Tobacco Induced Diseases
Research Paper
Smoker characteristics and trends in tobacco smoking in
Rakai, Uganda, 2010–2018
Fred Nalugoda1, Dorean Nabukalu1, Joseph Ssekasanvu1,2, Robert Ssekubugu1, Connie Hoe3,4, Joseph Kagaayi1,5, Nelson
K. Sewankambo1,6, David M. Serwadda1,7, Maria J. Wawer1,2, Kate M. Grabowski1,2,8, Steven J. Reynolds1,9,10, Godfrey
Kigozi1, Ronald H. Gray1,2, Ping T. Yeh1,3, Larry W. Chang1,2,9
ABSTRACT
Tobacco use is a major public health concern, particularly in
low- and middle-income countries where 80% of the world’s smokers reside.
There is limited population-based data from rural Africa on patterns of
tobacco smoking and smoker characteristics. We assessed trends in rates
of smoking, characteristics of smokers, and factors associated with smoking
using repeat population-based cross-sectional surveys in south-central
Uganda.
METHODS Data accrued over five survey rounds (2010–2018) of the Rakai
Community Cohort Study (RCCS) from consenting individuals aged 15–
49 years including sociodemographic and behavioral characteristics and
smoking status. Proportions of smokers per survey were compared using
χ2 test for trends, and factors associated with smoking were assessed by
multivariable logistic regression.
RESULTS The prevalence of tobacco smoking in the general population declined
from 7.3% in 2010–2011 to 5.1% in 2016–2018, p<0.001. Smoking rates
declined among males (13.9–9.2%) and females (2.2–1.8%) from 2010–
2011 to 2016–2018. Smoking prevalence was higher among previously
married (11.8–11.7%) compared to currently (8.4–5.3%) and never married
persons (3.1–1.8%) from 2010–2011 to 2016–2018. Older age (≥35 years)
was associated with higher odds of smoking (AOR=8.72; 95% CI: 5.68–
13.39 in 2010–2011 and AOR=9.03; 95% CI: 5.42–15.06 in 2016–2018)
compared to those aged <35 years (AOR=4.73; 95% CI: 3.15–7.12 in
2010–2011 and AOR=4.83; 95% CI: 2.95–7.91 in 2016–2018). Primary
and secondary/higher education level was significantly associated with
lower odds of smoking (AOR=0.20; 95% CI: 0.14–0.29 in 2010–2011 and
AOR=0.26; 95% CI: 0.18–0.39 in 2016–2018) compared to no education
(AOR=0.43; 95% CI: 0.31–0.59 in 2010–2011 and AOR=0.48; 95% CI:
0.34–0.68 in 2016–2018). Number of sexual partners and HIV status were
not associated with smoking.
CONCLUSIONS We observed declining trends in tobacco smoking in the
Rakai region of rural Uganda. Smoking was more prevalent in men, older
individuals, individuals who were previously married, and individuals with
lower education. The decline in smoking may be due to tobacco control
efforts, but there is a continued need to target sub-populations with higher
smoking prevalence.
INTRODUCTION
AFFILIATION
1 Rakai Health Sciences Program,
Kalisizo, Uganda
2 Department of Epidemiology, Johns
Hopkins Bloomberg School of Public
Health, Johns Hopkins University,
Baltimore, United States
3 Department of International Health,
Johns Hopkins Bloomberg School
of Public Health, Johns Hopkins
University, Baltimore, United States
4 Heidelberg Institute of Global
Health, Heidelberg University Hospital,
Heidelberg, Germany
5 Department of Epidemiology and
Biostatistics, School of Public Health,
College of Health Sciences, Makerere
University, Kampala, Uganda
6 Department of Medicine, College of
Health Sciences, Makerere University,
Kampala, Uganda
7 Department of Disease Control
and Environmental Health, School
of Public Health, College of Health
Sciences, Makerere University,
Kampala, Uganda
8 Department of Pathology, Johns
Hopkins School of Medicine, Johns
Hopkins University, Baltimore, United
States
9 Division of Infectious Diseases,
Department of Medicine, Johns
Hopkins School of Medicine, Johns
Hopkins University, Baltimore, United
States
10 Division of Intramural Research,
National Institute of Allergy and
Infectious Diseases, National Institutes
of Health, Bethesda, United States
CORRESPONDENCE TO
Fred Nalugoda. Rakai Health Sciences
Program, P.O. Box 279, Kalisizo,
Uganda. E-mail: fnalugoda@rhsp.org
ORCID ID: https://orcid.org/00000001-6119-9293
KEYWORDS
tobacco, smoking, prevalence,
Uganda, Rakai
Received: 9 July 2021
Revised: 30 November 2021
Accepted: 6 December 2021
Tob. Induc. Dis. 2022;20(February):23
https://doi.org/10.18332/tid/144623
Published by European Publishing. © 2022 Nalugoda F. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International
License. (https://creativecommons.org/licenses/by/4.0/)
1
Tobacco Induced Diseases
Research Paper
INTRODUCTION
The World Health Organization (WHO) Report on
the Global Tobacco pandemic 2021 shows that the
prevalence of tobacco smoking among people aged
>15 years has increased from 22.7% to 17.5% 1.
While WHO also indicated that smoking rates have
decreased by 6.7% since 2000, they still estimate that
over 1 billion people around the world still smoke and
predict rapid increase in prevalence among African
men 2,3. WHO has attributed 8 million premature
deaths annually worldwide to tobacco smoking.
Uganda, a low-income country in Sub-Saharan
Africa, is undergoing rapid population growth,
urbanization, and improved survival to older age.
Non-communicable diseases are now a major burden
of disease in addition to communicable diseases. WHO
estimated that about 10% of Uganda’s population
(approximately 1.8 million people) smoked in 2010,
but data on smoking in the general population is
limited. A nationwide survey in 2014 revealed that
7.4% of participants were daily smokers of whom
79.3% were males, and the highest rate of smoking
was in those aged 30–49 years4. Cross-sectional
studies of tobacco smoking among school pupils aged
13–17 years reported a smoking prevalence of 5.3–
5.6% in Uganda’s capital city, Kampala5,6.
Currently, the surveillance of tobacco use among
adults in Uganda is done through the quinquennial
Uganda Demographic and Health Surveys (UDHS)
and the Global Adult Tobacco Survey4. The UDHS
2011 reported the prevalence of daily smoking as
15.7%, higher among men than women and increasing
with age7. The prevalence of smoking was 14–15%
among men and 1–2% in women in rural Uganda8.
Rural areas have higher smoking rates than urban
areas, potentially associated with lower income and
education level, and higher unemployment 9. In
addition, tobacco control policies and other regulatory
factors often benefit urban areas more than rural
areas10, and tobacco crops are a source of income for
many rural areas; thus, tobacco is more normalized in
the rural culture11. Tobacco smoking research focusing
on rural areas in Africa in addition to enforcing control
measures is therefore critically needed.
Given the paucity of data on patterns of tobacco
smoking and limited population-based data from
rural Africa, our primary aim is to examine trends
in the prevalence of tobacco smoking, characteristics
of smokers and factors associated with smoking
using data collected in 2010–2018 from the Rakai
Community Cohort Study (RCCS) in trading and
agrarian communities in south-central Uganda.
METHODS
Data from participants enrolled in RCCS between
2010 and 2018 in trading and agrarian communities
was used as repeat cross-sectional surveys for this
study. The RCCS is an open, population-based cohort
of consenting persons aged 15–49 years surveyed
on average every 14–18 months, covering different
calendar years in 36 communities in Rakai and
neighboring districts of south-central Uganda12. The
RCCS conducts a household census, followed by an
interview of eligible consenting individuals to collect
sociodemographic and behavioral data, including a
question on whether they currently smoke cigarettes
and/or pipes. A venous blood sample is collected for
HIV diagnosis at each survey. HIV testing is done in
the field using a parallel three rapid test algorithm.
Smoking prevalence was computed and compared
using χ2 for trends between survey rounds. Factors
associated with tobacco smoking were assessed using
unadjusted and adjusted odds ratios (AOR) with 95%
confidence intervals (CI) using logistic regression.
RESULTS
Approximately 9635 to 12500 participants were
enrolled per survey round. Prevalence of tobacco
smoking by round and by socio-behavioral factors
are presented in Table 1. The prevalence of tobacco
smoking declined from 7.3% in 2010–2011 to 5.1%
in 2016–2018. Smoking prevalence declined in
2015–2016 and remained constant at the most recent
time point in 2018, suggesting a plateau (Figure 1).
Prevalence of tobacco smoking was significantly
higher among men compared to women, 13.9 versus
2.2% (p<0.001) in 2010–2011 and 9.2 versus 1.8%
(p<0.001) in 2016–2018 (Table 1). Persons aged ≥35
years had a higher prevalence of tobacco smoking
compared to younger age-groups across all survey
rounds. Smoking prevalence was higher among the
previously married (11.8% and 11.7%) compared to
the currently (8.4% and 5.3%) and the never married
(3.1% and 1.8%) in 2010–2011 and 2016–2018,
respectively. Smoking was more common among
those reporting more than one sex partner (13.6% and
Tob. Induc. Dis. 2022;20(February):23
https://doi.org/10.18332/tid/144623
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Tobacco Induced Diseases
Research Paper
8.6%) compared to those with one partner (6.7% and
4.7%) or with no sexual relationship (4.2% and 3.1%)
during the same time periods. Smoking was higher
among truck drivers (20.2% and 8.2%) compared
to other occupations, and in HIV-positive (9.9%
and 6.2%) compared to HIV-negative individuals.
Smoking prevalence was higher among those with
no education (18.4% and 15.1%) compared to those
Table 1. Tobacco smoking prevalence by round and socio-behavioral factors in trading and agrarian
communities, 2010–2018
Characteristics
Overall
R14
2010–2011
n/N (%)
704/9635 (7.3)
R15
2011–2013
n/N (%)
R16
2013–2015
n/N (%)
878/10927 (8.0)
724/11732 (6.2)
R17
2015–2016
n/N (%)
R18
2016–2018
n/N (%)
616/12496 (4.9)
626/12323 (5.1)
Sex
Male
587/4219 (13.9)
722/4866 (14.8)
589/5168 (11.4)
492/5520 (8.9)
501/5463 (9.2)
Female
117/5416 (2.2)
156/6061 (2.6)
135/6564 (2.1)
124/6976 (1.8)
125/6860 (1.8)
Age (years)
15–24
60/3501 (1.7)
115/4103 (2.8)
62/4533 (1.4)
36/4742 (0.8)
49/4763 (1)
25–34
264/3454 (7.6)
299/3799 (7.9)
232/3773 (6.1)
180/3836 (4.7)
177/3596 (4.9)
35–44
307/2091 (14.7)
366/2399 (15.3)
320/2709 (11.8)
285/3076 (9.3)
284/3047 (9.3)
45–49
73/589 (12.4)
98/626 (15.7)
110/717 (15.3)
115/842 (13.7)
116/917 (12.6)
Marital status
Currently married
467/5535 (8.4)
567/6177 (9.2
441/6406 (6.9)
347/6795 (5.1)
349/6614 (5.3)
Previously married
148/1253 (11.8)
182/1433 (12.7)
191/1606 (11.9)
197/1739 (11.3)
208/1777 (11.7)
89/2847 (3.1)
129/3317 (3.9)
92/3720 (2.5)
72/3962 (1.8)
69/3932 (1.8)
Never married
HIV status
Negative
574/8325 (6.9)
721/9413 (7.7)
585/10189 (5.7)
495/10841 (4.6)
532/10818 (4.9)
Positive
130/1310 (9.9)
157/1514 (10.4)
139/1543 (9)
121/1655 (7.3)
94/1505 (6.2)
Number of sexual
partners (past 12
months)
One partner
404/6038 (6.7)
517/6841 (7.6)
359/6636 (5.4)
327/7476 (4.4)
334/7097 (4.7)
More than one
215/1584 (13.6)
249/1800 (13.8)
218/1942 (11.2)
190/2329 (8.2)
205/2378 (8.6)
85/2013 (4.2)
112/2286 (4.9)
147/3153 (4.7)
99/2691 (3.7)
87/2848 (3.1)
388/4647 (8.3)
344/4824 (7.1)
280/4881 (5.7)
323/5114 (6.3)
22/298 (7.4)
17/299 (5.7)
No sexual relationships
Occupation
Agriculture/housewife
Bar/restaurant
Truck
Trade/shop
Other
354/4399 (8)
15/205 (7.3)
18/89 (20.2)
34/264 (12.9)
26/248 (10.5)
12/302 (4)
27/249 (10.8)
11/289 (3.8)
30/364 (8.2)
93/1347 (6.9)
130/1614 (8.1)
102/1704 (6)
84/1875 (4.5)
82/1817 (4.5)
224/3595 (6.2)
304/4104 (7.4)
235/4657 (5)
213/5189 (4.1)
180/4739 (3.8)
105/2208 (4.8)
175/2834 (6.2)
125/3178 (3.9)
81/2987 (2.7)
107/2913 (3.7)
Religion
Christian
Muslim
Other
24/376 (6.4)
23/447 (5.1)
16/581 (2.8)
22/514 (4.3)
23/485 (4.7)
575/7051 (8.2)
680/7646 (8.9)
583/7973 (7.3)
513/8995 (5.7)
496/8925 (5.6)
Education level
None
65/353 (18.4)
73/417 (17.5)
68/395 (17.2)
51/388 (13.1)
56/371 (15.1)
Primary
515/5816 (8.9)
619/6554 (9.4)
531/6973 (7.6)
456/7198 (6.3)
448/7080 (6.3)
Secondary/Higher
124/3466 (3.6)
186/3956 (4.7)
125/4364 (2.9)
109/4910 (2.2)
122/4872 (2.5)
Tob. Induc. Dis. 2022;20(February):23
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Tobacco Induced Diseases
Research Paper
Prevalence of smoking by survey round and
gender, 2010-2018
Percentage of smokers
Figure 1. Tobacco smoking trends by survey round and gender
20
15
10
5
0
2010-11
–-–
2011-13
2013-15
Female
Male
who completed primary (8.9%, 6.3%), or secondary
school/higher education (3.6%, 2.5%), in 2010–2011
and 2016–2018, respectively. The observed general
decline in tobacco smoking prevalence over time was
consistent across most covariates.
Table 2 shows unadjusted and adjusted logistic
regression analyses of odds of smoking by sociobehavioral characteristics in 2010–2011 and 2016–
2018. Being female was associated with lower odds
2015-16
2016-18
Overall
of smoking compared to males (AOR=0.10; 95% CI:
0.07–0.12 in 2010–2011 and AOR=0.13; 95% CI:
0.10–0.17 in 2016–2018). The odds of smoking
increased with age across all survey rounds. Previously
married individuals (AOR=2.04; 95% CI: 1.61–2.59
in 2010–2011 and AOR=3.12; 95% CI: 2.52–3.87 in
2016–2018) had increased odds of smoking compared
to those who were currently married. Primary and
secondary/higher education level was significantly
Table 2. Multivariable logistic regression for tobacco smoking prevalence in trading and agrarian communities
Characteristics
Round 14 (2010–2011) Round 14 (2010–2011) Round 18 (2016–2018) Round 18 (2016–2018)
OR (95% CI)
AOR (95% CI)
OR (95% CI)
AOR (95% CI)
Sex
Male (Ref.)
1
1
1
1
Female
0.14 (0.11–0.17)***
0.10 (0.07–0.12)***
0.18 (0.15–0.22)***
0.13 (0.10–0.17)***
15–24 (Ref.)
1
1
1
1
25–34
4.75 (3.75–6.31)***
4.73 (3.15–7.12)***
4.98 (3.62–6.86)***
4.83 (2.95–7.91)***
35–44
9.87 (7.44–13.09)***
8.72 (5.68–13.39)***
9.89 (7.28–13.44)***
9.03 (5.42–15.06)***
45–49
8.11 (5.69–11.56)***
7.22 (4.44–11.76)***
13.93 (9.89–19.62)***
11.48 (6.73–19.61) ***
Currently married (Ref.)
1
1
1
1
Previously married
1.45 (1.19–1.77)***
2.04 (1.61–2.59)***
2.38 (1.99–2.85)***
3.12 (2.52–3.87)***
Never married
0.35 (0.28–0.44)***
0.97 (0.68–1.37)
0.32 (0.25–0.42)***
1.02 (0.66–1.57)
Negative (Ref.)
1
1
1
1
Positive
1.49 (1.22–1.82)***
1.10 (0.88–1.39)
1.29 (1.03–1.62)*
0.82 (0.63–1.05)
One (Ref.)
1
1
1
1
More than one
2.19 (1.84–2.61)***
0.91 (0.74–1.10)
1.91 (1.60–2.29)***
1.00 (0.82–1.23)
No sexual relationships
0.62 (0.48–0.78)***
0.81 (0.61–1.09)
0.64 (0.50–0.81)***
0.83 (0.62–1.11)
Age (years)
Marital status
HIV status
Number of sexual partners
Continued
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Tobacco Induced Diseases
Research Paper
Table 2. Continued
Characteristics
Round 14 (2010–2011) Round 14 (2010–2011) Round 18 (2016–2018) Round 18 (2016–2018)
OR (95% CI)
AOR (95% CI)
OR (95% CI)
AOR (95% CI)
Occupation
Agriculture/housewife (Ref.)
1
1
1
1
Bar/restaurant
0.90 (0.53–1.54)
1.39 (0.79–2.44)
0.59 (0.32–1.08)
0.92 (0.47–1.83)
Truck
2.90 (1.71–4.91)***
1.23 (0.70–2.15)
1.33 (0.90–1.97)
0.71 (0.47–1.09)
Trade/shop
0.85 (0.67–1.07)
0.69 (0.54–0.90)**
0.70 (0.55–0.90)**
0.70 (0.53–0.91)**
Other
0.76 (0.64–0.90)**
0.89 (0.70–2.15)
0.59 (0.49–0.71)***
0.79 (0.63–0.98)*
Christian (Ref.)
1
1
1
1
Muslim
1.37 (0.86–2.16)
1.22 (0.74–2.01)
1.31 (0.82–2.07)
1.29 (0.76–2.20)
Other
0.78 (1.44–2.20)***
0.81 (0.64–1.03)
1.54 (1.25–1.91)***
0.64 (0.50–0.81)*
None (Ref.)
1
1
1
1
Primary
0.43 (0.32–0.57)***
0.43 (0.31–0.59)***
0.38 (0.28–0.51)***
0.48 (0.34–0.68)***
Secondary/Higher
0.16 (0.12–0.23)***
0.20 (0.14–0.29)***
0.14 (0.10–0.20)***
0.26 (0.18–0.39)***
Religion
Education level
AOR: adjusted odds ratio. *p<0.05, **p<0.01, ***p<0.001.
of tobacco smoking could be attributed to the
enacting of tobacco control measures by the Ugandan
government. In 2007, Uganda became a Party to the
WHO Framework Convention on Tobacco Control
(FCTC)15. The FCTC mandates that every party to
the treaty adopt policies such as smoking bans, health
warnings, and promotion, advertising and sponsorship
bans. The country progressively implemented these
policies16, overlapping with this study period. Taxes
and price increases are considered the most impactful
and powerful tool for reducing tobacco use, and it
is estimated that a tax increase which raises tobacco
prices by 10% can decrease consumption by as much
as 8% in LMICs17. In Uganda, between 2004 and
2011, the excise tax on tobacco was increased from
0% in 2005–2006 to 5.3% in 2007–2009, followed
by a further increase of 10% in 2011–201218. In
subsequent years, tobacco taxes fluctuated between
8–10% until 2017–2018 after the amendment of the
2017 excise duty Act19. The excise tax on tobacco
and amendments of the excise duty Acts resulted in
increased tobacco prices, which, together with other
policies, laws and regulations may have contributed to
decreased tobacco consumption observed in our study.
These are encouraging findings since the decline in
tobacco smoking over time is likely to contribute to
a reduction in tobacco-attributable diseases such as
associated with lower odds of smoking (AOR=0.20;
95% CI: 0.14–0.29 in 2010–2011 and AOR=0.26;
95% CI: 0.18–0.39 in 2016–2018) compared with
no education (AOR=0.43; 95% CI: 0.31–0.59 in
2010–2011 and AOR=0.48; 95% CI: 0.34–0.68 in
2016–2018). Multiple sexual partners, HIV status,
and religion, were not significantly associated with
tobacco smoking.
DISCUSSION
Our study findings show that tobacco smoking
prevalence declined by about 30% between 2010 and
2018. Prevalence of smoking was higher among men
than women, was greater among previously married
persons, and increased with age in rural south-central
Uganda. The declining trend in smoking prevalence is
evident through 2015 and plateaued thereafter.
The decline in tobacco smoking prevalence
between 2010–2018 is compatible with WHO
projections2. Findings of higher smoking prevalence
among men than women are consistent with other
studies conducted among adults in a rural populationbased cohort in Uganda8, elsewhere in the region, and
widely in Sub-Saharan Africa7,13,14, and globally2. The
Ugandan study also showed high smoking prevalence
among illiterate residents.
We hypothesize that the decline in the prevalence
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Tobacco Induced Diseases
Research Paper
lung and heart diseases, chronic respiratory diseases,
cancers, and diabetes 1 . It is important for the
government to intervene by enforcing existing tobacco
smoking control guidelines and regulations, as well as
targeting sub-populations with high prevalence, and
illiterate residents in rural areas.
underscored.
Future research should focus on comprehensive
assessment of types of tobacco consumption including
cigarettes, pipes, chewing, and snuff, and whether
tobacco is locally grown or commercially purchased,
and on passive smoking to determine the magnitude
of tobacco use.
Strengths and imitations
The study’s strength is that it uses data from
communities in rural Uganda, where growth of leaf
tobacco as an economic activity is likely to happen.
The ability for the study to comprehensively measure
tobacco use was limited since only one question was
asked at each survey; questions about other methods
of tobacco use, such as tobacco chewing and snuff,
were not asked. Questions on type of tobacco use (e.g.
commercial or home grown), or quantity and duration
of smoking, were not asked. However, studies on
agricultural practices in similar rural settings in
Uganda show that more than 30% of households grow
some tobacco, largely for personal consumption or
local sale20, and should also be targeted for control
interventions. Tobacco smoking is therefore likely to
be higher than what this study suggests. In addition,
Uganda, as the rest of Sub-Saharan Africa has
experienced rapid population grown over the years
contributing to a large denominator of the population
surveyed in this study. This may have also contributed
to the decline in the proportions of smokers at the
different time points.
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geographic disparity: Rural and urban cigarette smoking
trends in the United States. Prev Med. 2017;104:79-85.
CONCLUSIONS
The decreasing trend of tobacco smoking in this
study should not deter further tobacco control
and prevention interventions. Rather, our findings
could help inform intervention programs targeting
sub-populations with higher smoking prevalence,
especially in rural areas. Such interventions include
community engagement highlighting deleterious
health effects of tobacco use, peer education programs
on benefits of not smoking since tobacco use is
partly peer pressure driven, and identification and
engagement of change agents from within targeted
sub-populations with messages that prevent tobacco
smoking. It is crucial that involvement of the local
community administrative structure to ensure
appropriate implementation of the interventions and
adhering to control guidelines to prevent smoking is
Tob. Induc. Dis. 2022;20(February):23
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Tobacco Induced Diseases
Research Paper
doi:10.1016/j.ypmed.2017.03.011
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Roots: Tobacco Use in Rural Communities. American
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https://healthforward.org/wp-content/uploads/2015/07/
cutting-tobaccos-rural-roots.pdf
12. Chang LW, Grabowski MK, Ssekubugu R, et al.
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fishing communities in Rakai, Uganda: an observational
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doi:10.1016/S2352-3018(16)30034-0
13. Uganda Bureau of Statistics. Uganda Demographic and
Health Survey 2016. UBOS, ICF International; 2016.
Accessed November 30, 2021. https://dhsprogram.com/
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doi:10.18697/ajfand.77.16065
ACKNOWLEDGEMENTS
We thank the staff of Rakai Health Sciences Program, the RCCS study
participants, the local community leadership, the Rakai and neighboring
Districts’ Directorates of Health services and the Uganda Virus Research
Institute for supporting this work.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for
disclosure of potential conflicts of interest. The authors declare
that they have no competing interests, financial or otherwise, related
to the current work. F. Nalugoda and L.W. Chang report that since the
initial planning of the work and in the past 36 months their
institution received funding from the National Institutes of Health.
C. Hoe reports that in the past 36 months she was funded by a grant
from Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco
Use. J. Kagaayi, D.M. Serwadda and G. Kigozi report that since the
initial planning of the work they received funding from National
Institutes of Health. M.J. Wawer reports that in the past 36 months is
a paid consultant to the Rakai Health Sciences Program (outside of
this work) and serves on its Board of Directors and that this
arrangement has been reviewed and approved by the Johns Hopkins
University in accordance with its conflict of interest policies. R.H.
Gray reports that in the past 36 months he is a member of the Rakai
Health Sciences Program Board.
FUNDING
This study was jointly supported by the National Institute of Allergy
and Infectious Diseases, Division of Intramural Research (SJR and Grant
numbers: R01AI110324, R01AI110324, and R01AI102939), the National
Institute of Mental Health (Grant number R01MH107275), the Bill and
Melinda Gates Foundation (Grant numbers 08113 and 22006.02), and
the National Institutes of Health Fogarty International Center (Grant
number D43TW010557).
ETHICAL APPROVAL AND INFORMED CONSENT
Participants gave informed consent at baseline and at follow-up
as needed depending on whether they are baseline or follow-up
participants. Consent forms were translated in the local language
of the region (Luganda) and back-translated to English before they
were certified by the department of languages of Makerere University,
Kampala, Uganda. They were then submitted for review and approval
by the ethics review boards. The study was approved by the Uganda
Virus Research Institute Research and Ethics Committee, Uganda
National Council for Science and Technology, and the Western
Institutional Review Board in the US (REC/UVRI, FWA 00001354, expiry
31 August, 2023).
DATA AVAILABILITY
The data supporting this research are available from the authors on
reasonable request.
AUTHORS’ CONTRIBUTIONS
FN led conceptualization and design of the study. FN and DN analyzed
and interpreted data and wrote the manuscript. JS, CH, RS, JK, NKS,
DMS, MJW, MKG, SJR, GK, RHG, PTY and LWC supported concept
development, data interpretation, and manuscript editing. All authors
participated in data interpretation, manuscript revisions, and final
manuscript approval.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
Tob. Induc. Dis. 2022;20(February):23
https://doi.org/10.18332/tid/144623
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Ronald Gray