoing support.
Pharmacological interventions
Pharmacological interventions
Pharmacotherapies include nicotine-based and non-nicotine-based medications that are given to smokers.
- Nicotine Replacement Therapy (NRT): This is the remedial administration of nicotine to the body by means other than tobacco to facilitate quitting. NRTs are a safe alternative to cigarettes. With NRTs, a patient can absorb less nicotine at much slower rates than smokers. NRTs include nicotine patches, nicotine gums, nicotine inhalers, nicotine lozenges, and nicotine nasal sprays. NRTs lessen craving and nicotine addiction withdrawal symptoms by providing a low controlled dose of nicotine without the toxins found in cigarettes. NRT doses are gradually reduced over time to help the tobacco user get used to less and less nicotine stimulation. All forms of NRT are better than no treatment. For instance, nicotine gum increases the chance of quitting by 43% compared to no treatment, while, nicotine a patch increases the chance of quitting by 66% compared to no treatment.
- Non-nicotine pharmacotherapies:
Bupropion: Bupropion was originally used as an antidepressant. It lessens some nicotine withdrawal symptoms such as anxiety, irritability, and depression.
It affects the urge to smoke by acting on the chemicals (neurotransmitters) in the brain.Varenicline: Varenicline is a new drug developed specifically for smoking cessation. It acts as a nicotine antagonist and agonist. As an antagonist, it blocks nicotinic receptors in the brain, thereby reducing the pleasurable effects of cigarettes and other tobacco products and potentially the risk of full or temporary lapses. As a partial nicotine agonist, it attaches to and partially stimulates nicotine receptors in the brain, thereby reducing cravings and withdrawal symptoms.
Naltrexone: Naltrexone is a prescription medication used to treat alcohol and opioid use disorders. It has several beneficial effects in the treatment of nicotine dependence. It improves quit rates, increases time to smoke their first cigarette after waking up, reduces the number of cigarettes smoked and smoking urges, and lessens the amount of weight gained.
Intensive behavioral support
Intensive behavioral support
Behavior support refers to multiple individual or group counseling sessions aimed at helping people stop tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting. It also provides resources to develop skills and strategies for changing behavior.
Cessation clinics
Cessation clinics
These are clinics specializing in tobacco cessation services. These clinics offer intensive behavioral support, and where appropriate, medications or advice delivered by specially trained practitioners.
These clinics, however, are not available in Ethiopia.
Effectiveness of Medications Used to Treat Tobacco Addiction
Varenicline and NRT (nicotine gums, transdermal patches, nicotine nasal sprays, nicotine inhalers, and nicotine sublingual tablets) are the leading treatments for sustained smoking cessation.
Use of pharmacotherapy remedies for seven to twelve weeks increases the likelihood of successful smoking cessation. Health provider training programs and rewards for providing cessation support are similarly beneficial.
Availability of Health Facilities Providing Cessation Services
There are only 26 substance use disorder treatment centers spread across the 7 regions and two city administrations in Ethiopia, half of which are located in Addis Ababa. However, plans are in place to provide tobacco cessation services at primary healthcare facilities across the country.
Nineteen of these treatment centers are government owned, three are managed by non-government organizations, and four are run by private sector entities. Four regions (Benishangul Gumuz, Gambella, Southwest Ethiopia and Somali Regions) have no known substance abuse treatment centers.
Facilities Providing Substance Treatment Services
Please select a region to reveal the cessation facilities available, which will be displayed as orange dots in the map. Then hover over the dot to display more information.
- Number of Facilities|
- 1 - 2
- 3 - 4
- ≥ 5
- No Facility
Source: Ministry of Health
Several capacity building activities have been carried out across the country to integrate tobacco cessation services within the existing primary healthcare system:
- Over 300 healthcare providers have received training on smoking cessation advice as part of hypertension management training.
- More than 50 physicians and mental health professionals from tertiary and general hospitals across Ethiopia have received training on tobacco cessation from the WHO Africa office since 2015.
- About 119 health professionals from 80 health centers and hospitals across the Oromia, Addis Ababa, and Dire Dawa regions have received basic training on tobacco dependence treatment in recent years.
- More than 2000 health centers are currently implementing primary health clinical guidelines.
In addition, 38 counselors and public relations officers who operate the Ethiopian Ministry of Health’s 952 toll-free line have received virtual training sessions designed to help callers quit their smoking addictions.
Examples of Tobacco Cessation
Best Practices
In 2018, only 23 countries (16 high-income, 6 middle-income, and 1 low-income) offered comprehensive cessation support to tobacco users seeking help to quit.
Brief advice offered at the primary care level, national toll-free tobacco quitlines, partially or fully cost-covered NRTs, cessation interventions integrated into universal health coverage platforms, and digital and mobile technologies that empower those who want to quit, can all be regarded as best practices.
Successful Tobacco Cessation Programs
India has greatly increased access to cessation services through an innovative program that allows participants to enroll and receive tailored support on their mobile phones.
This innovative program – called QuitNow – was established in 2015. Also referred to as a ‘mCessation’ program, QuitNow’s development was supported by several entities, including WHO, the Indian Ministry of Health and Family Welfare, the Indian Ministry of Communication and Information Technology, and the International Telecommunication Union’s “Be He@lthy, Be Mobile” initiative. The beneficiaries enroll to the program by sending a text message to a toll free telephone number. Depending on the user’s tobacco use habits and their preferred timeline to quit, the beneficiary receives tailored cessation packages.
Out of a million people who registered in 2015, 19% of the users of the service reported that they had abstained from smoking for 30 days.
In Brazil, tobacco control measures that are implemented concurrently have significantly better outcomes than corresponding interventions undertaken in isolation.
In Brazil, a national quitline was displayed in the graphic health warning messages printed on cigarette packages. The coupling of these two measures had a magnified impact on cessation – in fact, the quitline in Brazil received an unprecedented six million calls in its first year (2011), more than all other quitlines globally at that time.
Pakistan, Bangladesh and Nepal have integrated behavioral support services into specialized healthcare programs as a tobacco cessation measure.
In these countries, behavioral support services have been integrated into tuberculosis (TB) treatment programs. Specifically, health workers are trained to provide brief behavioral support, and TB case reports include the smoking status of patients. Research on cessation has also been embedded into TB treatment programs.
Altogether, this integration has had a positive effect on cessation across the three countries. The training builds the confidence of health workers in delivering cessation support to patients, and the changes to reporting forms provide program-level data on tobacco use among TB patients (as well as the cessation support being offered to such patients). Interviewed TB patients who used tobacco confirmed that they had received brief advice to quit.
Moreover, training materials were disseminated beyond the national TB healthcare sites across the three countries, indicating that there was a horizontal scaling up of cessation efforts.
Thailand earmarked revenue from tobacco taxes for cessation.
In Thailand, revenues from tobacco and alcohol excise taxes have been directed into the Thai Health Promotion Fund since 2009. The Thai Health Promotion Fund uses these revenues to financially support the National Tobacco Quitline as well as improve cessation services in government hospitals. The Ministry of Health has used this financial support to treat up to 22,000 smokers a year with a smoking cessation rate of 33%.
Recommendations for Ethiopia
1.
To overcome access challenges across the country and increase smoking quit rates across all population groups, diverse interventions should be developed and implemented.
Furthermore, the tobacco cessation guidelines
and diverse tobacco cessation interventions should be made available across different levels of the healthcare delivery system in Ethiopia.2.
Brief, large-scale interventions should be carried out across Ethiopia’s primary healthcare delivery system.
Intensive behavioral counseling sessions should be scaled across all public hospitals. Efforts should also be made to provide NRT within tertiary hospitals. Providers of cessation services should be trained and equipped with the necessary skills to help patients quit smoking.
3.
Complete and comprehensive addiction treatment and rehabilitation facilities should be built in all accessible areas of the country.
Benefits of Quitting
Tobacco
Over time, people who quit smoking see many benefits to their health. After a person smokes their last cigarette, the body begins a series of positive changes that continue for years.
Life Cycle of Recovery
How Quickly Health Improves after Quitting Smoking
Infographic References:
52. WHO (2020). https://www.who.int/news-room/questions-and-answers/item/tobacco-health-benefits-of-smoking-cessation
