This study investigated the social risk factors for daily tobacco smoking and binge drinking among Zambians using a nationally representative sample from the 2017 WHO STEPS survey. The overall prevalence of daily tobacco smoking was 9.04%, while 11.6% of participants engaged in binge drinking, both of which were higher among men than women. Being male, older age, and having primary or no education were significant factors related to daily tobacco smoking. Compared to employed participants, students and homemakers had a lower risk of daily tobacco smoking. Binge drinking was associated with being male and living in an urban area. Again, students and homemakers had a lower risk of binge drinking than employed participants.
The high prevalence of tobacco smoking amongst Zambian men (17.1%) has been reported in other studies, although slightly higher at 20% [21, 22]. This gender difference was expected due to the differing social norms regarding gender that promote tobacco use. Tobacco smoking is much more tolerated in men than women, owing to dominant internalised gender stereotypes such as masculinity, meaning smoking is socially approved for men but not women [10]. Although tobacco smoking trends in Zambia have fluctuated over the years, they clearly indicate a major public health threat, particularly among men, that requires urgent attention from policy makers. Men from Zambia, in addition to those from Ethiopia, Malawi and Rwanda, have some of the highest smoking rates in SSA [32]. The American Cancer Society further reports that there are more than 695,200 men in Zambia who smoke tobacco daily, 107 of whom die every week due to tobacco-related complications [33].
This study found that older age was significantly associated with tobacco smoking. Similar findings were reported in a systematic review of smoking data from 30 SSA countries [34]. A possible explanation may be that in some SSA cultures, tobacco smoking is viewed as a practice reserved for elderly people [10]. However, other studies in countries such as Kenya and Burkina Faso have reported that tobacco smoking is more common in younger people [35, 36]. Our findings suggest that tobacco smoking in Zambia may have been more popular among younger groups some years back, resulting in higher consumption among elderly individuals now. This highlights a need for public health interventions to target all age groups to effectively fight the tobacco epidemic.
A lower education level was significantly associated with daily tobacco smoking, which confirms the already established association reported in other studies [34, 37, 38]. This finding has huge implications for current tobacco control efforts in Zambia. Indeed, studies have pointed out that poor people and those with a lower education status tend to be missed by large public health prevention efforts [39]. Perhaps this could be the case in the Zambian setting, where public health interventions such as health education and anti-tobacco smoking campaign efforts are only reaching those with some form of literacy.
Compared to the employed, students and homemakers had a lower risk of daily tobacco smoking. Similar findings have been reported in studies from other LMIC such as Ethiopia, Madagascar and Nepal [40–42]. These studies found that adult manual laborers engaging in activities such as construction or farming were more likely to smoke than their formally employed counterparts. Such occupations are likely to lead people to smoke tobacco as a form of stress relief [23, 43]. The results of our study could be explained by the fact that most students were young and subjected to rules at school that prohibit smoking while homemakers were women.
To reduce tobacco smoking, prevention efforts should focus on factors early in life that influence smoking risk over the adult life span, because nearly 9 out of 10 adults who smoke cigarettes daily first tried smoking at a younger age [37, 44]. Adolescent smoking has been highlighted in previous studies in Zambia [45–47]. The need to address tobacco in youths is even more urgent given that the tobacco industry is targeting this vulnerable age group in Africa [48]. It is critical that health providers cater for people with a lower education level when designing tobacco control efforts by ensuring that tobacco messages are delivered in the most simple and effective way possible across a spectrum of media platforms [35].
The prevalence of binge drinking was higher in men than women but slightly lower than the overall WHO estimate among the Zambian population > 15 years old of 13.5%. The high level of binge drinking among men could be explained by the fact that culturally, binge drinking by men is more acceptable, and such a risky behaviour may even indicate power and strength [49]. In other countries like South Africa, the overall prevalence of binge drinking among people aged > 15 years was reported to be 18.3%, and it was also higher in men than women (22.8% vs. 6.4%) [14, 50]. The few studies on binge drinking in Zambian subpopulations have described a much higher prevalence [25, 51, 52]; for instance, 81.4% among people living with HIV [25]. Binge drinking varies across different subpopulations and tends to be worse in HIV-positive people, those in psychiatric settings and college students compared to the general population [25, 51, 52]. These subpopulations may be binge drinking as a way to overcome stressful situations.
The risk of binge drinking was significantly lower among rural residents compared to those from urban areas. This finding has also been reported in studies from other countries, such as South Africa [18]. According to Letsela et al., in urban areas, alcohol is cheap, easily accessible and highly marketed through rigorous advertising in the media, facilitating its consumption [53, 54].
We found that students and homemakers were less likely to binge drink compared to people who were employed. Similar findings were reported in an Ethiopian study which found that the likelihood of heavy episodic drinking was lower among housewives compared to farmers [55]. Our finding could possibly be due to students still living with their parents, while homemakers are women [56]. Furthermore, after stratifying by sex, unemployed women had a higher risk of binge drinking than employed women. Interestingly, most evidence seems to show a strong association between the volume of alcohol consumed and chronic social problems such as unemployment, but less so for drinking patterns such as binge drinking [57, 58]. However, our finding may indicate the presence of related issues, such as feelings of boredom, loneliness, loss of job and depression, which may contribute to binge drinking among unemployed women in the Zambian context [59, 60].
Addressing binge drinking will require the strengthening of interventions such as early screening and referrals for treatment and counselling services for alcohol-dependent individuals within primary healthcare facilities to ensure access to services at the lowest level of care [61]. In addition, multilevel interventions, including increased taxation, regulation of alcohol advertising and awareness of the general population of problems associated with binge drinking, are required [18].
The predictors for tobacco smoking and binge drinking tend to be similar in most contexts, as people who smoke tobacco are also likely to engage in binge drinking. However, in our study, rural residents smoked more, and urban residents drank more. This finding emphasises the importance of local, tailored tobacco and alcohol control interventions to ensure relevance and utility.
Strengths and limitations of the study
The major strength of this study was the national representativeness of the data, and consequently, the generalisability of our findings. The STEPS survey uses validated and reliable tools and has a methodologically sound design. In addition, although the response rate was lower among men than women, this was adjusted by weighting. Since survey weights are constructed with the aim to build a population-representative sample, this should compensate for the potential non-randomness of drop-outs; however, there may still be residual non-randomness that could bias the results. One limitation of this study is that some of the variables, such as binge drinking, were answered retrospectively, which could be affected by recall bias. Another limitation is the lack of data on HIV/AIDS in our study participants, as this variable tends to be a major predictor of both tobacco smoking and binge drinking in the Zambian context. Lastly, we are aware that the merging of small variable categories for education, age and employment may have also affected our estimations. Despite these limitations, our findings are valuable for informing tobacco and alcohol control efforts in Zambia.