Dual use of tobacco and khat in eastern Ethiopia: a qualitative study

Background: Tobacco-khat co-use is common in Ethiopia, where khat is cultivated. However, information is limited regarding tobacco-khat co-use among adults in the study setting. Aims: (1) Explore behavioural patterns of tobacco-khat co-use and (2) investigate the factors associated with tobacco-khat co-use in Haramaya district, and Maya City, eastern Ethiopia. Methods: We conducted eight focus groups (FGs) with adult males (n=36, four FGs) and females who use tobacco (n=18, two FGs), and community leaders (n=17, two FGs). Participants were purposively recruited. The interview guide addressed tobacco-khat co-use behaviours and related factors. The data were analysed using thematic analysis. Results: The male participants had a mean age of 37.7 (SD±12.4), while the females had a mean age of 44.9 (SD±15.5) years. Males initiated tobacco and khat use at a younger average age compared with females. All participants acknowledged the widespread co-use of tobacco-khat in the region. Two key themes emerged: (1) Tobacco use is tied to khat consumption, reflecting distinct behavioural patterns of co-use. (2) Multiple drivers of co-use included deeply rooted social and cultural practices, progression from habitual use to dependence and accessibility and affordability. Conclusion: Findings suggest that male participants begin tobacco and khat use at an earlier age, driven by sociocultural norms and gendered expectations. This co-use is sustained by multiple reinforcing drivers: perceived synergistic stimulation between khat and tobacco, deeply rooted social and cultural practices, progression from habitual use to dependence and accessibility and affordability, which perpetuate the behaviour. Thus, effective cessation programmes must address co-use and be adapted to sociocultural realities.