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Smoking in Syria: Profile of a Developing Arab Country

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Smoking in Syria: Profile of a Developing Arab Country INT J TUBERC LUNG DIS 6(3):183–191 REVIEW ARTICLE © 2002 IUATLD Smoking in Syria: profile of a developing Arab country W. Maziak Institute of Epidemiology and Social Medicine, University of Muenster, Germany SUMMARY One of the main obstacles to tobacco control in the Middle among youths with low academic performance or socio- East lies in the shortage of reliable, standardised data on economic status. Smoking in women, evaluated by data the spread and patterns of tobacco use in society. In from physicians, tends to start later than in men and Syria, a project aiming at drawing an epidemiological continues to increase with age. Women’s smoking in map of the tobacco epidemic in this country was started Syria is related to their level of social liberalisation. Data 4 years ago. Overall, nine studies have resulted, with a show that active smoking is associated with an increased total of 6780 participants. The crude prevalence of cur- risk of respiratory diseases among smokers, and that rent smoking among adults in Syria, based on combined exposure to environmental tobacco smoke (ETS) is asso- information from all studies, is 48% and 9% for males ciated with an increased risk of respiratory symptoms in and females, respectively. The prevalence of current children. Knowledge about the harmful effects of smok- smoking among high school adolescents is 16% and 7% ing and the desire to quit are disproportionate to the rate for boys and girls, respectively, and was strongly associ- of successful cessation. The evidence collected indicates ated with parental and sibling smoking. High school stu- possible avenues for tobacco control in Syria, including dents from families with parents and/or siblings who price increases, smoking cessation programmes, restric- smoked were 4.4 times more likely to be current smokers tion of adolescents’ access to cigarettes, and intensive than those from non-smoking families. The biggest prevention work among women. influx of new smokers among males in Syria is occurring KEY WORDS: smoking; epidemiology; profile; Syria in the early twenties, but an earlier pattern can occur FOUR YEARS AGO a project aiming at providing a students and physicians. Nine studies resulted from descriptive picture of the spread, patterns and dynam- this project, with a total of 6780 participants, looking ics of tobacco smoking in Syria was started. Prior to at different aspects of the smoking problem in differ- that, there were no published data about smoking in ent groups of Syrian society (Table 1). All categories Syria, other than the official figures for annual per of smoking behaviour used in these studies were stan- capita cigarette consumption, which do not account dardised according to World Health Organization for the huge illegal traffic of cigarettes in Syria.1 (WHO) guidelines,12 to allow for comparison between The task, however, was troublesome. In order to studies and with the international literature. Only cig- obtain an overall estimate of the smoking prevalence arette smoking was investigated in these studies, as of adults in Syria, we needed to assess smoking in a this constitutes the most common form of regular sample representative of this population, or at least of tobacco use in Syria. part of it, such as adults in a major city such as Aleppo. This review summarises the results of these studies This proved either very difficult to do or required re- in order to provide an overall epidemiological map of sources beyond our capacity. On the other hand, poor the smoking epidemic in Syria. The information pro- registries and demographic information hindered the vided in this report represents an important docu- application of standard, systematic sampling proce- mentation of various facets of the smoking problem dures. Furthermore, other survey options such as ran- in a developing country model. It can also be of value dom telephone or mail surveys are not suitable for to other countries in the Middle East, which share Syria because of the unequal levels of access to these many aspects of Syria’s socio-demographic makeup. means of communication in this country.2,3 Furthermore, some of the populations studied in We therefore opted to look at smoking in sub- Syria and reported here are amongst those that are populations of the society, such as low-income women, traditionally under studied in the Middle East, such Correspondence to: Wasim Maziak, Institute of Epidemiology and Social Medicine, Domagkstr. 3, 48129 Muenster, Ger- many. Tel: (149) 0251 83-55649. Fax: (149) 0251 83-55300. e-mail: [email protected] Article submitted 19 June 2001. Final version accepted 26 November 2001. 184 The International Journal of Tuberculosis and Lung Disease Table 1 The prevalence of smoking among Syrian males and females according to different studies Response Smoking Smoking Sample rate Mean males females Population Survey method/year size (%) age (%) (%) Adults in Aleppo2 Mail survey/1997 313 39.0 39 45.2 —* High school students, Aleppo4 Self-administered questionnaire/1998 1587 96.6 15.9 15.9 6.6 Physicians in northern Syria5 Self-administered questionnaire/1998 863 98.0 42 40.7 11.4 Schoolteachers in northern Syria6 Self-administered questionnaire/1999 314 90.0 35 52.1 12.3 Patients of paediatric clinics in Aleppo7 Physician-administered questionnaire/ 1859 97.0 — 57.5 7.5 1998 University students in Aleppo8† Self-administered questionnaire/1999 576 93.0 20 23.3 — Military recruits in northern Syria9† Self-administered questionnaire/1999 596 98.0 20 46.1 — Low-income women in Aleppo10 Interviewer-administered questionnaire/ 412 97.2 28 — 16.5 2000 Low-income women in Aleppo11 Interviewer-administered questionnaire/ 260 88.0 29 — — 2000 * Sample size too small. † Only males were studied. as low-income women, schoolteachers and military A note of caution should be mentioned here re- recruits, offering an important glimpse of the smok- garding the overall estimate of smoking among ing problem in these populations. women. The biggest sample of women that was in- Before moving to a description of smoking profiles cluded in the calculation of this estimate comes from in Syria, I would like to point out some of the limita- the study on the effects of environmental tobacco tions of the current review. First, the overall preva- smoke (ETS) on the health of children.7 The informa- lence rates of adult smoking in Syria were arrived at tion about parental smoking in this study, which in- by calculating the unweighted means of different cluded 1859 families, was collected by physician- prevalence estimates for the different populations administered questionnaires (Table 1), mainly from studied. This does not necessarily reflect the smoking mothers who accompanied their children. As women prevalence of adults in Syria, as the populations studied are less likely to report their smoking behaviour are not representative of the Syrian society as a when presenting to the physician with a sick child, it whole. Second, all studies were cross-sectional sur- is likely that the low prevalence of women’s smoking veys, and as such should be interpreted within the reported in this study (7.5%) was an underestimate context of this design, especially when comparing dif- that subsequently considerably reduced the overall ferent age groups or assessing correlates of smoking. prevalence figure due to the large sample size of this The term current smoking used in this review is study. Moreover, women’s smoking in the upper so- defined as smoking at the time of the survey, either cial strata, where smoking is likely to be more prev- daily or occasionally.12 Finally, because Syria has alent, based on our finding that smoking among implemented a ban on tobacco advertising, the influ- women follows a social pattern, has not been stud- ence of tobacco companies’ marketing strategies has ied. Therefore, the prevalence of women’s smoking in not been studied in Syria. We believe, however, that the general population is likely to be higher than the such an influence exists through printed and televised 9% estimate. media from adjacent Arab countries, and that it war- Our estimate of adult male smoking in Syria is rants evaluation. comparable to that of the WHO for developing coun- tries, put at 48%.1 In comparison, the prevalence of current smoking among adult males in a country with PREVALENCE AND PATTERNS a successful anti-tobacco policy, like the US, is 28%.14 OF SMOKING IN SYRIA Males in Syria not only smoke more than females, but Generally, smoking is more prevalent among males they also consume more cigarettes daily.5,6 For exam- than females in Syria. Adult male smoking levels exceed ple, daily smokers among male schoolteachers and those of females in all studied groups (Table 1).5–7 The physicians consume about one pack a day compared to recently published Country Profile Project puts the level about half a pack a day for females in the correspond- of adult smoking in Syria, based on our data, at 53% ing populations.5,6 Accordingly, male smokers in Syria for males and 9% for females.13 However, these esti- are more likely to show signs of addiction and nicotine mates are calculated without including the figures for dependence. Nicotine dependence, judged by the time males aged 19–23 years. Including these figures lowers the first cigarette is smoked in the morning, was the overall smoking prevalence among adult males related to both the duration of smoking and the num- (aged over 18 years) to 48%. The prevalence of current ber of cigarettes smoked daily among male physicians smoking among high school students in Syria is 16% (Figure 1). It was found that more than half of daily and 7% for males and females, respectively.4 smokers among high school students, schoolteachers Smoking in Syria 185 Figure 1 The relation between the time the first cigarette was smoked in the morning and duration of daily smoking together with the number of cigarettes smoked per day, for male doctors who were daily smokers.
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