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Smoking Habits and the in Uence of War on Cigarette and Shisha

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Smoking Habits and the in Uence of War on Cigarette and Shisha Smoking Habits and the Inuence of War on Cigarette and Shisha Smoking in Syria Ameer Kakaje ( [email protected] ) Damascus University Faculty of Medicine https://orcid.org/0000-0002-3949-6109 Mohammad M Alhalabi Damascus University Faculty of Medicine Ayham Alyousbashi Damascus University Faculty of Medicine Ayham Ghareeb Damascus University Faculty of Medicine Laura Hamid Damascus University Faculty of Medicine Ala’a B. Al-Tammemi Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary https://orcid.org/0000-0003-0862-0186 Research article Keywords: Smoking, Cigarette, Shisha, Middle East, Syria, War Posted Date: April 13th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-15601/v2 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published at PLOS ONE on September 2nd, 2021. See the published version at https://doi.org/10.1371/journal.pone.0256829. Page 1/14 Abstract Background: Tobacco smoking is a major risk factor for various preventable medical conditions. Our present study aimed at assessing Shisha and cigarette smoking in a sample of the Syrian population as well as assessing the interactions between smoking status and various war-related and sociodemographic variables. Methods: A community-based cross-sectional survey was conducted from March to April 2019 using an anonymous online questionnaire. The survey questionnaire solicited data on sociodemographic prole, medical history, smoking status and patterns along with some war-related impacts. Results: The sample comprised of 987 participants and had a mean age of 24.69 years. Around two-thirds of the overall cohort were females. Concerning smoking, a total of 371 participants (37.9%) were identied to be smokers, of whom 211, 84, 76 were exclusive shisha smokers, exclusive cigarette smokers, and dual smokers, respectively. Cigarette and shisha smoking was more common in males with p<0.0001. Males also smoked cigarettes and shisha daily, and in larger quantities than females p<0.05, while females were found to be more social smokers. Although cigarette smoking was more prevalent in older ages, shisha use was more prominent in younger ages. Losing someone close due to war was associated with smoking cigarettes p=0.002, and smoking in general p<0.001 Conclusions: In our study, males tend to smoke more and be heavier smokers than females while females smoked shisha more frequently and socially. War and peer pressure were among the major contributors to smoking. Policies should aim to target young adults as shisha is becoming more popular among them. 1. Background Tobacco smoking is a major risk factor for various preventable medical conditions with an estimation of eight million deaths every year. Smoking can cause substantial expenses for healthcare, and it can also contribute to poverty, as it is an addictive habit that can cause individuals to prioritize buying tobacco over their basic needs (1). Around 80% of smokers are living in developing countries. Second- hand smoking can also be harmful like rst-hand smoking, as it was proven to cause serious cardiovascular and respiratory diseases (1). On the other hand, shisha, also known as hookah, waterpipe or narghile, is a popular form of smoking that is more harmful than combustible cigarettes. It is becoming an epidemic and has been spreading since the 1990s, especially after the introduction of avored and aromatic shisha tobacco (known as Ma’assel) (2). Shisha smoking is considered a pleasurable social experience that may contribute to the growing popularity of shisha, while cigarette smoking is seen as a personal addiction (3). Shisha or Shisha is mostly smoked indoors in cafés, shisha bars, or at home, and this may harm many non-smokers who are exposed to second-hand smoking. Benzene and 3-hydroxypropylmercaptruic acid were found in the urine of second-hand smokers, while nitrosamine from tobacco and acrolein were found in children who lived with shisha smokers (4-6). Syria has been in war for ten years which left millions seeking refugee status in other countries while millions who remained in the country require humanitarian assistance as more than 80% of the population are under the poverty line. Moreover, mental disorders increased dramatically due to war and dicult living conditions such as Post Traumatic Stress Disorders (PTSD), depression, and anxiety (7). The war and its related psychological pressure may have serious impacts and could be associated with risky behaviours such as an increased rate of smoking or substance abuse. Moreover, Syria has a unique environment and practices such as the notable popularity of waterpipe/shisha smoking as a part of daily socialization and this might possess an effect on people and increase their susceptibility to certain disorders such as allergic rhinitis (8), and laryngopharyngeal reux (9). Shisha is most common among young people, as smoking amongst high school students in Syria reached a prevalence of 16% in males and 7% in females in 2000 (10). It has been over 10 years since a proper study was conducted on smoking in Syria and the possible war effects. Therefore, our present study aimed to assess smoking patterns in Syria during wartime, the prevalence of cigarette and waterpipe/shisha smoking, and their interaction with other variables, especially that shisha smoking was not previously examined when an individual is being exposed to certain events such as war crisis or stressful events, expensive costs of living, and political instability, that the majority of the Syrian population suffered from over the past 10 years. 2. Methods And Materials 2.1 Study Design and Sampling Page 2/14 This was an online questionnaire-based cross-sectional survey that was conducted in Syria from March 2019 to April 2019. The survey questionnaire was disseminated on social media groups to reach as a large proportion of the Syrian population as possible. Arabic- speaking individuals who lived in Syria in the past year were eligible to participate in the study. A convenience sampling technique was employed to recruit participants. 2.2 Questionnaire and Measures Basic sociodemographic data that were solicited included gender (male; female), age (in years), marital status (single; in a relationship; engaged; married; divorced; widowed) educational level (primary school; high school; college or higher institute certicate; masters or Ph.D.), the eld of education (medicine; pharmacy; dentistry; engineering; natural sciences; and social sciences including arts, literature, economy), the province of current residence (Damascus, Rif-Dimashq, and Aleppo; Homs and Hama; Al-Jazira region; Southern Syria; Syrian coast; and Idlib), employment status (employed; unemployed), type of work (laborer; trained worker or merchant; technician; post- graduate job ). Socioeconomic Status (SES) cannot reliably be assessed in Syria as asking for monthly income is not socially acceptable and due to the difference between the living expenses between Syria and other countries where SES questionnaires were validated (7). Nevertheless, SES in our study was assessed by using three items: education and profession of the providing family member, estimated monthly family income, and the profession of the respondent. As a result, SES was divided into ve different categories: lower, upper-lower, lower-middle, upper-middle, and upper. Also, participants were asked to report if they had any diagnosed medical condition (gastrointestinal; pulmonary; cardiac; endocrine; urinary; neurological; skeletal; asthma; allergic reaction), and whether they were on medications (no; yes, some supplements; yes, over the counter drugs; yes, prescribed drugs). Participants were requested to answer few items regarding war including changing the place of living due to the war, losing someone close, a relative being endangered by the war, and having distress from war-related noises. War- related items had yes/no responses. Smoking behaviors were assessed through ve items, two items were related to combustible cigarette smoking including the estimated number of packs smoked per day and duration of cigarette smoking in years, while three items were related to waterpipe/shisha usage behavior including the number of shisha sessions per week, duration of a single session, and the preferred time of day for smoking shisha. 2.3 Data Analysis Data were processed using IBM SPSS software version 26 for Windows (SPSS Inc, IL, USA). Chi-square test and one-way ANOVA were performed to determine statistical signicance between groups. Pearson correlations were also calculated. We calculated the odds ratio (OR) and 95% condence intervals (CI) for the groups using Mantel–Haenszel test. A two-tailed p-value less than 0.05 was considered statistically signicant. Also, Bonferroni correction was used to reduce type 1 error. Finally, many questions had missing data and we only excluded participants who did not respond to the basic demographic questions (gender and age). 2.4 Ethical Considerations The ethical permission was obtained from the faculty of medicine at Damascus University in Syria. All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained as a prerequisite before starting the questionnaire. This study did not include
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