Flavored Tobacco Use Among People Living with HIV in Nigeria

The proliferation of flavored tobacco products in sub-Saharan Africa represents an emerging public health threat, particularly for medically vulnerable populations such as people living with HIV (PLWH). However, data on the prevalence, patterns, and determinants of flavored tobacco use among African PLWH remain scarce, creating a critical evidence gap.

We conducted a cross-sectional study among 762 PLWH attending HIV treatment clinics in Nigeria. A structured questionnaire assessed sociodemographic and HIV clinical characteristics, current tobacco use, flavored product use (cigarettes, electronic cigarettes, and waterpipe), health information sources, risk perceptions, and quality of life using the WHOQOL-HIV BREF instrument. Analyses of flavored tobacco use patterns and correlates were restricted to current smokers (n = 410). Comparisons between flavored and non-flavored tobacco users were conducted using chi-square tests and t-tests. Multivariable logistic regression was used to identify independent predictors of flavored tobacco use.

Among current smokers, 62.9% (258/410) reported using flavored tobacco products. Flavor adoption was near-universal among electronic cigarette users (138/145, 95.2%) and waterpipe users (245/252, 97.4%). Menthol was the predominant flavor among cigarette smokers (109/118, 92.4%), while mango was most commonly reported among electronic cigarette users (40/138, 29.0%) and apple was most commonly reported among waterpipe users (136/382, 35.6%). Independent predictors of flavored tobacco use included friends’ use of flavored products (adjusted odds ratio [aOR] = 3.52, 95% CI 2.34–5.30), belief that flavored products are less harmful (aOR = 2.68, 95% CI 1.77–4.06), poly-substance use (aOR = 2.86, 95% CI 1.90–4.30), social media as the primary health information source (aOR = 2.38, 95% CI 1.60–3.54), younger age (< 30 years; aOR = 2.42, 95% CI 1.58–3.70), male sex (aOR = 1.52, 95% CI 1.03–2.24), higher income (≥ 71,000 Naira; aOR = 1.64, 95% CI 1.08–2.48), and higher educational attainment (aOR = 1.84, 95% CI 1.23–2.75). Flavored tobacco users reported significantly lower quality of life across all WHOQOL-HIV BREF domains, including physical, psychological, social, environmental, and HIV-specific concerns, with moderate effect sizes (Cohen’s d range: 0.52–0.66; all p < 0.001).

Flavored tobacco use is common among Nigerian PLWH and is associated with younger age, male sex, education, reliance on social media, misperceptions of reduced harm, and significantly impaired quality of life. These findings highlight the urgent need for regulatory action on flavored products, targeted digital health interventions, and integration of tobacco screening and cessation support within HIV care to mitigate this emerging public health threat.