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FEDERAL-STATE AUTONOMOUS EDUCATIONAL

INSTITUTION FOR HIGHER EDUCATION

NATIONAL RESEARCH UNIVERSITY

HIGHER SCHOOL OF ECONOMICS

Faculty of Social Sciences

Master thesis

Socioeconomic and demographic factors associated with cigarette smoking among men in Zambia

SAMSON MARK MHINA



ABSTRACT

The use of tobacco particularly via cigarette smoking represents the major cause of premature death and disease that can be prevented. Worldwide, being estimated to be accountable for about a billion deaths occurring over this century. Factors are characteristics linked with smoking behaviours such as; social issues, poverty, lack of education, and awareness about effects caused by smoking behaviour. Intention of this study is examining men's wealth index classes and education level attainment in the link to smoking behaviour among Zambian men, and the influence these factors have. Using bivariate analysis and chi-square test to examine the relationship between smoking and wealth index, educational level attained as well as other SES and demographic factors associated with smoking. Multivariate analysis employed binary logistic regression analysis to predict the effects wealth index, educational level attained and other socio-economic and demographic factors have on cigarette smoking behaviour of Zambian men.

Findings shows that 20.4 % of men was cigarette smokers while 79.6% was non-smokers among the Zambian men. The major factors correlated with smoking were age, wealth index, level of education, occupation, marital status, religion, place of residence and region. The odds for increased smoking cigarettes was significant and consistently high for men aged 20-29 years old (OR:6.759; CI:5.37-8.50), men aged 30-39 years (OR:9.326; CI: 7.22-12), men aged 40-49 years old (OR:13.180; CI:10.1-17.1), men aged 50-59 years (OR:11.451; CI: 8.67-15.1). Smoking cigarettes was significant and consistently low for men from the middle household wealth index (OR:0.566; CI:0.49-0.64) and men from the rich household wealth index category (OR: 0.375; CI: 0.31-0.44). Men's educational level attained, smoking was significant and consistently low for men with secondary education (OR:0.623; CI:0.50-0.76) higher education (OR: 0.287; CI:0.21-0.39) in comparison to men with no education. Men's occupation was significant and consistently high for clerical and sales workers (OR:1.264; CI:1.02-1.55), men with agricultural occupation (OR:1.424; CI:1.18-1.71), men with skilled and unskilled manual occupations (OR:1.557; CI:1.27-1.89) and men with service and other occupations (OR:1.763;CI:1.40-2.21) in comparison to men with not working. With reference to men's marital status, the trends was significant and consistently high for men who were separated (OR:2.110; CI:1.70-2.60) in comparison to men who were never married. With reference to men's religious affiliation, the likelihood of cigarette smoking was significantly low for men who were affiliated to the protestant religion (OR:0.684; CI:0.61-0.76) in comparison to men affiliated to the Catholic religion (reference category). Again, trends of cigarette smoking was significantly high for men who affiliated to other religions (OR:1.769; CI:1.24-2.52) in comparison to men affiliated to the Catholic religion. With reference to men's residences, the likelihood of cigarette smoking was significantly low for men resident in the rural areas (OR:0.617; CI:0.57-0.78) comparison to men resident in the urban areas (reference category). The trends of cigarette smoking was significantly high for men resident in Copperbelt region (OR:1.873; CI:1.52-2.29), men resident in Luapula region (OR:1.644; CI:1.31-2.05), men resident in Muchinga region (OR:1.443;CI:1.13-1.83) and men resident in Western region (OR:1.808;CI:1.42-2.28) in comparison to men resident in the Central region of Zambia (reference category).

A combination of action is required, with wider attempts to address SES differences, risks and health consequences related to cigarette smoking among the Zambian population in large. Handle with care for those groups with high prevalence of smoking during sensitization programs is in a higher demand. Concerted efforts are needed to empower men to eliminate smoking, promote education and encourage the utilization of entrepreneurship targeting the rural poor men. tobacco cigarette smoking death

Keywords: Socioeconomic, Demographic, Cigarette, Smoking, Zambia



INTRODUCTION

Introduction

This section of the thesis provides the background to the study, the study objectives, novelty of the study, research design and the organization of the study.

Background to the study

The use of tobacco particularly via cigarette smoking represents the major cause of premature death and disease that can be prevented, being estimated to be accountable for about a billion deaths occurring during this century (Murray et al., 1997). At the same time when the tobacco-related epidemic is experiencing a decline in many high-income countries, the use of tobacco is rising in many low and middle-income countries (Jha et al., 2013). The sub-Saharan African region represents a region where the tobacco-related epidemy could possibly have a great consequence. Even though the current use of tobacco in Sub-Saharan Africa is at low levels, cigarette smoking prevalence is estimated to increase to about 39% by 2030 (Salloum et al., 2015).

Zambia is a lower-middle-income country located in the sub-Saharan African region, where cigarette smoking rates are regarded as relatively moderate with male prevalence rate estimated at 15.6% and female prevalence rate at 0.5% (Pampel, 2008). The WHO estimates an increase in Zambia's present cigarette smokers from approximately 1.2 million in 2015 to about 1.5 million by 2025 resulting from population growth (WHO, 2015). The International Tobacco Control Policy Evaluation Survey (ITC) in 2014 estimated 22.7% of men and 0.7% of women aged 15-49 years old in Zambia to be cigarette smokers (ITC, 2014). The rise in cigarette smoking is placing a heavy burden on the Zambian society. The number of deaths resulting from cigarette smoking which occur in Zambia have been estimated to increase in 1990 from about 3000 per year (43 per 100000) to about 8000 per year (46 per 100000) in 2015 (Institute for Health Metrics and Evaluation, 2016).

The use of tobacco via cigarette smoking exerts a great burden on Zambia's economic development. The costs of cigarette smoking in Zambia is realized via expenditures on health, losses in productivity, undernutrition, as well as under investments in terms of education since spending on cigarettes diverts resources required for basic and essential goods and services in Zambia (Chelwa et al, 2014).

Zambia approved the WHO Framework agreement on the control of tobacco use in 2008. Before approving the FCTC, Zambia via the National Public Health Act of 1992 had enacted the tobacco control legislation. This act placed emphasis on warning labels on cigarette packaging, a ban on smoking in several public places as well as a ban on selling cigarettes to people under 16 years old (ITC report,2014). There was a failure in the proper enforcement of these regulations (Siziya et al, 2011). The cigarette smoking ban was extended to places considered as public places by 2008 which included any building, premises, conveyance or place which the public had access. The Ministry of Health took further steps by 2009 in enforcing the laws creating punishments such as fines worth up to the equivalent to $ 67 or higher as well as a two-year jail term for cigarette smoking in public places. In Zambia, there is currently no ban on direct cigarette advertisements, promotions and sponsorship (ZHD report 2003).

In Zambia, the prevalence of cigarette smoking has been observed to be higher among men, resident in urban areas, with low levels of educational attainment, with low socioeconomic status and those who have manual occupations (Pampel, 2008). Due to the high prevalence of cigarette smoking observed amongst Zambian men, it is imperative to examine men's educational level attained and household wealth index category as pivotal factors associated with and influence men's cigarette smoking behaviour in Zambia. Also, it is necessary to examine other socioeconomic and demographic factors associated with and have an influence cigarette smoking behaviour among Zambian men.

General Objective

From a general perspective, this study examines the SES and demographic factors linked with cigarette smoking behaviour among men in Zambia.

Specific Objectives

1. Examine the association and effect men's educational level and household wealth index category have on their cigarette smoking behaviour.

2. Identify the socioeconomic and demographic factors associated with men's cigarette smoking behaviour in Zambia

3. Examine the influence socioeconomic and demographic factors have on men's cigarette smoking behaviour in Zambia.

Novelty of Study

A general study on cigarette smoking prevalence may hide facts about where it is most, prevalent as well as the possible socio-economic and demographic factors attributed to such prevalence. This study is aimed at the enhancement of understanding of the cigarette smoking behaviour of Zambian men in relation to the influence of necessary factors such men's educational level and household wealth index category. Identification of other socioeconomic and demographic factors associated with smoking behaviour among Zambian men. This could go a long way in helping at institutional levels as well as local policy-making levels on the reality of cigarette smoking behaviour, its relative prevalence as well as inspire possible ways of ameliorating the situation as well as identification of specific groups of men to targeted during sensitization programs in Zambia.

Research Design

The is study uses data from the 2014 Zambian Demographic and Health Survey (ZDHS), as well a quantitative approach, using bivariate analysis with the use of chi-square test to show the association between Zambian men's cigarette smoking behaviour and men's educational level attained, household wealth index category as well other socio-economic and demographic factors. The study equally uses multivariate analysis via binary logistic regression models to estimate the influence men's educational level attained, household wealth index category as well other socio-economic and demographic factors have cigarette smoking behaviour among men in Zambia.

Structure of the Study

This study is organized as follows: following the introductory section, Chapter 1 includes literature review, theories, country overview, origin of tobacco and, trends of smoking in Zambia, socioeconomic and demographic factors associated with smoking cigarette, summary of the literature reviews, research hypotheses and conceptual framework. Chapter 2 provides data and methodology. Chapter 3 presents the study findings and testing hypothesis. Finally, Chapter 4 includes discussion of the findings, limitation, concludes the study and offers some recommendations to empower men to eliminate smoking behaviour.



1. LITERATURE REVIEW

1.0 Introduction

Looking at the factors influencing smoking cigarette behaviour this study, therefore, has utilized previous studies. This section reviewed different subtopics such as; theories, country overview, origin and trends of tobacco and smoking in Zambia. Socioeconomic and demographic factors associated with smoking cigarette habit. Summary of the literature and research hypotheses presented.

1.1 Theories

The study establishes the use of theories in other to identify the associations and effects between cigarette smoking behaviour and educational level attained, household wealth index category as well as other socioeconomic and demographic factors. There is no single universally accepted model that can directly describe all sorts of tobacco smoking practice among human beings over time (Mettlin, 1973), and same holds true in the Zambian case. There are many criteria to consider when defining cigarette smoking behaviour because it's a combination factors such as biological, psychological, social, economic and cultural. Cigarette smoking theories and approaches differ accordingly to the importance of the existing relationship between the above criteria and the extent to which it is concentrating on one of the most common problems. Hence, this study focuses on the health behaviour theory, and economic theory on cigarette smoking to examine the Zambian situation.

The health behaviour theory is an attempted holistic approach proposed and applied to male cigarette smoking behaviour by Dweck et al. (1995) , health behaviour described as actions of individuals, groups, organizations and their decisions, relationships and outcomes, including social change, policy development and implementation, improving the ability to cope with the quality of life. According to this theory, personal quality, faith, expectations, motives, values, views, and other cognitive aspects; personality attributes, including states, state conditions and attributes to behaviour related to health care, restoring health, and improving health are more likely to be displayed in the cigarette smoking habit of a person (Blackwell et al.,2007). Research on cigarette smoking behaviour has identified via the implementation of theories of behavioural change and models of action different groups of people (Zedelius et al.,2017). In the best use of drugs, it assumed that successful responses for various risk factors increase the level of knowledge, thus reducing the risk of return (Palov's theory). Another study has shown a connection between self-control and recipient (DiClemente, et al 1985). A person learns to act in a certain very good or bad and behaves according to the way he or she has learned slowly but eventually becomes part of his or her life (Infante et al.,1997). In addition, it is believed that environment and relationships affect ones and others behaviour ( Hashim et al., 2007).

From the psychological analysis and behaviour change, health behaviour has been considered from the socioeconomic position of a person or group as an important element of cigarette smoking behaviour (Leva et al., 2017). A review by Rogers (1995), point out four stages to define cigarettes smoking practice. At the first stage, smoking is spinning around the high socioeconomic groups that are innovations. At the second stage, cigarettes smoking spread to other residents, including lower-socioeconomic groups that are laggards. The third step deals with the onset of abolition in higher socioeconomic groups, male leading, and the increase in female smoking. Finally, in the fourth stage, smoking is declining among the top social groups, but it is still high among the lowest socioeconomic groups (Wang et al., 2018). Cigarette smoking behaviour, therefore, addiction described in detail as physical and / or psychological dependence on drugs.

The Economic theory posits three alternative patterns of the concept used by economists to explore cigarette smoking habits, intelligence, inequality, and drug abuse (Sloan and Wang, 2008). The theory gives evidence in specific ways to describe adult smoking. In addition, Suranovic et al. (1999), argue that the economic theory is well suited as its use at some time depends largely on the oldest systems of use whereby smoking is physical and psychological (as associated with signs and behaviour). People can share two obstacles in their minds and reacting to one of them. Three concepts used to show drugs as well as tobacco addiction such as tolerate, strengthen and eliminate (Suranovic et al., 1999). When a person persists in this substance, over an excessive use of the old, low consumption depends on the current consumption rate. In other words, the body used for drugs, and much more is needed to satisfy the desire. The concept of strengthening directly linked to the benefits of use (pleasure, nicotine, psychological effects, and signs) and costs avoided to eliminate disappointment (Suranovic et al, 1999). According to Plaks et al (2009), factors that contribute to smoking behaviour among human beings are stimulated and contribute to many aspects of life. Furthermore, they argue that humans smoke cigarettes for several purposes. Cigarette smoking habits are stimulated either, to cope with the systematic problems in life, confusion, type of social intervention, entertainment habits, and a strategy for increasing or maintaining personality (Plaks., 2009).

1.2 Country overview

Formally, Zambia was namely Northern Rhodesia under British rule towards the end of 19th century which later joined Nyasaland (Malawi), and Southern Rhodesia (Zimbabwe) to form the Central African Republic of Rhodesia and Nyasaland (ZDHS,2014). These two countries are major tobacco leaf producers. Zambia is divided into 10 regions and 74 districts. The ten regions; Central, Middle East, Muchinga, North, Luapula, Northwest, West, and South-rural areas as well as two major cities, namely Lusaka and Copperbelt. The capital is Lusaka in the south-central part of the country (ZDHS,2014). This regions and neighbour countries grow tobacco and produce cigarette is presented in figure 1.1 below

Figure 1.1. Shows administration regions of Zambia and bordering countries

In the census held in 2010, the Zambian population was 13.1 million people with a growth rate of 3 percent per annum (ZDHS, 2014). The population increased dramatically from 5.7 million 1980 to 13.1 million in 2010. During the period of 2000-2010, growth rates were different from within the regions of the country, from 2 percent in the West to 5 percent in Lusaka. However, the currently estimated population is 17 million people (CSO, 2014)

The density of Zambia's population was 22.3 per square kilometre in 2016. Between 1967 and 2016, the density of Zambia's population increased significantly from 5.1 to 22.3 people per square kilometre at an annual rate up of 3.57 percent in 1974 and decreased to 3.05 percent in 2016 (Google search). Evidence shows the two most populated regions and at the same time urbanised are Lusaka and Copperbelt (CSO, 2014). In Zambia, 40% of the population lives in the Urban while 60% lives in the rural (CSO, 2014).

Agriculture, construction, mining, manufacturing, and tourism sectors are the key economic activities in Zambia (CSO, 2014). Historically, the country's economy has been derived from the copper industry, accounting for 95 percent of annual sales revenue and contributing 45 percent of government revenue during the 10 years after independence 1965-1975 (ZDHS, 2014). Since the increase in oil prices and decline in copper prices, the country's economy has declined and yet recovered and stabilised, and many of the Zambians live in poverty (ZDHS, 2014). In 2010, 60 percent of the Zambian population were regarding as poor (CSO, 2014). In Zambia's context, poverty is defined as lack of income, employment opportunities, and rights, including voluntary use of goods and services, housing and other basic needs. By 2010, poverty continued to widespread among rural residents (78%) than among urban residents (28%) (CSO, 2014) This could be a possible factor accounting for the psychological problems among Zambians characterized by living under conditions of depression with a predominant respond of engaging into cigarette smoking behaviour.

1.3 Origin of Tobacco and smoking in Zambia

African men who worked in colonial plantations and farms found themselves engaged in tobacco use as a source of inspiration due to the hard work and so many life's situations (Kulikoff, 1986). In 19th century, slaves in Angola were given tobacco weekly as a doze for protection against diseases. Angola shares borders with Zambia, with their people sharing lots common practices such as work as well as the practice of cigarette smoking inherited from Angola (Duvall, 2017). Existing studies show African emperors exchanged their people for cigarettes during the slave trade era (Kulikoff, 1986). By the 19th century, tobacco products from the U.S were smuggled into the massive plantations of Western settlers throughout the Eastern and Southern parts of Africa (Duvall, 2017). Cigarette manufacturing was dormant in the continent of Africa by the 1930's. Raw materials imported from Europe and the United States of America (Duvall, 2017). Evidence shows that Portugal transported tobacco as raw material to European factories and subsequently returned consumable cigarettes and distributed to the local authorities, and many people found themselves craving to smoke cigarettes as well as smoking as a new lifestyle for African men, "Africans Who Find Their Waves" (Kulikoff, 1986). These has contributed much to the Zambian men who worked in different tobacco plantations in the former British empire Nyasaland (nowadays Zimbabwe, Malawi and Zambia)

In addition, colonial powers encouraged tobacco farming/production as cash crops in Zambia, Rhodesia and Malawi instead of food crop production. The leading cigarette manufacturing factories are in Malawi and Zimbabwe which simplifies and institutes cigarette smoking in the region (Duvall, 2017). As a result, until the 20th century, cigarette smoking has become increasingly common in the Zambian society.

1.4 Trends of cigarette smoking in Zambia

Early in the 19^th-century cigarette, smoking in Zambia was mainly among the chiefs and other high ranking male members of society. However, a new lifestyle has strong influence, cigarette smoking behaviour has been widespread in the country (Duvall, 2017). For Zambian men, cigarette smoking peaked 31% in 2000, smoking was perceived as a symbol of modernity and freedom (Brathwaite et al.,2015). According Figure 1.2, after this peak, male smoking prevalence steadily declined as follows; 29.3% in 2005,27.8% in 2010, 27.3% in 2012 and 26.5% in 2015 (World Bank, 2018).

Figure 1.2. Shows Trends of adults males smoking in 2000-2015

Source: World Bank, 2018



1.5 Socioeconomic and demographic factors associated with cigarette smoking

Socioeconomic status defined as an individual's position or location in society's structure (Hiscock et al.,2012). The link between economic and social factors can be defined as social hierarchy such as wealth index/income and education. This social hierarchy is defined by the way economic and social factors are associated in daily life (education and income) (Hiscock et al., 2012). Cigarette smoking is a combination of behaviour affected by the biological, psychological, and environmental interactions (Prochaska et al., 2017). These factors can work as risk or protective components. Risk factors increase the risk of cigarette smoking and the possibility of continuous use, known as the increase in circulation rate. On the other hand, protective factors reduce the risk of cigarette smoking. In the case of Zambia, the risk and protective factors related to cigarette smoking are divided into seven main domains: age, wealth index, education level attainment, occupation, marital status, residence, and religion. Globally, existing studies have focused on these factors and how they are related to cigarette smoking behaviour.

1.5.1 Age

Age is one of the factors that influences many people to smoke cigarettes (WHO report, 2018), the WHO report shows that age and cigarette smoking have a strong relationship globally. Studies suggested agemates and seeking popularity among peers are the causes of many people involved in the use of cigarettes (Ozer and Fernald, 2008; Nishio et al., 2018). Age processes play a major role in determining the risk of cigarette smoking initiation (Steinberg, 2007). Brain changes and development, as well as emotional, are the factors that are changing from one stage to another as well as the age does over time (Flora and Chassin, 2005). From the period of adolescence to ages 18-25 years old has some developmental significance related to cigarette smoking behaviour (Emmy, 2013). Many dangerous behaviours during this period, including the level of drug use, which includes cigarette smoking (Flora and Chassin, 2005). These changes in life are often associated with cigarette smoking lifestyle. From these perspectives, we can predict those men who start smoking cigarettes in the early age (adolescent) might continue smoking during their adult lifetime.

A study from the U.S Breslau and Peterson, (1996), has shown that age in the initiation of cigarette smoking could led a person to be addicted and hard to avoid cigarette smoking until he/she dies. However, cigarette smoking has been linked with the other major problems including illiteracy, long-term smoking, type of job, low income, emotions and nicotine dependence (Kaplan et al., 1990; Escobedo et al., 1990). Another study in Nepal (Aryal et al, 2014) and Brazil (Peixoto et al., 2006), found that people who had SES difficulties were more likely to use cigarette throughout all ages of their life. In sub-Saharan Africa investigating the effects of SES and demographic factors on cigarette smoking have shown age to be associated with cigarette smoking habit (Madagascar, (Mamudu et al, 2013); Ghana, Lesotho (Doku et al, 2013; Dickson and Ahinkorah, 2017).

1.5.2 Wealth index

While analysing the link between SES and cigarette smoking, income is closely related to the differences in smoking conditions within the population (Hiscock et al., 2012). In the WHO (2015) report, it was revealed that cigarette smoking has a direct role and correlated to the poverty cycle among the poor people in the European community. Those people in low-income groups are more likely to smoke cigarette (Jarvis and Wardle, 2005). In most high-income countries such as Japan and U.S in the early prevalence of cigarette smoking was linked to high- income people, but eventually, the epidemic changed direction to the poor in the early 21^st century (Hosseinpoor et al., 2012). Shin et al, (2013), in their study in California, found cigarette smoking prevalence by income was high among the low -income group. Table 1.1 below shows the different prevalence of smoking cigarette by income in California in 2010. The high income the low risk to smoke while the low in income the higher risk to smoke.

Table 1.1 Shows Prevalence of smoking cigarette by income

INCOME	CIGARETTE SMOKING PREVALENCE
Less than $ 15,000	17.7%
$ 15,999 - $ 24,999	16.2%
$ 25,000 - $ 34,999	15.6%
$ 35,000 - $ 49,999	11.5%
$ 50,000	7.9%

Source: Source: Shin et al., 2013

On the other hand, the link between SES and the use of cigarette found in developing countries, such as India, Thailand and Malaysia (Derek, 1992; Hosseinpoor et al., 2012). Groups that are in poor economic or financial circumstances are associated with the effects of poor health care, good condition in daily life, and sometimes when there is no proper decision regarding smoking and thus weakening the health (Wang et al.,2018). Health and longevity, recognizing the existing order and relationships are fundamental in daily life, meaning that health care expenses and other basic human needs can be affordable by those who are wealthier than the poor in the society. Perhaps the best known of the consequences of smoking reduces the attraction to behaviour among the rich. In Malaysia, higher income people significantly linked to self-denial smoking (Wang et al., 2018). As a result, the socioeconomic consequences of cigarette smoking habits may vary in countries with different levels of economic development.

1.5.3 Education level attained

Education can reflect on one's knowledge and ability to make health decisions, including cigarette-smoking habits (Keeler. 2013). Therefore, education, which has generally been the decisive factor during adolescent and adult health, can have a major implication equally for tobacco use and smoking behaviour. Education works in different ways and contributes to the social health in the community by affecting the lifestyle of a person (Villanti et al., 2016). SES change and access to education has increased the risk of cigarette smoking among the youth in the U.S (Mettline, 1973), in China among the factors influencing cigarette-smoking education was a key determining factor in relation to cigarette smoking behaviour (Wang et al., (2018). In addition, Escobedo and Peddicord, (1996), in their study found that education has had a close relationship with every aspect of life. There is a link between education and cigarette smoking a link that contributes to the health effects of cigarette smoking in an individual, which brings about a difference in social, health and lifestyle (Woelfel et at.,1970).

Educational level is one of the most widely used indicators in the economics of health studies (Liberators et al., 1988; Shin et al.,2013). Despite this, the educational achievement still seems to be a danger to young people from prosperous communities. These dynamics may focus on how and what to do or not to do, and how poor education may have an effect the individual's ability to read health warnings despite the existence of natural education systems that can deliver messages. This can help investigate the value and the role of health-enhancing innovation, such as the implementation of warnings on the packaging of tobacco products. Educations enable people to understand both negative and positive effects of cigarette smoking (Villanti et al., 2016). Education and cigarette smoking are associated both at individual and societal levels in that the individuals who have a middle or higher educational level are considerably less likely than less educated individuals to become cigarette smokers. Low educational expectations have been pinpointed as a contributing factor. There is a gap between level of education and cigarette smoking (Breslau and Peterson, 1996).

1.5.4 Occupation

The types of job and income has also been found to have a close connection with cigarette smoking (Rogers and Everett, 1995). In the U.S cigarette smoking prevalence among adults working groups vary according to job types (Centres for Disease Control and Prevention,2011). Those in the Mining industry, construction workers and other low paying jobs are more likely to be cigarette smokers as seen from existing studies in U.S. (Kim S and Kim J,2015; Zyaambo et al.,2011). Evidence shows that the type of job is the measurement of one's economic position in the society than other socioeconomic indicators (Nagelhout et al.,2012).

1.5.5 Marital Status

Studies carried out by Lindstrцm et al., (2000), in the Scandinavian countries have shown that marriage is a protective factor against cigarette smoking among people especially those who are married. There is an importance of institution of the family in society where a person with difficulties can find solutions and comfort: parental smoking, family surveillance (Hill et al., 2005; Loke et al., 2010), reduces the mental disorder. Studies have shown that when there is a strong bond within the family it contributes significantly to eliminate and avoid cigarette smoking and drug abuse. Family meal is also an indicator of measuring connections or integration within the family, which seemed to be the key factor to avoid cigarette smoking habits in both the developed and developing countries as studies in the U.K, U.S, Japan and Indonesia have shown positive effects of strong family ties in communities (Loke et al., 2010, Hill et al., 2005). Lindstrцm et al, (2000) and Izumi (2016), examined the link between smoking behaviour and other factors such as Psychological factors, economic conditions and other characteristics, in their findings, they discovered and highlighted the family and social involvement in cigarette smoking behaviour was closely associated with current smoking habits.

1.5.6 Residence

According to Siziya et al (2011), and Drope (2011), the place of residence is a useful measure of the change from rural behaviour to urban behaviour. Significant differences in urban-rural men and cigarette smoking are partly the result of the effects of new lifestyle and education in urban areas in comparison to rural areas. Residence has an influence on cigarette smoking, education attainment and income tend to divide people where to work and live (Shakib et al., 2005). In addition, differences in access to health information can count with implications on the differences in cigarette smoking behaviour and livelihoods (Dickson and Ahinkorah, 2017). The residential area has been found to predict cigarette smoking behaviour (Pampel, 2008), although some studies have not seen the ratio in this forecast (Doescher et al., 2006). With the emergence of the new lifestyle of cigarette smoking in many cities and towns in Sub-Saharan African countries, will increase cigarette smoking behaviour in the region as well as have an impact on the health burden of their people (WHO,2008). New lifestyle starting from the cities/towns and later spread to the rural areas. However, shops and cigarette manufacturing are mainly located in cities which simplifies and encourages cigarette smoking habits in urban areas (Lo et al.,2013).

1.5.7 Religion

Religion plays an important role in the daily lives of some people. However, behavioural barriers vary greatly between religion (Nakhaee et al., 2009). The largest religions were established before the advent of tobacco consumption; so, their basic teaching does not directly mention cigarette smoking. Modern scholars of religion, however, view the smoking of cigarettes based on their religious convictions (Nakhaee et al., 2009). All religions have the value of human welfare.

According to WHO's report on Tobacco and Religious held at WHO headquarters in May 1999, Christians-welcome anti-cigarette smoking efforts (WHO, 1999). Some Christian scholars maintaining that cigarette smoking behaviour is a part of the evil that Satan, as an enemy of virtue, tries to spread and that cigarette smoking can weaken the Christian's relationship with the Lord (Garrusi et al., 2012). Quoting the Qur'an, Muslims prohibit cigarette smoking behaviour among their members, "Do not destroy yourself” and "do not hurt” (Garrusi et al., 2012). By referring to the lines mentioned and considering that cigarette smoking behaviour affects the health of a person and causes a loss of money, most of the religious scholars recommend a ban on cigarette smoking (Garrusi et al., 2012). Judaism, Hinduism, and Buddhism believe that anything damaging the body or mind should be avoided (Wang et al., 2015). According to the International Workshop on Drugs and Alcohol, tobacco is a dangerous substance thus "all cigarette marketing should be banned" and are advised to avoid cigarette smoking among their member (Wang et al., 2015). Religion has a strong connection in society, constituting a social network where not only do social support exists but also behaviour shared (Shakib et al., 2005; Garrusi et al., 2012). Consequently, religion promotes and enhances behaviour change such as no cigarette smoking, alcohol use, and other many bad habits among their followers (Lakew et al., 2015; Doku et al, 2013)

1.6 Summary of the literature reviews

Literature review reveals that SES can measures for a person's development or behaviour. It measured by age and how many years a person has spent in school, how much money a person earns in a year. Factors influence smoking habit are Age, wealth index, education level attainment, occupation, marital status, residence and religion. These factors has increase or decrease the risk on smoking behaviour. Being in a state of crisis, poverty, or emotional stress has identified as key risk of initiating smoking habit. A person with middle/rich wealth index or a graduate degree, can predict higher than average income and steady full-time job, while a person with a lower SES may have less than a high school education, low income that not having enough money, hence lead to uncomfortable life due to unemployed or work in a low-paying job and affect all his or her decisions making concerning life matters. In the form of cigarette smoking, a positive attitude can involve personal attention related to the effects of cigarette-caused by smoking. Hence, understand and belief of a person on smoking effects in the social life empowered by knowledge have. Since this views differs in force, so we can expect the individual smoking rate varies, and to make smoking more or less desirable or individual acceptance. Therefore, it is important to identify factors influencing smoking and groups with high risk on smoking habits and equip as well as monitor them.

1.7 Research Hypotheses

The following hypotheses are formulated based existing studies reviewed as well as the relevant theories and current trends in the discussion on cigarette smoking behaviour worldwide.

H1. Men who belong to the middle or rich category of the wealth index in Zambia are less likely to initiate cigarette smoking behaviour than their counterparts who are in the poor wealth index category.

H2. Men with higher education level are less likely to initiate cigarette smoking behaviour than their counterparts who have lower or no education.

Figure 1.3 Conceptual framework, factors associated with smoking behaviour



2. DATA AND METHODOLOGY

2.0 Introduction

This study employed quantitative data in explaining the factors associated with cigarette smoking behaviour among men in Zambia. Levels of analyses ranged from simple descriptive statistics, bivariate analysis using chi-square tests and multivariate analysis using binary logistic regression models.

2.1 Data source and description

The study uses data from the 2014 Zambia Demographic Health Survey (ZDHS), a nationally representative survey of 14,773 men between the ages 15- 59 from 15, 920 households. Three questionnaires were used for the survey, namely the household, women's, and men's questionnaires. These questionnaires based on population and health issues relevant to Zambia. From the data set, seven variables used for this analysis were selected these included; age, wealth index, education level, occupation, marital status, religion, place of residence, and region. The ZDHS is a nationally representative survey conducted within five years interval. Every five years the ZDHS conducts a nationwide survey with the major focused on maternal health and child, fertility, non-communicable disease as well other health issues such as health insurance coverage, alcohol use, physical activity and the use of tobacco in the population. Information collected in households on several issues related to respondent's socio-economic, cultural, ethnic, demographic characteristic including Їfertility, marriage, family care, nutrition, adult and child mortality, HIV/AIDS, and domestic violence using an internationally standardized questionnaire (ZDHS, 2014).



2.2 Data processing and analysis

The study used STATA version 13 to generate frequencies, cross tabulations and binary logistic regression analysis. Cross tabulations were used to examine the association of the socio-economic and socio-demographic variable on the prevalence of cigarette smoking among men. A binary logistic regression model used to predict the influence of socio-economic and socio-demographic factors on cigarette smoking.

Logistic regression is a regression method that involves an outcome variable that is categorical and dichotomous and predictor variables that are continuous or categorical.

The outcome variable employed for this study was cigarette smoking, where the variable derived from the question "do you currently smoke cigarettes?" (Yes, No). The 'yes' responses were coded '1' and the 'no 'responses were coded '0'.

Method used to observe variables that were not significant in the model, based on the p-value. The log likelihood ratio statistics equally observed. It used 3 models, and these included:

Model 1 fitted the independent variable men's age; household wealth index category and men's educational level attained. This was in order to find out how these variables influence cigarette smoking.

Model 2 controls for men's individual background characteristics such as occupation and marital status to assess the influence they have on men's cigarette smoking behaviour in Zambia.

Model 3 controls for men's individual characteristics such as religion, residence and region

2.3 Dependent variable

In choosing the dependent variable, there was the combination of; non-smokers of cigarettes and smokers of cigarettes. The use of logistic regression is because the dependent variable is treated as dichotomous because it can only take on two values: 0 or 1. In this case, a man can be either a non-smoker or a smoker. Hence, cigarette smoking is categorized as 0= non- cigarette smokers, 1=Smokers of Cigarettes

2.4 Independent variables

This study makes use of three independent variables which are age, household wealth index category and educational level attained.

2.5 Control variables

Under the control variables, these are; occupation, marital status, residence, religion and region of residence.



3. FINDINGS

3.0 Introduction

To investigate factors associated with cigarette smoking among men in Zambia. The following were employed: descriptive analysis used to inspect the frequency distributions of the various factors, bivariate analysis using chi-square test employed to examine the association between of the dependent variable (cigarette smoking) and independent variables (age, wealth index and educational level attained) as well as the control variables (Occupation, Marital status, Religion, Residence and Region). The multivariate analysis using binary logistic regression used to determine the effects of the independent and control variables on the dependent variable.

3.1 Descriptive analysis

According to table (3.1), out of the sample size of 14,772 Zambian men, 20.40 percent were cigarette smokers while 79.60 percent were non-smokers. With reference to distribution of the sample size by men's age groups, the highest proportion of the sample size was composed of men aged 20 - 29 years old (28.70%) while the least proportion of the sample population was composed of men aged 50 -59 years old (8.41%). With reference to the distribution of the sample size by household wealth index category, the highest proportion (44.01%) of the sample size was composed of men from the rich household wealth index category while men from the middle household wealth index category made up the least proportion of the sample population of men (21%). Examining the composition of the sample size by men's educational level attained, the highest proportion (47.57%) of sample size was composed of men with secondary educational level of education while the least proportion (3.75%) in sample size were men with no education. With reference to occupation, the highest proportion (41.95%) of the sample size was composed of men with agricultural occupations while the least proportion (5.11%) were men with professional, technical and managerial occupations.

About marital status, the highest proportion of the sample size was composed of men who were married (55.01%) while the least proportion of the sample size was composed of men living with partner or cohabitation (0.66%). In terms of religious affiliation, the highest proportion of the sample size was composed was men who belonged to the protestant religion (78.30%) while the least proportion of the sample population was composed of Muslim men (0.74%). With reference to residence, the highest proportion of the sample size was composed of men resident in rural areas (53.78%) while the least proportion were urban resident men (46.22%). Concerning residence by regions within Zambia, the highest proportion of the sample size was composed of men residing in the Copperbelt region (11.01%) while the least proportion of the sample size was composed of men resident in the Western region (6.88%).

Table 3. 1 Frequency distribution of sample size by selected background characteristics

Background Characteristic	Frequency (N)	Percentage (%)
Smoke Cigarettes:
Non-Smoker	11,758	79.6
Smoker	3,014	20.4
Age:
15-19 years old	3,344	22.64
20-29 years old	4,240	28.7
30-39 years old	3,565	24.13
40-49 years old	2,381	16.12
50-59 years old	1,243	8.41
Wealth Index:
Poor	5,170	35
Middle	3,102	21
Rich	6,501	44.01
Education:
No Education	554	3.75
Primary Education	5,981	40.51
Secondary Education	7,023	47.57
Higher Education	1,205	8.16
Occupation:
Not Working	2,767	18.82
Professional/Technical/Managerial	751	5.11
Clerical/Sales	1,742	11.85
Agriculture	6,167	41.95
skilled/Unskilled manual	2,240	15.24
Service/others	1,033	7.03
Marital Status:
Never Married	5,924	40.1
Married	8,127	55.01
Living with a partner	98	0.66
Separated	624	4.22
Religion:
Catholics	2,929	19.9
Protestants	11,522	78.3
Muslims	109	0.74
Other	156	1.06
Residence:
Urban	6,828	46.22
Rural	7,945	53.78
Region:
Central	1,192	8.07
Copperbelt	1,627	11.01
Eastern	1,970	13.34
Luapula	1,368	9.26
Lusaka	1,854	12.55
Muchinga	1,273	8.62
Northern	1,454	9.84
North western	1,343	9.09
Southern	1,675	11.34
Western	1,017	6.88



3.2 Bivariate Analysis using chi-square

Selected background characteristics crossed tabulated with cigarette smoking to determine the relationship between the dependent variable and independent variables. Figure. 3.1- 8 shows results from the cross tabulations.

According to figure (3.1) men, aged 40-49 years made up the largest proportion (33.01%) of cigarette smokers in the sample size while men aged 15-19 years old made up the least proportion (2.93%) of smokers in the sample size. The link between cigarette smoking and age depicts a significant relationship (p-value < 0.001) where cigarette smoking increased with age till age 40-49-year-old where it reached its peak and decreased (31.24%) slightly from 50-59 years old.

Figure 3.1 Shows %of male smokers by age

Source: ZDHS, 2014

According to figure (3.2) examining the household wealth index category, the highest proportion (30.31%) of men who smoke cigarettes came from the poor wealth index category households while the least proportion (13.12%) of men who smoked cigarettes were from the rich wealth index households. Correlation between cigarette smoking and men's wealth index household category was a significant relationship (p-value <0.001) with cigarette smoking decreasing as household wealth index category increased

Figure 3.2. Shows % of male smokers by wealth index in Zambia

Source: ZDHS,2014

According to figure (3.3), the educational level attained, the highest proportion (36.1%) of men who smoked cigarettes were those with no education while the least proportion (9.54%) of men who smoked cigarettes were those with higher educational attainment. Correlation between cigarette smoking and men's educational level attained was a significant relationship (p-value <0.001) with cigarette smoking decreasing as the educational level attained increased.



Figure3.3. Shows % males Smoking by level of education

Source: ZDHS,2014

According to figure (3.4), men's occupation, the highest proportion (26. 61%) of men who smoked cigarettes were men who had agricultural occupations while the least proportion (6.65%) of men who smoked had no occupation. The link between cigarette smoking and occupation was a significant relationship (p-value < 0.001) with men's cigarette smoking varying depending on the type of occupation.

Figure .3.4. Shows % of male smoking by occupation

Source: ZDHS, 2014



According to figure (3.5), marital status, the highest proportion (43.75%) of men who smoked cigarettes were those separated either via divorce, death of a partner or separation from a partner. While the least proportion (8.98%) of men who smoked cigarettes were never married men, correlation between cigarette smoking and marital status was significant (p-value <0.001) with cigarette smoking varying across the different marital status.

Figure 3.5. Shows Percentage of male smokers by their marital status

Source: ZDHS,2014

Findings revealed that by religion, the highest proportion (42.31%) of men who smoked cigarettes were men who belonged to religious groups classified in Zambia as others. While the least proportion (18.86%) of men who smoked cigarettes were men affiliated to the protestant faith. Correlation between cigarette smoking and religion was a significant relationship (p-value <0.001) with variations across the various religious groups



Figure 3.6. Shows % of male smokers by religion

Source: ZDHS,2014

According to figure (3.7), examining the link between men's cigarette smoking behaviour and residence, the highest proportion of men who smoked cigarettes were men who reside in the rural areas (23.4%) while the least proportion (16.98%) of men who smoked cigarettes resided in the urban areas. The link between cigarette smoking and residence was significant (p-value <0.001), with cigarette smoking increasing as men's residence changes to the rural areas and decreasing with residence in the urban areas.

Figure 3.7. Shows % of male smoking by residence