INT J TUBERC LUNG DIS 8(7):882–889 © 2004 IUATLD

Prevalence and characteristics of narghile among university students in

W. Maziak,*† F. M. Fouad,* T. Asfar,* F. Hammal,* E. M. Bachir,* S. Rastam,* T. Eissenberg,‡ K. D. Ward§ * Syrian Center for Studies, , Aleppo, Syrian Arab Republic; † Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany; ‡ Department of Psychology, Virginia Commonwealth University, Richmond, Virginia; § Center for Community Health, University of Memphis, Memphis, Tennessee, USA

SUMMARY

SETTING: Narghile (waterpipe) smoking is increasing in narghile smoking was its social pattern, where most users all Arab societies, but little is known about its pattern of initiated and currently smoked narghile with friends. use. Narghile and smoking were related among stu- METHODS: In 2003, a cross-sectional survey was con- dents, with narghile smoking most prevalent among daily ducted among students at Aleppo University using an cigarette smokers. Multivariate correlates of narghile interviewer-administered questionnaire. A representa- smoking were being older, male, originating from the city, tive sample of 587 students participated (278 males, 309 smoking , having friends who smoke narghile, females; mean age 21.8 2.1 years; response rate and coming from a household where a greater number 98.8%). of narghiles were smoked daily. RESULTS: Ever narghile smoking was seen among 62.6% CONCLUSIONS: Narghile smoking is prevalent among of men and 29.8% of women, while current smoking was university students in Syria, where it is mainly practiced seen among 25.5% of men and 4.9% of women. Only by men, intermittently, and in the context of social activ- 7.0% of the men used narghile daily. Age of initiation ities with friends. was 19.2 2.2 and 21.7 3.2 years for men and KEY WORDS: narghile smoking; waterpipe; university women, respectively (P 0.001). The salient feature of students; prevalence; Syria

IN THE PAST FEW YEARS there has been an alarm- narghile smoking has been associated with low birth ing increase in narghile (waterpipe) smoking in the weight among pregnant women, and levels of nico- Eastern Mediterranean (EM) region.1 A national sur- tine or its metabolites in the blood and bodily fluids vey in Kuwait has shown that 57% of men and 69% of smokers can become higher after narghile smoking of women had used narghile at least once.2 The habit, compared to cigarettes.5,6 This increasingly popular which was traditionally confined to older men in Syr- method of tobacco use is thus an important public ian as well as other Arab societies, is now spreading health concern, and more work must be done to to other groups, notably women and youths. Data understand and curb its use.7 from the Global Youth Tobacco Survey (GYTS), per- Efforts to address the growth in narghile use in formed in 2001 in five Arab populations, shows that the EM region are hindered by the scarcity of data about 10% of youths 13–15 years of age use tobacco regarding this centuries old method of tobacco use, products other than cigarettes, most likely narghile.3 and building a knowledge base related to narghile is On the other hand, a recent study of smoking prac- therefore an important goal for scien- tices among Arab American adolescents found that tists in this region. Besides understanding the physio- 26.6% of the studied youths use narghile,4 emphasiz- logical effects of narghile use (e.g., toxicant exposure, ing the universality of the increasing trend of this dependence liability), understanding who uses it and form of smoking among Arabs. There is a common the social circumstances surrounding its use may be belief that this habit is associated with fewer adverse critical to prevention and treatment efforts. This study, health effects than cigarette smoking, due to the pur- the first to address the patterns of narghile smoking ported filtering effect of water through which the among university students in Syria, is part of a larger smoke passes before it is inhaled. Available evidence, project undertaken by the Syrian Center for Tobacco however, does not support this belief. For example, Studies (SCTS) aiming to characterize this method of

Correspondence to: Dr Wasim Maziak, Syrian Center for Tobacco Studies, P O Box 16542, Aleppo, Syrian Arab Republic. Tel: (963) 21 2644 246. Fax: (963) 21 2649 9150. e-mail: [email protected] or [email protected] Article submitted 10 July 2003. Final version accepted 25 November 2003. Patterns of narghile smoking in Syrian students 883 smoking on a variety of levels, using epidemiological, cess. For the purpose of analysis, year of study was behavioral, and clinical laboratory-based approaches.7 categorized into first year vs. advanced, and field of study into health-related, science-related, and arts, law, humanities. In addition to age of initiation, narghile SUBJECTS AND METHODS smokers were asked about their first attempt at This study’s target population is the 43 000 students narghile (alone, with friend/s, with family member/s); (studentship in 2001) of Aleppo University, the sec- current use of narghile (mainly alone, mainly with ond largest university in Syria which serves the north- others, no particular pattern); most common place of ern part of the country. On the Aleppo University cam- narghile smoking (open question); whether they usually pus there are 12 men’s and 7 women’s dorms, each shared the same narghile with others (if yes, they were with approximately 700 students. The study was a asked about the person they usually shared narghile cross-sectional survey of the population, using an inter- with as an open question); periodic increase of nar- viewer-administered questionnaire. ghile smoking (if yes, when and why were asked as Four women’s and four men’s dorms were selected open questions). Narghile smokers were asked about randomly from all 19 dorms in an attempt to obtain the type of narghile tobacco they smoked, categorized a representative sample of university students of all into Maasel (a new specially flavored narghile tobacco), fields and grades. Within each selected dorm a sampling Ajami (a traditional form of narghile tobacco), or frame was prepared, whereby interviewers would other. Both narghile and cigarette daily smokers were sample one participant from each room (3–4 students/ asked about their monthly expenditure on smoking. room) in the dorm until about 75 participants from Finally, the participants were asked about the number each dorm were recruited. The questionnaire was and smoking habits (narghile only, cigarettes only, developed in Arabic from relevant instruments used both) of close friends and adult household members for the assessment of cigarette smoking (Inter- (in their family house). national Union Against Tuberculosis and Lung Disease Because of the difficulties in assessing economic [IUATLD], World Health Organization [WHO]), and status in the Syrian society, income was assessed indi- from previous questionnaires used in Syria,8–10 modi- rectly using the density index (DI), a proxy measure fied to suit narghile smoking. Prior to use, to maxi- developed and tested previously,12,13 which is calcu- mize item clarity and relevance, the questionnaire was lated by dividing the number of household members modified based on testing with members of the target by the number of rooms in the house. population. Because of the traditional nature of the Syrian soci- Statistical analysis ety, the questionnaire was administered to each sub- Measures of central tendency were calculated for ject by an interviewer of the same sex . For this pur- continuous variables and expressed as mean stan- pose four male and four female surveyors underwent dard deviation (SD). Study participants were strati- a special 4-hour training course on survey and question- fied according to their narghile smoking status and naire administration, based on WHO World Health basic socio-demographic indicators. Comparison in Survey guidelines,11 delivered by SCTS researchers narghile use was made across gender, where dichoto- experienced in survey methodology.10 The protocol and mous variables were compared using the 2 test, and informed consent document were approved by the Insti- continuous variables using the Student’s t-test or the tutional Review Boards of the SCTS and the University Mann-Whitney test, as appropriate. Two-sided tests of Memphis. The questionnaire was anonymous and were used, with an level of 0.05 considered accept- informed consent was obtained prior to all interviews. able. Open-ended questions were summarized individ- The survey was conducted in 2003. Ever narghile ually and common themes were identified, grouped, smoking was defined as ever having smoked narghile; and coded for further analysis. Logistic regression anal- current narghile smoking was identified based on ysis was performed to assess correlates of narghile responses to a question about past month narghile smoking in the population studied. The main socio- use; daily narghile smoking was defined as any cur- demographic variables and variables known or sus- rent narghile smoking on a daily basis; and occasional pected of having a relation to narghile smoking based narghile smoking was defined as any current narghile on the medical literature were entered in the model smoking not occurring on a daily basis. These defini- and were allowed to be backward eliminated based tions were adapted from WHO guidelines,9 and were on the Wald statistic (Table 1). Adjusted odds ratios also used for cigarette smoking in this study to allow (OR) and 95% confidence intervals (95%CI) were for comparison. Daily narghile and cigarette smokers reported for correlates of the outcome variable. were asked about consumption patterns and about time of first narghile/cigarette smoked in the morning RESULTS (categorized into within 1 hour of waking up vs. later). Ex-cigarette smokers (ex-daily smokers) were A total of 592 participants were sampled; five indi- also asked about number of quit attempts before suc- viduals were not Syrian citizens and data from these 884 The International Journal of Tuberculosis and Lung Disease

Table 1 Logistic regression analysis of correlates of narghile women students (P 0.001). Most narghile smokers smoking among university students in Syria (97.7%) smoked Maasel. Distribution of narghile OR* 95%CI smoking according to the basic characteristics of the study population showed distinctive gender, age, and Age 1.1 1.0–1.3 Sex (male vs. female) 3.8 1.9–7.5 economic status related patterns (Table 2). In addi- Residence (city vs. country) 1.7 0.9–3.0 tion to being more likely to be male, narghile users Current cigarette smoking 4.1 2.3–7.4 were slightly older than non-users and had a lower den- Total number of narghiles smoked daily in the house 2.1 1.2–3.5 sity index, suggesting a higher average socio-economic Number of close friends smoking only narghile 1.7 1.4–2.0 status. Daily narghile and cigarette smokers spent on Number of close friends smoking both narghile average 680 507.0 and 858 431.8 Syrian Lira and cigarettes 1.2 1.1–1.4 (50 Syrian Liras US$1) monthly, respectively. * Adjusted odds ratio with the following variables entered in the model: age; Cigarette smoking was reported by 30.9% (24.8% sex; residence; year of study; field of study; religion; marital status; number of close friends smoking (only narghile, only cigarettes, both); number of daily and 6.1% occasional) of men and 7.5% (5.2% adults in house smoking (only narghile, only cigarettes, both); total number daily and 2.3% occasional) of women. Men who of narghiles smoked daily in the house; total number of cigarettes smoked daily in the house; and DI. were daily cigarette smokers consumed 16.3 7.7 OR odds ratio; CI confidence interval; DI density index. cigarettes on average, compared to 13.5 7.3 ciga- rettes for women (P 0.19). Among daily cigarette individuals were excluded from all subsequent analy- smokers, 58.8% smoked within an hour of waking ses. Of the remaining 587 individuals, 52.6% were fe- up; these consumed, on average, more cigarettes per male. Age ranged from 18 to 30 years, with a mean of day (18.3 7.3) than non-first hour smokers (12.1 21.9 2 and 21.6 2.1 years for male and female 6.7) (P 0.01). Age at initiation of daily cigarette students, respectively. The response rate was 98.8%. Ever narghile smoking was seen among 62.6% of Table 3 Prevalence and basic characteristics of narghile men and 29.8% of women, while current narghile smoking among university students in Aleppo, Syria smoking was seen among 25.5% of men and 4.9% of women. Only 7.0% of male narghile smokers (5/71) Men Women were daily users, with no daily narghile users among n (%) n (%) women. No daily user smoked narghile within 1 hour Narghile smoking Ever 174 (62.6) 92 (29.8)* of waking. Age of initiation of narghile smoking was Current 71 (25.5) 15 (4.9)* 19.2 2.2 years for men and 21.7 3.2 years for Daily 5 (1.8) 0 (0) First attempt at narghile Alone 2 (2.8) 0 (0) Table 2 Basic characteristics of the study’s population With friend/s 61 (85.9) 8 (53.3) in relation to current narghile smoking With family member/s 8 (11.3) 7 (46.7) Current use of narghile Narghile Narghile Mainly alone 1 (1.4) 0 (0) smokers non-smokers Mainly with others 62 (87.3) 7 (46.7) n (%) n (%) No particular pattern 8 (11.3) 8 (53.3)* Sex Sharing the same narghile 68 (95.8) 15 (100) Men 71 (25.5) 207 (74.5) Person narghile usually shared with† Women 15 (4.9)* 294 (95.1) Friend 68 (100) 10 (66.7) Residence Family member 0 (0) 5 (33.3)* Urban 43 (16.0) 225 (84.0) Most common place for narghile smoking Rural 43 (13.5) 276 (86.5) Home 15 (21.1) 3 (20) Year of study Dorms 26 (36.6) 4 (26.7) First 20 (13.3) 130 (86.7) Friend’s places 5 (7) 1 (6.7) Advanced 66 (15.1) 371 (84.9) Cafes/restaurants 19 (26.8) 5 (33.3) Field of study Other/no specific answer 6 (8.5) 2 (13.3) Health-related 12 (10.2) 106 (89.8) Periodic increase in narghile smoking 48 (67.6) 12 (80) Science-related 50 (17.7) 233 (82.3) Period of increase in narghile smoking‡ Arts, law, humanities 24 (13.0) 161 (87.0) Holidays 10 (20.8) 5 (41.7) Religion Exams 10 (20.8) 0 (0.0) Muslim 81 (14.5) 478 (85.5) Season (summer/spring) 26 (54.2) 5 (41.7) Christian 5 (18.5) 22 (81.5) Time of stress/happiness 1 (2.1) 1 (8.3) Marital status Ramadan 1 (2.1) 1 (8.3) Married 1 (20) 4 (80) Reason for increase in narghile smoking‡ Single 85 (14.7) 493 (85.3) Weather and outdoor recreation 13 (27.1) 2 (16.7) Mean SD Mean SD Stress relief 9 (18.8) 1 (8.3) Meeting and socializing with friends 8 (16.7) 7 (58.3) Age, years 22.3 2.3† 21.7 2.0 Time availability and boredom 16 (33.3) 2 (16.7) Economic status (DI) 2.0 0.7† 2.2 0.9 Other/no specific answer 2 (4.2) 0 (0.0)

* P 0.05 for 2 analysis by narghile smoking. * P 0.05 for 2 analysis across gender. † P 0.05 for comparison of means by narghile smoking. † Asked as an open question to students reporting narghile sharing. SD standard deviation; DI density index. ‡ Asked as an open question to students reporting periodic increase. Patterns of narghile smoking in Syrian students 885

Table 4 Relation between current narghile and cigarette smoking among university students in Aleppo, Syria

Narghile Narghile smokers non-smokers n (%) n (%) Current cigarette smoking Yes 41 (37.6) 68 (62.4) No 45 (9.4) 433 (90.6)* Frequency of cigarette smoking Daily 33 (38.8) 52 (61.2) Intermittent 8 (33.3) 16 (66.7) Ever daily cigarette smoking (ex-smokers) Yes 8 (36.4) 14 (63.6) No 37 (8.1) 419 (91.9)* Mean SD Mean SD Number of quit attempts† 3.6 6.7 3.1 3.3 Age at initiation of daily cigarette smoking‡ 18.8 2.4 19.1 2.2 Current daily consumption of cigarettes‡ 14.3 6.2 16.7 8.4 Number of adults in the household 4.5 1.5 4.8 2.0 Number of adults within household smoking Only narghile 0.4 0.9 0.2 0.6 Only cigarettes 0.9 1.2 0.9 1.0 Both 0.3 0.7 0.2 0.5§ Number of close friends 6.6 4.5 5.2 3.2§ Number of close friends smoking Only narghile 1.5 2.4 0.4 0.8§ Only cigarettes 1.5 2.3 0.9 1.7§ Both 2.4 3.4 0.6 1.5§ Number of narghiles smoked daily in the house 0.3 0.8 0.1 0.4§ Number of cigarettes smoked daily in the house 15.9 23.0 13.6 20.2

* P 0.05 for 2 analysis across narghile smoking status. † For ex-daily cigarette smokers. ‡ For daily cigarette smokers. § P 0.05 for the difference in means. SD standard deviation. smoking was 18.7 2.1 years for men compared to of people living in their households who smoked 20.4 2.3 years for women (P 0.01). narghile and who used both narghile and cigarettes. Because of the importance of gender differences in In addition, narghile users had a greater number of the smoking behaviors in this region,10,14 Table 3 close friends who smoked narghile, cigarettes, and describes various indices related to patterns of both narghile and cigarettes. narghile use stratified by gender. Data in Table 3 show Results of the logistic regression analysis for corre- the dominant social character of narghile smoking in this population, especially for men. The vast majority of men who smoked narghile initiated smoking, cur- rently smoked, and even shared the same narghile with friends. This pattern was observed, although not as distinctly, in women students, of whom approxi- mately half first smoked narghile with family members and reported no particular pattern to their current use in terms of whether they smoked alone or with others. For both men and women, narghile smoking occurred most commonly in dormitories or cafes/restaurants, and was most likely to increase during exams and dur- ing the spring or summer. Narghile and cigarette smoking were closely related in this sample (Table 4), with narghile smoking most prevalent among daily cigarette smokers (Figure). Narghile users also re- Figure Relation between cigarette and narghile smoking ported greater exposure than non-users to both among university students in Aleppo, Syria. * For difference be- narghile and cigarette smoking in their social environ- tween narghile smoking levels according to different cigarette ments. Narghile users had a greater average number smoking categories. 886 The International Journal of Tuberculosis and Lung Disease lates of narghile smoking among the population studied related patterns in the future or among younger sec- are shown in Table 1, where age, male sex, city resi- tions of society cannot be excluded. This argument is dence, cigarette smoking, friends’ narghile smoking, supported by recent data from Arab American adoles- and number of narghiles smoked daily in the house cents, where most smokers in a focus group study had showing significant association with narghile smoking. their initial smoking experience with narghile, and not cigarettes.17 Other distinctive features in the pattern of use between narghile and cigarettes seen in this popu- DISCUSSION lation were the intermittent vs. daily use of narghile Given the dearth of epidemiological data describing and cigarettes, respectively. Again, considering the different aspects of this potentially major public mean age at initiation of narghile use (19.6 years) and health problem in the EM region,7 this study provides the mean age of the participants (21.7 years), these the first insights into the spread and characteristics of narghile smokers may have been surveyed relatively narghile smoking and a detailed description of narghile early in their narghile use, so that surveys among older use among university students in Syria. According to narghile users may report more daily use. Moreover, our results, narghile smoking among university stu- unlike cigarette smoking among youths, for which there dents has become popular, with about half having is no usual place of smoking,12 our study elicited a ever smoked and about a quarter of males currently spatial pattern of narghile smoking where students smoking narghile. Although we have no previous esti- smoked mainly in dorms and in cafés/restaurants, mates to compare them with, these results suggest a especially in association with outdoor recreation with dramatic increase in narghile smoking among youths friends. in Syria, as the practice was uncommon in Syria and This last observation takes us to the main trait other Arab countries only a decade ago.15,16 Similar to revealed in this study, which is the social nature of cigarette smoking in the Syrian society,10 a male pre- narghile smoking in the population studied. We dominance was seen again with the narghile, as its use already know that cigarette smoking plays a bonding was five times higher in male than female students. The and group belonging role among youths.3,12,17,18 The study also gives novel information about cigarette social dimension of narghile smoking, however, is smoking among university students in Syria, where taken to a new level where narghile smoking among current smokers constitute about a third of male stu- university students is not so much a social identity as dents and less than a tenth of female students, and a means for socialization with others and an activity where, unlike the narghile, most cigarette smokers are rarely practiced outside the social context. Only two daily smokers with signs of nicotine dependence. Of current narghile smokers first smoked narghile alone, particular interest in this study is the social nature and only one of 86 current narghile smokers among of narghile smoking: most narghile smokers initiated students mainly smoked alone. It seems that narghile smoking, currently smoked, and even shared the same smoking in this population is something practiced narghile with friends. The seasonal pattern of narghile when students wish to socialize, and thus friends, free smoking related to outdoor leisure time and socializa- time, and the narghile become essential elements defin- tion with peers emphasizes the predominance of the ing leisure for these students. Moreover, narghile social pattern of this smoking method. smokers in our population not only tend to have more The distinctive gender- and age-related pattern of friends than non-narghile smokers, but are also more cigarette smoking, previously observed in Syria as well likely to have narghile-smoking friends, indicating as in other Arab countries,10,14 was again evident with how the habit can shape the social environment of narghile, whereby female students smoke less and start youths. According to Kamel Chaouachi, of the Uni- narghile smoking later than their male counterparts. versity of Paris, an important component in the socio- As narghile is closer to the local traditions and may be anthropological dimension of narghile lies in the less subject to taboos related to women’s cigarette peculiar conviviality the artefact generates. He identified smoking in Syrian society, we anticipated less gender three main elements related to this issue: playing with difference in patterns of narghile use. Nonetheless, the the flexible tube, the conversation, and the passage late pattern of initiation of narghile smoking among of time within the situation created.19 Thus, a multi- women suggests that this population of young students disciplinary research approach combining medical might not reflect the real spread of narghile smoking and socio-anthropological sciences seems optimal for among adult women in Syrian society. On the other the study of the narghile. The dominance of the social hand, based on this survey and previous data on ciga- dimension in narghile smoking is also evident in the rette smoking among adolescents,12 it would seem that very common practice of sharing the same narghile, cigarette smoking dynamics precede those of narghile where friends are the main smoking companions. Shar- among young people in Syrian society. We must be ing the same narghile, on the other hand, raises an careful in ascertaining such a pattern, however, given additional health concern related to the potential to that the current surge in narghile use is only a few spread infectious agents (TB, herpes, and even SARS) years old, and the likelihood of seeing different age- by this means, particularly given that the temperature Patterns of narghile smoking in Syrian students 887 of the narghile smoke coming out of the mouthpiece are expected to share the neuropharmacological com- is usually equal to that of the ambient air.20 ponent of nicotine-related addiction. Alternatively, The predominance of intermittent and social patterns youths with negative attitudes towards smoking can of narghile use observed in this study has some impli- presumably easily identify narghile as another form cations for our ability to adopt measures, definitions, of smoking. In a broader sense, it is possible that and concepts used for the assessment of cigarette smok- the social environment (family, friends) that favors ing and dependence for narghile. First, the intermittent, the adoption of one type of smoking will also influ- seasonal, and most likely irregular use of narghile ren- ence the other. Given all these arguments, our data ders measurement of frequency of use (daily vs. occa- suggest a novel notion, where environment-specific sional; daily consumption) less informative in assess- cues for one type of smoking can exist in addition to ing dependence on narghile compared to cigarettes. cues related to smoking in general. This is supported Very few students in our population smoked daily or by the findings that only friends who smoke narghile consumed more than one narghile per day, and even if and number of narghiles smoked in the household we consider daily use as a strong indicator of depen- were related to narghile smoking among students, dence, the time and setup needed for narghile prepa- while similar cigarette-related indices did not relate to ration can make questions about the first narghile narghile smoking among students. Moreover, in contrast smoked in the morning unnecessary. Unlike ciga- to our previous results showing no relation between rettes, where daily consumption was strongly associ- city residence and cigarette smoking,23 our current data ated with time of first cigarette smoked in the morn- suggest that narghile smoking can have an urban trend. ing in our population, these indices offered no insights We recognize some limitations in this study. First, for the assessment of narghile dependence. In this the estimation of narghile smoking into only two cat- regard, the intermittent and social nature of cigarette egories of use, daily and occasional, has obscured dif- smoking seen in adolescents can provide a useful model ferent levels of use in this particularly intermittent that can be adopted for the assessment of narghile form of smoking in our student population. However, dependence. Measures used to assess the evolution of because of the lack of data related to the patterns of cigarette dependence among adolescents, such as the use of narghile, we opted to use the same categories Hooked on Nicotine Checklist (HONC),21 are thus usually used with cigarette smoking to allow for a likely to be of value in informing the development of comparison of patterns of use of the two methods. assessment tools for narghile dependence. Second, the Also, analysing responses to open-ended questions is strong association between narghile and cigarette smok- problematic, and concerns are always raised about ing in the population studied makes it hard to study the misinterpretation or misclassification of responses. We evolution of narghile-induced nicotine dependence. To dealt with such questions, however, with extreme address these challenges we intend to study adult care using the exact words of respondents in the first narghile smokers in cafes and restaurants in Aleppo, stage to record responses. In the next stage responses in anticipation of identifying more regular patterns of were sorted into different categories until we had no smoking as well as individuals who use narghile only, new information, and in the final stage we grouped without concurrent use of other tobacco products. categories that gave the same information. The same Although the social context seems different between procedure was repeated by a separate investigator cigarette and narghile smoking, both practices are and all differences were dealt with on a case by case closely associated in this population, where cigarette basis. On the other hand, we believe that for ques- smokers are about four times more likely to be narghile tions about which we have no prior information such smokers than non-cigarette smokers. In addition, an approach is preferred to using prepared categories narghile smokers are more likely to be ex-smokers without sufficient formative work. (former daily cigarette smokers), raising the possibil- The current study provides timely insight into the ity that some cigarette smokers might have substi- spread and patterns of use of a rapidly increasing tuted cigarettes with narghile. The fact that narghile smoking habit in all EM countries, and among Arabs smokers who were ex-smokers had more quit attempts worldwide. The young students in this population, espe- before successfully quitting cigarettes can give sup- cially women, are at their initial stages of narghile use port to this idea, which does not exclude other expla- where intermittent and seasonal patterns predomi- nations such as that narghile is gaining ground among nate. Two levels of factors appear to be connected to society groups where is more prev- narghile smoking in this population: the first is broad alent (upper classes). This issue requires further study and generally related to smoking, while the second is because of its implications on cessation. On the other more narghile specific. Narghile smoking in this con- hand, it is likely that the addictive nature of tobacco text has social, temporal, and spatial patterns distinct and general attitude towards smoking would render from cigarette smoking, each of which merits further cigarette smokers more susceptible to narghile. 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RÉSUMÉ

CADRE : Le fumage au narghilé (pipe à l’eau) augmente ghilé est son caractère social, puisque la plupart des uti- dans toutes les sociétés arabes et on sait très peu au sujet lisateurs ont commencé à fumer et fument actuellement des modalités de son utilisation. le narghilé avec des amis. Le fait de fumer le narghilé est MÉTHODES : En 2003 on a mené une enquête transver- en étroite relation avec le fumage de cigarettes dans cette sale parmi les étudiants de l’Université d’Alep en utili- population où le fumage au narghilé est le plus prévalent sant des questionnaires administrés par des interviewers. parmi les fumeurs quotidiens de cigarettes. Les corréla- Un échantillon représentatif de 587 étudiants a participé tions multivariées du fumage au narghilé parmi les étu- à cette étude (278 hommes, 309 femmes ; âge moyen diants sont le fait d’être plus âgé, de sexe masculin, de 21,8 2,1 ans ; taux de réponse 98,8%). provenir d’une résidence urbaine, de fumer des cigarettes, RÉSULTATS : La prévalence des fumeurs ou ex-fumeurs d’avoir des amis fumant le narghilé et de provenir d’un au narghilé a été de 62,6% chez les hommes et de 29,8% ménage où un plus grand nombre de narghilés sont fumés chez les femmes, alors que le fumage actuel existait chez quotidiennement. 25,5% des hommes et 4,9% des femmes. Sept pour cent CONCLUSIONS : Le fumage au narghilé est prévalent seulement des hommes fumaient le narghilé de façon parmi les étudiants universitaires en Syrie, où il est pra- quotidienne. L’âge d’initiation est en moyenne de 19,2 tiqué principalement par les hommes de façon intermit- 2,2 ans chez les hommes et de 21,7 3,2 ans pour les tente ainsi que dans le contexte d’activités sociales avec femmes (P 0,001). Le trait principal du fumage au nar- leurs amis. Patterns of narghile smoking in Syrian students 889

RESUMEN

MARCO DE REFERENCIA : El hábito de fumar el narguile principal del hábito de fumar narguile es su connotación (pipa de agua) está aumentando en todas las sociedades social, dado que la mayoría de los fumadores se habían árabes y se sabe muy poco sobre las modalidades de este iniciado y fumaban actualmente en compañía de amigos. método de su utilisación. En esta población, había una estrecha relación entre MÉTODO : En 2003 se llevó a cabo un estudio transver- fumar narguile y fumar cigarrillos, con mayor prevalen- sal en los estudiantes de la Universidad de Aleppo, utili- cia del hábito de fumar narguile entre los fumadores zando un cuestionario administrado por entrevista. Una cotidianos de cigarrillos. El análisis multivariado muestra muestra representativa de 587 estudiantes participaron una correlación entre la prevalencia del hábito de fumar en este estudio (278 hombres y 309 mujeres : el prome- narguile y la edad, el sexo masculino, el origen de una dio de edad era de 21,8 2,1 años y la tasa de respuesta residencia urbana, el tabaquismo de cigarrillos, el hecho fue de 98%). de tener amigos que fuman narguile y el hecho de prove- RESULTADOS : El 62,6% de los hombres y el 29,8% de nir de un hogar donde se fuma diariamente un gran las mujeres habían fumado narguile alguna vez y el número de narguiles. 25,5% de los hombres y el 4,9% de las mujeres fumaban CONCLUSIÓN : El hábito de fumar narguile es prevalente en el momento de la encuesta. Sólo el 7% de los hombres en los estudiantes universitarios de Siria y es practicado fumaba narguile diariamente. La edad de iniciación era principalmente por los hombres, de manera intermitente de 19,2 2,2 años para los hombres y de 21,7 3,2 y en un contexto de actividades sociales con amigos. años para las mujeres (P 0,001). La característica