Background: Developing countries are at high risk of epidemic increases in tobacco smoking, but the extent of this problem is not clearly defined because few collect detailed smoking data. We have surveyed tobacco smoking in the Ashanti region of Ghana, a rapidly developing African country with a long-established tobacco industry. Method: We took a random sample of 30 regional census enumeration areas, each comprising about 100 households, and a systematic sample of 20 households from each. These were visited, a complete listing of residents obtained and questionnaire interviews on current and past smoking, age at smoking uptake, sources of cigarettes and other variables carried out in all consenting residents aged 14 or over. Results: Of 7096 eligible individuals resident in the sampled households, 6258 (88%; median age 31 (range 14–105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%) and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking was more common in older people, those of Traditionalist belief, those of low educational level, the unemployed and the less affluent. Smokers were more likely to drink alcohol and to have friends who smoke. About 10% of cigarettes were smuggled brands. About a third of smokers were highly or very highly dependent. Conclusions: Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence in Ghana is low, particularly among younger people. This suggests that progression of an epidemic increase in smoking has to date been avoided. Smoking is the largest avoidable cause of death and major non-communicable disease worldwide.1 2 Although historically prevalent in economically developed countries and rare in the developing world, this pattern of smoking is now beginning to reverse as smoking prevalence rises in the developing world, particularly among men.3 Consequently, approximately 70% of the 10 million deaths from tobacco-related causes expected by 2030 will occur in developing countries,4 where epidemic increases in smoking prevalence will inflict major public health impacts throughout the 21st century.5 6 Smoking surveillance and prevention should therefore be high priorities in these countries,1 but although many have committed to implement the World Health Organization Framework Convention on Tobacco Control (FCTC),7 the tobacco control resources available to do so are typically very limited. Reliable data on country prevalence and trends in prevalence in the developing world are few.8 Ghana is a country in sub-Saharan Africa with a population of about 22 million, a gross national income (in 2005) of $450 per capita, has had a stable democracy since 1992 and recent economic growth of around 6% per year.9 British American Tobacco has had a manufacturing presence in Ghana for most of the past 50 years.10 Ghana is therefore likely to be at a relatively high risk of involvement in the tobacco epidemic, but detailed information on smoking in the general adult population is not available. This study was carried out in the most populous region of Ghana to investigate the extent of tobacco use in Ghana, measuring current and ever smoking, age and year of uptake of smoking, the demographic characteristics of smokers, the main risk factors for smoking and main sources of tobacco, smoking cessation patterns and other variables, to characterise and describe the extent to which tobacco smoking has become prevalent.