Factors associated with khat chewing and tobacco smoking among adult household members in Somaliland using multilevel analysis of the 2020 Somaliland Health and Demographic Survey

Objectives This study aimed to assess the prevalence, regional variation, and factors associated with smoking cigarettes/tobacco, chewing khat/miraa, and psychoactive substance use among adult household members in Somaliland. Methods A total of 5,993 adult household members aged 18 years and above were included. Cigarettes/tobacco smoking, chewing khat/miraa, and psychoactive substance use were examined as outcomes. Multilevel logistic regression was used to identify factors associated with each outcome, with results presented as adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Statistical significance was set at p < 0.05. Results Khat/miraa chewing was significantly associated with sex and wealth. Females had lower odds of chewing than males (AOR = 0.01, p < 0.001), as did those in the highest wealth category compared with the lowest (AOR = 0.21, p = 0.005). Smoking was significantly associated with sex, wealth, and region. Females had lower odds of smoking than males (AOR = 0.02, p < 0.001), while those in the highest wealth category had lower odds than those in the lowest (AOR = 0.26, p = 0.006). Compared with Awdal, lower odds of smoking were observed in Marodijeh (AOR = 0.91, p = 0.021), Togdheer (AOR = 0.49, p < 0.001), Sool (AOR = 0.39, p < 0.001), and Sanaag (AOR = 0.44, p < 0.001). Conclusion These findings highlight the importance of targeted, region-specific interventions to reduce substance use among high-risk populations.