|Year : 2023 | Volume
| Issue : 3 | Page : 333-339
Exposure to tobacco advertisements, promotions, and sponsorships among in-school adolescents in Lagos, Nigeria: A cross-sectional study
Oluwakemi Odukoya1, Olamide Ladapo2, Ifeoma Okafor2, Olatokunbo Osibogun3, Kolawole Okuyemi4
1 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria; Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, Nigeria
2 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
4 Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
|Date of Submission||28-Apr-2022|
|Date of Decision||17-Oct-2022|
|Date of Acceptance||17-Feb-2023|
|Date of Web Publication||4-Jul-2023|
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos; Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The Nigerian government implemented the National Tobacco Control Act (NTCA) in 2015, which prohibits tobacco advertising, promotion, and sponsorship (TAPS) exposure to children under 18 years of age. This study was conducted to assess the prevalence of attitudes and exposure to TAPS among in-school adolescents in Lagos State, Nigeria, 5 years after the implementation of the Act and to identify the factors associated with TAPS exposure among the adolescents. Materials and Methods: This cross-sectional study was conducted among 968 in-school adolescents selected through multistage random sampling. The data were collected using self-administered questionnaires adapted from the Global Youth Tobacco Survey. Results: Overall, 77% had been exposed to at least one form of TAPS in the past 30 days. The most frequently reported channel of exposure was through product placements, with 62% reporting exposure in films, TV, and videos. Up to 15.2% and 12.6% were exposed to TAPS through promotional activities and sponsorships, respectively. The majority (82.3%) had pro-tobacco attitudes, while about a third (33.1%) had pro-TAPS attitudes. Factors associated with TAPS exposure were having pro-TAPS attitudes (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 2.3–5.3), being female (OR: 2, 95% CI: 1.4–2.7), and residing in a rural area (OR: 1.6, 95% CI: 1.2–2.3). Conclusion: Five years after implementing the NTCA, more than two-thirds of the adolescents reported exposure to TAPS, mainly through films, TV, and videos. This suggests that the NTCA is poorly enforced. Efforts to ensure the effective implementation of comprehensive TAPS bans are warranted. Gender-sensitive strategies that target adolescents' attitudes and school-level factors should be emphasized.
Contexte: Le gouvernement nigérian a mis en œuvre la loi nationale sur le contrôle du tabac (NTCA) en 2015, qui interdit la publicité pour le tabac, exposition à la promotion et au parrainage (TAPS) des enfants de moins de 18 ans. Cette étude a été menée pour évaluer la prévalence des attitudes et l'exposition au TAPS chez les adolescents scolarisés dans l'État de Lagos, au Nigéria, 5 ans après la mise en œuvre de la loi et d'identifier les facteurs associés à l'exposition aux TAPS chez les adolescents. Matériels et méthodes: Cette étude transversale a été menée auprès de 968 adolescents scolarisés sélectionnés par chantillonnage aléatoire à plusieurs degrés. Les données ont été recueillies à l'aide de questionnaires auto-administrés adaptés de l'Enquête mondiale sur le tabagisme chez les jeunes. Résultats: Dans l'ensemble, 77 % avaient été exposés à au moins une forme de TAPS au cours des 30 derniers jours. Le plus Le canal d'exposition le plus souvent signalé était le placement de produits, 62 % d'entre eux déclarant avoir été exposés dans les films, la télévision et les vidéos. Jusqu'à 15,2 % et 12,6 % ont été exposés à TAPS par le biais d'activités promotionnelles et de parrainages, respectivement. La majorité (82,3 %) avaient des attitudes pro-tabac, tandis qu'environ un tiers (33,1 %) avaient des attitudes pro-TAPS. Les facteurs associés à l'exposition au TAPS étaient les attitudes pro-TAPS (rapport de cotes [OR]: 3,5, intervalle de confiance [IC] à 95 % : 2,3 à 5,3), être une femme (OR : 2, IC à 95 % : 1,4 à 2,7) et résider dans une zone rurale (OR: 1,6, IC à 95 % : 1,2 à 2,3). Conclusion: Cinq ans après la mise en œuvre de la NTCA, plus des deux tiers des adolescents ont déclaré avoir été exposés aux TAPS, principalement par films, télévision et vidéos. Cela suggère que la NTCA est mal appliquée. Efforts pour assurer la mise en œuvre effective de TAPS complets les interdictions sont justifiées. Il convient de mettre l'accent sur les stratégies sensibles au genre qui ciblent les attitudes des adolescents et les facteurs au niveau de l'école.
Mots-clés: Adolescents, promotion et parrainage, publicité au tabac
Keywords: Adolescents, promotion and sponsorship, tobacco advertising
|How to cite this article:|
Odukoya O, Ladapo O, Okafor I, Osibogun O, Okuyemi K. Exposure to tobacco advertisements, promotions, and sponsorships among in-school adolescents in Lagos, Nigeria: A cross-sectional study. Ann Afr Med 2023;22:333-9
|How to cite this URL:|
Odukoya O, Ladapo O, Okafor I, Osibogun O, Okuyemi K. Exposure to tobacco advertisements, promotions, and sponsorships among in-school adolescents in Lagos, Nigeria: A cross-sectional study. Ann Afr Med [serial online] 2023 [cited 2023 Sep 26];22:333-9. Available from: https://www.annalsafrmed.org/text.asp?2023/22/3/333/380165
| Introduction|| |
The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than eight million people a year globally. Cigarette smoking is the most common form of tobacco use. Smoking causes cancer, diabetes, heart disease, stroke, and lung diseases, including chronic obstructive pulmonary disease. Smoking also increases tuberculosis, certain eye diseases, and rheumatoid arthritis. Tobacco use is initiated and established primarily during adolescence, putting adolescent smokers at significant risk of future morbidity and mortality. Among adults who have ever smoked daily, 87% had tried their first cigarette by the time they were 18 years., People who start smoking at an early age are also more likely to develop a severe addiction to nicotine.
The World Health Organization (WHO) describes tobacco addiction as a communicated disease, communicated through advertising, promotions, marketing, and sponsorship. As global tobacco control efforts clamp down on traditional modes of advertising, tobacco advertising, promotion, and sponsorship (TAPS) have emerged as the primary marketing strategy employed by tobacco companies to boost sales and expand markets.,, The industry spends billions of dollars on aggressive and deliberate youth-targeted marketing of tobacco products as adolescent exposure to TAPS influences the initiation and progression of tobacco smoking.,, To counteract this, Article 13 of the WHO-Framework Convention on Tobacco Control (WHO-FCTC) mandates a comprehensive ban on all forms of TAPS. Comprehensive TAPS bans are proven to substantially reduce tobacco consumption by 7%–16%, protect youth from smoking initiation, and prevent the tobacco industry from attracting new users.,
Over the years, the decline in the sales of tobacco products in high-income markets has resulted in a shift by transnational tobacco companies to emerging markets in Africa, where comprehensive TAPS bans are often poorly enforced., Nigeria, the most populous country in Africa, lies at the forefront of this shift, being both a tobacco-producing and tobacco-consuming nation. Increasing marketing activities by tobacco companies, inadequate governmental implementation of tobacco control measures, and a sizeable adolescent population make such countries a prime target for the tobacco industry.
The effectiveness of TAPS and its influence on youth smoking behavior correspond directly with the level of country-level enforcement of TAPS bans. In Nigeria, TAPS is legally prohibited among youth; however, the National Tobacco Control Act (NTCA) allows tobacco retailers and manufacturers to promote and advertise tobacco products to consenting adults and allows sponsorship aimed at consenting adults. This opens a window of opportunity for tobacco companies to employ creative ways to advertise their products and circumvent existing TAPS bans, for example, youth-targeted attractive tobacco product packaging and so-called corporate social responsibility campaigns. Therefore, it is vital to assess youth exposure to TAPS in emerging markets like Nigeria. The NTCA was passed in 2015, and since then, few studies have comprehensively assessed youth exposure to TAPS in Nigeria. One study assessed exposure to TAPS among Nigerian youth but used secondary data from 2008 (several years before the passage of the NTCA). The current study assesses the attitudes, exposure to TAPS, and the factors associated with TAPS exposure among adolescents 5 years after the passage of the NTCA.
| Materials and Methods|| |
Study population and sample size estimation
This cross-sectional study was carried out among adolescents attending senior secondary schools in Lagos state, the economic capital of Nigeria. Eligible respondents were in senior school (Years 10–12 of schooling), 13 years and older, but <18 years old. Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital (NHREC/19/08/2019B).
The minimum sample size of 770 was estimated using the formula for calculating sample size for descriptive studies: N = 2 × z2pq/d2, with a 95% confidence level, assuming a p of maximum variability (0.5%) and a design effect of 2. An allowance of 20% nonresponse rate was made, and the final minimum sample size was 924.
A multistage sampling method was used for this study. Lagos state comprises 20 local government areas (LGAs); two LGAs, one urban and rural, were randomly selected. Then, a list of public and private secondary schools was obtained, and two private and two government-owned senior secondary schools were selected from each LGA, making eight selected schools. There are three arms (SS1-SS3) corresponding to years 10–12 of schooling in each senior secondary school. One senior class in each arm was selected by simple random sampling. Twenty-four classes from the eight schools were selected for the study. All the 1,008 eligible and consenting students in each selected class were invited to participate in the study. Of these, 968 participated in the survey giving a response rate of 96%.
Data collection tool
A questionnaire adapted from the WHO Global Youth Tobacco Survey (GYTS), core questionnaire, was used for data collection. The questionnaire obtained information on sociodemographic variables, awareness and attitudes toward TAPS, and tobacco use – exposure to various channels of TAPS as well as patterns of tobacco use among the respondents. The data were self-administered and collected during school hours after written informed consent. Each questionnaire took about 20 min to complete. The survey was carried out between June and July 2021.
We defined TAPS according to Article 1 of the FCTC as any form of commercial communication, recommendation, or action with the aim, effect, or likely effect of promoting a tobacco product or tobacco use either directly or indirectly. In contrast, tobacco sponsorship was defined as any form of contribution to any event, activity, or individual with the aim, effect, or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.
Attitudes toward tobacco advertising, promotion, and sponsorship
Respondents' attitudes toward tobacco advertisements and promotions were addressed by three questions: willingness to accept a tobacco branded items offered by a best friend, a tobacco company sales representative, and a favorite celebrity who promoted a tobacco product. Possible responses were on a four-point Likert scale, i.e., “definitely not”, “probably not,” “probably yes,” and definitely yes. Participants with responses other than “definitely not” in each of the three questions were categorized as having pro-TAPS attitudes.,
Attitude toward tobacco
Respondents attitudes toward tobacco were six questions: to assess respondents' willingness to try using a tobacco product if a best friend or a family member smokes; if the respondents think they would be using tobacco products in the next 12 months; their perception of how easy they think it is to quit smoking; the perception of smoking at social gatherings and if they may enjoy smoking. Responses were on a four-point Likert scale in order of decreasingly supportive attitudes toward tobacco. Participants with responses other than the most positive responses were categorized as being pro-tobacco.
The pattern of tobacco use
This was assessed using survey questions adopted from the GYTS questionnaire that assessed ever and current use of cigarettes and other tobacco products. Ever use was assessed if respondents reported having ever tried a cigarette, even one or two puffs, (for cigarettes), or having ever tried other smoked or smokeless tobacco products. Current tobacco use was assessed by asking if they had used cigarettes, other smoked tobacco or smokeless tobacco product within the past 30 days.
Exposure to tobacco advertising, promotion, and sponsorship
In line with the definition of TAPS, five channels of TAPS exposures were assessed and categorized as follows.
Paid or unpaid tobacco product placements/communication
This was assessed using two questions adopted from the GYTS. “During the past 30 days, did you see or hear any tobacco advertisements on television, radio, Internet, billboard, posters, newspaper, and magazines?” “During the past 30 days, did you see any people using/smoking tobacco when you watched TV, videos, or movies?” Respondents who reported “Yes” to either of these questions were categorized as being exposed to this TAPS channel.
Social media/Internet marketing
This was assessed using the following questions: “during the past 30 days, did you see or hear any tobacco advertisements or promotions of social media?,” “during the past 30 days, did you receive any messages on various social media channels or chat groups about tobacco products (e.g., Whatsapp, Instagram, Facebook, Tiktok)?”, and “during the past 30 days, did you see any celebrity promoting tobacco products on various social media channels (such as Tiktok, Instagram, Facebook)?” Possible responses were “Yes,” “No,” and “I did not have access to the Internet in the past 30 days.” Respondents who reported “Yes” to one or more of these questions were categorized as exposed to this TAPS channel.
Promotional activity at points of sale
This was assessed using the question: “During the past 30 days, did you see any advertisements or promotions for tobacco products at points of sale (neighborhood kiosks, stores, supermarkets)?” Possible answers were “Yes,” “No,” and “I did not have access to the Internet in the past 30 days.” Respondents who reported “Yes” to this question were categorized as being exposed to this TAPS channel.
This was assessed using two questions: “During the past 30 days, did you see or hear any tobacco messages/posters at sports events, fairs, concerts, or community events/social gatherings?” and “during the past 30 days, did you see any sponsorship activities by tobacco companies (such as road works, borehole projects, and school/sports center renovations) in your area?” Possible answers were “Yes,” “No,” and “I did not attend any community events or social gatherings in the past 30 days.” Respondents who reported “Yes” to one or both of these questions were categorized as exposed to this TAPS channel.
This assessed respondents' exposure to free tobacco product giveaways and logo branding. Respondents were asked the following questions: “Has a person working for a tobacco company ever offered you a free tobacco product?,” “Do you have something (for example, t-shirt, pen, backpack, water bottle, face cap, nose mask, hand sanitizers) with a tobacco product brand logo on it?” and “Do you use or wear something that has a tobacco company or tobacco product name or picture on it (such as a lighter, t-shirt, hat, or sunglasses)?” Possible responses were “Yes” and “No.” Those who stated “yes” were categorized as exposed to this TAPS channel.
The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23 (IBM SPSS Co. LTD., New York, USA; March 4, 2015). Descriptive analyses of the variables were computed as simple frequencies, mean, and standard deviation (SD) as appropriate, while bivariate tests to investigate the factors associated with exposure to TAPS were conducted using the Chi-square test. Statistically significant variables (P ≤ 0.05) were imputed into a logistic regression model, to determine the factors associated with TAPS exposure. Colinear variables were removed from the model. Adjusted odds ratios and 95% confidence interval (95% CI) were reported.
| Results|| |
The adolescents were aged 13–17, with a mean (SD) age of 15.4 (1.2) years. They were mostly female; 534 (55%) and 502 (52%) attended government-owned schools [Table 1]. The pattern of tobacco use among the respondents showed that 165 (17%) had ever experimented with tobacco products, while 31 (4%) were current tobacco users. In [Table 2], 320 (33.1%) respondents reported positive pro-TAPS attitudes, 797 (82.3%) expressed positive pro-tobacco attitudes, and 119 (14.8%) of “never users” students reported the likelihood of initiation to use tobacco products within the next 12 months. [Table 3] shows that of the 968 respondents, 745 (77%) reported exposure to tobacco advertisements and promotions within the past 30 days. Up to 606 (62%) of the respondents reportedly noticed tobacco use in films, TV, and videos, which accounts for the highest exposure channel to TAPS, while 31 (3%) of the respondents reported exposure to free tobacco product giveaways, the least exposure channel to TAPS. However, considering exposures to each of the five channels of TAPS, 615 (43.6%) of the respondents reported exposures to paid or unpaid product placements/communications (this was the most reported exposure channel), followed by exposure to TAPS through social media/Internet marketing. Two hundred thirty-one (16.4%), 214 (15.2%), and 178 (12.6%) were exposed to TAPS through promotional activities and sponsorships, respectively. The least reported exposure channel was brand marketing/free tobacco product giveaways, with 173 (12.3%) of adolescents reporting exposure through this channel.
|Table 1: Sociodemographics characteristics and pattern of tobacco use among the respondents|
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|Table 2: Attitudes toward tobacco smoking and tobacco advertising, promotion, and sponsorship|
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|Table 3: Exposure to tobacco advertisements, promotions, and sponsorships|
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[Table 4] shows the bivariate analysis of the factors associated with exposure to TAPS. Gender (P < 0.001), LGA (P = 0.004), and pro-TAPS attitudes (P < 0.001) were found to be significantly associated with exposure to TAPS. Following a logistic regression in [Table 5], respondents who resided in rural areas had 1.6 times (odds ratio [OR]: 1.6, 95% CI: 1.2–2.3) higher odds of being exposed to TAPS than those in urban areas. While females had two times (OR: 2.0, 95% CI: 1.4–2.7) higher odds than males to be exposed to TAPS, and students with pro-TAPS attitudes had 3.5 times (OR: 3.5, 95% CI: 2.3–5.3) higher odds to be exposed to TAPS.
|Table 4: Factors associated with exposure tobacco advertising, promotion, and sponsorship|
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|Table 5: A logistic regression mowdel of the factors associated with exposure to tobacco advertisements and promotions|
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| Discussion|| |
We observed exposure to all channels of TAPS despite existing national advertising bans and Nigeria being a signatory to the WHO FCTC., Before the passage of the 2015 NTCA, a similar study done in 2008 reported high levels of exposure to TAPS among adolescents in Nigeria. The NTCA 2015 prohibits any form of advertisements and promotions of tobacco and tobacco products to minors, However, 5 years after this law was enacted, gross violations exist as Nigerian children are still being exposed to multiple channels of TAPS. The WHO recommends that signatories to the FCTC convention are expected to take appropriate measures for comprehensive TAPS bans 5 years after entry into force of the convention. Nigeria is currently past the 5-year time frame, and her inability to enforce a complete ban on TAPS both contravenes the obligation to the FCTC convention and frustrates the effectiveness of tobacco control efforts in the country. Poor enforcement of TAPS bans correspond directly with adolescent exposure to TAPS.,,
The implementation of TAPS ban in South East Asia after the ratification of the WHO FCTC revealed that enforcement of a comprehensive TAPS ban was one of the crucial areas that still needs to be addressed by several countries in the region. For instance, in Bangladesh, despite having established tobacco control laws, exposure to TAPS was still reported among minors, especially exposure to tobacco use in TV, movies or videos, and magazines. Similarly, children aged 13–15 in Bhutan also reported very high exposure to pro-tobacco advertisements in TV and magazines. Enforcing comprehensive TAPS bans has proved to be a daunting task for many countries, many of which have focused on eradicating traditional or direct forms of TAPS such as adverts on TV and radio, print media, and billboards but have not successfully curtailed other indirect forms of TAPS such as point of sale, social media, and sponsored events. In an evaluation of the adoption of country-level TAPS bans from 2007 to 2014 among WHO FCTC signatories, there was a significant increase in adoption in several high-income countries; however, low-income countries seemed to be lagging, with the lowest levels of compliance observed for point of sale and sponsorship bans. We observed similar findings and provided empirical evidence of poor implementation in Nigeria, thereby limiting the effectiveness of these policies.
The most predominant exposure channel to TAPS in this study was exposure to product placements, particularly in films, TV, and videos; this is consistent to findings in the USA reporting high levels of smoking scenes in Hollywood movies rated for young people, a proof that tobacco companies may be channeling their advertisements to more subtle forms even in emerging markets. In our study, the Internet also served as a predominant exposure channel to TAPS. Similar studies have revealed that Internet exposure to TAPS has been primarily high among youth in Vietnam and Australia., With the advent of Internet-enabled mobile phones, increasing accessibility, and the adoption of communication technology, such as social media, adolescents are regularly exposed to the Internet and at risk of exposure to TAPS through this channel. Tobacco companies use such viable channels to create product visibility and promotions, as the global nature of the Internet makes it challenging to regulate online advertisements. In addressing this exposure channel among adolescents, it is imperative to amend the tobacco control legislation to include domains in cyberspace yet untapped because the tobacco industry is often fast paced in creating product visibility through new and unregulated domains/channels.
Of all the five channels surveyed, the least predominant exposure channel to TAPS was brand marketing/free product giveaways. Other studies have reported similar findings., Article 16 of the FCTC prohibits the sale of tobacco products to minors, brand stretching, and the distribution of free samples. Perhaps, this channel is the least predominant because it requires contact between a tobacco company representative and the consumer, i.e. adolescents, and as such may put the tobacco company at risk of sanctions. However, this is not to say that the practice is wholly abolished; our study findings showed that more than 10% of the students reported this exposure channel.
In the study, exposure to TAPS was strongly linked to having pro-TAPS attitudes. The cross-sectional nature of this study does not allow us to determine if exposure preceded such attitudes or vice versa. However, this may imply that adolescents who would use tobacco branded items (offered by friends, tobacco company representatives, and promoted by celebrities) may have a higher chance of being exposed to TAPS than their counterparts or vice versa. Direct receipt of tobacco promotional gift items may influence initiating tobacco use among adolescents. On this basis, necessary actions must be implemented to identify and truncate the brand marketing activities of tobacco companies targeted at adolescents.
Although several studies have reported higher tobacco use among male adolescents which may be due to societal perceptions of smoking as a show of masculinity.,,,, Another study showed that females may be more predisposed to sensation-seeking behaviors. In this study, being female was significantly associated with TAPS exposure, a finding reported by similar studies., Tobacco companies may exploit this as a marketing strategy to influence female adolescents and gender-specific anti-TAPS measures may be warranted to curb this.
This study is one of a few that assesses TAPS exposure among adolescents in Nigeria after enacting the NTCA. However, it has some limitations and findings should be interpreted with caution. Responses were obtained by self-report and are prone to recall bias, under- or over-reporting. However, we used a standardized GYTS tool for data collection. Furthermore, no causal associations can be made because of the study's cross-sectional nature. Nevertheless, it provides empirical evidence on the state of implementation of the NTCA related to TAPS and the specific channels that the tobacco industry exploits among minors in an emerging market like Nigeria.
The protected time of Oluwakemi Odukoya for this research was supported by the Fogarty International Center of the National Institutes of Health under Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]