{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T17:49:26Z","timestamp":1782150566177,"version":"3.54.5"},"reference-count":49,"publisher":"BMJ","funder":[{"DOI":"10.13039\/100000054","name":"U.S. National Cancer Institute","doi-asserted-by":"crossref","award":["R01CA262319"],"award-info":[{"award-number":["R01CA262319"]}],"id":[{"id":"10.13039\/100000054","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Tob Control"],"accepted":{"date-parts":[[2026,6,5]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>(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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The male participants had a mean age of 37.7 (SD\u00b112.4), while the females had a mean age of 44.9 (SD\u00b115.5) 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/tc-2025-059800","type":"journal-article","created":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T17:20:25Z","timestamp":1782148825000},"page":"tc-2025-059800","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Dual use of tobacco and khat in eastern Ethiopia: a qualitative study"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0648-4662","authenticated-orcid":false,"given":"Shiferaw","family":"Letta","sequence":"first","affiliation":[{"name":"School of Nursing, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3014-0325","authenticated-orcid":false,"given":"Maleda","family":"Tefera","sequence":"additional","affiliation":[{"name":"Department of Pediatric and Child Health Nursing, School of Nursing, Haramaya University College of Health and Medical Sciences, Harar, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tara","family":"Wilfong","sequence":"additional","affiliation":[{"name":"College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5615-723X","authenticated-orcid":false,"given":"Jennifer H","family":"LeLaurin","sequence":"additional","affiliation":[{"name":"Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rahma S","family":"Mkuu","sequence":"additional","affiliation":[{"name":"Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9628-8584","authenticated-orcid":false,"given":"Magda","family":"Montague","sequence":"additional","affiliation":[{"name":"Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3708-3925","authenticated-orcid":false,"given":"Dima","family":"Bteddini","sequence":"additional","affiliation":[{"name":"Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abebe","family":"Tolera","sequence":"additional","affiliation":[{"name":"School of Public Health, Haramaya University College of Health and Medical Sciences, Harar, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Damen","family":"Haile Mariam","sequence":"additional","affiliation":[{"name":"School of Public Health, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8800-5591","authenticated-orcid":false,"given":"Rima","family":"Nakkash","sequence":"additional","affiliation":[{"name":"Global and Community Health Department, George Mason University, Fairfax, Virginia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustafa","family":"al\u2019Absi","sequence":"additional","affiliation":[{"name":"Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8139-2418","authenticated-orcid":false,"given":"Ramzi G","family":"Salloum","sequence":"additional","affiliation":[{"name":"Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"key":"2026062210201761000_tc-2025-059800v1.1","first-page":"4610","article-title":"Tobacco Use and Health Hazards: A Literature Review for Smoking Cessation","volume":"6","author":"Abujaber","year":"2024","journal-title":"AfrJBioSc"},{"key":"2026062210201761000_tc-2025-059800v1.2","unstructured":"WHO . Effects of tobacco on health. 2025. 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Effect of khat on health: rapid evidence review. knowledge translation directorate. Addis Ababa, Ethiopia Ethiopian Public Health Institute; 2020. 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Ethiopian-national-tobacco-control-strategic-plan-from-2023-2031. 2023."},{"key":"2026062210201761000_tc-2025-059800v1.30","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2007.12.003"},{"key":"2026062210201761000_tc-2025-059800v1.31","unstructured":"WHO . 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The significance of yemeni khat: traditions and practices. cso yemen. 2025."},{"key":"2026062210201761000_tc-2025-059800v1.45","doi-asserted-by":"crossref","first-page":"55","DOI":"10.11648\/j.innov.20250603.12","article-title":"Psychosocial Consequences, Experiences, and Motives in Quitting Khat Among Daily Users: A Qualitative Study in Gondar City","volume":"6","author":"Adinew","year":"2025","journal-title":"Innov"},{"key":"2026062210201761000_tc-2025-059800v1.46","doi-asserted-by":"crossref","first-page":"001","DOI":"10.29328\/journal.jatr.1001020","article-title":"Khat use and users readiness to quit khat, qualitative research in the case of street people in Addis Ababa","volume":"6","author":"Lemma","year":"2022","journal-title":"J Addict Ther Res"},{"key":"2026062210201761000_tc-2025-059800v1.47","doi-asserted-by":"publisher","DOI":"10.1080\/1067828x.2015.1103346"},{"key":"2026062210201761000_tc-2025-059800v1.48","doi-asserted-by":"crossref","first-page":"435","DOI":"10.2174\/1874944502114010435","article-title":"Substance Use and Associated Factors Among in School Adolescents in South Africa","volume":"14","author":"Khoza","year":"2021","journal-title":"TOPHJ"},{"key":"2026062210201761000_tc-2025-059800v1.49","doi-asserted-by":"publisher","DOI":"10.1136\/tc-2023-057931"}],"container-title":["Tobacco Control"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tc-2025-059800","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T17:20:34Z","timestamp":1782148834000},"score":1,"resource":{"primary":{"URL":"https:\/\/tobaccocontrol.bmj.com\/lookup\/doi\/10.1136\/tc-2025-059800"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,22]]},"references-count":49,"alternative-id":["10.1136\/tc-2025-059800"],"URL":"https:\/\/doi.org\/10.1136\/tc-2025-059800","relation":{},"ISSN":["0964-4563","1468-3318"],"issn-type":[{"value":"0964-4563","type":"print"},{"value":"1468-3318","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,22]]}}}