التدخين بالانجليزي ، بحث عن التدخين بالانجليزي ، مقال عن التدخين باللغة الانجليزية ، تقرير عن التدخين بالانجليزي

التدخين بالانجليزي ، بحث عن التدخين بالانجليزي ، مقال عن التدخين باللغة الانجليزية ، تقرير عن التدخين بالانجليزي

التدخين بالانجليزي ، بحث عن التدخين بالانجليزي ، مقال عن التدخين باللغة الانجليزية ، تقرير عن التدخين بالانجليزي ، تعبير عن التدخين بالانجليزي



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معدل انتشار التدخين، وسن البدء بالتدخين في الإسكندرية، مصر

رندا يوسف، سامية أبو خطوة، هبة فؤاد

الخلاصـة: تم إجراء مسح مستعرض شمل جميع القطاعات حول تعاطي التبغ في مدينة الإسكندرية، في مصر، باستخدام استبيان مرتكز على الدلائل الإرشادية لمنظمة الصحة العالمية، يتم استكماله أثناء مقابلة الـمُسْتَجْوَبين. وقد أُجريت الدراسة في عام ألفَيْن وشملت 2120 مشاركاً يتراوح عمرهم من 15 إلى 86 عاماً. وكان أكثر من ربع المشاركين (27.2%) من المدخنين الحاليين (25.5% يدخنون يومياً، و1.7% من المدخنين غير المنتظمين)، في حين كان 3.5% منهم ممن سبق له التدخين. وبيَّنت الدراسة أن المدخنين الحاليين ينفقون 23.1% من دخـل الأسـرة على التبـغ. كما بيَّنت الدراسة أن معـدل انتشـار التدخين أعلى بين الرجـال (48.5%) منه لدى النسـاء (1.5%)، وأن متوسط سنّ البدء بالتدخين أقل بين الرجال (18.1 عاماً) منه لدى النساء (22.6 عاماً). وثـَمَّة قلق من ارتفاع معدل انتشار تعاطي التبغ بين الرجال، ومن احتمالات زيادة انتشاره بين النساء. ويستلزم الأمر مزيداً من الدراسة للعوامل التي تقي من الشروع في التدخين والتي تساعد على الإقلاع عنه

ABSTRACT A cross-sectional survey on tobacco use in the city of Alexandria, Egypt, used an interview questionnaire based on World Health Organization guidelines. The study in 2000 included 2120 participants aged 15 to 86 years. More than a quarter (27.2%) were current smokers (25.5% daily smokers and 1.7% occasional smokers) and 3.5% were ex-smokers. Current smokers spent 23.1% of their family income on tobacco. The prevalence of current smoking was significantly higher among men (48.5%) than women (1.5%) and the mean age of initiation of smoking was lower among men (18.1 years) than women (22.6 years). The high prevalence of tobacco use among men is of concern, so too is the likelihood that tobacco use will increase among women. Further research is needed into factors that prevent people from starting smoking and assist them stopping smoking.
Prévalence du tabagisme et âge de l’initiation tabagique à Alexandrie (Egypte)
RESUME Une enquête transversale sur la consommation de tabac dans la ville d’Alexandrie (Egypte) a été réalisée à l’aide d’un questionnaire par entretien basé sur les directives de l’Organisation mondiale de la Santé. L’étude menée en 2000 comprenait 2120 participants âgés de 15 à 86 ans. Plus d’un quart des participants (27,2 %) étaient fumeurs au moment de l’étude (25,5 % de fumeurs quotidiens et 1,7 % de fumeurs occasionnels) et 3,5 % étaient des anciens fumeurs. Les fumeurs dépensaient 23,1 % de leur revenu familial pour le tabac. La prévalence du tabagisme au moment de l’étude était significativement plus élevée chez les hommes (48,5 %) que chez les femmes (1,5 %) et l’initiation tabagique avait lieu à un âge moyen plus jeune chez les hommes (18,1 ans) que chez les femmes (22,6 ans). La forte prévalence de la consommation de tabac chez les hommes est préoccupante, tout comme la probabilité de voir le tabagisme augmenter chez les femmes. D’autres recherches sont nécessaires sur les facteurs qui dissuadent les gens de commencer à fumer ou les aident à arrêter de fumer.
Introduction

The use of tobacco has been described as a global epidemic, with rates of smoking peaking among men in most industrialized countries but increasing now among men in developing countries and women in virtually all countries [1]. Since the mid 1980s the estimated annual global cigarette consumption has remained constant at a rate of 1600 cigarettes per adult per year [2,3]. This is because the decline in industrialized countries has been offset by an increase in developing countries [2]. In industrialized countries, per capita cigarette consumption is falling at a rate of about 1.5% per year, whereas it is increasing by 1.7% per annum in developing countries [4,5]. Now that sales of tobacco products are decreasing in the United States and western Europe, owing to the growing awareness of the health risks of smoking, the tobacco industry is increasingly targeting the developing world as a source of new markets [5].
Information on tobacco consumption and prevalence of use are key indictors that should be monitored by each country to draw attention to smoking and health issues [6,7] and to support anti-smoking measures [4,5]. When repeated at regular intervals, such surveys illustrate trends over time and suggest priorities for tobacco control interventions [6,7]. Indeed, collecting information on tobacco use is one of the main components of the plan of action of the World Health Organization (WHO) for the years 1966–2000 [8].
In Egypt, the last community-based tobacco survey, conducted in Cairo in 1982 [9], revealed a prevalence of tobacco use of 39.8% among men and 1.0% among women. The study aimed to discover what changes have taken place since 1982. To portray the whole scope of the problem for broad age groups as well as for men and women, a cross-sectional survey was conducted in the city of Alexandria between May and August 2000, targeting people aged 15 years and older.
Methods

Sampling technique
A cluster sample technique was used. To obtain an adequate sample size to ensure the reliability of the estimated prevalence, the sample size was calculated as described by Lwanga et al. [10] using the prevalence of smoking reported by the 1982 Cairo survey [9]. We assumed a 0.40 prevalence of tobacco use (p) and 0.60 prevalence of non-use (q) with a degree of precision (d) of 0.03 at 95% confidence intervals along with a correction for design effect. The sample size was calculated by the following equation [(Z2 × p × q)/(d2)] × 2. The sample size was calculated based on the higher prevalence of tobacco use, namely that among men, to obtain a larger sample size. The total number of subjects estimated was 2048, equally distributed over the 30 identified clusters.
In the 30 clusters, 1017 households were surveyed. Subjects aged 15 years and older were eligible to participate in the interview. A total of 127 of 2247 eligible subjects refused the interview, resulting in a non-response rate of 5.7%. A proportion of non-respondents were substituted from the same district. Excluding interviews where data was missing, the total sample reached was 2120 subjects.
Questionnaire

The households selected were first visited and information was collected on households on a separate sheet. Then all eligible participants were interviewed.
Data were collected using a pre-tested, pre-coded interview questionnaire. Section I covered the demographic characteristics of the surveyed households (family size, number of rooms and family income) and the participants (age, sex, education, occupation, and marital status).
Section II covered the status and pattern of tobacco use. Based on household information, status of tobacco use was assessed by the percentage of current smokers in the household. Based on interviews with participants, tobacco use was defined based on the WHO core questions for tobacco surveys [5] as follows: current smokers (daily smokers and occasional smokers); non-smokers (ex-smokers and never smokers); and ever smokers.
Questions about patterns of tobacco use included: type and amount of tobacco products consumed, age of initiation of smoking, duration of tobacco use and state of nicotine dependence for daily smokers (the time lapse between wakening up and the first cigarette of the day). For occasional smokers, the weekly average consumption was divided by seven to represent the daily consumption. This was useful for comparing amount of tobacco used between daily and occasional smokers. For hookah smokers, the amount of tobacco used in one hagar was calculated as equivalent to about 2.5 cigarettes [11].
Data analysis

Data for families and for interviewed participants were analysed using SPSS, version 8 and Epi-Info, version 6.04. The prevalence of smoking and the corresponding 95% confidence intervals as well as the mean, standard deviation (s) and the 95% confidence intervals (CI) of the mean were computed. The chi-square and Student t-test were used to test the significance of the results at the 5% level.
Results

Of the 2120 participants in the study, 1162 were men (54.8%) and 958 women (45.2%). The age range was from 15 to 86 years (mean 35.01 ± standard deviation 13.81 years). Excluding students and those below the legal age of marriage of 18 years (n = 309, 14.5%), the majority of eligible participants were married (77.5%); the remainder were single (21.0%) divorced or widowed (1.5%).
Among the participants, 10.8% (n = 228) were students at different educational levels. For the remainder (n = 1892), nearly half (51.2%) were illiterate or just able to read and write, 14.3% had finished basic education, 22.9% had a high school certificate and 11.6% were university graduates. Excluding students, a minority of women (n = 117, 13.6%) and the majority of men (n = 875; 84.8%) were employed at the time of the survey. For employed men, more than half (53.0%) were manual labourers, 18.2% were drivers, traders and fisherman, while the others were professionals or semiprofessionals (15.3%) and skilled or semiskilled workers (13.5%).
Only a quarter of the 1017surveyed households (24.4%) were tobacco-free, whereas 75.6% had up to 6 household members who were current smokers (mean 1.26 ± 0.62 smokers per household). Tobacco-free households were similar to those with current smokers with respect to family size (6.97 ± 1.86 versus 7.03 ± 1.88, P = 0.665), number of persons per room (1.69 ± 0.97 versus 1.80 ± 0.97, P = 0.101) and per capita monthly income (86.11 ± 67.69 Egyptian pounds (LE) versus 79.82 ± 53.82 LE, P = 0.135).
Of the 5067 total inhabitants of the surveyed households, 4153 were over the age of 15 years, and 1050 of them were reported to be current smokers, yielding a smoking prevalence of 25.3% in the households. Among the 3866 people living in households with current smokers, 2816 (72.8%) were exposed to smoke and a quarter of these passive smokers (n = 728; 25.9%) were children below the age of 15 years.
Table 1 summarizes the use of tobacco products among interviewed participants. Nearly one-third of interviewees (30.7%) were ever users of any tobacco products. The prevalence of current smoking was 27.2%, which was similar to the 25.3% estimated prevalence based on information from households (c21= 2.730, P = 0.0982). The prevalence of daily smoking was much higher (25.5%) than that of occasional smoking (1.7%) (Table 1).

Ever-use of tobacco products was reported by a significantly higher percentage of men (54.5%) than women (1.9%). Just less than half of the surveyed men were current smokers (48.5%) compared with only 1.5% of women. The prevalence of daily smoking was significantly higher among men (45.5%) than women (1.1%). Similarly, the proportion of occasional smokers was significantly higher among men (2.9%) than women (0.4%). Few participants were ex-smokers (3.5%). The proportion of ex-smokers was significantly higher among men (6.0%) than women (0.4%) (Table 1).

Examining tobacco use among men in 10-year age intervals (Table 2) revealed that the highest proportion of ever smokers (67.6%) was among those aged 45–55 years. This age group also had the highest proportion of current smokers (63.8%), particularly daily smokers (61.1%). On the other hand, the highest prevalence of occasional smokers (6.8%), was in the 65+ years age group. The 25–35 year age group had the highest proportion of ex-smokers (7.7%). In the 15–25 year age group, the proportion of ever smokers (34.0%), current smokers (28.1%) and daily smokers (25.7%) was significantly lower than older age groups. Among women, the proportion of never smokers exceeded 90% in all age groups except for those aged 65 years and older where it was 100% (Table 2).

Regarding the type of tobacco used, all current smokers were smoking manufactured cigarettes. In addition, 6.6% (n = 38) of them were water pipe (hookah) smokers, all of them men. Only one person was using snuffed tobacco (neshouk) in addition to manufactured cigarettes. No other type of tobacco was used in the surveyed population.
After adjusting for the amount of tobacco consumed in hookah, Table 3 reveals that the mean number of cigarettes consumed per day, by both daily and occasional smokers combined, was 23.19. The mean number of cigarettes smoked by women (12.85) was significantly lower than that smoked by men (23.45). The same sex difference was observed among daily and occasional smokers.
Current smokers initiated the habit at a mean age of 18.21 years (ranging from 10 years up to 36 years) (Table 3). The mean age of tobacco initiation was comparable for daily (18.16years) and occasional smokers (18.89 years). The mean age of initiation of tobacco use among women (22.64 years) was higher that that of men (18.10 years) but the difference was not statistically significant. Among daily smokers, women started smoking significantly later (mean age 24.09 years) than men (mean 18.04 years) whereas for the 3 women occasional smokers they started earlier (not statistically significant).

The mean age of initiation of tobacco use was studied in successive birth cohorts classified at 10-year intervals. The mean age of initiation of tobacco use was significantly lower in the age group 15–25 years (16.06), whereas it was significantly higher among those aged 65 years and older (23.22). On the other hand, between the ages of 25 and 64 years, tobacco use was initiated at similar ages (Table 4).

Current smokers continued tobacco use for an average duration of 21.06 years (Table 3). No significant difference was observed between daily and occasional smokers in this respect. The mean duration of tobacco use was longer among men (21.20 years) than women (15.35 years) but the difference was not statistically significant. Similar findings were observed among men and women who were daily and occasional smokers. The age of initiation and duration of tobacco use did not vary with number of cigarettes consumed per day (Table 5).

Among current daily smokers, 9.6% reported taking the first cigarette of the day less than 5 minutes after waking up, 5.9% between 5–30 minutes of awakening, 54.3% between 30–60 minutes and 30.2% after 60 minutes.
From the number of cigarettes smoked per day reported by current smokers, the total monthly expenditure on tobacco at the time of the study was estimated at about 40 000 LE, which represented 23.1% of the monthly income of these families (Table 6).
Discussion

The reported prevalence of current smokers in the surveyed population was 27.2%. This figure should be considered approximate in view of the likelihood of under-reporting, particularly by women and children [4] since smoking status was determined by interview without any biochemical validation. Comparisons with other studies need to consider variations in the methods used and the populations surveyed, as some surveys include only those above the age of 18 years [4]. Furthermore, smoking status was only reported for daily smokers while other studies have included occasional smokers as well [1]. We judge that participants in the study adequately reflected the state of tobacco use for all household inhabitants as the prevalence rate obtained from participant interviews was very similar to that reported for the household population.
The prevalence of smoking among men in the present survey was 48.5%, a rate close to the global estimate of 47% and almost identical to the 48% reported for developing countries [1]. However, it is higher than the rate of 35% reported by the WHO Regional Office for the Eastern Mediterranean [4]. Comparing the rate of smoking among men with that of seven other Arab Muslim states, it appears that the population of Alexandria ranks fifth highest. The prevalence of smoking among men is higher than that reported from Bahrain, Iraq and Morocco, which ranges from 35% to 40%, but lower than that reported from Jordan, Tunisia, Saudi Arabia and Kuwait, which ranges from 52% to 60% [4]. The current high rate of smoking among men in the city of Alexandria is of concern, especially as it suggests a continuous increase in smoking prevalence in Egypt overall, as it is higher that the 39.8% reported from Cairo in 1982 [9] and the 40% estimated rate in 1999 [12].
The profile for women was very different from men, as only 1.5% reported being current smokers. This rate is slightly higher than the 1.0% reported in Cairo in 1982 [9]. Such a rate is the lowest reported in countries in the Eastern Mediterranean region [4] and is lower than for women in other developing countries (range from 2% to 10%) [13]. We should not be complacent about the low rate of smoking among women, as it is more likely to reflect social traditions and women’s low economic resources rather than health awareness [14]. The prevalence of smoking among women in Egypt, as elsewhere in the developing world, is expected to increase in view of the weakening of cultural norms [13], women’s increased spending power and the tactics of the tobacco company in targeting women as new consumers [15].
The finding that there were no differences in the demographic characteristics of households with and without smokers implies a homogeneous distribution of smoking across all social strata and indicates that Alexandria is currently passing through the second stage of the smoking epidemic. In the first stage, smoking is unusual and mainly a habit of higher socioeconomic groups. In the second stage, smoking becomes increasingly common and peaks at 50% to 80% among men and tends to be spread equally across socioeconomic groups. Women’s patterns usually lag 10 to 20 years behind those of men. In the third stage, women reach their peak rate around 35% to 45%, along with a decline in the rate among men to 40%. By the end of this stage, the rates among women will start to decline. The slow but continuous decline of the prevalence rate among men and women, until smoking becomes a habit of the lower socioeconomic groups, is a demarcation of the fourth stage of the epidemic [6]. However, these stages, based on the experience in industrialized countries of the United States and Western Europe, may not be duplicated in developing countries.
There is a great public concern about the extent of current smoking and the hazards to which smokers expose themselves. This is magnified further if we take account of the other 72.8% of the population who are at risk because of their passive exposure to smoke in the environment.
WHO guidelines for tobacco surveys recommend that current smokers should be classified into daily or occasional smokers, and reported separately for both men and women and in different age groups, in order to draw reliable conclusions [4]. However, in our survey this is difficult for women who are current smokers because of their very small number.
Among men, the proportion of ever-smokers peaked in the age group 45–54 years and the second highest figure was among the age group 35–44 years. This profile resembles that reported from Egypt by Omar et al., where the peak was between 40 and 60 years of age [16]. These two peaks may reflect the circumstances of earlier generations, who established their smoking habit 25 to 34 years ago during the beginning of the smoking epidemic in developing countries when scarce data were available to the public about the harmful consequences of tobacco [2,17].
Occasional smoking, which is a long-term pattern among some of the current smokers, is practised by less than 5% of most populations and the present survey is no exception; only 2.9% of the men were occasional smokers [18]. The prevalence rates of occasional smoking in different age groups show that the highest two values are in the oldest two age groups. We cannot judge whether the high proportion of occasional smokers among the oldest age groups reflects a long-standing behaviour or attempts at reducing tobacco consumption.
Prevalence of tobacco use is the net product of the two opposing processes of initiation and cessation. In any population, greater health awareness leads to increases in the utilization of curative services before preventive ones. Thus cessation rates are likely to increase before the rates of initiation decrease. In the present survey, the proportion of ex-smokers was low and fluctuated across different age groups without a clear pattern. However, it is important to note that the highest two rates were in the age groups 25–34 years and 55–60 years. It is possible that those between the age group of 25–34 years have started to realize the consequences of the bad habit and decided to quit, whereas those in the age group 55–60 years have been forced to do so because of the effects of smoking on their health.
We expected to observe the highest percentage of never smokers, with the lowest proportions of ever and current smokers, in the youngest age group 15–24 years, because it is in this age interval that young people start to take up and establish the habit. Intervention programmes should give the highest priority to this age group and equip them with the skills of resilience to avoid starting smoking.
The mean age of initiation at about 18 years among current smokers is in accordance with the global estimates [3,13]. Relevant studies have documented that the age of smoking initiation has dropped over the past four decades [19,20]. This can be seen among our youngest cohort of current smokers, as the age at which they initiated the habit (16 years) was lower than other groups. This was in agreement with an Egyptian survey conducted in 1990, which reported an age of smoking initiation between 12 to 16 years among a nationwide representative sample of secondary schoolboys [21]. It has been revealed that initiation between 14 and 17 years carries a higher chance of nicotine dependence than initiation either before or after that age [22]. Unfortunately, this places the smokers from our survey in the most vulnerable group.
Previous research suggested that early smoking initiation predicts longer duration of smoking, heavier daily consumption, and increased chances of nicotine dependence [23,24]. This was not the case in the present research as the age of initiation, as well as the duration of tobacco use, were not significantly associated either with the number of cigarettes smoked, or the fact of being a daily or occasional smoker. Moreover, the majority of our daily smokers fell in the lowest categories of nicotine dependence.
With a daily average of 23 cigarettes, tobacco consumption among smokers in this study is far higher than the 13 cigarettes reported for the Eastern Mediterranean region [4] and the 14 cigarettes for less developed countries. Moreover, it is even higher than an average of 22 cigarettes tabulated for more developed countries. In 1997, WHO forecast a narrowing of the gap in cigarette consumption between developed and developing countries [4]. With such heavy consumption, it is not surprising that families with a smoker spent 23% of their income on tobacco. This is a low estimate, based on the low prices of local brands of cigarettes: foreign brands are more expensive. It clear, however, that many poor families spend a major proportion of their household income on tobacco instead of food and other useful items. In addition, these families may need to spend even larger sums on treating tobacco-related ailments.
The findings indicate that tobacco use in Egypt is high and concerted efforts are needed to curb the epidemic. All community sectors, health professionals, governmental and non-governmental agencies should be mobilized to tackle the problem. Activities that should be carried out concomitantly include: public health education, avoiding role models for tobacco use in the media, strengthening legislation (to enforce compliance with non-smoking areas and limiting tobacco sales to minors) and increasing taxation with the purpose of encouraging cessation and preventing initiation. The youngest age groups, and women, should be the target for the latter measures to ensure that they will remain tobacco-free. Increasing the burden of taxation will have a positive impact on young people, as they are more sensitive to tobacco prices than adults [13]. Further research is needed to determine the predictors of cessation and, more importantly, the factors that prevent initiation by young people.
Acknowledgement

This research was funded by the WHO Regional Office for the Eastern Mediterranean.

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التدخين بين تلاميذ المدارس الثانوية في البحرين: معدل الانتشار وعوامل الاختطار

نزار الحداد، رندة حمادة
الخلاصـة: للتعرُّف على معدل انتشار التدخين بين تلاميذ المدارس الثانوية في البحرين، وعلى عوامل الاختطار التي تفضي للتدخين، قمنا بإجراء مسح لعينة عشوائية لتلاميذ المدارس الحكومية باستخدام الاستمارات. وقد تبيَّن أن معدل انتشار التدخين يبلغ 26.6% بين تلاميذ السنة الأولى الثانوية، و25.5% بين تلاميذ السنة الثانية، و25.4% بين تلاميذ السنة الثالثة، وكان من الشائع استخدام السجاير (21.0)، والغليون (13%)، والسيجار (1.6%). ويتساوى المدخنون مع غير المدخنين في المرتسمات الاجتماعية والاقتصادية، ولكنهما يختلفان في درجة شجب التدخين من قِبَل الأصدقاء الحميمين وفي درجة كون هؤلاء الأصدقاء الحميمون مدخنين. إن معدلات انتشار التدخين بين تلاميذ المدارس الثانوية في البحرين لم تتناقص رغم الجهود المكثفة لمكافحة التدخين في العقد المنصرم، مما قد يشير إلى فعالية كبيرة للدعاية والترويج تقوم بهما شركات التبغ للإيقاع بالشباب.
ABSTRACT To determine the prevalence of smoking among male secondary school students in Bahrain and to identify their risk factors for smoking, we surveyed a random sample of students by questionnaire. The prevalence of smoking was 26.6%, 25.5% and 25.4% among first-year, second-year and third-year students respectively. Cigarettes (21.0%), water-pipes (13.0%) and cigars (1.6%) were popular. Smokers and non-smokers had similar socioeconomic profiles, but differed in degree of disapproval of smoking shown by close contacts and whether close contacts were smokers. The prevalence of smoking among male secondary-school students in Bahrain did not decline despite intense anti-smoking efforts in the last decade, perhaps indicating the effectiveness of tobacco advertising and promotions that target youth.Le tabagisme chez les étudiants du secondaire à Bahreïn : prévalence et facteurs de risque
RESUME Afin de déterminer la prévalence du tabagisme chez les étudiants du secondaire à Bahreïn et d’identifier les facteurs de risque pour le tabagisme, nous avons procédé à une enquête par questionnaire dans un échantillon aléatoire d’élèves d’une école gouvernementale. La prévalence du tabagisme s’élevait à 26,6 %, 25,5 % et de 25,4 % chez les élèves de première, de deuxième et de troisième année respectivement. Les cigarettes (21,0 %), le narguilé (13,0 %) et les cigares (1,6 %) étaient populaires. Les fumeurs et les non-fumeurs avaient des profils socioéconomiques similaires, mais il y avait une différence dans le degré de désapprobation du tabagisme exprimé par les proches et si ces derniers étaient eux-mêmes fumeurs ou non. La prévalence du tabagisme chez les étudiants du secondaire à Bahreïn n’a pas diminué malgré les efforts intenses de lutte antitabac déployés au cours des dix dernières années, indiquant peut-être l’efficacité de la publicité en faveur du tabac et la promotion des produits du tabac ciblant les jeunes.
Introduction

Regular tobacco use is a form of drug dependence and the pharmacological and behavioural effects of nicotine are similar to those that determine addiction to other drugs, such as heroin and cocaine [1,2]. Tobacco is a gateway drug and a risk marker for other forms of drug use [2]. Smoking usually starts in childhood or adolescence and in high-income countries eight of ten smokers begin smoking in their teens [3]. Young smokers are at risk of developing drug dependence to tobacco and to other drugs as the inhalation of cigarette smoke by young people leads to early pharmacological dependence on cigarettes [2,4].
In most industrialized countries, male adolescent tobacco use declined in the 1970s and the beginning of the 1980s but increased in the 1990s [5,6]. Smoking rates among boys in developing countries, including member countries of the Gulf Cooperation Council (GCC), are generally similar to those of industrialized countries, but the overall prevalence of smoking among all youth in GCC countries is much lower due to far fewer female smokers [7–10].
Risk factors for youth smoking have been extensively studied in industrialized nations [2,4,11] and in some countries of this Region [9,12–14]. These risk factors include:
• socioeconomic factors, such as parents’ education and occupation;
• environmental factors, such as parents’ acceptance of smoking, availability of cigarettes, perceptions about tobacco use as the norm, peer and sibling attitudes, parents’ smoking, best friends’ smoking and cigarette advertising [15,16];
• behavioural factors, such as low academic achievement, rebelliousness, alienation from school and lack of skills to resist offers of cigarettes;
• personal factors, such as low self-esteem, type of personality and belief that smoking confers future social advantages.
The most frequently reported reasons for starting to smoke by adolescents are curiosity, defiance of social norms, peer pressure and desire to imitate others [17,18]. Smoking by a friend is a major factor for current smoking in youth, although addiction or habit is the most frequently reported reason [12,17]. Smoking among other male family members is also significantly associated with current smoking among boys [11].
In Bahrain, the government education system is mostly separated into single-sex schools. Private schools, however, are usually coeducational. Following elementary education, the government schools provide 3 years of intermediate and 3 years of secondary education. At the secondary level, the majority of schools are traditional, i.e. few schools are vocational/technical. Traditional schools are separated into science and literature sections.
Smoking control in Bahrain is in collaboration with other GCC countries and is based on legislation and public education. To reinforce anti-smoking efforts Amiri Decree promulgating Law 10, the anti-smoking law, was issued in 1994 and included control measures to regulate tobacco use by the young. The anti-smoking law bans sales of cigarettes and other tobacco derivatives to minors (< 18 years of age), the import of vending machines and smoking in educational establishments. It also prohibits promotion of tobacco through sponsorship of sports and cultural events [19].
The aim of the present study was to estimate the prevalence of smoking among secondary-school boys in Bahrain in the 1990s, to identify risk factors for their smoking and to compare smoking prevalence with that of the 1980s. Female secondary-school students were excluded from the study because of the low reported prevalence of smoking among females in Bahrain in general and among young females in particular [19–21]. However, the exclusion of female students from this study and from previous studies examining smoking among school students means that baseline and trend data on the prevalence of smoking among female school students in a community which is undergoing rapid lifestyle changes have yet to be collected [22,23].
Methods

A cross-sectional study was conducted in all 7 government secondary traditional boys schools. According to Bahrain Ministry of Education statistics, 65.1% of government male secondary students attended traditional schools (6814 of a total of 10 464) and 34.9% attended vocational/technical and theological schools during the academic year 1996–1997. We excluded vocational/technical and theological schools from the study as only a select group of students enrol in them whereas the majority of students enrol in the traditional schools. From the 6814 eligible students, a minimum sample size of 300 was needed for our study based on an estimate of 20% smoking prevalence and 95% confidence level [24]. This estimate of prevalence was based on the results of two studies in the 1980s among male secondary students [22,23]. Although the minimum sample size required was 300 students, we used a sample of 600 students. From each of the 7 schools, 3 classes were randomly chosen, i.e. 1 class from each grade. All students from these selected classes were included in the study.
Consent for the study was obtained from the Ministry of Education and the school administration. An anonymous self-administered questionnaire was distributed to the students in each class by one of the authors in the presence of the teacher. We explained the aim of the study to the students and informed them that their participation was voluntary and that their responses would be anonymous. The questionnaire was based on World Health Organization (WHO) guidelines for the conduct of tobacco smoking surveys for young people with additional questions taken from a study in China [18,25].
‘Smokers’ were those who smoked any type of tobacco at the time of study, whether daily or weekly or less than weekly. ‘Ex-smokers’ were those who had smoked before, but were not smoking at the time of the study. ‘Non-smokers’ were those who had never smoked (‘never smokers’) and ex-smokers combined [25].
Parental education was divided into 3 levels: low (illiterate or able to read and/or write but with no formal education), middle (primary, intermediate or secondary schooling) or high (university education or above). Employment was defined as remunerated work. The occupational level of the father was categorized as low (unskilled and partly skilled workers), middle (skilled workers) or high (professionals). The occupations of the mothers were not ranked by level because the great majority worked for no pay within the family home. Data were managed and analysed using the SPSS version 9.0. Statistical associations between smoking status and study variables were tested with chi-squared distribution. The level of significance was set at P < 0.05. Odds ratios (OR) and 95% confidence intervals (CI) were computed.
Results

During the study, 602 students were attending the randomly selected classes. The questionnaires of 2 students were excluded from the analysis because they were incomplete. Of the remaining 600 students, 309 (51.5%) were in the science programme and 291 (48.5%) in the literature programme. There were 207 (34.5%) first-year, 204 (34.0%) second-year and 189 (31.5%) third-year students. Their ages ranged from 13 to 20 years with a mean age of 16.5 ± 1.1 years. The majority of parents had middle educational level and fathers had mostly middle level occupations (Table 1).
Of the 600 students, 155 were smokers (25.8%), 140 ex-smokers (23.3%) and 305 (50.8%) never-smokers. The prevalence of cigarette smoking was 21.0%, water-pipe smoking 13.0% and cigar smoking 1.6% (Table 2). The mean age at which smoking commenced was 16.8 ± 1.1 years. The prevalence of smoking was 20.4%, 24.3% and 37.8% for those aged 13–15, 16–17 and 18–20 years respectively. The prevalence of smoking among first-year secondary students was 26.6%, second-year students 25.5% and third-year students 25.4%. Students in the literature programme had a slightly higher prevalence of smoking (28.2%) than their counterparts in the science programme (23.6%); the difference was statistically significant.
The educational levels of the parents of smokers and non-smokers were similar. Most smokers (58.1%) and non-smokers (54.2%) had fathers with middle educational levels. However, 34.8% of smokers’ mothers had low and 51.6% had middle educational levels. The comparative figures for non-smokers’ mothers were 40.7% and 47.0% respectively (Table 3). The occupational level of fathers and the employment status of mothers of smokers and non-smokers were also similar. Most fathers of smokers (60.6%) and non-smokers (63.8%) had middle occupational levels. Mothers of smokers (79.0%) and non-smokers (78.0%) were mostly unpaid workers in the family home. The majority of smokers (84.5%) and non-smokers (87.2%) lived with both parents. The remainder lived with one parent or other relatives.

Higher percentages of fathers, mothers, brothers, sisters, friends and teachers of non-smokers disapproved of student smoking (Table 4). The differences were statistically significant except for the attitude of fathers. The highest OR was obtained for the attitude of friends, followed by the mother’s attitude. Non-smokers were 3.32 times more likely (CI: 2.27–4.86) to have friends who disapproved of smoking and 2.40 times more likely (CI: 1.42–4.03) to have mothers who disapproved of smoking than smokers.
The smoking status of the mothers of smokers and non-smokers were similar (6.4% and 5.7% respectively). Student smokers were also twice as likely to have sisters who smoked; this difference, however, was not statistically significant (Table 5). The smoking status of fathers, brothers, best friends and favourite teachers were significantly different between smokers and non-smokers. Smokers were 4 times more likely to have smokers among their best friends. The ORs were similar for smoking by students’ fathers (1.87), brothers (1.86) and teachers (1.89) compared with non-smoking.
A higher percentage of non-smokers (47.2%) wanted to continue their education after age of 20 years compared with smokers (38.1%) and the difference was statistically significant (P = 0.028).

Discussion

Our study supports previous findings regarding the inability of the intense smoking control efforts in the 1980s and 1990s to reduce the prevalence of smoking in the population [19]. The overall prevalence of smoking among male secondary students (25.8%) in our study was higher than reported in 1982 (14.8%) and in 1989 (21.4%) [22,23]. This is partly explained by differences in the definitions of ‘smoker’; in the two previous studies the definition was restricted to cigarette smoking. Nonetheless, the prevalence of cigarette smoking in our study (21.0%) was similar to that reported in 1989 [23]. The inability to reduce prevalence might result from the success of tobacco advertising and promotional activities that target the young. The prevalence of smoking among male secondary students was also higher than reported in the Republic of Yemen (21.9%), Saudi Arabia (20.0%), Syrian Arab Republic (15.9%) and Oman (6.5%), but lower than in Kuwait (50.0%) [7,8,14,26]. However, these variations are partly due to the differences in the definition of smokers.
As in other countries, cigarettes were the most commonly used type of tobacco in our study, but other types, especially the water-pipe, are becoming increasingly popular among young males in Bahrain. For example, a study in Bahrain in the 1980s reported a 1.0% prevalence of water-pipe smoking among Bahraini males aged 20–29 years, whereas 13.0% of students aged 13–20 years in our study smoked water-pipes [20].
The level of education of the parents is a predictor of the uptake of smoking among the young, according to the United States Surgeon General’s Report [4]. This has also been reported in studies in the Region [13,14]. In our study, however, there was no difference in the educational level of parents of smokers and non-smokers, the occupational level of the father or the employment status of the mother. This may be due to the homogeneous socioeconomic status of students in government schools. However, the results should be regarded with caution as the reliability of student-reported data relating to parental education and occupation may be questionable.
Parental attitude towards smoking plays a major role in the uptake of smoking among the young. Many studies have shown that smoking is more common among young people whose parents have tolerant attitudes towards smoking by their offspring [27]. In our study, the fathers’ attitudes towards smoking were similar between smokers and non-smokers. However, the attitudes of mothers, sisters and brothers towards smoking by the student were significantly different for smokers and non-smokers. Most studies have consistently shown that parental smoking is strongly associated with youth smoking [12–14,27,28]. In our study, mothers’ and sisters’ smoking status were not associated with the student’s smoking status, but this may be due to the low prevalence of smoking among females in Bahrain [7,19].
Smoking by a best friend was reported as the main factor in the increase in smoking prevalence among adolescents in some Eastern European countries [29]. In a recent study in the United States of America, the smoking behaviour of the adolescent’s best male friends was constantly associated with the transition from non-smoking to regular smoking and from experimental smoking to regular smoking [30]. Peer influence was reported as the single most important factor in determining with whom and when smoking was initiated, and conversely, to influence young smokers to become non-smokers [2,31]. Previous studies in Bahrain identified the important role peers play in uptake of smoking among schoolboys [22,23]. In our study, the student’s smoking status and having a friend who smoked were strongly related to smoking and were statistically significant. Of the smokers, 43.2% stated that their best friend was a smoker compared with 15.4% of non-smokers. This was similar to studies in Bahrain [22,23], the Republic of Yemen [8], Kuwait [14], Saudi Arabia [12,13], Syrian Arab Republic [9] and elsewhere [17,18].
Many young people regard their teachers as role models and authority figures. Their attitudes towards smoking and their smoking habits can legitimize the habit of smoking among students. In this study, more smokers than non-smokers thought that their favourite teachers did not mind their smoking and believed that their teachers smoked.
A higher percentage of non-smokers (47.2%) planned to continue their education than did smokers (38.1%), which may reflect higher self-esteem among them. Smoking has been reported to be related to low self-esteem and low scores in school performance [11].
Conclusion

Our study strongly suggests that research needs to focus on the inadequacy of the current youth smoking control measures in Bahrain. School smoking control efforts should target parents, teachers and students and should start as early as primary school. Emphasis on the exemplary role of parents and teachers should be stressed in these programmes. Empowering young people with skills to resist peer pressure and to critically and objectively appraise their responses to the emotionally charged techniques used in the advertising and promotion of cigarettes by marketers and manufacturers should also be a priority. School ‘quit’ programmes should be considered to combat the addictive nature of tobacco. Finally, government commitment and social support are vital if these programmes are to be implemented and sustained.

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معدل انتشار التدخين بين البالغين من سكان لبنان
رفيق بدورة وكارول وهبه - شدياق

الخلاصـة: تم عشوائياً اختيار 727 شخصاً ممن بلغوا التاسعة عشرة أو تجاوزوها لتحديد معدل انتشار التدخين في لبنان، في إطار دراسة تستخدم فيها استبيانات إميل رو وفاغرستروم. وتم تعريف المدخّنين على أنهم كل من يجيب بكلمة نعم على السؤال القائل (( هل تدخن حالياً؟ )). وقد اعتبر إحراز 6 درجات فأكثر، بحسب ما حدَّده فاغرستروم، دليلاً على شدة إدمان النيكوتين. وتبيَّن من الاستبيان أن معدل انتشار التدخين قد بلغ 53.6%. وكانت نسبة المدخّنين إلى المدخِّنات 1.23%، وتم تصنيف 67% من المدخّنين كمدمنين. وكان سبب الفشل في الإقلاع عن التدخين مرتبطاً بأعراض الامتناع، وعلى رأسها التهيُّجية (57%) وزيادة الوزن (%20). وقد ذيِّلت الدراسة بتوصيات لمكافحة المعدلات المرتفعة للتدخين.

ABSTRACT To determine the prevalence of smoking in Lebanon, 727 individuals aged ³ 19 years were randomly selected for study using Emile Roux and Fagerstrom questionnaires. Smokers were defined as those answering "yes" to the question, "Do you currently smoke?" A Fagerstrom score ³ 6 indicated strong nicotine addiction. The prevalence of smoking was 53.6%. The male/female ratio was 1.23, with 67.0% of smokers categorized as addicted. Failure to quit was related to withdrawal symptoms, mostly irritability (57%) and weight gain (20%). Recommendations are given for combating this high prevalence of tobacco use.

Prévalence de l’usage du tabac dans la population adulte libanaise

RESUME Afin de déterminer la prévalence du tabagisme au Liban, 727 personnes d’âge ³ 19 ans ont été choisies au hasard pour l’étude en utilisant le questionnaire Emile Roux et le questionnaire de dépendance de Fagerstr&#246;m. Les fumeurs étaient définis comme ceux ayant répondu « oui » à la question « Fumez-vous actuellement ? ». Un score ³ 6 au questionnaire de Fagerstr&#246;m indiquait une forte dépendance &#225; l’égard de la nicotine. La prévalence du tabagisme était de 53,6 %. Le rapport hommes/femmes était de 1,23, 67,0 % des fumeurs étant classés dans la catégorie des dépendants. L’échec de l’arrêt du tabagisme était lié aux symptômes du sevrage, principalement l’irritabilité (57 %) et le gain de poids (20 %). Des recommandations sont données pour lutter contre cette forte prévalence de l’usage du tabac.

Introduction

Although cigarette consumption in the United States of America (USA) in the years 1986–1997 decreased by 17%, production of tobacco products in the USA during the period increased by 400%, with exports to other countries taking up the increased output. Particularly in countries of the developing world, consumption of tobacco products has increased as countries have absorbed the US export-led production. Given the power of the vested interests in maintaining this situation, multilateral arrangements aimed at controlling the epidemic of cigarette smoking are unlikely to be put in place and acted on any time soon [1]. Smuggling of tobacco products has come to play an increasingly significant role in the international tobacco trade, particularly in areas of the world suffering ongoing war and armed conflict. The increased tobacco consumption in developing countries experiencing demographic transition is likely to have an extremely negative impact on the health and well-being of the population of those countries. To reduce this impact, the World Health Organization has strengthened noncommunicable disease control and prevention in the developing regions, particularly in the Middle East.
Although data on smoking in Lebanon are limited, the magnitude of the problem is obviously great. Lebanon ranks fourth in the world in terms of the consumption of American cigarette brands, and nineteenth in terms of overall cigarette consumption [2]. In Lebanon, anti-smoking legislation is effectively non-existent. The trading and advertising of tobacco products constitute a significant part of the Lebanese economy. Tobacco advertising is completely unrestricted. The country’s mass media organizations are affiliated to the different political parties and they derive substantial revenues from tobacco and alcohol advertising. Many political leaders and social figures smoke during television interviews. Schools are rarely involved in educational programmes aimed at smoking prevention and control. Schools are not smoke-free areas, and most hospitals are still not smoke-free areas. Public campaigns on smoking-related health hazards remain limited to a single one-day activity throughout the year. Fieldwork is essentially carried out by nongovernmental organizations, which lack adequate support. The medical community is poorly committed to smoking prevention and awareness policies. Medical curricula do not include the community dimension of tobacco-related diseases. A review of the medical literature reveals that only a few studies on smoking in Lebanon have been carried out, most of which relate to specific categories of the population, such as patient groups or small social and professional groups [3–8]. Our survey aimed to assess the pattern of tobacco use in the Lebanese adult population: in particular, the prevalence of smoking, nicotine addiction and the quit ratio (QR).

Methods

In 1997, we surveyed a sample of the Lebanese population aged ³ 19 years, with 825 individuals randomly selected using a multilevel cluster sampling technique stratified by district. All individuals in the sample were asked to respond to a series of questions in a face-to-face interview, which was conducted by a trained team of young people of both sexes under the supervision of a private sector specialist survey management organization, IPSOS-STAT. The survey comprised four parts. The first part related to questions designed to elicit sociodemographic variables. The second related to smoking behaviour, for which an Emile Roux questionnaire was used. The third part was designed to determine a Fagerstrom score for nicotine addiction, and the fourth part used the Hamilton scale for anxiety and depression (HAD).
The sociodemographic variables elicited included age, sex, marital status, education and profession. Smokers were defined as those who answered "yes" to the question "Do you currently smoke?" Ever-smokers, among the non-smokers, were those who answered "yes" to the question, "Have you ever smoked before?", and non-smokers were those who answered "no" to both questions.
Smoking behaviour was described with respect to the following:

• circumstances of onset;
• duration of smoking;
• preferred time and place for smoking;
• factors inducing positive reinforcement (including: mental, e.g. the ability to cope with stress or to concentrate; and physical, e.g. the smell and taste of tobacco);
• factors inducing negative reinforcement (e.g. experiencing loss of memory, cough, expectoration).

Smoking behaviour was also described relative to the attitudes of respondents to the smoking habits of others, distinguishing between those who encouraged others to smoke, those who did not seek to influence the smoking behaviour of others and those who forbade others to smoke.
The intensity of smoking was measured by the quantity of tobacco smoked per day, whether in the form of cigarettes, cigars, cigarillos, pipe tobacco or hookah (shisha).
Nicotine addiction was measured using the Fagerstrom scale, which includes the following items:

• number of cigarettes per day;
• nicotine content, defined as regular, light and ultralight;
• inhaling or not inhaling tobacco smoke;
• smoking more in the morning or more in the afternoon;
• whether or not the preferred cigarette is early in the morning;
• the ability to abstain from smoking where forbidden, or while ill.

Each of the questions in this part of the survey were closed-end answer-type questions, with answers rated 0, 1, or 2, according to the associated level of addiction. The ratings were totalled to provide the respondent’s Fagerstrom score, for which a value ³ 6 is equivalent to the presence of significant nicotine addiction and ³ 8, to strong addiction.
Similarly for depression and anxiety-related symptoms, a score was calculated by summing the values obtained from answers to the HAD questionnaire, these being rated from 0 to 3, according to the associated level of depression or anxiety. A threshold of 12 is recommended for anxiety items and a threshold of 8 for depression items.
Statistical analysis included the chi-squared test for qualitative variables and an analysis of variance (ANOVA) for quantitative variables. A significance level of P < 0.05 was used.

Results

Prevalence of smoking

Our sample included 825 individuals, 727 of whom agreed to be surveyed (88% response rate). The mean age was 40.1 years [confidence interval (CI): 39.0–41.2], and the male/female ratio 0.95. Prevalence of smokers (Figure 1) was 53.6% (CI: 50.0–57.2). A greater percentage of smokers were male (male: 60.7% versus female: 46.9%, P = 0.00018), giving a male smoker/female smoker ratio of 1.23 (Figure 2). Our study showed prevalence varying with age (Figure 3). The highest prevalence (59.5%) was among 30–39-year-olds, an age group constituting 31.5% of the general population. The prevalence of ex-smokers was 13.7% (CI: 11.0–16.2).

Figure 1 Prevalence of smoking in the adult Lebanese population

Figure 2 Prevalence of smoking by sex in the adult Lebanese population

Figure 3 Prevalence of smoking by age in the adult Lebanese population

Smoking behaviour

The mean age at starting smoking was 19.7 years (CI: 19.3–20.3), with a range of 10–50 years; 90% had started before age 25 years. The average duration of smoking was approximately 20.4 years (CI: 19.0–21.8). Among ex-smokers, the average duration of smoking was approximately 14 years, and average duration of quitting was approximately 10 years. Cigarettes were the most common form of tobacco consumption, reported by 94.9% of participants. Among all types of cigarettes, filter cigarettes were the most widely smoked (95%), although most were brands containing high tar and nicotine levels. Other forms of tobacco consumption included shisha (14.6% of respondents), cigars (1.5%), pipe tobacco (1.3%) and cigarillos (0.5%). Of those who smoked the shisha, 63.2% did so daily, with half of this group smoking more than two pipes per day.
The average number or cigarettes smoked per day was 23.3 (CI: 21.7–24.9), although 20% smoked ³ 40 cigarettes/day, 67.4% smoked ³ 20 cigarettes/day, 15.9% smoked 6–19 cigarettes/day, and 10.8% smoked £ 5 cigarettes/day. The daily number of cigarettes smoked also varied by sex and professional status — males smoked 27.4 cigarettes/day and females 18.3 cigarettes/day (P < 0.000001); teachers smoked the least (16.8 cigarettes/day) and the unemployed the most (34.8 cigarettes/day) (P = 0.000001). Interestingly, there was no significant difference in daily consumption when analysed by level of education.
Positive reinforcement of smoking was reported by respondents to be more of a mental than a physical experience, with 55.9% reporting that they felt more able to concentrate when smoking, 82.3% reported obtaining relief from stress and 52.1% attributed increased alertness to their smoking. Only 18.6% reported that their smoking was positively reinforced by being able to manipulate a cigarette in their hands, while 44.7% said they appreciated the taste and 68.7% the smell of tobacco. Negative reinforcement of smoking was considered to be more physical than mental, with 43.3% reporting cough, 29.0% expectoration and 40.2% bad breath, as negative reinforcements; 12.0% reported memory troubles, 27.0% feelings of decadence and 46.0% feelings of guilt.

Tobacco addiction

The level of nicotine addiction, using the Fagerstrom score, averaged 6.4 (CI: 6.2–6.6) among all smokers, with 67.0% (CI: 62.24–71.76), scoring ³ 6 and 32.4% (CI: 27.66–37.14) scoring ³ 8. There was a statistically significant difference between the average score for males (6.8) and females (5.8) (P < 0.0001). However the Fagerstrom score did not correlate with age.

Quitting

The observed QR was 0.25, with an insignificant difference between males (0.23) and females (0.28) (P = 0.05). The QR increased significantly with age (P = 0.002), and varied by level of education and professional status. The average QR among individuals with a university level of education was 0.44, while among the unemployed it dropped to 0.05.
The ill-health effects of tobacco were reported as the reason for considering quitting by 83.5% of the sample. Principal reasons quoted were cancer (65.8%), myocardial infarction (63.6%), bronchial disease (66.2%) and premature ageing (51.5%). Only 45.4% of women quoted tobacco’s harmful effects on pregnancy. Medical counselling was reported by 43.3% and social influence by 40.7%. Feelings of being a prisoner of tobacco as a consequence of addiction were often a motivation to consider quitting. Proving oneself was reported by 64.5% of individuals.
Quitting smoking was frequently associated with withdrawal symptoms such as irritability and weight gain, reported by 57% and 20% of the participants respectively. Approximately 50% of the sample reported these reasons as being the reason for not quitting. Other reasons given were social or economic difficulties (17%) and a culture and environment in which tobacco products are widely promoted and accepted, readily available and frequently offered (13%).

Discussion

Our study revealed a smoking prevalence in the adult population in Lebanon of 53.6%. The percentage of ex-smokers was estimated to be 13.7%. By contrast, the reported prevalence of smoking in the USA in 1992 was 25.6% [9], and has continued to decline since that year, emphasizing just how unacceptable is the Lebanese prevalence. It is interesting to note that the prevalence of smoking among Lebanese immigrants living in the Detroit area is higher than that for the US population overall [2], although the prevalence among all inhabitants of the Detroit area may also be higher than the overall US prevalence. The prevalence of smoking in Lebanon is also higher than in western European countries. In France, the reported prevalence in 1992 was 40% [10], with a subsequently decreasing trend greatly accelerated after 1993 as a result of legislative restrictions on tobacco advertising. At the time of our study, the prevalence of smoking in western Europe overall was 33.1% among men and 29.0% among women [11].
Our study showed smoking prevalence in our population varying with age, with the highest prevalence among the 30–40 years age group. This is similar to what has been reported in the literature [10]. The proportion of smokers decreased progressively after the age of 60 years, not necessarily because people quit smoking by that age, but more likely because many fewer smokers live to that age than do non-smokers. The decrease seen in our sample is less than that observed in France, and is considerably delayed in comparison to the USA, where the proportion starts to decline around the age of 45 years [10,12]. By comparison, the results obtained in our study are similar to those obtained from other developing countries in the early eighties: China 56% (1981 figures); Egypt 40% (1982); India 61% (1985); Indonesia 61% (1984); and Tunisia 58% (1984) [1]. However, the ratio of male to female smokers in our sample more closely resembles that of the industrialized world [13].
The average age at starting smoking in our study was 19.7 years, with 90% of smokers starting smoking before the age of 20 years. In Western countries, the age at starting smoking is between 11 and 15 years, which not unexpectedly, is lower than what we observed (everyone aged < 19 years was excluded from our study) [14–16].
Intensity of smoking was also comparatively high in our population. The average daily number of cigarettes smoked daily was 23, compared to 15 in France, with 67.4% of our sample smoking > 20 cigarettes/day compared to 27% in the USA [12]. The figure for those smoking < 5 cigarettes/day (10.8% in our sample) is similar to that for the USA [17].
The average number of years of smoking in our sample was 20.4 years. Shisha, a particularity of oriental populations, is relatively common in Lebanon. In our sample, the percentage of individuals who reported smoking the shisha was 14.6%, two-thirds of whom were regular shisha smokers. This proportion is important since it has been shown that the urine cotinine level after two shisha is equivalent to that after 30 cigarettes [18].
The number of addicted individuals in our study was very high, with 67.0% of smokers having a Fagerstrom score ³ 6, and approximately one-third with a "highly addicted" Fagerstrom score of ³ 8.
Smoking in Lebanon is socially entrenched, with cigarettes commonly offered during many types of social occasions, both celebratory and sorrowful. Our study confirms the ready acceptance of smoking in our society, with 8.5% of smokers in our sample disposed to encourage others to smoke and 70% reporting that they like to offer and receive cigarettes. Furthermore, non-smokers in our sample were accepting of others’ smoking habits. Of the smokers in our sample, 13% who sought to quit reported that they were often discouraged from doing so by the temptations and pressures of a culture and environment where tobacco products are widely promoted and accepted, readily available and frequently offered.
Passive smoking in the general population is frequent. Non-smokers reported being exposed to a smoking environment in 93.7% of cases. One Iranian study assessing passive smoking among pregnant women reported that 39.75% were exposed to passive smoking [19], suggesting that passive smoking in developing countries deserves far greater attention than it has been given up to now.
Willingness to quit was reported by 59.2% of smokers in our sample, a figure which compares poorly with the USA and Western Europe, where information on the health hazards of tobacco consumption is widely disseminated [20,21]. In the USA, the proportion of women expressing their intention to quit in 1993 was estimated at 73% [22]. The QR there increased between 1965 and 1987 from 0.029 to 0.45 among both males and females (more among adults than teenagers), and thus contributed to the observed decrease in smoking prevalence among adults in that country [23]. The positive effect on quitting of knowing and being conscious of potential tobacco health hazards that we observed in our sample has been reported elsewhere in Europe [14]. The positive influence of environmental factors was reported by 40.7% of respondents in our study, and of medical counselling by 43.3%. Unfortunately, quitting remains a late event in smoking behaviour — the average number of years of smoking before quitting was approximately 19 years in our study, possibly because the ill-effects of smoking are often not readily apparent until a smoker is in his or her 40s and 50s.
It is relevant to note that medical intervention remains limited in Lebanon with regard to smoking prevention. Medical curricula are wanting in this regard, particularly as it has been shown that medical counselling increases the chances of an individual quitting (although it is insufficient by itself) [25].
Effective strategies to control and prevent smoking are essential to improving health outcomes of populations, particularly in countries where other factors predispose to less than optimal health, such as poverty, poor nutrition, polluted cities, and diversion of resources to armed conflict. While the need is most urgent in countries defined by their lack of adequate resources, most of the anti-smoking initiatives are being taken by the wealthier countries to protect their own populations. For example, in June 1996, the Council of State and Territorial Epidemiologists in the USA agreed to add smoking to the list of reportable diseases to the Centers for Disease Control and Prevention, thereby requiring the involvement of health professionals in anti-smoking public health policies [26]. The World Health Organization’s noncommunicable disease prevention and control programmes in developing countries are likely to boost community involvement — an important prerequisite for effective prevention and control of tobacco consumption. Prospective surveys are contemplated to measure the effectiveness of potential public health interventions [27]. The global burden of disease initiative can also trigger additional public health awareness of the negative impact on health of tobacco consumption [28].

Recommendations

Based on the results of our study, the following actions are needed in Lebanon to combat tobacco use.

• Promote sustainable prevention programmes to control the tobacco epidemic by targeting adolescents in schools and health professionals in health care facilities and medical faculties. Occupational health could be addressed from the perspective of the ill effects of direct and passive tobacco smoking.
• Enact and implement legislation to restrict tobacco advertising in electronic and print media and in public places, and to promote smoke-free areas and smoke-free television programmes.
• Create the necessary primary health care facilities supporting people who are considering quitting smoking. Such facilities would operate in collaboration with secondary care facilities.
• Plan and implement prospective surveys to assess the effectiveness of the implementation of the above-mentioned activities, to be carried out by academic institutions, in concert with the national policies aimed at preventing and controlling noncommunicable diseases, of which tobacco is a prominent risk factor.

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