Selamawit Hirpa

Background: Tobacco advertising and promotion remain major drivers of tobacco use, particularly at points of sale (PoS). Ethiopia has enacted comprehensive tobacco control laws, including bans on TAPS at PoS. However, little is known about how these laws are implemented, monitored, and enforced in practice. This study explored the facilitators and barriers to implementing, monitoring compliance with, and enforcing TAPS laws at PoS in Ethiopia. Methods: Qualitative interviews with 41 key informants were conducted between December 2022 and January 2023 across 10 purposively selected cities. Participants included policy implementers and stakeholders from government agencies, civil society organizations (CSOs), and international partners. Participants were purposively selected from national and sub-national actors involved in tobacco control, including government agencies (MoH, EFDA, Ministry of Trade, regional health and trade authorities, regulatory bodies, and research institutions) and non-governmental stakeholders (WHO Ethiopia, professional associations, and CSOs). Semi-structured interview guides were developed and administered in local languages. Interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed thematically using ATLAS.ti software. Results: Key facilitators included strong tobacco control laws (Proclamation No. 1112/2019), federal-level political commitment, and the national tobacco control committee (NTCC). Barriers included the absence of EFDA structures at lower administrative levels, a lack of regionally adapted tobacco control laws, limited dedicated tobacco control departments, unclear enforcement mandates, advertisement of illicit tobacco products, not being a prioritized agenda, low awareness among non-health departments and retailers, tobacco industry interference, and, in some areas, a culture that normalizes tobacco smoking. Conclusions: Strong legislation banning 100% of TAPS and the presence of a national tobacco control committee support implementation; however, enforcement remains limited by structural, operational, and socio-cultural challenges. Enhancing compliance requires strengthening regional regulations, establishing clear institutional frameworks, raising stakeholder awareness about the tactics of the tobacco industry, and ensuring adequate allocation of human and financial resources, particularly in regions with a high prevalence of illicit tobacco products, to achieve the intended public health impact of TAPS laws in Ethiopia.

Background: Ethiopia has made significant strides in adopting comprehensive smoke-free laws aligned with the World Health Organization’s Framework Convention on Tobacco Control, which mandates that all public places, including hospitality venues, public transportation, and workplaces, be 100% smoke-free. However, effective implementation across regions remains uneven. This study examines the barriers and facilitators influencing the enforcement of smoke-free legislation in Ethiopia. Methods: This qualitative study was conducted in 10 major cities in Ethiopia, involving 41 key informant interviews with individuals working on tobacco control. For this study, a framework comprising five key concepts, namely, institutions, agendas, networks, socioeconomic conditions, and ideas, was employed. Semi-structured interview guides were developed in English and then translated into local languages. All audio-recorded interviews were transcribed verbatim and translated into English. Deductive thematic analysis was conducted using ATLAS. Ti Scientific Software. Results: The study identified several key facilitators of compliance with smoke-free laws in Ethiopia, including a well-established legal framework, clear institutional structures, especially in the capital city (Addis Ababa), strong political leadership, stakeholder collaboration, supportive cultural and religious norms, and growing public awareness of the harms associated with tobacco use. However, significant barriers remain, particularly in regional areas. These include the absence of dedicated tobacco control units, lack of region-specific implementation guidelines, competing policy priorities, limited budget and human resources, and insufficient law enforcement engagement. Cultural acceptance of smoking in some communities, economic reliance on tobacco farming, and misconceptions about products like shisha further undermine compliance with smoke-free laws. Additionally, weak coordination across sectors and limited ownership of tobacco control responsibilities among non-health actors hinder effective implementation. Conclusion: The study highlights the need for region-specific guidelines, accountable institutions, improved coordination, targeted education, and the addressing of socioeconomic barriers. Leveraging existing strengths and addressing identified challenges will be critical to achieving equitable and effective enforcement of smoke-free laws nationwide.

Objectives The objective of this study was to assess adherence to smoke-free laws at points-of-sale (PoS), that is, retail outlets that sell various goods including tobacco products, and to identify predictors of low adherence. Methods This cross-sectional observational study was conducted in December 2022 across 10 Ethiopian cities covering 1323 PoS such as regular shops, permanent kiosks, khat shops, supermarkets and minimarkets. Sampling was performed using a two-stage cluster design, with random selection of PoS. Data were collected using checklists through covert observations. Logistic regression identified predictors of low adherence. Results More than half of PoS (52.5%) showed good adherence, 23.2% moderate, 20.8% poor or none and only 3.4% met full adherence. Supermarkets/minimarkets had the highest rates of good or full adherence (83.9%), while kiosks and khat shops had the lowest (40.7% and 35.4%, respectively) rates of good or full adherence. Low adherence was higher in kiosks (adjusted OR (aOR)=7.02, 95% CI: 3.76 to 13.13) and khat shops (aOR=6.26, 95% CI: 3.48 to 11.26). Low adherence was also observed in Semera-Logia (aOR=21.27, 95% CI: 13.26 to 34.12) and Gambella (aOR=12.07, 95% CI: 7.64 to 19.08). Predictors of indoor smoking included being a khat shop (aOR=3.13, 95% CI: 1.29 to 7.60), being located in Semera-Logia (aOR=8.47, 95% CI: 3.49 to 26.54), presence of outdoor smoking (aOR=3.38, 95% CI: 2.07 to 5.51) and lighters (aOR=5.26, 95% CI: 3.05 to 9.06). Conclusions The study highlights enforcement gaps at PoS, particularly in khat shops, kiosks, and in Semera-Logia and Gambella cities. Strengthening smoke-free law implementation requires region-specific interventions for high-risk areas and retail outlets.

Introduction: In Ethiopia, a comprehensive smoke-free law that bans smoking in all public areas has been implemented since 2019. This study aimed to evaluate compliance with these laws by measuring the air quality and conducting covert observations at 154 hospitality venues (HVs) in Addis Ababa. Methods: Indoor air quality was measured using Dylos air quality monitors during the peak hours of the venues, with concentrations of particulate matter 2.5) used as a marker of second-hand tobacco smoke. A standardized checklist was used to assess compliance with smoke-free laws during the same peak hours. The average PM_2.5 concentrations were classified as good, moderate, unhealthy for sensitive groups, unhealthy for all, or hazardous using the World Health Organization’s (WHO) standard air quality index breakpoints. Results: Only 23.6% of the venues complied with all smoke-free laws indicators. Additionally, cigarette and shisha smoking were observed at the HVs. Overall, 63.9% (95% confidence interval: 56–72%) of the HVs had PM_2.5 concentrations greater than 15 µg/m³. The presence of more than one cigarette smoker in the venue, observing shisha equipment in the indoor space, and the sale of tobacco products in the indoor space were significantly associated with higher median PM_2.5 concentration levels (p < 0.005). Hazardous level of PM_2.5 concentrations—100 times greater than the WHO standard—were recorded at HVs where several people were smoking shisha and cigarettes. Conclusions: Most HVs had PM_2.5 concentrations that exceeded the WHO average air quality standard. Stricter enforcement of smoke-free laws is necessary, particularly for bars and nightclubs/lounges.

Background: Tobacco, khat, alcohol, and marijuana are the main risk factors for non-communicable diseases. There are limited studies on substance use in Ethiopia, especially among secondary school students. This study aims to determine the epidemiology of substance use among secondary school students in Ethiopia.Methods: This cross-sectional study was conducted in March 2020 in four large regions of Ethiopia and the capital Addis Ababa. We collected data from 3,355 grade 9 and grade 10 students in 36 randomly selected high schools. Data were collected on tobacco, khat, alcohol and other substances. Mixed effect logistic regression models were fitted to determine the predictors of cigarette smoking.Results: 157 (4.7%) of the participants ever smoked cigarettes and 81 (2.4%) were current smokers. 106 (3.2%) ever used smokeless tobacco, 1,342 (41.8%) had ever drunk alcohol, 290 (8.7%) ever used khat, 137 (4.8%) chewed khat regularly and 76 (2.3%) ever used marijuana. There was a significant regional variation in substance use patterns; cigarette and khat use was the highest in southern regions, whereas alcohol use was highest in the northern areas. Availability of cigarette and khat shops within a 100-meter radius of the school compound was reported by 1,229 (37.5%) and 816 (25%) students, respectively. Three hundred fifty-four (10.9%) students had ever seen someone smoking a cigarette in the school compound. Ever use of smokeless tobacco (Adjusted Odds Ratio (AOR) = 9.4, 95%CI: 4.9–17.9), ever use of shisha (AOR = 8, 95% CI: 3.9–16.3), ever use of khat (AOR = 4.1, 95%CI: 2.5–6.8), ever use of alcohol (AOR = 2.3, 95%CI: 1.4–3.7), having a friend who smoked a cigarette (AOR = 2, 95%CI: 1.2–3.5), and ever seen someone smoking a cigarette in the school compound (AOR = 1.9, 95%CI: 1.1–3.4) were associated with ever use of cigarettes.Conclusion: Substance use prevalence in Ethiopia has regional variations and prevention strategies should be tailored to the needs of the regions. Although this study reported a lower prevalence of cigarette smoking, students could access cigarettes and khat in nearby school areas. The existing tobacco control laws that prohibit selling tobacco products to children and adolescents under 21 years of age and ban establishing tobacco shops close to school compounds should be enforced.

The provision of psychosocial services has a substantial impact on cancer care by reducing emotional distress and improving both the quality of life and survival of patients, but the availability and utilization of such services have not been well studied in developing countries, particularly, Ethiopia. Therefore, we explored the types of psychosocial services available for breast cancer patients in Addis Ababa, Ethiopia. A mixed method study was conducted using a cross‐sectional survey involving 428 breast cancer patients, followed by a qualitative study. A total of nine in‐depth interviews (IDIs) were conducted with four breast cancer patients and five key informants using two separate interview guides. In addition to descriptive statistics, logistic regression was performed to identify factors associated with the provision of psychosocial services. Thematic analysis was used for the qualitative data, using NVivo 12 plus software. Only 47 (11.1%) patients received psychosocial services in the form of counselling, emotional support, or information provision. Health professionals reportedly provided such services along with their routine activities, and patients predominantly received social/emotional support from family members, friends, and colleagues. There were no well‐structured counselling services, emotional support, or group discussion sessions for breast cancer patients in these health facilities. The main reasons for not providing these services were high patient flow/workload, inadequate space, lack of training, and not having qualified professionals to organise and deliver psychosocial services in these hospitals. Only one in ten breast cancer patients received psychosocial services from health professionals, and the services were not delivered in a structured way. Therefore, psychosocial services should be integrated in both private and government health facilities in Ethiopia.

Background: Shisha smoking predisposes the users to cardiovascular diseases, cancer, and infections, such as tuberculosis, hepatitis, and herpes. In Ethiopia, there is little data on the adolescents’ shisha smoking experience. This study aimed to explore the lived experience of high school students and inform ongoing and future prevention and control interventions. Methods: This study was conducted in Addis Ababa and Adama cities in Ethiopia. Twenty-five secondary school students aged 15-22 years who had shisha smoking experience participated in this study. A topic guide was used to facilitate the in-depth interviews (IDIs) and a digital audio recorder recorded the interviews. Interviews varied between 40-90 minutes and were conducted in private open-air spaces where only the interviewee and researcher were present. Each transcript was coded using Atlas.ti version 8 software. The analytical approach was iterative, with interview transcripts analyzed at the time of coding and re-analyzed after a preliminary result was drafted to search for additional themes. Results: Students described two key factors that influenced their decision to initiate shisha smoking: peer influence and perceiving it as a means to release stress. After initiating shisha use students maintained the behaviour because of: peer influence, khat chewing, enjoyment of shisha smoking, having prolonged leisure time, and accessibility to shisha. Students regretted the impact shisha use had on their lives, such as conflict with their families, poor academic performance, and spending money on shisha smoking. Female students were also concerned about reproductive health risks related to shisha use. Conclusions: Peer influence played a major role both in initiating and maintaining shisha use. However, students admitted concern over the impact of shisha smoking on academic performance and their relationship with their families. Since shisha use is associated with khat chewing; shisha smoking control programs cannot be successful without controlling khat. Especially young girls had worries about their reproductive health risks associated with shisha use. This suggests that targeted awareness raising programs highlighting the dangers of shisha use for both health and safety; especially for young women is required.

Introduction This paper explores implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control in Ethiopia. The analysis highlights how operationalising key requirements of Article 5.3, such as minimising policy engagement with the tobacco industry, has been mediated by path-dependent processes of stakeholder consultation and collaboration that have persisted following privatisation of Ethiopia’s state-owned tobacco monopoly. Methods We conducted semistructured interviews with key officials (n=21) working in tobacco control policy, with high levels of access secured across ministries and agencies beyond health. Results We found contrasting levels of awareness of Article 5.3 across government sectors, with extremely limited awareness in departments beyond health. The data also highlight competing ideas about conflict of interest, in which recognition of a fundamental conflict of interest with the tobacco industry is largely confined to health actors. Beyond limited cross-sectoral awareness and understanding of Article 5.3, gaps in implementation are exacerbated by assumptions and practices around stakeholder consultation, in which attempts to minimise policy interactions with the tobacco industry are mediated by institutionally embedded processes that presume active engagement. The results also highlight a continuation of the close relationship between the Ethiopian government and tobacco monopoly following its privatisation. Conclusion The Ethiopian government’s recent achievements in tobacco control legislation require that policymakers are actively supported in reconciling perceived tensions and requirements for stakeholder consultation. Effective tobacco control governance would be further enhanced by enabling government agencies to more clearly identify which interactions with the tobacco industry are strictly necessary under Article 5.3 guideline recommendations.

Shisha smoking is also known as hookah, water pipe, goza, and nargile. Shisha use among the young is increasing globally. Shisha smoke results in a high concentration of carbon monoxide, tar, nicotine, and heavy metals which can be toxic to humans, especially with chronic exposure. This study aims to determine the prevalence and risk factors of shisha smoking among in-school adolescents in Ethiopia. Four regional states in Ethiopia (Oromia, Amhara, Southern Nations, Nationalities, and Peoples’ Region, Tigray) and the capital city (Addis Ababa) were the study areas. A two-stage cluster sampling approach was employed to produce a representative sample. From the sampling frames in the study areas, 36 high schools were selected randomly. A multi-level logistic regression analysis was used to account for cluster-specific random effects, the effect of individuals’, and school-level variables for ever-use of shisha. A total of 3355 secondary school grade 9 and 10 students aged between 13 and 22 years took part in this study. A total of 86 (2.6%) and 20 (0.6%) of the study participants, reported that they had ever smoked or were current smokers of shisha, respectively. Of all study participants, 38.6% perceived shisha as less harmful than cigarettes and 48.5% reported that they do not know which was more harmful to health. Students were more likely to ever use shisha if they had friend/s who smoke shisha (AOR = 16.8, 95% CI: 6.4–44.3), ever smoked cigarettes (AOR = 8.2, 95% CI: 3.4–19.8), ever used khat (AOR = 4.2, 95% CI: 1.9–10.4), ever used marijuana (AOR = 3.9, 95% CI: 1.4–11.1), ever used smokeless tobacco (AOR = 3.1 95% CI: 1.1–8.4), and students had received income from their parents (AOR = 3.1 CI: 1.1–8.8). Prevalence of ever and current use of shisha among high school students is low in Ethiopia compared to many countries in Africa. The majority of adolescents perceived shisha as less harmful to health than cigarette smoking. Health education about the harmful effects of shisha should be delivered to adolescents, along with information on other substances like khat, cigarettes, marijuana, and smokeless tobacco to prevent initiation of substance use.

Cervical cancer is one of the most common causes of morbidity and mortality among women in developing countries including Ethiopia. Unlike other types of cancers, the grave outcomes of cervical cancer could be prevented if detected at its early stage. However, in Ethiopia, awareness about the disease and the availability of screening and treatment services is limited. This study aims to determine the role of health education on cervical cancer screening uptake in selected health facilities in Addis Ababa. Two-pronged clustered randomized controlled trial was conducted in 2018 at eight public health centers that provide cervical cancer screening services using visual inspection with acetic acid (VIA) in Addis Ababa, Ethiopia. Each of the eight health centers were randomly assigned to serve as either an intervention or a control center. A two-pronged clustered randomized controlled trial was conducted in eight public health care centers. All the selected facilities provided cervical cancer screening services using visual inspection with acetic acid (VIA). Four health centers were randomly assigned to the intervention and control arms. The study participants were women aged 30–49 years who sought care at maternal and child health clinics but who had never been screened for cervical cancer. In the intervention health centers, all eligible women received one-to-one health education and educational brochures about cervical cancer and cervical cancer screening. In the control health centers, participants received standard care. Baseline data were collected at recruitment and follow-up data were collected two months after the baseline. For the follow-up data collection, participants (both in the intervention and control arms) were interviewed over the phone to check whether they were screened for cervical cancer. From the 2,140 women who participated in the study, 215 (10%) screened for cervical cancer, where 152(71%) were from the intervention health centers. Seventy-four percent of these participants reported that they learned about the benefits of screening from the one-to-one health education or the brochure. Women from the intervention health centers had higher odds of getting screened (AOR = 2.43,95%CI;1.58–2.90) than the controls. Women with the educational status of the first degree and those who have a history of sexually transmitted infections (STIs) had higher odds of getting screened (AOR = 2.03,95%CI;(1.15–2.58) and (AOR = 1.55,95%CI;1.01–2.36), respectively. Providing focused health education supported by printed educational materials increased the uptake of cervical cancer screening services. Integrating one-to-one health education and providing a take-home educational material into the existing maternal and child health services can help increase cervical cancer screening uptake.