ABSTRACT

Background: Khat (an evergreen plant with amphetamine-like properties) and alcohol are
widely consumed among the youth of Ethiopia. The chewing of khat has been practiced for
years and is, to a large extent, socially accepted in Ethiopia, Kenya, Madagascar and Somalia,
Yemen; some of these countries are introducing control measures to discourage the cultivation
and use of khat. Apart from the habitual use of khat, it is reported that it is used by students to
improve their academic performance, by truck drivers to keep themselves awake and by
laborers to supply the extra vigor and energy they need for their work.

Objective: To assess the prevalence and risk factors of khat chewing among in school and out
of school youth (15-24 years of age) in Gondar town.

Methods: A cross-sectional study was conducted in February 2007 in Gondar town, north west
Ethiopia. In-school and out of school youth were selected from randomly selected high schools
and house holds systematically. Self administered questionnaire was used for school youth
and interview for out of school youth.

Results: The study revealed 37.1% life time prevalence rate of khat chewing, 14.6% of
cigarette smoking, and 47% of alcohol drinking. The current prevalence rates of chewing,
smoking and drinking were 31.4%, 11.9%, and 36.6% respectively. One hundred fifty three
(13.1%) use khat and cigarette, 314(26.9%) khat and alcohol. Of the respondents, 155(13.3%)
have ever used khat, cigarette, and alcohol.

Conclusion: The prevalence of khat chewing is increasing and along with it other substances
such as cigarette smoking and alcohol drinking are being used. More over, illicit substances
including shisha and hashish are also being taken. The problem is especially worrisome
among out of school youth who have no job or who are daily laborers. This summons that
attention is to be given to educate the youth and find means of controlling substance use at
least in public entertainment places.

1
BACKGROUND

Khat (Catha edulis)--also known as African salad, bushman's tea, gat, kat, miraa, qat, chat,
tohai, and tschat--is a flowering shrub native to northeast Africa and the Arabian Peninsula.
The plant grows mainly in Ethiopia, Yemen and other African countries along the cost of the
Indian Ocean. It has been used for centuries as a mild stimulant. For most youths chewing
khat is a method of increasing energy and elevating mood in order to improve work
performance. Khat plants typically are grown among crops such as coffee, legumes, peaches,
or papayas. Fresh khat leaves contain cathinone--a Schedule I drug under the Controlled
Substances Act; however, the leaves typically begin to deteriorate after 48 hours, causing the
chemical composition of the plant to break down. Once this occurs, the leaves contain cathine,
a Schedule IV drug (1-4).

Schedule I. This placement is based upon the substance's medical use, potential for abuse,
and safety or dependence liability (30)

• The drug or other substance has a high potential for abuse.

• The drug or other substance has no currently accepted medical use in treatment.

• There is a lack of accepted safety for use of the drug or other substance under medical
supervision.

• Examples of Schedule I substances include Amphetamine, Khat(cathinone),Cocaine, heroin,

lysergic acid diethylamide (LSD), marijuana, and methaqualone.

Schedule II

• The drug or other substance has a high potential for abuse.

• The drug or other substance has a currently accepted medical use in treatment in the United
States or a currently accepted medical use with severe restrictions.

• Abuse of the drug or other substance may lead to severe psychological or physical
dependence.

• Examples of Schedule II substances include morphine, phencyclidine (PCP), cocaine,

methadone, and methamphetamine.

Schedule III

• The drug or other substance has less potential for abuse than the drugs or other substances
in schedules I and II.

2
• The drug or other substance has a currently accepted medical use in treatment.

• Abuse of the drug or other substance may lead to moderate or low physical dependence or
high psychological dependence.

• Anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates
are examples of Schedule III substances.

Schedule IV

• The drug or other substance has a low potential for abuse relative to the drugs or other
substances in Schedule III.

• The drug or other substance has a currently accepted medical use in treatment.

• Abuse of the drug or other substance may lead to limited physical dependence or
psychological dependence relative to the drugs or other substances in Schedule III.

• Examples of drugs included in schedule IV are Darvon, Talwin, Equanil, Valium, Xanax, and
Cathine

Schedule V

• The drug or other substance has a low potential for abuse relative to the drugs or other
substances in Schedule IV.

• The drug or other substance has a currently accepted medical use in treatment.

• Abuse of the drug or other substances may lead to limited physical dependence or
psychological dependence relative to the drugs or other substances in Schedule IV.

• Cough medicines with codeine are examples of Schedule V drugs.

The chewing of khat has been practised for years and is, to a large extent, socially accepted in
Ethiopia, Kenya, Madagascar and Somalia; some of these countries are introducing control
measures to discourage the cultivation and use of khat. Apart from the habitual use of khat, it
is reported that it is used by students to improve their academic performance, by truck drivers
to keep themselves awake and by labourers to supply the extra vigour and energy they need
for their work (3). The psych-stimulant effect of khat is due to the alkaloid ingridient cathinone,
which has a similar structure to Amphetamine (1). Khat is consumed primarily for its
amphetamine-like stimulant and euphoric effects (1-7,21,23,24,28).

3
The use of substances such as alcohol, khat and tobacco is not new in Ethiopia. Home-brewed
spirits and beers such as arrack, tej and tella are served in bars and restaurants throughout
the country. Until recently the highland population had been relatively free of the habit of
chewing khat; the use of khat had been confined to other population groups and to specific
rituals. Today, however, it is consumed everywhere in the country by all population groups. In
smaller cities and towns it is brought to market as produce. People publicly chew it and it is
offered to visitors as a mark of hospitality (4). Several case reports and population studies
have shown that there is a clear association between heavy consumption of khat and
psychosis. It may produce extreme loquacity, inane laughing, and eventually semicoma. It may
also be a euphorient and used chronically can lead to a form of delirium tremens. Galkin and
Mironychev (1964) reported that up to 80% of the adult population of Yemen use khat. Upon
first chewing khat, the initial effects were unpleasant and included dizziness, lassitude,
tachycardia, and sometimes epigastric pain. Gradually more pleasant feelings replaced these
inaugural symptoms. The subjects had feelings of bliss, clarity of thought, and became
euphoric and overly energetic. Sometimes khat produced depression, sleepiness, and then
deep sleep. The chronic user tended to be euphoric continually. In rare cases the subjects
became aggressive and overexcited. (1 - 6, 22).
In some business circles khat is chewed at meetings where major decisions are reached. It is
also a highly valued export commodity, being marketed extensively in countries in the Horn of
Africa and in the Middle Fast. Paradoxically, as the production, marketing and export of khat
become more lucrative, khat use seems to gain social respectability and it becomes more
difficult for Governments to deal with the problem(4). The use of khat is accepted within the
Somali, Ethiopian, and Yemeni cultures, and in the United States khat use is most prevalent
among immigrants from those countries.
Abuse levels are highest in cities with sizable populations of immigrants from Somalia,
Ethiopia, and Yemen, including Boston, Columbus, Dallas, Detroit, Kansas City, Los Angeles,
Minneapolis, Nashville, New York, and Washington, D.C. In addition, there is evidence to
suggest that some nonimmigrant in these areas have begun abusing the drug (27).

Khat (Catha edulis) is an evergreen plant that grows mainly in Ethiopia, Yemen and other
African countries along the coast of the Indian Ocean. It has been used for centuries as a mild

4
stimulant. The fresh leaves are chewed or consumed as tea. For most youths chewing Khat is
a method of increasing energy and elevating mood in order to improve work performance (1-4,
7-8, 27-28). The psycho-stimulant effect of Khat is due to the alkaloid ingredient cathinone,
which has a similar chemical structure to amphetamine (1, 7). Several case reports and
population studies have shown that there is a clear association between heavy consumption of
khat and psychosis (1-2, 15). There are no physical symptoms on withdrawal of the type
experienced with alcohol, morphine, or the barbiturates. Abandoning the habit, however, is
followed by depression. This is demonstrated by lack of interest, loss of energy, and increased
desire to sleep. The severity of depression varies and may lead to agitation and sometimes
sleep disturbances. Khat is widely consumed among the youth of Ethiopia as shown by several
prevalence studies (1, 3-5, 26).

According to a community based survey conducted on 1200 adults at Adamitulu district, south
Ethiopia in 1997 the prevalence rate of khat chewing was 31.7 %( 7). A study conducted on
students of Gondar College of medical sciences showed a 22.3% prevalence rate (26). A
similar study done among students of four colleges( Gondar college of medical sciences,
Gondar teachers` education college, Bahrdar university engineering faculty, and Bahrdar
university education faculty revealed a life time prevalence rate of khat chewing to be
26.7%(5). According to a study in Addis Ababa and other 24 towns across the country, there
was a significant increase in the number of Ethiopians chewing khat. khat which was
previously known to grow mainly in the eastern part of Ethiopia, was cultivated in all parts of
the country. Khat consumption, traditionally confined to a certain segment of the population
had become popular among all segments and khat chewing often led to abuse of illicit drugs
(4). A nation wide survey carried out among 20,234in school and and out of school youth aged
between 15 and 24 years showed that over 23% of out of school youth used khat every day or
once weekly and 7.5% of in school youth did so(1). A cross-sectional house to house survey
conducted in Jimma town from January to September 2000 showed a prevalence rate of khat
chewing to be 30.6 %(6).

Several other studies conducted at different times in African countries including Ethiopia, The
Middle East, Europe and the USA have explored extensively the effects of khat on the different

5
parts of the body and the physical, social, economical and psychological consequences of khat
chewing. It is estimated that several million people are frequent users of khat in regions where
it is grown and this number is now increasing fast not only in endemic areas but also
globally(2,3,11,12-18,21,23).
One of the important targets manifesting the effect of khat chewing is the brain. In its action on
the brain, some of the chemical components of khat have resemblance to amphetamine in
many aspects (2, 10, 15, 16, 22-25).
This effect of khat is manifested by euphoria, increased alertness, garrulousness, hyperactivity,
excitement, aggressiveness, anxiety, elevated blood pressure and manic behavior. Insomnia,
malaise, dizziness and lack of concentration almost always follow. True psychotic reactions
occur but with much less frequency than with amphetamines. Although physical dependence
on khat is less likely to occur, mental depression, sedation and social separation may follow
withdrawal because of rebound phenomenon. A state of mild depression can follow periods of
prolonged use. Taken in excess, khat causes extreme thirst, a sense of exhilaration,
talkativeness, hyperactivity, wakefulness, and loss of appetite. Repeated use can cause manic
behavior with grandiose delusions, paranoia, and hallucinations. It also can cause damage to
the nervous, respiratory, circulatory, and digestive systems. Abusers claim that the drug lifts
spirits, sharpens thinking, and increases energy--effects similar to but less intense than those
caused by abusing cocaine or methamphetamine. Psychic dependence on khat occurs with
less intensity than with amphetamine but this effect makes daily consumption of khat the norm.
It should therefore be borne in mind that although khat can provide some pleasurable effects
temporarily, its overall effects on the brain are not desirable and could even be damaging,
particularly with chronic consumption (1, 3, 10, 12,22-25).
Gastro-intestinal side-effects are often encountered with khat use. Constipation is the most
common gastrointestinal symptom caused by the tannins and alkaloid components of khat.
Stomatitis, esophagitis and gastritis which are believed to be due to the presence of astringent
tannins are noted in chronic users. Other reported oral side-effects include periodental
diseases, dental caries, temporomandibular joint dysfunction and keratosis of buccal mucosa.
Oral cancers have been observed in some groups of population with chronic khat chewing ( 5,
9-11,14,23-25).
After ingestion, khat produces cardiovascular effects within 15-30 minutes and these effects

6
include tachycardia, palpitation and increased blood pressure. Chronic use of khat has also
been implicated in hypertension. This is contrary to what some consumers claim that the use
of khat is associated with antihypertensive effect (23,25)
Loss of sexual desire is reported frequently by men during khat use. Although libido initially
may be enhanced, a loss of sexual drive, spermatorrhea (which is sometimes accompanied by
testicular pain) and subsequent impotence soon follow. Inhibition of blood flow to the penis and
neurological effects are believed to partly play a role in this impairment. However, the situation
is often the opposite in female khat users as far as sexual desire is concerned. With chronic
use, khat causes a more severe reproductive toxicity including reduction in sperm count and
motility, and the appearance of abnormal sperm cells (8,10,23,25).
It has been shown that babies born to women who chew khat habitually are smaller and their
mothers produce less milk. This demonstrates that the use of khat by mothers can retard the
development of their babies and this may have long-term consequences (23,25).
Other physiological effects of khat linked primarily to sympathomimetic stimulation include
hyperthermia, sweating, mydriasis, “xerostomia”, decreased intraocular pressure, and
increased respiratory and pulse rate. More severe adverse effects have been associated with
khat use, particularly in the elderly and predisposed individuals. These effects include
migraine, cerebral hemorrhage, myocardial infarction, pulmonary edema, disabling
neurological illness, and abnormalities in bone marrow. Hepatic cirrhosis has also been noted
in khat users. Poor diets and the potentially hepatotoxic effects of khat tannins have been
suggested to be contributing factors for this condition (7, 23, 25).
Considering subcellular actions of khat, studies have demonstrated that extract of khat leaves
is an inhibitor of nucleic acid synthesis, and one of its components, cathinone, causes
clumping and condensation of chromosomes, sticky metaphases and anaphasic bridges.
Some of these effects are hypothesized to be responsible for the carcinogenic and teratogenic
properties of khat(23,25).
In addition to the effects of khat per se, some substances consumed together with it are also
known to produce significant adverse effects by themselves. One such substance is tobacco
taken as a cigarette smoke for brain stimulation. The consumption of tobacco is associated
with a number of serious adverse effects including cardiovascular and respiratory disorders,
lung cancers, anorexia and addiction. In this regard, increased prevalence of respiratory

7
problems has been reported in khat users smoking cigarettes heavily. The concomitant use of
alcohol to counteract the stimulant and insomniac effects of khat raises the risk of alcohol
abuse. The abuse of alcohol results in a range of public health and medical problems
depending upon the amount and duration of consumption. Recently, it has been observed that
people with alcohol-use disorders are more likely than the general population to contract HIV. It
is therefore possible that the use of khat can promote this process through alcohol
consumption, among other possibilities. It is not also difficult to hypothesize that in persons
already infected, the combination of khat use and HIV can be associated with increased
medical and psychiatric complications. There are also cases of infection with Fasciola hepatica
following chewing khat leaves. Fasciola hepatica contamination might occur most likely with
fresh picked, damp leaves (1-5, 10, 11, 14-16).
The pleasure stimulation (euphoria) obtained when chewing khat induces many users to abuse
the drug. This may have damaging effects from social and economic point of view. Some
people may arrive at spending a great part of their earnings on khat, thus failing to ensure for
themselves and their families important and vital needs. Excess of khat chewing may lead to
family disintegration. The chewer very often shows irritability, becomes quarrelsome, and
spends much of the time away from home. These facts and the failure of sexual intercourse (in
male users) after chewing may endanger family life. In the communities where khat is
consumed, there is a general agreement among observers that there is high incidence of
absenteeism and decreased productivity, which lead to unemployment and poverty. In addition,
the increased susceptibility and risk to infectious diseases and the threat to normal
development of the children of the chronic users can be important public health problems.
Added to these problems are the well-recognized negative socioeconomic effects of the
substances that are usually consumed with khat—tobacco and alcohol (1, 6, 8, 17-25).
In some countries where the use of Khat is widespread, the habit has a deep-rooted social
and cultural tradition. This is particularly true for Yemen, Somalia and Ethiopia where many
houses have a room called a muffraj, Mafrashi, and Bercha respectively that are specially
arranged for regular sessions of Khat chewing. The buyers select from among various types of
Khat available, which also vary considerably in price, the most expensive (because the most
potent) material being, in general, the freshest and that with the youngest leaves(21,27,31).
For the consumption of Khat in the traditional social setting, the chewers meet in a house

8
some time after noon, usually bringing their own supply. After being welcomed and carefully
seated according to their social position, the guests begin to masticate the leaves thoroughly
one by one. The juice is swallowed, while the residue of the leaves is stored in the cheek as a
bolus of macerated material for further extraction, and is finally ejected. Altogether, each
person takes some 100to 200g of the leaves( 6-9birr/100grams); young leaves are most
favored, mainly because they are more potent but also because they are more tender to chew.
During the session, the group may smoke from water pipes, and there is a generous supply of
beverages. The Khat session also plays an important role at weddings and other family events.
Khat is frequently used during work by craftsmen, laborers, and especially by farmers, in order
to reduce physical fatigue (31). Besides these traditional forms of consumption, Khat is
nowadays also chewed by single individuals idling in the streets, particularly in towns and cities
where it has been introduced within the last decades. In these regions, Khat is also consumed
(sometimes along with alcoholic beverages and other drugs) at gatherings which lack the
restraint and well-defined social setting described above(21,30-31).
During the first part of a khat session, there is an atmosphere of cheerfulness characterized by
optimism, high spirits, and a general sense of well-being. The excitement brought out by the
consumption of khat reduces social inhibitions and causes loquacity. Later, depressive
tendencies appear, and a mood of sluggishness prevails. The desirable effects of khat leaves,
as perceived by experienced users, are relief from fatigue, increased alertness and energy
levels, feelings of elation, improved ability to communicate, enhance imaginative ability and
capacity to associate ideas, and heightened self confidence. These effects seem to be more
readily perceived by the habitual user.
The objectively observable effects of khat use consist of mild euphoria and excitement
accompanied by episodes of logorrhea and then verbal aggressiveness. There is also an
increased sensitivity to sensory stimulation; excessive khat use may cause hyperesthesia.
Hyperactivity may be observed and the associated behavioral syndrome can be described as
hypothemania; a manifestation of irresponsible fearlessness has also been reported. In
exceptional cases, khat consumption may produce an immediate dysphoric reaction which
might, however, be due to excessive expectations with regard to potency of a given batch of
khat. The late effects of khat use are mainly an inability to concentrate, and insomnia.
Impairment of mental health may also be the result of long-term khat consumption; long-term

9
chronic users may develop personality disorders and suffer mental deterioration.
The symptoms described above, particularly that of toxic psychosis are reminiscent of those
induced by amphetamine. A further analogy with amphetamine is that the habitual use of khat
is in many instances compulsive, as indicated by the tendency of the chewers to secure their
daily supply of the leaves at the expense of vital needs. Drug dependence of the khat type has
been described by Eddy et al., and it appears that its only major difference from amphetamine-
type dependence is the physical impossibility of increasing the ingested dose beyond a certain
limit. Any definitive investigation of tolerance or withdrawal symptoms would, however, require
a thorough clinical study involving monitoring of the blood levels of the active khat constituents.
An important effect of khat, the induction of anorexia, was already reported in the early Arab
literature. This anorexia, along with the tendency of habitual khat users to divert their funds
from food to khat, would account for the generally observed malnutrition which predisposes the
users to disease.
Consumption of khat, like that of amphetamine, causes a number of sympathomimetic effects.
At the cardiovascular level, there are arrhythmias and an increase in blood pressure
depending on the amount and potency of the material absorbed. The cardiovascular response
to physical effort is exaggerated. Acute cardiovascular problems, particularly in older people,
have been reported. Habitual use of khat may lead to chronic hypertension which, upon
abstinence from the drug, can change into a transient hypotensive state. A further
sympathomimetic reaction to khat use is mydriasis. Khat chewing is known to seriously impair
male sexual function and to lead to a high incidence of spermatorrhea which is sometimes
accompanied by testicular pain. Long-term chronic use may lead to permanent impotence.
Dryness of the mouth is commonly, felt during khat chewing, and this may be explained either
by the sympathomimetic effect of the drug or by its astringent taste. Since khat leaves have
high tannin content, khat chewing frequently causes periodontal disease, mucosal lesions, and
a number of irritative disorders of the upper gastrointestinal tract. A common ailment of khat
users is constipation, probably caused by the astringent properties of khat tannins.
The khat-induced changes appeared to be less pronounced in chronic users, which would
indicate that tolerance may develop to the sympathomimetic effects of khat(11,12,15,32,33)

10
OBJECTIVES

General Objective.

The purpose of this study is to determine the magnitude and associated risk factors of Khat

11
chewing among school and out of school youth in Gondar town

Specific objectives

1. To determine the prevalence of Khat chewing among in and out of school youth

2. To identify the commonest risk factors of Khat chewing

METHODS
A cross-sectional school based and house to house survey was conducted from January to
February 2007 in Gondar town, North West Ethiopia.
Sampling procedures
Study design
In order to address the main research question, school-based and a house to house cross
sectional survey will be conducted in October 2006 in Gondar town, North West Ethiopia.
Study area
The study area, Gondar town is the capital of North Gondar zone and one of the 21 districts of
the zone which ranks sixth in population. The estimated population of the town is
194,773(97625 male and 97148 female) (29). There are four secondary (9-10th) and one
preparatory school in the town. During the 1999 academic year there were 10275(4923 male
and 5352 female) students from grades 9-10 who had been enrolled. There is one pre-college

12
(preparatory) school in the town. A total of 2212(1370male and 842 female) students were
enrolled. The total number of students who were enrolled for the academic year was
12487.The estimated number of youth; age 15-24 is 35539(20.3%)(29)
There for the estimated number of out of school youth is 23052. The former 21 kebeles in the
town have now been condensed to 12 and given names instead of numbers. Five kebeles
selected randomly (Abbajalie, Azezo- Dimaza, Medhanealem, Kirkos and Maraki) will be
included in the study for the out of school youth.
Study population
The study populations are students of grade 9-12 in Gondar town and out of school youth in
the age bracket 15-24 residing in Gondar town.
Sample size and sampling procedures
Taking the prevalence rate of khat chewing which was found to be 23%, for out of school
youth and 7.5% for school youth and all over prevalence was 15%(1) the required sample size
for this study, "n", at confidence interval of 95% and a marginal error of 3%, was determined
by:
n = D(z2)xp1(1-p1)
W2
Where: n = the required sample size
D = 2( design effect as two populations are to be studied)
z = 1.96(at 95% confidence interval)
p = 0.15 (proportion of youth with the out come from a previous study)
w = 0.03( 3% marginal error)
This gives 1088 adding 10% for non-response the required sample size was 1197

Sampling procedures

The following criteria were used in selection of the study subjects:

(1) In-school youth: aged 15–24 years, daytime high school students attending grades 9–12

(2) Out-of-school youth: aged 15–24 years, not attending day or night school, unemployed or

13
employed.

Two randomly selected schools Fasiledes and Edget feleg were included in the study for
school youth age 15-24 years and proportional samples to the number of students were drawn
from each school. For grade 11-12 students, the only preparatory school in the town, Fasiledes
secondary school, was taken. The sampling frames for selection of study subjects were
prepared in consultation with the zonal education department and district Education office and
respective schools (to obtain details of classes and number of students in each grade).
Probability proportional to size sampling (PPS) was used to select classes in the first stage
and then systematic sampling was applied to select students in the second stage. A list of
classes from each selected school with their corresponding measures of size were prepared.
They were listed using the numbering system of the school so that they can be identified
easily. Starting at the top of the list, the cumulative measure of size (per sex) was calculated
and these figures were entered in a column next to the measure of size for each class. The
required sample size from each school was allocated proportional to the number of students in
each grade of that particular school. Using an average cluster size, and equal sample size for
males and females, the sampling interval (SI) was calculated by dividing the total cumulative
measure of size by the number of students to be selected. A random starting number (RS) was
then selected between 1 and SI. The unit within whose cumulated measure of size for the RS
falls is the first sampling unit and subsequent subjects were selected by adding the SI to the
RS. Once inside the classroom, starting from the front right hand seat of the class, a random
number was picked and the required number of students was systematically selected. Then
the selected students were asked to go to a separate hall where they were oriented on how to
fill the questionnaires. They were then seated separately and the questionnaires were
distributed. The questionnaires were checked while in the class room for completeness.

Out-of-school youth (OSY) were selected from randomly selected kebeles in Gondar town
(Medhanealem, Abajalie, Kirkos, Maraki and Azezo-dimaza). The sampling frames for
selection of OSY were prepared using the projection of the1994 census report. House holds of
the selected kebeles were systematically selected. The sample sizes were distributed to each
kebele proportional to the population size of the kebeles. The house holds in each of the

14
selected kebeles were obtained from the kebele offices and samples that are required from
each kebele were determined proportionally. For example, if a kebele has 1000 house holds
and the required sample size for that particular kebele was 100, every 10th house would be
visited. Then, the house holds were identified systematically and target youths were selected
by lottery system if more than one youths were found in a house hold. A face-to-face
household interview was conducted to obtain the needed information. When the identified
respondent was not available on the day of visit to a household, appointments were made to
return for the interview. The data collectors were advised to go to the house holds at times
when the youths would likely be at home such as early in the morning. When it was not
possible to trace the identified individual after two attempts, the next household was taken as a
substitute

Data collection and processing

Data collection was done using a standardized pre-coded and pre-tested questionnaire. Ten
male and female interviewers were selected from Gondar town. Interviewers had completed
high school and had some previous experience of collecting survey data. They were given a
two days intensive training about the interview processes and on how to administer the
questionnaire. Pilot-testing was carried out in Gondar town on 20 in-school and 30 out of
school youths with similar characteristics to the study subjects.

Socio-demographic characteristics, history of substance use ( Khat, alcohol, cigarette and

others) both for life time prevalence and current prevalence were obtained using the interview
instrument. Those who have ever chewed khat, drunk alcohol and smoked cigarette were
defined as life time users and those who currently use any of the substances were considered
as proportions for current prevalence of that particular substance. Symptoms of substance
abuse and dependence were also assessed according to the diagnostic criteria of DSM-IV-TR(
Diagnostic Statistical Manual of mental disorders by the American psychiatric association
fourth edition Text Revised

The Diagnostic and Statistical Manual-IV (DSM-IV) defines abuse as:

15
 • A maladaptive pattern of substance use leading to clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring within a 12-month
period:
1. recurrent substance use resulting in a failure to fulfill major role obligations at
work, school, home (e.g., repeated absences or poor work performance related
to substance use; substance-related absences, suspensions, or expulsions from
school; neglect of children or household)
2. recurrent substance use in situations in which it is physically hazardous (e.g.,
driving an automobile or operating a machine when impaired by substance use)
3. recurrent substance-related legal problems (e.g., arrests for substance-related
disorderly conduct)
4. continued substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance
(e.g., arguments with spouse about consequences of use, physical fights)

DSM-IV defines dependence as:

• A maladaptive pattern of substance use, leading to clinically significant impairment or

distress, as manifested by three (or more) of the following, occurring at any time in the
same 12-month period:
1. tolerance, as defined by either of the following:
 a need for markedly increased amounts of the substance to achieve the
desired effect
 markedly diminished effect with continued use of the same amount of
substance
2. withdrawal, as manifested by either of the following:
 the characteristic withdrawal syndrome for the substance
 the same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms
3. the substance is often taken in larger amounts or over a longer period than was
intended

16
 4. there is a persistent desire or unsuccessful efforts to cut down or control
substance use
5. a great deal of time is spent in activities to obtain the substance, use the
substance, or recover from its effects
6. important social, occupational or recreational activities are given up or reduced
because of substance use
7. the substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (e.g., continued chewing despite recognition that
an ulcer, depression, or loss of appetite was made worse by khat consumption)

The following operational definitions are appropriate to this study

Life time prevalence of khat chewing: the proportion of youth who had ever chewed khat

life time prevalence of smoking: the proportion of youth who had ever smoked cigarette

Life time prevalence of drinking: the proportion of youth who had ever drunk alcohol

Current prevalence of khat chewing: proportion of youth who chew currently and have chewed
in the moth of data collection

Current prevalence of smoking: the proportion of youth who smoke currently with in the month
of data collection

current prevalence of drinking: the proportion of youth who were drinking in the month of data
collection

The data collected were thoroughly checked, incompletely filled questionnaires were
discarded. Questions with multiple responses were coded. The data were entered into EPI6
and exported to SPSS 10.0 for analysis. Frequencies, cross tabulations, descriptive statistics
such as mean ages of starting chewing, smoking, standard deviations, were computed.
Correlations, bivariate and multivariate analyses and regressions were also employed. The

17
dependent variables current khat chewing and ever chewing were compared with the
independent variables such as sociodemographic characteristics and uses of alcohol, cigarette
and other substances. Those variables found to have association with the dependent variables
in the bivariate analyses were entered into logistic regression to adjust for confounding. The
dependent variables were ever chewing and current chewing of khat. As independent
variables, the following were included in the model: sex, age, school status (in or out of
school), educational attainment, cigarette, alcohol and other substance use, religion, marital
status, occupation, father was chewing, mother was chewing, parents live together, parents
control. In addition, the diagnostic criteria of substance abuse and dependence of DSM-IV-TR
were included in the questionnaire and analyzed for frequency of symptoms and associations
with duration of chewing.

Ethical considerations

Ethical clearance for the study was obtained from the university of Gondar research and
publication office. Official letters were collected from the zonal education department and
woreda education office to the respective schools and from the town mayor's office to the
selected kebeles. Participation of respondents was strictly on voluntary basis. Informed
consent was solicited orally. Measures were taken to ensure the respect, dignity and freedom
of each individual participating in the study. Measures were also taken to assure confidentiality
through anonymous data collection at places separate from other persons.

18
RESULTS
Out of the 1197 questionnaires administered, a total of 1167 youth aged between 15 and 24
years were included in the study, making the response rate 97.49%.Thirty questionnaires were
discarded for they were incompletely filled. Six hundred ninety nine (59.9%) were males and
468(40.1%) were females. Out of these, 680(58.3%) were below 20 years of age. Concerning
marital status, 106(9.1%), 1049(89.9%), 4(0.3%), 8(0.7%) were married, single, divorced and
widowed respectively.
Eight hundred seventy one (74.6%) were orthodox Christians, 57(4.9% protestant, 233(19.1%)
Muslim, 9(0.8%) catholic and 7(0.6%) others. Of these, 655(56%) were out-of-school youth.
Among the out of school youth, 460(70.2%) were males and 195(29.8%) were females. And
among the in-school youth, 239(46.7) were males and 273(53.3%) were females. One hundred
sixteen (9.9%) have attended higher education and 16% are below grade 9. This accounts for
28.8% of the out of school youth.

19
Table 1: Socio-demographic characteristics of the study population of in-school and
out-of school youth, Gondar town Ethiopia 2007

20
 Characteristics Number(percent) (n = 1167)
In-School Out-of school Total
Sex
Male 239(46.7) 460(70.2) 699
Female 273(53.3) 195(29.8) 468
Age
15-19 years 479(93.6) 201(30.7) 680
20-24 years 33(6.4) 454(69.3) 487
Religion
Orthodox 428(83.6) 443(67.6) 871
Protestant 8(1.6) 49(7.5) 57
Catholic 2(0.4) 7(1.1) 9
Muslim 73(14.3) 150(22.9) 223
Others 1(0.2) 6(0.9) 7
Education
can't read - 3(0.5) 3
and write
can read - 24(3.7) 24
and write
1-4 grade - 18(2.7) 18
5-8 grade - 144(22) 144
9-12 grade 512(100) 350(53.4) 862
above grade 12 - 116(17.7) 116
Occupation
No job 112(17.1)* 112
Daily labourer 114(17.4) 114
Shoe shiner 23(3.5) 23
House wife 29(4.4) 29
Living with 219(33.4) 219
family
Government 96(14.7) 96
employee
Petty trader 18(2.7) 18
Lottery and news 16(2.4) 16
paper distributor
Street vendor 28(4.3 28
* the
percentages are calculated from the out of school youth

Two hundred forty nine (38%) of the out of school youth are either job less or daily laborers.

21
 The life time prevalence of khat chewing was found to be 37.1% and current prevalence
31.4%. Among those who currently chew khat 36% have chewed for more than 2 years and
32.1% chew daily. More than 7% of the ever chewers started chewing below age 15 years, the
least age of initiation being 11 years. About 55% started chewing before age 18 years.
Thirty six percent of the chewers chew in public recreation areas and 30.7% chew in special
rooms arranged for daily chewing session. At each session, different proportion of money is
spent and 20.1% spend more than 10 birr per session. Out of those who chew khat 70.1%
experience one or more of the withdrawal symptoms and the frequency of symptoms increase
with the duration of chewing. The symptoms experienced were: weakness, 110(25.4%),
depression 210(48.4%), nausea and abdominal discomfort 17(3.9%), tremor 35(8%),
frightening dreams 31(7.1%), loss of appetite 51(11.7%), irritability 22(5%), and anxiety 26(6%)

Table 2: Prevalence of khat chewing and associated socio-demographic factors in

Gondar town, Northwest Ethiopia, 2007

Variable Population (%) Current khat users

Number (%)
Sex
Male 699(59.8) 283(40.4)
Female 468(40.1) 84(17.9)

22
Age
15-19 years 680(58.4) 100(14)
20-24 years 487(41.6) 267(54)
Religion
Orthodox 871(74.6) 243(27.8
Protestant 57(4.9) 6(10.5)
Catholic 9(0.8) -
Muslim 223(19.1) 112(50.2)
Others 7(0.6) 6(85.7)
Marital status
Married 106(9.1) 47(44.3)
Single 1049(89.9) 377(35.9)
Divorced 4(0.3) 4(100)
Widowed 8(0.7) 5(62.5)
School status
In-school 512(43.9) 47(9.2)
Out-of school 655(56.1) 320(48.8)
Occupation
No job 112(17.1)* 64(57.1)
Daily laborer 114(17.4) 84(73.6)
Shoe shiner 23(3.5) 13(56.5)
House wife 29(4.4) 11(37.9)
Living with family 219(33.4) 84(38.3)
Government employee 96(14.7) 40(41.6)
Petty trader 18(2.7) 8(44.4)
Lottery and news paper 16(2.4) 4(25)
distributor
Street vendor 28(4.3) 12(42.8)

* The percentages are from the out of school youth

Table 3. Subjective reasons given by respondents for chewing khat, Gondar town,
Northwest Ethiopia, 2007

23
 Reason frequency percent*
Easily availability of khat 41 3.5
Ignorance about the harmful effects 29 2.5
For adventure 32 2.7
Peer pressure 86 7.4
Dissatisfaction at home 68 5.8
Lack of job 121 10.4
To fulfill religious rituals 54 4.6
To relieve emotional problems 48 4.1
To get concentration for work, study 116 9.9

Family disintegration 31 2.7

To pass time and relax 26 2.2
Other** 8 0.8 * Percentages do
not add up to 100 because one respondent gave more than one reason
** Other includes: to relieve hunger (3), to increase sexual pleasure (3), and to treat illness (2)

Of the chewers, 17% have chewed for less than 1 year, 38% for 1-2 years and 44.8% for
more than 2 years. Among the khat chewers, 72.9% also drink alcohol and 57.3% of those who
drink alcohol also chew khat. Ninety percent of the cigarette smokers chew khat and 35.3% of
chewers smoke cigarette. Females account for 22.8% of the current chewers. Of all the
chewers, 10.9% were married, 87.1% single, 0.9% divorced and 1.2% are widowed.
Concerning school status, 87.2% of the current chewers were out-of school youth and 12.8%
were in-school youth. Currently, 9.2% of in school and 48.8% of out of school youth chew khat.
The minimum age of khat chewing was 11 years and the mean age of starting chewing was
18.14 years and standard deviation 2.38. The minimum age of smoking was also 11 years with
mean age 18.11 years and standard deviation 2.51.
The life time prevalence of smoking cigarette was 14.6% and current prevalence was 11.9%.
Of all the cigarette smokers 16(9.4%) are females and among the respondents 22.1% of males
and 3.4% of females are life time cigarette smokers.
Life time prevalence of drinking alcohol was 47.1% and current prevalence 38.6%.
Of those who currently drink alcohol, 24.8% drink daily. One hundred and twenty (10.3%) of
the respondents also use substances other than khat, alcohol and cigarette. This accounts for
32.3% of the current chewers. Other substances used were, shisha, hashish, benzene,
cocaine and crack. Out of all khat chewers 114%26.3%) also use shisha. This accounts for

24
9.8% of the respondents.
About fifteen percent of ever chewers and 18.2% of the ever smokers claimed to have stopped
chewing khat and smoking cigarette respectively. The subjective withdrawal symptoms
mentioned by the respondents were; depression, weakness, loss of appetite, tremor, disturbed
sleep, anxiety, and nausea and abdominal discomfort with the highest frequency of depression
where 210(48.4%) of the ever chewers mentioned it. the frequency of the other symptoms
were in the order they appear.

Table 4. Withdrawal symptoms experienced by khat chewers, Gondar town, Northwest

Ethiopia, 2007
Symptoms Frequency ( n = 433) Percent
Weakness 137 11.7
Depression 230 19.7
Nausea and abdominal 68 5.8
discomfort
Tremor 85 7.3
Frightening dreams 80 6.9
Loss of appetite 89 7.6
Irritability 69 5.9
Anxiety 76 6.5

Among in-school youth, 9.1% chew khat while among out of school youth 48.8% do so. Among
the current khat chewers (n = 367), 283(77.1%) are males and 84(22.9%) are females.
Muslims account for 30.5% of all current chewers and of all the Muslim respondents 89.6%
chew khat currently. Out-of school youth comprise 91.2% of all current chewers. Out of the 129
current smokers, 125(96.9%) also chew khat currently. Among the current drinkers, 258(88%)
also chew khat currently. One hundred and thirteen (97.4%) of those who use other
substances such as hashish, shisha, etc., also chew khat.
Those whose fathers had been chewing are more likely to chew khat than those whose fathers
had not been chewing (45.5%Vs25%). Among those whose mothers had been chewing, 69.1%
chew currently versus 29.5% of those whose mothers had not been chewing.
The older age groups (20-24years) are more likely to chew khat than the younger age group
(15-19 years) 58.9%Vs21.5%)

25
About two third (62.3%) of those whose fathers had been chewing versus 23.7% of those
whose fathers had not been chewing, chew currently.
Those who had been controlled by their fathers are less likely to chew khat than those who
had not been controlled (20.4% Vs 48.2%).
History of khat chewing by mother has association with chewing khat. Those whose mothers
had been chewing khat are more likely to chew than those whose mothers had not been
chewing(69.1%Vs29.4%).
There was negative association between khat chewing and mother alive, that is, those whose
mothers are dead are more likely to chew than those whose mothers are alive (57.3%Vs 32%).
Multivariate analysis of the dependent variable, ever chewing, with socio-demographic
predictors revealed that sex, age, religion, occupation, cigarette smoking, alcohol drinking,
other substance use, father was chewing, mother chewing and father was controlling, school
status ( being in or out of school) has strong association with current chewing(Table 8).
Therefore, males more than females, the older age group(20-24 years) more than the younger
age groups(15-19 years), Muslims more than any other religion, those who have no job and
daily laborers than other occupations, those who smoke cigarette than those who do not, those
who drink alcohol than those who do not, those who use other psycho-active substances than
those who do not use, those whose parents had been chewing than those whose parents had
not been chewing, those whose fathers had been controlling than those who had not been
controlled, out-of school youth more than in-school youth were found to chew khat(Table 8).
The subjective reasons for chewing given by the respondents were lack of job, to increase
performance and get concentration, peer pressure, dissatisfaction at home family
disintegration, to relieve tension, depression or anxiety, and to fulfill religious ritual among the
others(Table 5).
According to this finding, 32.3% of the life time chewers fulfilled the DSM-IV-TR diagnostic
criteria of substance abuse and 33.2% dependence.

Table 5. Symptoms of khat abuse experienced by respondents according to DSM-IV-

TR, Gondar town, Northwest Ethiopia, 2007

26
Symptom Frequency
(n=433) Percent*
Recurrent substance use resulting in a failure to fulfill 200 46.2
major role obligations at work, school, home (e.g.,
repeated absences or poor work performance related to
substance use; substance-related absences, suspensions,
or expulsions from school; neglect of children or
household)

Recurrent substance use in situations in which it is 140 32.3

physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance use)

Recurrent substance-related legal problems (e.g., theft, 170 39.2

quarrels, arrests for substance-related disorderly conduct)

Continued substance use despite having persistent or 249 57.5

recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (e.g.,
arguments with friends, family, spouse or, physical fights)

*
Percentages do not add up to 100 because one respondent may have more than one
symptom

27
Table 6. Symptoms of khat dependence by ever chewers in Gondar town, Northwest
Ethiopia, 2007
Symptom n = 433 Freque Percent*
ncy
Tolerance, as defined by either of the 166 38.3
following: a need for markedly increased
amounts of the substance to achieve the
desired effect markedly diminished effect
with continued use of the same amount of
substance
Withdrawal, as manifested by: the 306 70.7
characteristic withdrawal syndrome for the
substance or; the same (or a closely
related) substance is taken to relieve or
avoid withdrawal symptoms
The substance is often taken in larger 154 35.6
amounts or over a longer period than was
intended
There is a persistent desire or unsuccessful 152 35.1
efforts to cut down or control substance use

A great deal of time is spent in activities to 146 33.7

obtain the substance, use the substance, or
recover from its effects
Important social, occupational or 149 34.4
recreational activities are given up or
reduced because of substance use
The substance use is continued despite 144 33.2
knowledge of having a persistent or
recurrent physical or psychological problem
that is likely to have been caused or
exacerbated by the substance (e.g.,
continued chewing despite recognition that
an ulcer, depression or loss of appetite was
made worse by khat consumption)
* Percentages do not add up to 100 because one respondent may have more than symptom

Table 7: Status of substance use among youth in Gondar town, Northwest Ethiopia,

28
2007
Variable frequency of substance use percent
( n = 1167)
Ever chewer 433 37.1
Current chewer 367 31.4
Ever drinker 548 47
Current drinker 450 36.2
Ever smoker 170 14.6
Current smoker 139 11.9
Other substance user 120 10.3
Ever chewer and ever 314 27
drinker
Ever chewer and ever 153 13.1
smoker
Ever smoker and ever 155 13.3
drinker
Ever chewer, ever 155 13.3
smoker
and ever drinker
Current chewer and 125 10.7
Current smoker
Current chewer and 258 22.1
current drinker
current smoker and 126 10.7
current drinker
Current chewer, current 126 10.7
smoker and current
drinker

29
Symptoms Duration of chewing
<1 year 1-2 years > 2 years Total
N(%) N(%) N(%) (n=433)
ABUSE
Failure to fulfill role obligation
Yes 23(11.5) 73(36.5) 104(52) 200
No 101(43.3) 80(34.3) 52(22.3) 233
Taking the substance in physically
hazardous situations
Yes 14(10) 60(42.9) 66(47.1) 140
No 110(37.5) 93(31.7) 90(30.7) 293
Substance related legal problem
Yes 23(13.5) 61(35.9) 86(50.6) 170
No 101(38.4) 92(35) 70(26.6) 263
Substance related social problem
Yes 33(13.3) 92(36.9) 124(49.8) 249
No 91(49.5) 61(33.2) 32(17.4) 184
DEPENDENCE
Tolerance
Yes 14(8.4) 68(41) 84(50.6) 166
No 110(41.2) 85(31.8) 72(27) 267

Withdrawal
Yes 51(16.7) 117(38.2) 138(45.1) 306
No 73(57.5) 36(28.3) 18(14.2) 127
Taking the substance in larger amount
and for longer duration than intended
Yes 9(5.8) 62(40.3) 83(53.9) 154
No 115(41.2) 91(32.6) 73(26.2) 279
A great deal of time is spent to obtain, take
the substance and recover from its effect
Yes 6(4.1) 62(42.5) 78(53.4) 146
No 118(41.1) 91(31.7) 78(27.2) 287

Giving up important social, occupational and

recreational activities due
to substance use 7(4.7) 61(40.9) 81(54.4) 149
Yes 117(41.2) 92(32.4) 75(26.4) 284
No
Unsuccessful attempts to cut down or control substance
use
Yes 9(5.9) 63(41.4) 80(52.6) 152
No 115(40.9) 90(32) 76(27) 281
Continue to use the substance despite knowledge that
the substance is causing harm
Yes 8(5.6) 59(41) 77(53.5) 144
No 116(40.1) 94(32.5) 79(27.3) 289

DISCUSSION

30
Epidemiological studies on khat chewing are rare. Particularly, studies conducted on the youth
are very scarce. Most publications on khat deal with the botanical, biochemical or
pharmacological aspects while West European scientists tend to focus on problems related to
khat. It is only for Yemen that a broader study of all aspects of khat, including social and
economic factors, has been carried out. Comparable research in northeast Africa, where khat
is equally important, has lagged behind. Only recently have more encompassing studies of
khat use in Western Europe and Australia been carried out. These are indications that the once
indigenous practice of chewing khat is becoming an international issue.

This prevalence study of khat chewing revealed that 31.4% of the youth chew khat currently.
This figure is higher than the other studies conducted on this age group and college students
(7% for in-school and 23% for out-of school youth and 17.5% for college students), [1, 5].This
could be explained by the fact that the cultivation and consumption of khat previously known
mainly in the eastern part of Ethiopia is spreading very rapidly to the Northwestern part of the
country. There is an increasing trend of khat chewing as indicated by subsequent studies
conducted for example among students of Gondar college of medical sciences, 22.3% in
1983(26) and 26,7% in 2001(5). The prevalence of khat chewing determined in this study is
comparable to the ones that were reported for Adamitulu(31.7%),[7 ] and Jimma town(30.6).
Although both studies conducted had included all age groups from 15 and16 years and above
respectively. The usual age of starting chewing khat is at adolescence and it appears to have
no upper age limit. This study however, revealed lower rates of lifetime and current khat
chewing prevalence compared to a study in Butajira, southwest Ethiopia in 1999, where life
time and current prevalence rates were found to be 55.7% and 50% respectively (28). This
could be due to the preponderance of Muslims in Butajira where they account for over 90% of
the population compared to 19.1% in this study. It is found that 56% of Muslims are ever
chewers compared to 33.9% of orthodox Christians that constitute 74.6% of the population.
According to this study, it seems that there is a significant association (P< 0.001) between
Muslim religion and Khat chewing habit. This finding is in line with those studies reported for
Adamitulu(22) and Butajira(28).

31
More males(77.1%) than females were found to chew khat in this study, OR(95%CI) = 3.4( 2.6,
4.4). This is consistent with other studies conducted in Jimma(13), Adamitulu(22) and
Butajira(28). This may be because females are more socially restricted than male counter
parts.

The lifetime and current prevalence rates of cigarette smoking among the study subjects in this
study were14.6% and 11.9% respectively. Compared to studies conducted on medical and
paramedical students of the Gondar college of medical scienses in 1983 which were 31.9%
and 26.3% respectively, there is a decrease both in lifetime and current prevalence rates.
However, there is an increase in both lifetime and current prevalence rates of smoking
compared to a study conducted in the same college in 2001, showing lifetime and current
prevalence rates of 13.1% and 8.1% respectively(5). This may be explained by: the previous
study was conducted among college students who came from different parts of the country
including rural areas where cigarette smoking is less practiced. This study was conducted
however, in a town only, where smoking is not socially strictly sanctioned. In addition khat
chewing is highly associated with smoking, therefore, as the prevalence of khat chewing
increases the prevalence of smoking may also increase. This finding on the prevalence rate of
khat chewing in Gondar town is found to be lower than reported in Butajira where the lifetime
and current prevalence rates were found to be 55.7% and 50% respectively (28). This could be
due to the preponderance of Muslims in Butajira where they account for over 90% of the
population. Muslim religion has significant assosiation with khat chewing habit (p = <.001)

This is in line with other studies conducted in Bitajira(28) and Jmma town(13). Males (77.1%)
were found to have been chewing more than females (p = <0.001) as in the Butajira(28) and
Adamitulu(7) studies showed. This may be because females are culturally more restricted than
males. In this study the habit of khat chewing was more frequent in the age groups 20-24
years compared with the younger age group, 15-19 years. As compared to the younger age
group, there are more out of school youth in the older age group and more khat chewers are
found in the out of school youth. This is consistent with the study conducted in all regions of
the country where prevalence rates of khat chewing among school and out of school youth
were found to be 7.5% and 23% respectively(1). This could be explained by the fact that

32
young people who are not attending school may have extra time to move around, meet with
new friends, and visit public entertainment areas and khat chewing sessions. These places are
the areas where most respondents claimed to have been chewing in such places. Contrary to
other studies(1,13), in this study no association was found betwwen khat chewing and
education. The possible explanation for this difference could be: most respondents in this study
(83.8%) were grade 9 and above compared with only 27(2.4%) who have not attended formal
education. The mean ages for starting khat chewing and cigarette smoking were 18.14 and
18.11 years respectively. This is similar with what were reported for college students in Gondar
college of medical sciences (26) and among four colleges including Gondar(5). The subjective
reasons given for khat chewing in this study were also in agreement with the above studies
which were "to get concentration", "peer pressure", and "relieve stress" among others. The
associations among khat chewing, cigarette smoking, alcohol drinking and other substance
use revealed by this study agree with other studies conducted in other parts of the country and
on college students including Gondar(1,26).

The habit of khat chewing by one or both parents has also indicated increased rates of
chewing among youth whose parents have been chewing. This agrees with a finding in Gondar
college of medicine students (5). This is a well established fact that young people tend to
imitate and exercise what they observe from their elders and parents. In addition, among the
muslims where khat chewing is taken as means of increasing concentration for prayer, children
are allowed to attend khat chewing sessions. It is difficult to say precisely how much khat is
chewed; the practice is widespread, but figures are not easy to come by. The use of khat was
long confined to the natural habitats of khat, for the leaves wither soon after harvest; the active
ingredients are dissipated and the leaves become unfit for use. This means that the leaves
must reach their destination within two days of harvesting. With rise of motorized and air
transport, the circle of khat use has become considerably wider.

33
Table 9: factors associated with ever chewing of khat among school and out of school
youth in Gondar town, Northwest Ethiopia, March 2007(n = 433)
Factor Ever chew OR(95%CI)
Number (%)

Age
15-19 years* 146(33.7)
20-24 years 287(66.3) 4.7(3.6-6.1

Sex
Male 334(77.1) 3.4(2.6,4.4)
Female * 99(22.9)

School status
In-school * 82(18.9)
out-of school 351(81.1) 3.1(2.2-4.4)

Ever smoke
Yes 153(35.3) 9.3(5.3-16.1)
No* 280(64.7)

Ever drink
Yes 314(72.9) 3.6(2.6-4.8)
No* 117(27.1)

Other substance use

Yes 116(35) 3.7(13.4-106)
No* 215(65)
father was chewing
yes 104(41.6) 4.4(2.7-7.2)
No* 146(58.4)
Mother was chewing
Yes 47(15.6) 2.5(1.2-5)
No * 254(84.4)
father controls
Yes* 93(39.1)
No 158(62.9) .28(.18-.46)

* reference
category

34
As khat chewers spend more time chewing khat than working, khat abuse affects the
productivity of the countries involved. Khat users from the lower income group may spend as
much as half of their daily earnings on khat. In this study multiple substance use was found to
be very common,153(13.1%) of the respondents claimed to have been taking khat, cigarette,
and alcohol at the same time. This finding is in line with an other study conducted in 1996, in
Addis Ababa and other 24 towns in Ethiopia (4). The reasons given by respondents for
substance use were also similar with the above study(Table )

The symptoms of khat use using the diagnostic criteria of DSM-IV-TR for substance abuse and
dependence have been tried to be assessed and the frequencies of the symptoms were very
high. However, literatures on khat abuse and dependence are very rare. More over, different
studies have come up with controversial findings.
It is the young economically active age group that chew khat in group and waste away their
time. A considerable amount of money is being spent for khat and this can affect the economy
of the family. Long term use of khat results in family breakdown and violent behavior and other
harmful effects on the body and psyche. Users of khat report increased levels of energy,
alertness, self-esteem, sensations of elation, enhanced imaginative ability and capacity to
associate ideas when chewing. However, over stimulation of the central nervous system can
lead to psychiatric disorders and there are case reports of people developing psychosis after
use of khat.

Limitations of the study

35
The response rate was not 100%, and the non-responses were from school youths. This is of
course one of the limitations of self-administered questionnaires. The respondents may not
also say what really the situations were with respect to their status of substance use for fear of
social disapproval. This might underestimate the prevalence of khat, cigarette, alcohol and
other substance use. The questionnaires were not administered by health professionals.
Therefore, questions of abuse and dependence might not clearly communicated and this could
have resulted in exaggerated responses. Because researches on abuse and dependence of
khat are lacking, it was found to be difficult to compare this finding with other studies.
Moreover, the very few researches available have inconclusive or controversial remarks. For
this reason it is difficult to rely on the findings, especially those of subjective symptoms of
dependence. Prevalence studies on khat chewing among the youth in areas where khat is not
cultivated are rare. Therefore, comparisons made with this study were to those findings where
khat has been widely consumed by all age groups. This might be a reason to interpret that
khat is chewed less frequently compared to the other studies conducted in areas where khat is
endogenous. Had there been any study conducted in area like Gondar where khat does not
grow it would have been possible to conclude that khat consumption is increasing, decreasing
or the same.

CONCLUSION
Although the literature on khat (Catha edulis Forsk) and its prevalence among different

36
segments of the population in Ethiopia is fairly extensive, very few population based studies
exist in the study area.
While additional information is always desirable to enhance our understanding of the effects of
khat on the human body, enough is known now to say clearly that the use of khat should be
discouraged everywhere.
Despite the dramatic increase in the production and consumption of khat in Ethiopia in recent
years, no regulatory measures have been attempted to be taken by the authorities in charge. It
is particularly worrisome in view of the recent CIA categorization of Ethiopia as illicit drugs
transit hub. The cultivation of khat is financially attractive and spreads into new areas,
apparently at the expense of traditional staple and cash crops.

In Ethiopia, Khat has been used for centuries in the eastern part of the country. Today khat
consumption is widespread throughout the country. There are no laws restricting its use,
although the government discourages it. Khat abuse begins at a young age and there seems
to be no upper age limit for the average chewer.

Use of a substance is likely to lead to multiple drug use, abuse and dependence. Although khat
is a legal substance in Ethiopia, it can be an entry point to the use of other elicit drugs. This
has to be made aware to local governmental officials and other concerned bodies.

It is not only for the above reasons that research into the question whether or not the problem
of khat has not been addressed in earnest. The situation is complicated by uncertainty about
the official status of khat as a commodity.

In general the prevalence of khat chewing and cigarette smoking appear to have increased
among the young people compared to previous studies of khat and cigarette use. This finding
might seemed to be lower than the prevalence studies on the general population study
conducted in Butajira. However, that is a place where khat is endogenous and more Muslims
than Christians live contrary to Gondar. The high prevalence rate of khat chewing, cigarette
smoking and alcohol drinking as wellas use of substances other than these such as shisha and
hashish are striking and need attention by the government, health professionals and the
community for future plans on decreasing the consumption of these and other illicit

37
substances.
The habit of khat chewing has negative impact on health and socioeconomic matters. This is
because the habit of khat chewing reinforces the development of other habits such as cigarette
smoking, alcohol intake and use of other substances.

RECOMMENDATIONS
1. There is a very high felt need to educate the public with special emphasis to the young
people about the adverse effects of khat on physical, mental and social health.

38
2. The cultivation of khat should be discouraged by offering government subsidies for
alternative but equally rewarding cash crops.
3. Use of khat in public entertainment areas, work places, school compounds should be
restricted.
4. Heavy taxes should be imposed on khat circulation to discourage its widespread use.
5. The programs on HIV/AIDS control should include substance use prevention and favorable
conditions should be created for non-governmental organizations to establish substance abuse
prevention and control programs.
6. Government and non-governmental organizations should join efforts to provide adequate
access for recreational facilities for marginalized youth.
7. Control measures on circulation of illicit substances should be designed.
8. Teachers and parents have to be made aware the importance of open discussions and
follow-ups of young people.
9. Large scale surveys should be conducted periodically to determine trends and patterns of
use of khat and other substances of abuse.
10. Studies on khat use and induced disorders such as abuse, dependence, withdrawal
delirium, mood and psychotic disorders need to be carried out among those who chew for long
duration so as to draw a clear picture of its effect on mental health and recommend about its
legal status.

ACKNOWLEDGEMENTS
I am very grateful to professor Yigzaw Kebede who helped me throughout the course of this
paper from the proposal to the final report in guiding, advising, correcting and commenting in a
friendly approach and letting me feel free.

39
I sincerely acknowledge the university of Gondar for the financial coverage of the research.
My thanks should go to Ato Mohamedberhan Abdulwahib for providing me with most of the
reference materials.
I thank Ato Getu Degu for programming my computer with SPSS software and teaching me
how to use it.
I would like to thank Ato Sisay Melese who gave me encouragement and support with the
analysis.
So much thanks to the north Gondar zonal education department, Mayor's office, woreda
education office, heads of the selected schools, kebele administrators of the selected kebeles
and all the study subjects and data collectors as well as supervisors for their help.

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