Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria

Preventive Medicine 38 (2004) 479 – 484 www.elsevier.com/locate/ypmed

Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria W. Maziak, a,b,* S. Rastam, a T. Eissenberg, a,c T. Asfar, a F. Hammal, a M.E. Bachir, a M.F. Fouad, a and K.D. Ward a,d b

a Syrian Center for Tobacco Studies, Aleppo, Syria Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany c Virginia Commonwealth University, Richmond, VA 23298, USA d Center for Community Health, University of Memphis, Memphis, TN 38157, USA

Abstract Background. Narghile (waterpipe) smoking is increasing across the Eastern Mediterranean region (EMR), though little is known about the social attitudes and perceptions related to this method of tobacco use, and how those attitudes and perceptions are influenced by gender. Methods. Data from two cross-sectional surveys conducted in 2003 in Aleppo, Syria, were used to examine these issues. Overall, 855 participants were included (439 men, 416 women; mean age, 24.4 F 7.1 years; response rate, 97%). The current analysis focuses on responses to four similar nine-item questions tapping perceptions related to narghile smoking by women or men, and cigarette smoking by women or men. Scores on the nine items were summed to yield a total score to gauge participants’ perceptions about narghile and cigarette. Results. Generally, participants were less positive about women smoking relative to men smoking, and cigarette smoking relative to narghile smoking. Cigarette smoking by women was the behavior least associated with positive perceptions. Individuals who resided in the city, were economically better-off, and were Christian, had higher perception scores (i.e., more positive attitudes) toward all forms of smoking, whereas older and married participants had higher perception scores for narghile only. Smoking status of participants, especially narghile smoking, was also associated with more positive perceptions toward smoking in general. Conclusions. We conclude that preliminary analysis shows that views on different forms of smoking in Syria differ by gender and smoking status. D 2003 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved. Keywords: Narghile; Waterpipe; Syria; Attitude; Perception; Gender

Introduction Narghile (waterpipe) smoking is increasing across the Eastern Mediterranean region (EMR) [1]. For example, despite reports that this method of tobacco use was declining two decades ago [2], it is now practiced by a quarter of some populations in the region [3– 5], and is also on the rise among Arab –American adolescents [6]. Narghile smoking may be associated with significant health risks, and information on this issue is only beginning to accumulate [7– 9].

* Corresponding author. Syrian Center for Tobacco Studies, PO Box 16542, Aleppo, Syria. Fax: +963-21-26499150. E-mail addresses: [email protected], [email protected] (W. Maziak).

Similarly, there has been little research focusing on the social attitudes and perceptions related to narghile smoking. Probing perceptions and societal views related to narghile use is relevant to understanding current trends, and may help focus prevention interventions. Areas of particular interest include the extent to which perceptions regarding waterpipe differ according to gender and/or differ from those regarding cigarettes. In developed countries, smoking status rather than smoker’s gender is the major determinant of beliefs and attitudes toward smoking [10]. However, this finding may not generalize to Syria and the rest of the EMR, where gender is likely to play an important role in health-related perceptions and practices [11,12]. Interestingly, recent evidence suggests gender may interact with method of tobacco use: family attitudes toward smoking behavior involving younger fe-

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male members are more lax for narghile than for cigarettes [13]. This laxity regarding narghile use may have unfortunate public health implications in Syria, where it may predict the spread of tobacco smoking among women. Until recently in Syria, women have been relatively spared by the smoking epidemic [12]. The purpose of this study is to gain more insight on the social milieu surrounding this emerging form of smoking in Syria. The study uses cross-sectional survey methods to probe how attitudes and perceptions related to narghile differ from those related to cigarette smoking and across gender. Results can advance our understanding of the spread of this form of tobacco use, and may suggest areas in which to intervene to curb its spread.

Methods The study’s methods have been described in detail elsewhere [4,14]. Briefly, two cross-sectional surveys were administered in 2003 to a representative sample of students at Aleppo University and narghile smokers in cafe´s/restaurants in Aleppo, using interviewer-administered, anonymous questionnaires. Overall, 855 participants entered the analysis, 587 students (278 men, 309 women; age range, 18 –30 years; mean age, 21.8 F 2.1 years; response rate, 98.8%), and 268 cafe´/ restaurant customers (161 men and 107 women; age range, 18– 68 years; mean age, 30.1 F 10.2 years; response rate, 95.4%). The protocol and informed consent document were

Fig. 1. (a) Views on narghile smoking by men (asked to men). (b) Views on narghile smoking by women (asked to men). (c) Views on narghile smoking by men (asked to women). (d) Views on narghile smoking by women (asked to women).

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approved by the Institutional Review Boards at the SCTS and the University of Memphis. The questionnaire was developed in Arabic from standard instruments used for the assessment of smoking [4]. The questionnaire was piloted among members of the target population to maximize item clarity and relevance and was modified accordingly. The questionnaire included four 9item questions regarding participants’ view about narghile smoking by women, narghile smoking by men, cigarette smoking by women, and cigarette smoking by men. The nine items were; ‘‘Safe’’, ‘‘Personal decision’’, ‘‘Tradition abiding’’, ‘‘Looks familiar’’, ‘‘Looks energetic’’, ‘‘Sign of social status’’, ‘‘Looks balanced’’, ‘‘Looks attractive’’, and

Table 1 Perception scores related to smoking narghile and cigarettes according to different sociodemographic and smoking status characteristics Smoking narghile by males, mean F SD

Smoking narghile by female, mean F SD

Smoking cigarettes by males, mean F SD

Smoking cigarettes by females, mean F SD

Age of participants V22 years 5.8 F 3.1 >22 years 6.5 F 3.6*

3.4 F 3 3.7 F 3.1

5.7 F 3.3 6.1 F 3.4

2.7 F 2.3 2.6 F 2.5

Gender of participants Male 6.1 F 3.3 Female 6.3 F 3.4

3.4 F 3 3.7 F 3.1

5.7 F 3.2 6.2 F 3.5*

2.6 F 2.4 2.7 F 2.5

DI <2 z2

6.5 F 3.4 5.8 F 3.3*

4 F 3.3 2.9 F 2.6*

6.1 F 3.4 5.7 F 3.4

2.9 F 2.7 2.4 F 1.8*

Residence City Country

6.6 F 3.4 5.4 F 3.2*

3.9 F 3.3 2.8 F 2.6*

6.1 F 3.4 5.5 F 3.3*

2.8 F 2.6 2.4 F 2*

Marital Status Married 7.2 F 3.4 Not married 6 F 3.3*

4.3 F 3.5 3.4 F 3*

6.1 F 3.1 5.9 F 3.4

2.6 F 2.6 2.7 F 2.4

Religion Muslim Christian

3.4 F 3 4.5 F 3.5*

5.9 F 3.3 5.9 F 3.5

2.6 F 2.3 3.1 F 2.8*

Ever narghile smoking Yes 6.8 F 3.4 No 5.1 F 3*

4.1 F 3.4 2.5 F 2*

6.2 F 3.5 5.5 F 3.1*

2.8 F 2.6 2.4 F 2*

Current narghile smoking Yes 7.3 F 3.5 No 5.4 F 3 *

4.7 F 3.6 2.7 F 2.3*

6.3 F 3.6 5.6 F 3.2*

3 F 2.8 2.4 F 2*

Current cigarette smoking Yes 6.5 F 3.6 No 6.1 F 3.3

3.9 F 3.2 3.4 F 3

6.6 F 3.6 5.7 F 3.3*

3.1 F 2.7 2.5 F 2.3*

Ex-cigarette smoking Yes 7.2 F 3.6 No 6 F 3.3*

3.8 F 3.5 3.4 F 3

5.7 F 4.2 5.7 F 3.2

2.5 F 2.7 2.5 F 2.3

6.1 F 3.4 7 F 3.3*

* P < 0.05 for the difference in means according to sociodemographic and smoking status indices.

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‘‘Looks social’’. Options for answering each item were, ‘‘Yes’’, ‘‘No’’, and ‘‘Cannot determine’’ (Appendix A). Narghile and cigarette smoking were defined as any use of these products in the last 30 days. Income was assessed indirectly using the density index (DI), which is a proxy measure developed and tested previously [15]. The DI is calculated by dividing the number of household members by the number of rooms in the house. Statistical analysis Responses to the nine-item questions were first described as proportion of total responses for each item (Figs. 1 and 2). In the next stage, a quasi-perception score was devised for the nine-item question to assess indirectly the magnitude of positive perceptions related to these questions (all items are generally positive). ‘‘Yes’’ responses for each item were coded as 2, ‘‘Cannot determine’’ as 1, and ‘‘No’’ as 0. Means of total question scores were then analyzed according to demographic and smoking status using the Student’s t test, with alpha level < 0.05 considered statistically significant (Table 1). For the purpose of the analysis, age and DI were dichotomized around the median value.

Results The figures show the proportion of narghile smokers and nonsmokers (Fig. 1) and cigarette smokers and nonsmokers (Fig. 2) who endorsed each of the nine items within each question (narghile smoking by women, narghile smoking by men, cigarette smoking by women, and cigarette smoking by men). Generally, smoking by women was associated with less positive perceptions than by men, and smoking cigarettes less than narghile, with cigarette smoking by women being least associated with positive attributes. Table 1 shows the perception scores related to smoking narghile and cigarettes according to smoking status and other demographic characteristics. Among socioeconomic factors, perception scores were generally higher (i.e., more favorable) for all types of smoking (narghile smoking by men, narghile smoking by women, cigarette smoking by men, cigarette smoking by women) for city residents, betteroff participants (lower DI), and Christians, while older and married participants had generally higher perception scores for narghile only. Smokers generally associated more positive attributes to smoking regardless of gender, but were more positive about the method they use (i.e., cigarette smokers are more appreciative of cigarette smoking and vice versa) (Table 1).

Discussion The results presented here, using cross-sectional survey methods, are the first to examine, in the EMR, the

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Fig. 2. (a) Views on cigarette smoking by men (asked to men). (b) Views on cigarette smoking by women (asked to men). (c) Views on cigarette smoking by men (asked to women). (d) Views on cigarette smoking by women (asked to women).

perceptions of men and women regarding narghile and cigarette smoking. The influence of gender was assessed according to both gender of the participant and the gender of the smoker in the question. Data suggest some awareness of the health risks of smoking, an overall familiarity with narghile smoking, and differences in women’s enthusiasm regarding narghile smoking relative to cigarette smoking. Overall, the data presented here suggest a general consensus about the health risks of smoking, independent of tobacco use method (e.g., narghile and cigarettes). Thus, the spread of narghile across the EMR is occurring in the face of an appreciation of its potential health effects. In addition, these data suggest that among the populations

sampled, there is a less positive perception of women’s smoking and that the smoking status of individuals shapes their attitude and perception regarding smoking. Finally, type of smoking and gender of smoker were important factors affecting perceptions related to smoking, with narghile smoking being generally more positively perceived than cigarette smoking, especially for women. Understanding these intricate relationships, where personal factors are expressed within the general societal views considering different smoking practices, is of major importance to understand the current narghile epidemic as well as to predict its future trends. These data also demonstrate that narghile smoking is a familiar scene to study participants. In particular, narghile

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smoking by women was viewed as more familiar than cigarette smoking by women. Thus, despite the short history of the current narghile epidemic in Syria, this method of tobacco use is quickly establishing itself as a normative behavior. This finding is especially relevant, given that in more developed countries, changing normative behavior is an important component of tobacco control efforts. That is, just as the tobacco industry attempts to recruit new smokers by portraying smoking as normative (e.g., in advertisements), the public health community attempts to dissuade new smokers by opposing that portrayal [16,17] and shifting smoking outside of the normative domain (e.g., by restricting smoking in certain places; [18]). As narghile use in Syria and the EMR become more accepted, its prevalence might be expected to increase, thus leading to a cyclic increase in tobacco use behavior. One focus area for prevention interventions in the EMR includes opposing the image of narghile use as normative behavior. The most striking smoking-status-related difference in views was seen considering narghile smoking by women, where women narghile smokers were more enthusiastic about it than nonsmokers (see Fig. 1d). This enthusiasm was not observed for cigarette smoking by women, where even women cigarette smokers did not attach much positive value to it. Of particular interest in the current analysis is the view regarding the attractive attribute attached to smokers. Generally, about a quarter of narghile smokers view narghile smoking by both genders as attractive, where female narghile smokers are particularly positive about the attractiveness of smoking narghile by women. Astonishingly, cigarettes are considered a symbol of sexual attraction for women in developed countries [19], but in our population, over 40% of women viewed men who smoked cigarettes as attractive, while only around 20% of men viewed women who smoked cigarettes as attractive (Figs. 2b, c). This apparent gender difference appears to be an adult phenomenon: when adolescents in five EMR populations were asked to rate the attractiveness of adolescent males and females who either smoked or did not smoke, responses did not differ by respondent’s gender, with only about a 1/3 of participants viewing boys and girls who smoke as more attractive than nonsmokers [20]. However, the analysis did not differentiate between gender and smoking status of respondents [20]. Apparently, the sexual context (being attractive) of cigarette smoking develops as a function of age and accumulative exposure to tobacco advertisement. The perception score presented here (see Table 1) may not be an ideal quantitative measure of positive perceptions related to smoking, but it can help distinguish between major sociodemographic influences on peoples’ perceptions regarding different forms of smoking. In this regard, economic status (DI) was an important factor, with better-off participants attaching more positive perceptions to most forms of smoking. In addition, city residents were

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more positive regarding different smoking forms than country residents. Married couples were more positive than singles about narghile but not cigarette, which can be explained by the social character of narghile smoking and its frequent practice within the family [4]. Christians also were more positive regarding most forms of smoking, which may reflect a more liberal attitude toward women smoking in general [21]. Interestingly, ex-cigarette daily smokers, mostly men, reported more positive perception about men who smoke narghile but not men who smoke cigarettes. This difference may be the result of some cigarette smokers quitting cigarette and acquiring narghile smoking. This study has some limitations. Most importantly, while the students’ survey involved a representative sample of students and included smokers and nonsmokers, only narghile smokers were surveyed in the cafe´s/restaurants study. Although this difference in sampling can affect the age and composition of narghile nonsmokers, it is unlikely to have a major effect on the current study that did not focus on age trends but rather attitudes and perceptions related to different smoking methods. In addition, as indicated earlier, the perception score developed is a quasi-scale intended only to identify major lines along which perceptions tend to diverge. By giving particular attention to the gender-based differences in perceptions and attitudes related to cigarette and narghile use, this study brings new insights on the social milieu surrounding these methods of tobacco use in the EMR. These insights allow us to understand better current tobacco use trends, predict more accurately future trends, and inform more thoroughly smoking prevention and intervention efforts that are intended for cultures in the EMR. Based on the positive views expressed toward narghile, especially in the context of social taboos about women’s cigarette smoking in Syria, it is likely that narghile smoking will continue to spread in the society, particularly among women. More research in this area is necessary if we are to work effectively to stop the spread of tobacco-related addiction, disease, and death in the EMR.

Acknowledgments This work is supported by USPHS grants R01 TW05962, R21 TW006545, and DA11082.

Appendix A Format of the nine-item question used in the analysis (subsequent three questions used with underlined words are changed to narghile smoking by females, cigarette smoking by males, and cigarette smoking by females). For each statement I read please give me your opinion considering narghile smoking by males using yes or no or

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I cannot determine. Would you say narghile smoking by males is: a. b. c. d. e. f. g. h. i.

Safe Personal decision Tradition abiding Looks familiar Looks energetic Is a sign of social status Looks balanced Looks attractive Looks social

Yes Yes Yes Yes Yes Yes Yes Yes Yes

5 5 5 5 5 5 5 5 5

No No No No No No No No No

5 5 5 5 5 5 5 5 5

Cannot Cannot Cannot Cannot Cannot Cannot Cannot Cannot Cannot

determine determine determine determine determine determine determine determine determine

5 5 5 5 5 5 5 5 5

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