Attitudes of Youth Towards Alcohol in Muslim Majority Countries: Insights from Iraq

Mustafa Al Ansari

A thesis submitted in fulfilment of the requirements of the degree of Doctor of Philosophy

The University of Sydney School of Public Health Faculty of Medicine and Health

University of Sydney

2021

Table of Contents Authorship attribution statement ...... 6 Statement of originality ...... 8 Dedication ...... 9 Acknowledgements ...... 10 Transliteration ...... 12 Abbreviations ...... 13 Glossary ...... 14 List of figures ...... 15 List of tables ...... 16 Outcomes arising from this thesis ...... 17 Published manuscripts ...... 17 Submitted manuscripts ...... 17 Conference presentations/papers...... 17 Awards ...... 18 Abstract ...... 19 Chapter 1: Introduction ...... 20 Alcohol in the global context ...... 20 Alcohol use in Muslim Majority Countries (MMCs) ...... 21 Alcohol in Iraq ...... 23 Iraq at a time of change ...... 24 Gaps in the research literature ...... 26 Research questions ...... 27 Potential outcomes and significance ...... 27 Overview of the thesis ...... 28 References ...... 31 Chapter 2 – Methodology ...... 34 Socio-historical review: sources of evidence...... 34 Scoping review ...... 35 Mixed-method approach ...... 36 Sample selection and setting ...... 37 Possible obstacles, risks and limitations to alcohol research in Iraq...... 38 Mitigations and solutions to risks and obstacles ...... 39 Field work and data collection ...... 40 Quantitative component ...... 40 Survey tools and items ...... 42 Qualitative component ...... 44 2

The author as researcher (reflexive statement) ...... 47 Ethics approval ...... 49 References ...... 50 Chapter 3: Alcohol: From Mesopotamia to Modern Iraq ...... 51 Abstract ...... 52 Introduction ...... 52 Methods ...... 53 Findings ...... 54 Alcohol and Iraq in pre-Islamic history ...... 55 Alcohol and Islam ...... 57 Brief history of alcohol during the Islamic era (seventh-20th centuries) in Iraq ...... 58 Alcohol and modern Iraq ...... 59 Data on the prevalence of alcohol use in Iraq ...... 63 The next generation: alcohol and Iraqi youth ...... 64 Discussion ...... 65 Conclusion ...... 68 Acknowledgement ...... 68 References ...... 68 Chapter 4: Alcohol among young people in Iraq: A systematic scoping review ...... 75 Abstract ...... 76 Summary ...... 77 Introduction ...... 78 Methods ...... 79 Identifying the relevant studies ...... 80 Study selection ...... 80 Charting the data ...... 81 Patient and public involvement statement ...... 81 Results ...... 81 Study descriptions ...... 83 Prevalence and patterns of alcohol use ...... 85 Patterns/locations ...... 88 Attitudes, behaviours, and motives ...... 88 Discussion ...... 93 Limitations ...... 95 Conclusion ...... 96 References: ...... 97 Chapter 5: Alcohol and university students in Iraq: attitudes, availability, and use ...... 100

Abstract ...... 101 Introduction ...... 102 Alcohol consumption among university students in Iraq ...... 104 Methods ...... 105 Ethics approval ...... 106 Quantitative survey ...... 106 Sampling and Recruitment ...... 107 Data Analysis ...... 108 Results ...... 109 Sample ...... 109 Demographics ...... 110 Alcohol consumption ...... 112 Consumption of other substances ...... 113 Attitudes towards alcohol, alcohol policy and alcohol/drug users ...... 114 Media and war exposure and post-traumatic stress disorder ...... 116 Reliability of the included instruments ...... 117 Discussion ...... 117 Limitations ...... 123 Conclusion ...... 125 References ...... 126 Chapter 6: Alcohol use in Iraq: Perceptions of students at three Iraqi universities ...... 129 Abstract ...... 130 Summary ...... 131 Introduction ...... 132 Methods ...... 134 Settings ...... 135 Recruitment ...... 135 Qualitative interviews ...... 136 Translation and transcription ...... 137 Analysis ...... 137 Patient and public involvement statement ...... 138 Ethics ...... 138 Results ...... 138 Perceived prevalence of drinking ...... 139 Why people drink: “It’s natural for there to be various views” ...... 140 Individual motives ...... 141 Interpersonal motives ...... 142

Community-related motives ...... 144 Society-related motives and influences ...... 145 Globalisation and greater/external society related motives: ...... 147 Perceptions of those who drink – “Not even Christian girls like drinkers” ...... 149 Consequences of drinking ...... 151 View of policies towards alcohol ...... 152 Discussion ...... 152 Preventing alcohol misuse in Iraq ...... 154 Limitations ...... 158 Reflexivity ...... 158 Conclusion ...... 159 References ...... 160 Chapter 7 - Discussion ...... 163 Diversity and alcohol in Iraq ...... 164 Alcohol availability, affordability, and taxation ...... 167 Conflict, social unrest, terrorism, and trauma ...... 169 Globalisation, media, and social media ...... 170 Alcohol – males and females ...... 171 Overestimation or underreporting of student drinking? ...... 172 Risky and harmful behaviour among drinkers ...... 173 Importance of tailoring measures and priorities to the Iraqi context ...... 174 Prevention approaches...... 175 Screening in a MMC context ...... 177 Treatment and harm-reduction ...... 178 Sin, stigma, and punishment ...... 179 Limitations ...... 180 Future directions ...... 181 Conclusion ...... 183 References ...... 184 Appendices ...... 193 Appendix 1: Ethics approval ...... 193 Appendix 2: PRISMA statement ...... 194 Appendix 3: Search strategies ...... 196 Appendix 4: English survey ...... 200 Appendix 5: Arabic survey ...... 225 Appendix 6: Interview guide (English/Arabic) ...... 251

Authorship attribution statement

I conducted the research that is contained in this research under the supervision of Professor Kate

Conigrave and Professor Angela Dawson. I conceived and designed the study, with support of my supervisors and local Iraqi collaborator. I also recruited and liaised with in-country collaborators, and recruitment sites. With the support of my supervisors and with advice as needed from the in-country collaborators, I was responsible for:

• The literature reviews • The design of the survey tool and interview framework • Field work and ethics application • Data collection and interviews • Translation and transcription of interviews • Quantitative and qualitative data analysis • Drafting and submitting papers for publication

The results chapters of this thesis are either published or submitted for publication.

Chapter 3 contains an article published as:

Al Ansari M, Dawson A and Conigrave K (2019) Alcohol: from Mesopotamia to Modern Iraq, Journal of Ethnicity in Substance Abuse, DOI: 10.1080/15332640.2019.1657541.

I designed the study, searched for and analysed the data, and wrote the drafts of the MS with the support of my supervisors.

Chapter 4 contains a manuscript submitted for publication as:

Al Ansari M, Dawson A and Conigrave K (2020) Alcohol among Young People in Iraq: A Systematic Scoping Review (submitted for publication)

I designed the study, searched for and analysed the data, and wrote the drafts of the MS with the support of my supervisors.

Chapter 5 contains a manuscript submitted for publication as:

Al Ansari M, Dawson A, AbdulZahra M, Room R, and Conigrave K (2020) Alcohol and University Students in Iraq: Attitudes, Availability and Use (Submitted for publication)

I designed the study, collected and analysed the data, and wrote the drafts of the MS with the support of my supervisors. Professor AbdulZahra assisted with carrying out the study as the in-country collaborator. Professor Robin Room assisted with devising the appropriate survey tool for the setting.

Chapter 6 contains a manuscript submitted for publication as: 6

Al Ansari M, Dawson A, AbdulZahra M, and Conigrave K (2020) Alcohol Use in Iraq: Perceptions of Students at Three Iraqi Universities (Submitted for publication)

I designed the study, collected and analysed the data, and wrote the drafts of the MS with the support of my supervisors and as the in-country collaborator.

Statement of originality

This is to certify that to the best of my knowledge; the content of this thesis is my own work. This thesis has not been submitted for any degree or other purposes.

I certify that the intellectual content of this thesis is the product of my own work and that all the assistance received in preparing this thesis and sources have been acknowledged.

Signature

Name Mustafa Al Ansari

Dedication

The first word I ever said was “Pa” when I first opened my eyes to my father. It was the first time he had seen me after months– not knowing if I had died in the raging bombings and crossfire on Iraqi streets. He had not even asked my mother about me, in fear of turning the happiness of their reunion to grief at my loss.

From the moment I learnt my first words to this moment, my parents have always stood by us through thick and thin. They dodged bullets and rode the waves (literally) for us, so that we do not experience the oppression and difficulties they endured.

For that, and for all their sacrifices, support, and love - I dedicate this body of work.

Acknowledgements

Thanks be to God (Alhamdolilah). Although there are many that can be thanked during good times - there is a principle that only God can be thanked at any time – good or bad. As I always remember

God during times of difficulty, I would like to begin with thanking God first during times of success!

I would like to thank my supervisor, Professor Kate Conigrave, who throughout my candidature has gone above and beyond what anyone can expect from a supervisor, teacher, and mentor. If it were not for her support and encouragement- even in the most difficult of circumstances - I would not be clicking the submit button today. I thank her for being an inspiration and for being a role-model to look up to and follow.

I would also like to thank my auxiliary supervisor, Professor Angela Dawson, who has on numerous occasions combatted the heat and rain to join our meetings. She has provided irreplaceable guidance on the research and writing processes.

If it were not for our in-country collaborator, Professor Mohammad AbdulZahra, the whole project could not have come to fruition. I thank him for dedicating time from his busy schedule as the Dean of Medicine to support, guide and implement this study. I would also like to thank Dr Jawad Al-

Diwan and Dr Wisam al-Lami who helped facilitate our study and shared their expertise of carrying out public health research in Iraq.

I would also like to thank the universities, faculties and departments who eased and facilitated our data collection in Iraq. Similarly, we would like to thank all students and staff who helped us with recruiting participants for the study, namely students Mohammad Lazim, Sadiq Al-Radhi, Shams al-

Niaimi and Hussain al-Shadidi.

Furthermore, a special thank you is directed to Professor Robin Room who dedicated some of his busy schedule to advise on and review the quantitative components of our study. I would also like to thank Dr Michael Livingston for assisting us in devising and reviewing the survey. 10

There were also other great inspirations I met during my time working on this project. I had the honour of being mentored by Associate Professor Kylie Lee who dedicated her time to guide me through the research process including training me in systems of organisation. I would like to acknowledge Dr James Conigrave who shared his expertise and guidance about statistical analysis and rigour. I still dream of one day being literate in the processes of “R” which always occupy his screens.

I would also like to thank my mentor and inspiration, Dr Fouad Nagm, for days and nights he dedicated to assist me with navigating life as a research student. My friends who stood by my side and endured my absences, tiresome conversations, and repeated complaints – thank you for your patience and support.

To my loving parents, my appreciation for you is beyond what thoughts can comprehend or words can express! I owe all my success to my loving family – in Australia and abroad. Firstly, for those in

Iraq who hosted me and assisted me with the day-to-day activities of feeling home and safe while carrying out my field work. Mostly, I would like to thank my wonderful siblings – from the oldest

Muzaffar, who continuously lifted burden off my shoulders, to my brother, Basim, who shared his love of study and research and to my beautiful sister Farah who was the first of us to complete a PhD

– I say thank you for supporting me in my pursuit of this dream. Most of all, I would like to thank my sister and fellow alcohol researcher, Dr Basma Al-Ansari, who introduced me to this amazing project and team. If it were not for her encouragement, I would still be searching for a PhD topic today!

Finally, I would like to thank my beautiful wife, Sandra, who has stood by my side and peacefully tolerated my neglect and many sleepless nights in pursuit of completing this thesis.

Transliteration

Transliteration from Arabic or Persian languages in this thesis uses the International Journal of

Middle Eastern Studies (IJMES) system (IJMES, 2020).

Abbreviations

AUDIT Alcohol Use Disorders Identification Test

AUDIT-C Alcohol Use Disorders Identification Test – Consumption

CIDI Composite International Diagnostic Interview

DALYs Disability Adjusted Life Years

DSM IV Diagnostic and Statistical Manual of Mental Disorders (Version 4)

DSM V Diagnostic and Statistical Manual of Mental Disorders (Version 5)

EMR Eastern Mediterranean Region

ICD International Classification of Diseases

IMF International Monetary Fund

IMHS Iraqi Mental Health Survey

MMC Muslim Majority Country

PC-PTSD Primary Care - Post-Traumatic Stress Disorder test

SDS Severity of Dependence Scale

SSAI Survey of Substance Abuse in Iraq

UN United Nations

UNDESA United Nations Department of Economic and Social Affairs

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Children’s Fund

WHO World Health Organization

Glossary

ʿaraq Locally made spirit drink with 40%+ alcohol concentration

Ḥayaʾ Modesty/shyness

Manbūẓ Ostracised/outcast

Tafsīr Qur’anic exegesis

Fiqh Islamic jurisprudence

Sunnah The Prophetic tradition (and the tradition of the Imams for Shia Muslims)

Ḥadīth Sayings of the Prophet Mohammad (and the Imams for Shia Muslims)

Khamr Wine (may be inclusive of other intoxicants)

Khamriyyāt Arabic wine poetry (a genre prevalent in pre-Islamic and the medieval eras)

List of figures

Figure 1 Overview of thesis structure ...... 28 Figure 2 Locations of the major historical capitals within Iraq's modern borders...... 55 Figure 3 Timeline of alcohol in Iraq's history...... 56 Figure 4 Stages of alcohol prohibition in Islam...... 57 Figure 5 PRISMA flow chart for literature search ...... 82 Figure 6 Provinces where student/youth specific alcohol data are reported in peer-reviewed original articles ...... 84 Figure 7 Number of participants completing the different survey sections ...... 110 Figure 8 Substance use by participants (respondents re alcohol n=468, re other substances n=450) ...... 114 Figure 9 Participants’ views on the right response to regular substance use by a friend ...... 115 Figure 10 Socio-ecological framework for alcohol use in Iraq complemented by aspects of the motivational model as presented in Kuntsche et al, 2005 ...... 135

List of tables

Table 1 Laws regarding application for a license to sell alcohol ...... 62 Table 2 Laws regarding the operation of licensed stores ...... 63 Table 3 Inclusion and exclusion criteria for study selection ...... 80 Table 4: Findings of systematic scoping review (studies are ordered by year of data collection) ...... 90 Table 5 Findings of the included studies ...... 91 Table 6 Prevalence of lifetime and past-year alcohol consumption by selected demographic data ...... 111 Table 7 Independent predictors of consumption (using logistic regression) ...... 112 Table 8 Gender and faculty of participants (n = 40) ...... 139

Outcomes arising from this thesis

Published manuscripts

Al Ansari M, Dawson A and Conigrave K (2019) Alcohol: from Mesopotamia to Modern Iraq,

Journal of Ethnicity in Substance Abuse, DOI: 10.1080/15332640.2019.1657541.

Submitted manuscripts

Al Ansari M, Dawson A and Conigrave K (2021) Alcohol among Young People in Iraq: A

Systematic Scoping Review (submitted)

Al Ansari M, Dawson A, AbdulZahra M, Room R, and Conigrave K (2021) Alcohol and University

Students in Iraq: Attitudes, Availability and Use (Submitted)

Al Ansari M, Dawson A, AbdulZahra M, and Conigrave K (2021) Alcohol Use in Iraq: Perceptions

of Students at Three Iraqi Universities (Submitted)

Conference presentations/papers

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2019) University Student Perceptions of Alcohol Use in Iraq: Insights for Public Health Policy, Presented at the 13th Annual International Addiction Science Congress (ASC2019), Tehran on 21st of August 2019.

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2018) Alcohol and University Students in Iraq: Prevalence and Perception, Presented at the 12th Annual International Addiction Science Congress (ASC2018), Tehran on 6th of September 2018.

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2018) Attitudes Towards Alcohol and its Use Among University Students in Iraq: Policy Implications, Presented at the Emerging Health Policy Research Conference, University of Sydney on 26th of July 2018.

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2018) Alcohol and University Students in Iraq: Perceptions, Availability and Use, Presented at the Kettil Bruun Society (KBS) Meeting, Chiang Mai on 31st of May 2018.

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2017) Alcohol and other Drug Use among Iraq’s University Students: A Possible New Frontier, Presented at the 19th International Society of Addiction Medicine (ISAM) Conference, Abu Dhabi on 18th of October 2017.

Al Ansari, M.; Dawson, A.; AbdulZahra, M. and Conigrave, K. (2017) Consumption and Attitudes towards Alcohol among Iraqi University Students: Impacts on Policy, Presented at the Global Alcohol Policy Conference (GAPC), Melbourne on 6th of October 2017.

Al Ansari, M.; Dawson, A. and Conigrave, K. (2017) Alcohol Consumption among University Students in Iraq: Preliminary Findings, Presented at the Sydney School of Public Health Research Conference, University of Sydney on 18th of July 2017.

Al Ansari, M.; Dawson, A. and Conigrave, K. (2017) Student Drinking in Iraq: A Changing Context, Presented at the World Congress of Public Health, Melbourne on 5th of April 2017.

Al Ansari, M., Dawson, A. and Conigrave, K. (2016) Alcohol: From Mesopotamia to Modern Iraq, Presented at the Australasian Professional Society on Alcohol and Other Drugs (APSAD) Conference, Sydney on 31st of October 2016.

Al Ansari, M., Dawson, A. and Conigrave, K. (2016) Alcohol in Iraq’s History and its Potential Influence on Health Policy, Presented at the Menzies Emerging Health Policy Research Conference, University of Sydney on 13th of July 2016.

Awards

Bronze Award for Distinguished Research in Addiction Medicine 2019 Esmaeil Zamanian Addiction Medicine Award (EZAMA)

Best Presentation Award 2018 International Addiction Science Congress

Research Training Program Stipend Scholarship 2017-2018 Commonwealth of Australia

Edith Mary Rose (Travelling) Scholarship 2017 The University of Sydney

Australian Postgraduate Award (APA) Scholarship 2015-2016 Commonwealth of Australia

Abstract

Background: Anecdotal evidence indicates that alcohol is a growing public health concern in Iraq.

Internal and external factors such as war and resulting trauma, and global alcohol marketing are possible influences on attitudes towards alcohol among young people in Iraq. However, like many other Muslim Majority countries, there is scarce data about alcohol in the country.

Method: This research involved four components. The first is an overview of the historical socio- cultural background of alcohol in Iraq. Then a systematic scoping review identified available data in local and international peer-reviewed journals about alcohol and young people. This informed mixed- method research, which included an online survey and semi-structured interviews of university students. The survey included AUDIT-C and PC-PTSD screening tools, and items on attitudes towards alcohol and motivations for use.

Results: There have been diverse cultural, historical, and religious influences on attitudes towards alcohol in Iraq. Data on alcohol and young people is scarce in this context and mostly in non-alcohol- specific studies. The quantitative survey found a low prevalence of drinking (5.3%; 1.6% females,

10% males). However, two fifths (40%) of male drinking was risky (AUDIT-C score of 4+). Two fifths of the sample had been exposed to direct conflict and one third tested positive on the PC-PTSD.

Alcohol was said to be easily accessible by both survey and interview participants. Student interviewees shared a variety of perceived motives for drinking. They also reported on stories of alcohol harms among drinkers.

Discussion: Although prevalence of drinking is low, alcohol misuse among drinkers is high. Better health, legal and financial infrastructure in Iraq and ongoing research are needed to help design and implement tailored, evidence-based approaches. These should aim to maintain or reduce low prevalence of drinking while ensuring help is available for those with risky drinking.

Chapter 1: Introduction

Alcohol in the global context

Alcohol is a major contributor to poor health and social problems worldwide. Globally, alcohol is the leading risk factor for disease burden in those aged 15-49 years, responsible for almost 10% of deaths

(GBD 2016 Alcohol Collaborators, 2018). Developed countries account for the highest alcohol consumption levels per capita whilst consumption in Muslim majority countries (MMCs) and Muslim communities is significantly lower (Alcohol Public Policy Group, 2010; WHO, 2018a). In the majority of MMCs 80-100% of adults report consuming no alcohol over the past 12 months, contributing significantly to the global abstinence prevalence of 67.5% (GBD 2016 Alcohol

Collaborators, 2018). However, commercial production and marketing of alcohol is expanding in countries with low levels of alcohol consumption (Alcohol Public Policy Group, 2010). This is alarming due to the potential increase in public health problems associated with more widespread use of alcohol (GBD 2016 Alcohol Collaborators, 2018).

Alcohol is a risky behaviour among young people and can be associated with other risky behaviours.

Globally, alcohol-related burden of disease is highest among young people, with the largest proportion of disability-adjusted life years (DALYs) lost in those aged 15 to 49 years (GBD 2016

Alcohol Collaborators, 2018). The main contributors to this health burden were traffic accidents and alcohol use disorders (AUDs). Interpersonal violence is also a major risk associated with drinking, especially among young people, and may involve violence against strangers or acquaintances as well as sexual violence resulting in injury or death (WHO, 2006a, 2006c, 2015b). Alcohol use and misuse has been identified as a concern among university student populations in several countries (Carter et al., 2010; Linden-Carmichael et al., 2018; Peltzer et al., 2016), including in the Arab world (E. Karam et al., 2007).

Alcohol use in Muslim Majority Countries (MMCs)

Although per capita consumption is stable in developed nations, it is on the increase in several low- and middle-income countries, especially in the Central African and East Asian regions (Alcohol

Public Policy Group, 2010; WHO, 2010b). Alcohol and drug use is also identified as associated with health burdens with the highest annual increase in the Eastern Mediterranean region (EMR) (Mokdad et al., 2016). The latest WHO data on 5-year changes in drinking is from the 2006-2010 period.

Although most MMCs do not have conclusive data in regards to change in alcohol consumption between 2006 and 2010, an increase in estimates for per capita consumption has been observed for countries such as Turkey, United Arab Emirates, Qatar, Lebanon and Azerbaijan (WHO, 2010b). On the other hand, Morocco, Tunisia, Syria, Jordan, and Oman appeared to have a stable per capita consumption over those 5 years. The only MMCs with a decrease in consumption per capita were

Bahrain, Senegal, and Guinea-Bissau (WHO, 2010b). Although Muslim Middle Eastern countries were the lowest consumers of alcohol, the last WHO pattern of drinking score in 2006 listed their pattern of drinking as the second riskiest after the former Soviet countries of Eastern Europe (WHO,

2006a). Similarly, in 2016, among drinkers, the highest alcohol per capita consumption was in the

EMR (WHO, 2018a). The impact of such a drinking pattern may be experienced on an individual level (e.g. health complications, risk of impulsive behaviour), interpersonal level (e.g. risk of interpersonal violence), and societal level (e.g. burden on health system) (WHO, 2006c). As of 2016, there are no national alcohol monitoring systems in any EMR country except for Iran (only for health consequences) (WHO, 2018a).

MMCs in the EMR, including Iraq and Syria, are amongst the 66% of member states of the World

Health Organization (WHO) which do not have a formal written national alcohol policy (WHO,

2014a). Alcohol policy approaches in MMCs, however, vary. While some MMCs such as Turkey adopt a western style regulatory policy, other countries, such as Iran, only allow alcohol for non-

Muslims (Al-Ansari et al., 2015). Only five MMCs adopt a total prohibition policy, namely,

Afghanistan, Libya, Saudi Arabia, Somalia and Sudan (Al-Ansari et al., 2015). While some MMCs,

21 such as Oman and Turkey, have a high Alcohol Control Policy Index (ACPI), countries with recent or ongoing conflict such as Iraq and Syria have one of the lowest ACPI scores indicating their lack of cohesive alcohol policies (Madureira-Lima et al., 2018).

Religious prohibition and the prominent culture of abstinence may contribute to a perception that alcohol is not an issue, and to the limited availability of research on alcohol in MMCs. Alcohol is thus the least studied psychoactive substance in Arab countries (Sweileh et al., 2014). Calls have been made to increase alcohol research in settings outside of European and Anglophone countries, particularly in MMCs (Al Ghaferi et al., 2013; Kuntsche et al., 2017; Savic et al., 2016). The growing investment of the global alcohol industry in developing countries (Alcohol Public Policy Group,

2010) also suggests a need for further research, especially amongst vulnerable sectors such as youth and student populations. A 2009 review looking at substance use in the Arabian Gulf region identified that most studies on alcohol have been conducted in male clinical samples (AlMarri & Oei, 2009).

Similarly, a review of alcohol consumption in the Arab region in 2016 reports that less than half the countries in the region have studies on student consumption (L. Ghandour et al., 2016). Iraq had no studies focusing on young people or students. Of the four identified studies, three were in clinical settings and one on a sample of journalists and other professionals.

Despite the limited volume of research, existing studies in the EMR show that youth are a vulnerable sector of society and are exposed to alcohol. Abstinent older people in Lebanon and among Arabs in

Israel have disclosed that they used to drink in their younger years (Baron-Epel et al., 2015; Yazbek et al., 2014). A study conducted at two Lebanese universities indicated alcohol use and misuse among the student population; however, most of the sample was of the Christian faith (L. A. Ghandour et al.,

2009). In Egypt, a single-university study was conducted to research the practice and awareness of

Egyptian students about health risk behaviours (Refaat, 2004). It sampled a total of 687 students (of which 59% were female) and found a high awareness of the behavioural risks of alcohol amongst students. Just under a sixth (14.4%) of the sample had tried alcohol in their lifetime with a moderate correlation (r=0.457) between alcohol and risky sexual behaviour. The study found that no awareness

22 of alcohol was provided by family and that friends and the media were the main source of information about alcohol and drugs (Refaat, 2004).

Undertaking research on a young population in a MMC within the current evolving social, political, and cultural situation will contribute to enhanced understanding of the attitudes of youth towards alcohol and possible changing behaviours in MMCs. Iraq is a prime example of such a country that can serve to provide further insight into public health strategies that may be required in Iraq and other comparable MMCs.

Alcohol in Iraq

This section aims to provide a short introduction to highlight the context of this research. A detailed review of the historical socio-cultural setting and a systematic scoping review of available data on youth and student drinking in Iraq will be presented in Chapters 3 and 4.

Reported alcohol and drug use prevalence data for Iraq in global reports are typically estimates. For example, the data in the WHO ATLAS on Substance Use are based on expert estimates rather than on survey data (WHO, 2010a). However, there are two national household surveys in Iraq, from 2006 and 2014, which collected information about alcohol consumption. Lifetime prevalence of alcohol consumption among males seems to have increased from 6.8% to 16.7% over those years (US

Department of State et al., 2015; WHO, 2009). In an unpublished 2009 study with no details about the sample, the lifetime prevalence of alcohol use in Baghdad was found to be 17.8% and increasing

(Al-Hemiary et al., 2014). Together, these figures indicate a likely increase in alcohol consumption.

However, it is unknown whether these increases represent actual drinking behaviours in Iraq or differences in survey methods. There has been a negligible prevalence of reported alcohol use among female participants in all Iraqi surveys.

There was a very low prevalence of alcohol abuse (0.1%) in the total sample in the 2006 Iraqi Mental

Health Survey (WHO, 2009). However, among Iraqi drinkers, the rate of alcohol use disorders was one of the highest from a multinational WHO study: The World Mental Health Survey (Degenhardt

23 et al., 2019; Glantz et al., 2020). The 2014 Survey of Substance Abuse in Iraq (SSAI) indicates that on average, current drinkers consume more than 6 drinks per day on 10.5 days a month. The SSAI reports that more than two thirds of drinkers meet the criteria for dependence on the Severity of

Dependence Scale (SDS) (US Department of State et al., 2015). Similarly, a study at youth centres in

Baghdad found over a sixth of the sample met the DSM-IV criteria for alcohol abuse, with an onset age between 18 and 25 years (Al-Hemiary et al., 2015b).

Alcohol use is a hidden phenomenon in Iraq. This may be due to religious prohibition and social stigma surrounding drinking. Alcohol users often do not disclose their drinking to family, friends or anyone outside of their drinking circles in fear of losing face. The lack of clarity surrounding its prevalence and misuse may pose a challenge in the planning and delivery of effective measures and interventions by the already struggling Iraqi health system (Al-Hemiary et al., 2014). Iraq’s health system provides 6.1 physicians for every 10,000 populace, a rate that is half of the regional average

(WHO, 2014b).

Iraq at a time of change

Iraq is an upper-middle income developing country (UN, 2020) with a total population of over 38 million in 2017 (UNDESA, 2017). It is estimated that Iraq’s population is increasing by more than a million people per annum, with most of the population (60%) under the age of 24. By the year 2030, it is estimated that Iraq will have at least an additional 15 million people (UNDESA, 2017).

Iraq’s growing population has been subjected to multiple wars resulting in major political, economic, social and cultural change (Marr, 2018). Any study of mental health in Iraq must be presented against this backdrop. The Iraq-Iran war lasted eight years between 1980 and 1988. Three years later, the invasion of Kuwait in 1991 started the First Gulf War. This led to continued sanctions against

Saddam’s regime in Iraq until 2003, which saw the beginning of the second Gulf war. More recently,

Iraq fought a war against Islamic State (IS) after that group established itself in northern Iraq. Iraq

24 continues to be subjected to terrorism and international military presence. Iraqi youth and their parents have been directly exposed to at least one of these occurrences.

Despite research about the impact of the Gulf Wars on veterans returning to Coalition countries, public health research has not focused on the Iraqi population. Alcohol misuse was greater amongst

United States and United Kingdom combatants post-deployment than pre-deployment (Browne et al.,

2008; Wilk et al., 2010). There was a correlation between alcohol misuse and combat activity, amongst other factors. Although the sample of this study is different from both a cultural and occupational perspective to the Iraqi population, a possible relationship between experience of conflict and alcohol misuse exists (Lo et al., 2017). Such an association has also been shown in other

MMCs such as Lebanon (Yaacoub et al., 2019). The association of conflict and alcohol misuse is not surprising, given that alcohol use disorders frequently are triggered by or exacerbate other mental health disorders including post-traumatic stress disorder (PTSD) (Debell et al 2014 and Shivani et al

2002).

In addition to war and conflict, Iraqis have been exposed to a multitude of local and international social and mass media since the 2003 Gulf War (Abedalla et al., 2014). Many young people in the

Arab world are shown to regularly consume English-language media (Melki, 2010). English language exposure is likely to increase among youth given that English as a second language is now taught from the first year of elementary school instead of at the fifth or third grade as in the pre-2008 and pre-2013 Iraqi curricula respectively (AlTufaili, 2016). Many of Iraq’s university courses are also taught completely in English. Exposures to alcohol in the Iraqi setting include direct marketing, and indirect exposure to alcohol through film, social-media posts, and via other mediums. Such exposures have been associated with early uptake of alcohol by non-drinking adolescents and with increased drinking among drinkers (Anderson et al., 2009).

Although WHO indicates that there is no single written alcohol policy in Iraq, there are discrete alcohol-related policies or regulations imposed by sub-sections of tourism, council or trade laws.

Despite Iraq’s changing dynamics most of these regulations date from the pre-2003 conflict. These approaches have not considered the lived experiences of Iraq’s large and growing young population.

University students in other countries have been shown to be particularly vulnerable to alcohol use and drink more heavily than their non-student peers (Carter et al., 2010; E. Karam et al., 2007; Linden-

Carmichael et al., 2018; Peltzer et al., 2016). Drinking for social purposes is the main motive for alcohol use in non-MMCs (Mackinnon et al., 2017). In Iraq, university students are likely to have a higher exposure to alcohol than their peers in the general community due to their added English language skills. Universities in Iraq offer social spheres where young people form close bonds and interact freely with each other. They are also typically the only places where the opposite sexes interact. Students may be less likely to adopt traditional culture because of higher likelihood of living away from parents or travelling to locations with less alcohol restrictions. This is particularly important as, culturally, young Iraqis typically live with and/or are dependent on their parents until marriage. In addition, students are likely to also drink for coping purposes as in addition to their lived experiences of social and political instability, they are also under pressure from study load and social/familial expectations.

Gaps in the research literature

The scarcity of research about alcohol in MMCs, particularly in the Arab region (Sweileh et al., 2014), as well as the limited research on alcohol in post-conflict civilian populations (Wallace et al., 2013) demonstrate a need for research in this area. Limited published alcohol-specific studies in Iraq could be identified, particularly those with a student or youth focus. There is also limited information on alcohol’s place in Iraqi society and culture, or on attitudes towards alcohol in Iraq. Additionally, alcohol has not been the subject of any previous reviews or qualitative studies in Iraq. Given these constraints in the literature, there is a limited understanding of how Iraq’s changing dynamics may impact attitudes towards alcohol or prevalence of consumption among young people in Iraq.

Research questions

To address some of the identified gaps, this thesis set out to examine alcohol among young university students in Iraq. The definition of “youth” for this study is consistent with the international definition, as those aged between 17 and 24 (UNDESA, 2013). In particular, this research examines:

1. What is the context of alcohol research in Iraq and what is already known about youth or

student drinking within this context?

2. What are the prevalence and patterns of use/misuse among young Iraqi university students?

3. What are the attitudes towards alcohol and drinkers among young university students in Iraq?

Why do students have these attitudes? (with particular focus on assessing war and

globalisation as influencing factors)

4. How are these attitudes likely to impact the future of alcohol in Iraq, particularly with regards

to prevention and harm reduction?

Potential outcomes and significance

By describing the socio-cultural context of alcohol in Iraq and providing the scope of literature on young student drinking in Iraq, this thesis will inform a baseline for future alcohol research in Iraq.

The thesis provides the first voice for young Iraqis in alcohol research. This may encourage other researchers to involve young Iraqis and their perspectives in future health research.

This thesis can inform the potential need for the development of a national alcohol policy in Iraq. It may contribute to identifying areas where further research or health promotion initiatives are needed, with a hope to prevent alcohol becoming a greater public health concern in Iraq.

Examination of attitudes towards alcohol use within the selected sample will increase understanding of the potential factors contributing to changes in drinking behaviour among young people in MMCs.

As Iraq is a post-conflict country with recent exposure to globalisation, this research is likely to inform alcohol research in post-conflict civil populations, especially in other war-affected MMCs.

Understanding the influence of globalisation and war may help inform public health efforts to prevent alcohol-related harm in developing MMCs with similar contexts to Iraq.

Overview of the thesis

This report has been written as a thesis including publication. Chapter 3 includes an article which has been published in the journal of Ethnicity and Substance Abuse (Al Ansari et al., 2019). Chapters 4,

5 and 6 include manuscripts submitted for publication in peer-reviewed journals and currently under

Figure 1 Overview of thesis structure

28 review. While this thesis is written to form a cohesive whole, each chapter can also be read independent of the other chapters. Figure 1 sets out the structure of the thesis.

Chapter 1 introduced the research topic and focused on the research gaps and questions. This chapter was brief as the detailed background and literature review is presented in Chapters 3 and 4.

Chapter 2 sets out the methodology of this thesis. As detailed methods of chapters 3 to 6 are included within them, this methodology chapter will only focus on the overall thesis methods and approaches.

This chapter describes the challenges, risks and mitigations involved in conducting research on such a sensitive topic in Iraq.

Chapter 3 (Alcohol: From Mesopotamia to Modern Iraq) provides a background to understanding alcohol in the context of Iraq’s diverse ethnicities, religions, and cultures. It briefly summarises alcohol’s history in Iraq before describing the potential challenges, sensitivities, and socio-cultural influences in this context.

Chapter 4 is a systematic scoping review of research on student or young people and alcohol in peer- reviewed original literature. This review includes any study, regardless of alcohol-focus, that had information on alcohol among young people or students in Iraq. This sets out the need for the mixed- method study presented in chapters 5 and 6.

Chapter 5 presents the quantitative component of the mixed-method study. This chapter details the methods and results of the online questionnaire. It describes the prevalence of alcohol use/misuse using the short Alcohol Use Disorders Identification Test (AUDIT-C). It also presents the overall reported attitudes of young Iraqi university students towards motives for consumption/abstinence, alcohol exposure and policy.

Chapter 6 describes the qualitative research carried out as part of this mixed-method study. It presents the findings from the thematic template analysis of the 40 semi-structured student interviews carried out at three Iraqi universities. This chapter aims to deepen the understanding of students’ experiences and perspectives on drinking, and of alcohol harms and influencing factors.

As each chapter includes a focused discussion, chapter 7 will consolidate and discuss the findings of all chapters considering local, MMC and international literature. It will highlight the limitations and implications of this research before presenting the overall conclusions.

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Chapter 2 – Methodology

Chapter 1 introduced the focus of this research and the key research questions before presenting an overview of the thesis components. By investigating the attitudes of young university students in Iraq, this research aims to better understand the place of alcohol and the factors which influence young people’s attitudes to alcohol in Iraqi society. As each of next four chapters is written in a form suitable for publication, the methodological framework is presented within each section. This chapter provides additional information of the methodological approaches for the research. It also describes the challenges, risks, and mitigations for carrying out sensitive research of this nature in Iraq. A broad chronology of correspondence, field trips, engagements and collaborations will also be set out with the aim of helping future researchers navigate health research in Iraq. Finally, a brief ‘author as researcher’ statement will be shared to introduce the role of the author in the conduct of this research.

Socio-historical review: sources of evidence

The socio-historical review relied on Arabic, English and Persian primary and secondary literature to describe the social, cultural, religious, and historical position of alcohol in Iraq. This review was important to place this research in context by informing the place of alcohol among the overall population and among ethnically, culturally, and religiously diverse communities.

Below, the three main sections of this chapter and their sources are described:

The first section of this paper looked at alcohol in pre-Islamic Iraq and Arabia. Historical books and articles as well as linguistic works regarding alcohol were consulted. These were either searched online or at the University of Sydney library.

The second section provided an overview of alcohol’s place in Islamic jurisprudence and history. The main sources consulted were Quran Exegesis’ (interpretation of the Quran) and Hadith literature (the traditions, sayings, and life of the Prophet Muhammad). These were complemented with Islamic jurisprudential and scholarly works regarding the Islamic views and laws around alcohol as well as historical works regarding the place of alcohol in Islamic societies. Finally, works of poetry were

34 utilised for sections on khamriyyat (wine poetry). There were also consultations made with an Islamic religious scholar to help with identification and interpretation of religious resources.

The third section, Alcohol in Modern Iraq, was divided into two parts. One looked at alcohol from a social and legal perspective while the other provided an overview of health literature relating to alcohol in Iraq. For this section, sociological books, peer-reviewed alcohol and mental health literature, news media and WHO, government and non-government reports were consulted.

Scoping review

This systematic scoping review aimed to identify what is known about attitudes towards alcohol and prevalence of drinking in Iraq. Supplementary research questions assessed screening and diagnostic tools, influencing factors and preventative strategies for this setting.

A previous review from the region could not identify any student drinking data from Iraq (L.

Ghandour et al., 2016). The authors however limited their search to indexed papers which had a key focus on alcohol. The aim of this chapter was to identify all data published in peer-reviewed literature about youth or student drinking in Iraq, including in papers where alcohol was a subsidiary focus.

Indeed, most of the available data were not in alcohol-specific articles. A meta-analysis could not be employed as studies used varying methods, including a range of screening and diagnostic tools.

Several did not provide sufficient detail on methods to fully describe these. As we were not assessing an intervention, and our aim was to map out evidence in an emerging research area, a systematic scoping review was the best suited approach (Arksey et al., 2005; Peters et al., 2015).

As assessing prevalence of alcohol use and misuse is a primary aim, rather than assessing an intervention, this review utilised the CoCoPop (condition, context, population) approach instead of the traditional PICO (population, intervention, condition, outcome) (Munn et al., 2018). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009).

In addition to the systematic search that was undertaken in five international databases (MEDLINE

(OVID), Embase (OVID), PsycINFO (OVID), Scopus, Web of Science), we identified an online

35 database of local Iraqi journals (IASJ: Iraqi Academic Scientific Journals). We searched this database to ensure our scope included literature published in local peer-reviewed journals which are not indexed in international databases. The full strategy is attached as an appendix (Appendix 3). We also conducted a hand search to identify other articles that meet the inclusion criteria.

We employed broad inclusion criteria to identify any youth or student drinking data in Iraqi general or student population settings.

Mixed-method approach

To gain an understanding of attitudes to and use of alcohol among university students in Iraq, an analysis of prevalence of alcohol use and attitudes towards alcohol must be conducted. A mixed method approach was chosen so that the qualitative and quantitative components adequately complement each other, and to explain and contextualise the findings (Bryman, 2006; Schoonenboom et al., 2017). This provides a more complete picture of attitudes towards alcohol and alcohol consumption in Iraq. While a quantitative approach may provide some information about students’ alcohol use and attitudes, it may not adequately address the events, feelings and experiences that contribute to students’ behavior or attitudes. On the other hand, a qualitative approach may provide a lens into their real-life experiences but would stop short of providing a quantifiable estimate of the magnitude of the issue, behaviour or attitude.

Other possible methods included an observation or ethnographic approach – but due to the sensitivity of alcohol as a topic in Iraq, both these methods would not be practical. Alcohol is a hidden commodity within the Muslim majority population, and it is used cautiously – a researcher is not likely to encounter alcohol use with either of these methods unless they specifically approach certain locations or population groups. Such an approach is only practical if the research aims to target drinking populations.

A mixed-method approach (Schoonenboom et al., 2017) was utilised to present a quantifiable figure of the attitudes, behaviours and influences of alcohol. This is complemented with an in-depth explanation of the experiences and thoughts of participants about the interaction of the individual and

36 their environment in Iraq. Although change in behaviours and attitudes is not the primary purpose of this thesis, the use of both qualitative and quantitative research methods provided an opportunity to compare quantitative data with previous surveys and to enquire from students about alcohol and previous generations (Question 1 of Appendix 6). Together this helps to better understand the extent to which changes in the Iraqi context may have impacted on alcohol use or misuse.

This thesis employed an equal-status interactive mixed-method research, where both components are of equal value and weight (Schoonenboom et al., 2017). The quantitative and qualitative research was conducted concurrently in a convergent parallel design (Schoonenboom et al., 2017). This meant that although the research design and plan considered both components, each study was independent in its data collection and write up. The point of combining the two components was in the overall interpretation presented in the discussion (Chapter 7).

Sample selection and setting

A university student sample was chosen for this study for a number of reasons. Firstly, we anticipated that out of all general population groups, university students would be the most open to speak about this topic and share their thoughts. Secondly, we hypothesised that university students have a greater exposure to technology, globalisation, and media due to higher levels of English literacy. Thirdly,

Universities are secured locations and students are freer to communicate their thoughts and opinion, especially regarding sensitive topics. In addition, this setting offers a more acceptable location for students to communicate with others, especially those of the opposite sex.

Participants were required to be currently enrolled Iraqi university students to access the survey, however there was no way of verifying this without compromising anonymity. We only analysed data for students under the age of 24 to be consistent with the internationally accepted definition of youth

(UNDESA, 2013). In the qualitative study, however, it was not appropriate to ask for the participants’ age – especially if they were female. All our interviewees were undergraduate students and the oldest was a female in her sixth year of medicine. Based on their degree progress, it was assumed that they all fell within this age limit.

Possible obstacles, risks and limitations to alcohol research in Iraq

Some obstacles apply to any research conducted in Iraq, but others are specific to our research topic.

This section will introduce the potential obstacles and risks and then outline the mitigations which were applied.

The first obstacle was the unpredictable security situation in Iraq. When we set out on this program of research, Islamic State of Iraq and Syria (ISIS) was in control of the second largest Iraqi city,

Mosul, and controlled almost a third of Iraq’s territory. It was not clear that field work in Iraq would be possible. However, as the fighting in the ISIS territories intensified, the threat of terrorism in cities not controlled by ISIS reduced.

The second obstacle was navigating around the sensitivity of the topic in Iraq, where alcohol is largely forbidden. This involved introducing the topic to stakeholders, participants, and approvers, as well as people who were not directly involved in this research, such as family, friends and others who assisted in facilitating transport and accommodation.

Thirdly, confidentiality and anonymity of participants was crucial. Alcohol is a taboo in Iraq and a drinker may face social isolation, be disowned by his/her family and community, and may face other lifetime consequences. Given the rise of ISIS and other extremist groups in recent years, admitting to alcohol consumption could also have security consequences for the participant. For example, alcohol shops are known to be attacked or burnt and drinkers to be physically punished. Sometimes even associating with drinkers may have negative consequences for an individual. These concerns may drive participants to not disclose their drinking habits, or whether they know drinkers or their attitude towards alcohol and alcohol users. Similarly, because of changing cultures in Iraq, young participants with more conservative/traditional views of alcohol may also feel uncomfortable to share their opinions if they assume the interviewer has more liberal views. This may be because they would be perceived to be backward thinking or overly traditional.

Mitigations and solutions to risks and obstacles

We tailored our research design and data collection approaches to consider and mitigate these potential obstacles. We consulted on and investigated several possible approaches we could utilise to best collect quantitative and qualitative data in this setting.

When we first set out on this research project, we contacted the Australian Embassy in Baghdad outlining our research proposal and asking for any guidance or support that is available. The Embassy explained that they did not foresee a significant safety risk for us to conduct our research if we do not travel to ISIS controlled regions in Iraq. They provided the contact details of several private security companies that can provide personal security in Iraq.

The field work was conducted by the author, an Iraqi Australian of the Muslim faith. Although he has never lived in Iraq, he speaks Arabic fluently and is well versed with the culture and religion. In consultation with local academics and from experience, the presence of the first author in Iraq was not deemed more dangerous, eye-catching or risky than for the locals. The risk mitigations were to never speak English or travel alone outside the University and to always be accompanied by a local

Iraqi relative or friend. Inter-city travel was limited to that with a university-designated driver in a university-owned vehicle. This helped us to pass through the express lane at busy security checkpoints on the highway or at the entry of every province and city. The university-designated driver/guard stayed with the author throughout his travels outside of his main collaborator’s home city – except in his travel to Kurdistan, which is considered safe, with only one public terrorist attack there since the

2003 conflict.

The author has been to Iraq several times before and although the attacks are at times random, he was aware that avoiding certain gatherings and areas would largely reduce the risk – especially if one reduced the time in major cities with higher risk of attacks.

As Iraq is a country with an advisory level of “Do Not Travel” by the Department of Foreign Affairs and Trade, the insurance provided through the University of Sydney covered any normal occurrences but did not cover any war or terrorist-related activity. The author carried a portable phone charger

39 along with two mobile phones, one connected to a local Iraqi service and the other to an Australian roaming service. He checked-in with his supervisor back in Australia every 48 hours. There were procedures in place for the supervisor to follow if there was a missed check-in.

Field work and data collection

In 2016 the author travelled to Iraq to form collaborations, secure approvals to conduct this study at

Iraqi universities and seek in-country ethics approval.

During this trip, the author visited four universities, three in the Arab middle and south of Iraq and one in the Kurdistan region of Iraq. His main in-country collaborator, who is the dean of a medical faculty in Iraq assisted him in contacting all appropriate parties at these universities and seek in- person meetings were the potential for the conduct of this study can be discussed. The collaborators will not be identified to protect the confidentiality of the universities were data was collected. These meetings included a meeting with the president of a university, a dean of a medical faculty and the head of the department of public health of the third university.

After visiting these universities in person and submitting the proposal, written approvals from two universities (not included in appendix so as to not identify the universities) and a verbal approval from a third university was received. The fourth university, in Kurdistan, did not respond to in-person, phone or email invitations to participate in this study. The leadership of a second university in

Kurdistan was then contacted by email with the help of the in-country collaborator – similarly there was no response. In total three recruitment sites were secured for our study.

In 2017, the author returned to Iraq to conduct the data collection for this study. By now, Iraqi ethics approval had been granted, the survey and framework of the interview had been developed and were ready for in-country checking.

Quantitative component

The quantitative component of this study focused on assessing the prevalence of alcohol use and misuse within the student sample. It also aimed to quantify the attitudes of this young population towards different personal and policy approaches to alcohol. A mixture of convenience and snowball

40 sampling was utilised to recruit participants for this research. More details regarding sampling are contained in Chapter 5.

Several methods were initially assessed for recruitment and administration of the quantitative study.

The first was to conduct a pen-and-paper survey that is administered at the University in specifically- hired rooms that are divided by partitions, forming a voting-booth like setting. Students were to be invited to come in and fill the survey in the provided booths and to submit their survey by placing it in a ‘ballot’ box upon exiting the room. There were several concerns with this method. Firstly,

Universities in Iraq are divided by campuses and each faculty has its own building, even when on the same campus. This would mean we would either need to inconvenience students to walk to another campus/faculty or have a research workforce that is able to relocate the survey room to different faculties and universities. In addition, each survey may take 20 minutes or more and it would be difficult for students to be away from their studies or to wait for a booth to be available. The logistics of this was daunting and given the limits of funding, time, and difficulty of securing spaces through negotiations with buildings across University campuses, this method was deemed impractical for the purposes of this research.

We also considered conducting an in-lecture survey using software such as Socrative. This was to be conducted with permission from lecturers around the University campuses. Again, although this may have given us a larger (and possibly more representative) sample, it was not practical for a few reasons. Firstly, electricity supply in Iraq is not consistent. There are emergency generators, but these are not turned on in the faculties except in emergencies and only provide enough power to turn on lights and several other key devices. Secondly, given that this would be at the beginning or end of a scheduled university lecture, there will be very limited time to provide instructions, ask the questions and receive the answers. Such an approach is only practical for short polls and not for formal research surveys. The time to explain to students how to login and fill in the answers may already fill any time we are allocated for the entire survey, especially as not all students are tech-savvy. Thirdly,

41 confidentiality cannot be guaranteed as students sit next to each other in lecture theatres and it is likely they will be able to see each other’s screen and answers.

Both above methods also required navigating the intra- and inter-faculty bureaucracy to seek approvals and allocations. They also both required the assistance of research assistants to help the researcher in setting-up, assisting and packing-up.

When the above two possibilities were not found to be practical, we assessed the use of an online survey tool. SurveyGizmo (now Alchemer) was chosen as the software allows for surveys to be translated and to appear in various languages. It also includes an optional setting (that we turned on) that blocks the collection of any IP or device data from the participant – ensuring anonymity and hence extra safety for the participant. The participants were also able to fill in the survey at any time and place that is convenient for them, and anytime during the data collection window. SurveyGizmo also allowed for the data to be directly downloaded in SPSS – the software we used to conduct our analysis, removing any need for data entry.

Survey tools and items

To survey this Iraqi population group, we generated a self-report survey that addresses our research questions and provides adequate opportunity for participants to share their viewpoints. To this end, we formulated a survey based on several validated tools and past alcohol studies within similar or general populations in other countries. Our survey design mainly focused on two sources. The

Alcohol, Drugs and Student Lifestyle study (Bullock, 2004) is a large Swedish study based on the

2003 National Young Adult’s Drug Use telephone survey in Sweden. This tool was used to inform the attitude-related component of our survey. The survey assessed the attitudes of young people towards substances, substance users and to alcohol and drug policy. As alcohol is a culturally stigmatised substance in Iraq, it is likely to be perceived similarly to the way illicit drugs are perceived in a European country like Sweden. For this reason, the drug availability, attitudes, and policy component of this student-targeted Swedish survey were considered to provide appropriate questions about alcohol in the Iraqi context. In addition, use of published questions allows potential comparison

42 between findings on alcohol in Iraq with findings on alcohol and illicit drugs in western contexts such as Sweden.

Most questions were changed to suit the local context – for example, items such as “One can’t have many friends in this university if one doesn’t drink alcohol” were removed or replaced by the opposing view “One can’t have many friends in this university if one drinks alcohol”. Another example is that in the following items about illicit drugs, the word “drug” was replaced with “alcohol”

(responses use a Likert scale): “If a teenager tries drugs it is a sign of a much more serious problem” and “Trying drugs is a normal part of growing up when you are a student at university.” These simple changes were made based on the author’s own cultural understanding and were checked with local collaborators

The 2013 Australian National Drug Strategy Household Survey (Australian Institute of Health and

Welfare, 2013) is the largest national household study on alcohol and drugs in Australia. This validated survey was used to inform the demographic and substance use components of the survey.

In addition, three validated tools were also included: the Alcohol Use Disorders Identification Test

(AUDIT) (T. F. Babor et al., 2001), the Primary Care Post-Traumatic Stress Disorder screening test

(PC-PTSD) (Prins et al., 2003) and the MacArthur Scale of Subjective Social Status (Goodman et al.,

2001).

At first, we decided to include the full ten item AUDIT test to identify alcohol use and misuse within this sample. Rather than using the full ten item AUDIT, we used the shorter, three item version,

AUDIT-Consumption (AUDIT-C) (Bush et al., 1998). This was done for brevity purposes and because items of guilt (item 7) and others’ worry about one’s drinking (item 10) have been shown to be possibly misinterpreted in the Iraqi context (Al Mousawi, 2015). These items were shown to contribute to false-positive results because Muslim drinkers in abstinent or conservative areas may feel guilt even with after consuming even a small amount of alcohol. Consumption of any amount would also trigger friends and family to talk to the drinker about their alcohol consumption.

The PC-PTSD (Prins et al., 2003) was used to identify students with potential PTSD symptoms and triggers. This tool was used because of its brevity and it has been validated in several cultural settings

(4 items).

The MacArthur Scale of Subjective Social Status (Goodman et al., 2001) was used to self-report the social, economic, and educational level of participants within Iraqi society. We chose to use this method instead of income report as the social classes that exist within Iraqi society are not always based on wealth. It is likely one can find an Iraqi considered from a higher social class that is not considered wealthy relative to the general population and vice versa. Self-reporting also provides a lens into how students perceived their position within Iraqi society and how this impacted their reported behaviours and attitudes.

The demographic questions included university, faculty, age, sex, religion, marital and living status.

In our question about religion, we were careful not to ask about sect within Islam (Shia or Sunni) as the results may contribute to tension in the already sectarian situation in the country. This also did not impact our findings as all Islamic sects share alcohol prohibition.

The English survey (appendix 4) was first drafted and shared with the in-country collaborator. After finalising comments and reviews, the survey was translated to Arabic and circulated again (appendix

5). The survey was then piloted by two medical graduates and a student representative who assessed the content, translation, its cultural appropriateness, and the length of the survey. The survey took around 20 minutes to complete and although they thought that it was slightly long, they advised that the survey kept the participant engaged and that it was realistic to complete. Minor changes to phrasing were made as a result of the piloting. A random selection of translated survey and interview questions were back-translated by another colleague to assess translation accuracy. No translation discrepancy was reported.

Qualitative component

Collecting richer qualitative data about the experiences and perceptions of students required a face- to-face approach. We assessed that conducting the interviews via online video or phone services may

44 have been more challenging and sensitive for the student. This is because the participant could not see the interviewer or his reactions and may have had concerns about undeclared recording or interception of the interview.

In the semi-structured interviews, no questions were asked regarding the person’s own alcohol consumption or attitude towards alcohol. Rapport building prior to the interview increased the comfort of the student in speaking to the interviewer. In all questions, we asked about stories or things that the interviewee may know about the prevalence of alcohol in Iraq and of the attitudes of others towards alcohol. We also asked about their perspectives about what influences alcohol use behaviours in Iraq. This was done so that the questions did not make the participant feel ‘accused’, scared or uncomfortable during the interview. We used the assumption that by asking about other people’s experiences and views, we can have an insight to the participant’s own attitudes and thoughts.

Once the draft interview guide was finalised, the structure was shared with local medical staff (two medical researchers and a medical graduate) and cultural/religious expert (religious scholar) for comment. The interview was also practised with two medical graduates and a student representative to assess its appropriateness for the local setting. No amendments were suggested to the structure of the interview.

Iraq is a country that culturally practices sex segregation. For this reason, for maximum comfort, the gender of the interviewer and the interviewee ought to be the same. Ideally, a female research assistant would have been hired and trained in each study site as it is not always acceptable or possible for females to travel alone or with strangers in the local culture. Even in the case that we did find a female research assistant who was able to travel – all the travel costs and accommodation would need to be covered to each study site. These approaches were not practical considering the unfunded nature of this study and the limited time the researcher had at each study site in Iraq (due to the security situation and difficulty to secure trusted transport).

Female participants may not feel comfortable to be interviewed by a man, especially regarding a sensitive topic such as alcohol. In addition, females may not want to be observed talking privately

45 with a male and they may feel uncomfortable talking to males whom they do not know or are not related to. Also, in Iraq, it is not appropriate for members of the opposite sex to be in an enclosed space if they are not related by blood or marriage.

As there was not a female interviewer available, steps were undertaken to maximise comfort and cultural sensitivity when recruiting female participants. Most participants, regardless of gender, were recruited using an “arms-length” approach – that is that recruiters other than the researcher approached the students for participation (Nathan et al., 2019). Females were approached, where available, by another female who was a volunteer research assistant (at University A and B) or by other senior male students or staff members known to the students (at University A and C). This was to ensure that female participants did not feel uncomfortable. It was explained to the potential interviewee that we prefer to conduct a one-on-one interview at a distance from other students due to the sensitivity of the topic – but that if they preferred, we may either sit closer to other students or the female participant may be accompanied by one of her peers. If the interview was to be conducted in a room, we always ensured the door remained open.

We also tried our best to conduct our interviews in casual or outdoor university spaces – however, this was not always possible when the faculty provided us with interview rooms or offices (including the dean or associate dean’s office). The offer of an office was out of respect from the faculty for my research and me as an international researcher. It was also to ensure that interviews are conducted in a quiet room without disruption.

Rapport building is essential to ensure that participants share their knowledge and experience honestly and comfortably with the interviewer (Nathan et al., 2019). Before the interviews, the interviewer ensured that he introduced himself and the overall topic. The interviewer then casually conversed with the student about their day and study. The conversation on the research topic usually flowed naturally. Recording started when the student was comfortable. It was more challenging to build rapport with female students as they were reluctant to engage in casual conversation or to maintain eye contact. The interviewer ensured to follow general rapport building techniques such as

46 maintaining an open and approachable body language, eye contact and using visual and verbal cues throughout the interview. The questions were also first generic before being focused and more sensitive (Nathan et al., 2019).

All the interviews were translated to English and transcribed in a one-step method (Arabic Audio to

English Text) by the author. Initial interviews were translated verbatim, including anything said by the interviewer. However, due to the time-consuming nature of this exercise and the lack of funding for this research, only participants’ answers were translated in most of the interviews. Several (3-5) transcripts were checked by bilingual colleagues to assess validity. No obvious discrepancy was identified in the transcripts that were checked. Thematic template analysis method was used to code and analyse the data (King, 1998). Template analysis encourages the initial use of a priori themes informed by previous literature and expected to be relevant to the analysis (King, 1998). This template of themes and codes is then progressively modified as the analysis occurs. The final template serves as the basis for the overall analysis and interpretation of the data and write up (King, 1998). The method is explained in more detail in Chapter 6.

The author as researcher (reflexive statement)

The researcher undertaking any study has a conscious and unconscious impact on the entire research process (Dodgson, 2019). A reflexive statement reflects on the researcher’s involvement and how it shaped the research outcomes. This process helps identify the actual or potential impact of the researcher’s personal, contextual, and circumstantial aspects on the research design, data collection, analysis, and write-up. This in turn assists readers to understand and interpret the research in light of some of the researcher’s possible influence on the study (Dodgson, 2019).

To give this section some context, I will briefly provide an overview of my own life and experience in Iraq. Although born in Iraq, I have only ever lived there for the first five months of my life, which started amid war in 1991. For the next decade, my family and I were refugees, travelling through several countries in pursuit of a safe place we can call home before arriving to Australia. I mention this is to bring context to myself as a researcher in this setting – although I am an ‘insider’ (because

I speak the language fluently, am aware of the culture, religion, etc.), I am also an outsider, as a foreign traveler or researcher going to Iraq. This mix of familiarity and distance provided me a particular lens into the Iraqi situation.

My previous travels to Iraq (since 2008) have been brief and I have stayed the entire period with my family with limited interactions with outside circles. I was keen to change that from my first trip – I wanted to know more about Iraq than just my immediate family circle and this drove me to try to learn more about local peoples, the changing and evolving cultures and attitudes in Iraq as well as the ever growing tension between ‘tradition’ and ‘modernity’ – and because of this I started observing more things, asking more questions and having more conversations. This research for me was founded on these curiosities. Alcohol was the ideal topic to investigate, as opinions about it are so divided – in a way Iraqis “either love it or hate it”. Furthermore, the uniqueness of Iraq’s situation regarding vulnerabilities to alcohol and drug use is unmatched – making the research important on a global scale.

Iraq is unique – it is a MMC with historically considerable populations of non-Muslims and competing views regarding many social issues, perspectives and behaviours. By observation, alcohol is one of these examples of competing viewpoints. As described in Chapter 1, Iraq has gone through continuous war, sanctions, terrorism, and political unrest for at least the past forty years. Iraq’s young population is also growing at an exponential rate with over 60% under the age of 24. Since 2003, Iraq changed dramatically – from an enclosed authoritarian socialist state to a liberal capitalist democracy.

This meant that the media and all exposure to the outside world and internationalisation changed from being non-existent to being inside every household. When one drives past some of the poorest areas in Iraq, there is little there except large satellite dishes, some bigger than the roof of the sheds they supply. At the same time, unemployment is rife, social and health facilities are limited, education is at a low point, poverty and displacement have increased over the past few years and mental health is almost not mentioned. At the same time, alcohol is a taboo and there is no mention, education, or awareness about it except in limited health and religious programs and circles. My experience of Iraq

48 has shaped the research questions, helped inform the development and implementation of the methods, and the interpretation of the data.

Ethics approval

Ethics approval was sought and granted by the Medical Ethics Committee at the College of Medicine in the University of Kufa, Iraq (MECCM-0028 – appendix 1).

References

Al Mousawi, A. (2015). "Alcohol use disorder identification test use in Muslim countries." International Journal of Prevention and Treatment of Substance Use Disorders 1(3-4): 79- 92. Arksey, H. and L. O'Malley (2005). "Scoping studies: towards a methodological framework." International Journal of Social Research Methodology 8(1): 19-32. Australian Institute of Health and Welfare (2013). National Drug Strategy Household Survey. Canberra, Australian Institute of Health and Welfare (AIHW),. Babor, T. F., J. C. Higgins-Biddle, J. B. Saunders and M. G. Monteiro (2001). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. Geneva, World Health Organization. Bullock, S. (2004). Alcohol, Drugs and student lifestyle: a study of the attitudes, beliefs and use of Alcohol and Drugs among Swedish University students, Centrum för socialvetenskaplig alkohol-och drogforskning (SoRAD). Bush, K., D. R. Kivlahan, M. B. McDonell, S. D. Fihn and K. A. Bradley (1998). "The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test." Arch Intern Med 158(16): 1789-1795. Ghandour, L., A. Chalak, A. El-Aily, N. Yassin, R. Nakkash, M. Tauk, N. El Salibi, M. Heffron and R. Afifi (2016). "Alcohol consumption in the Arab region: What do we know, why does it matter, and what are the policy implications for youth harm reduction?" International Journal of Drug Policy 28: 10-33. Goodman, E., N. E. Adler, I. Kawachi, A. L. Frazier, B. Huang and G. A. Colditz (2001). "Adolescents' perceptions of social status: development and evaluation of a new indicator." Pediatrics 108(2): E31. King, N. (1998). Template analysis. Qualitative Methods and Analysis in Organizational Research: A Practical Guide. G. Symon and C. Cassell. London, Sage: 118-134. Moher, D., A. Liberati, J. Tetzlaff, D. G. Altman and P. G. The (2009). "Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement." PLOS Medicine 6(7): e1000097. Munn, Z., C. Stern, E. Aromataris, C. Lockwood and Z. Jordan (2018). "What kind of systematic review should I conduct? A proposed typology and guidance for systematic reviewers in the medical and health sciences." BMC medical research methodology 18(1): 5-5. Peters, M. D. J., C. M. Godfrey, H. Khalil, P. McInerney, D. Parker and C. B. Soares (2015). "Guidance for conducting systematic scoping reviews." JBI Evidence Implementation 13(3). Prins, A., P. Ouimette, R. Kimerling, R. P. Cameron, D. S. Hugelshofer, J. Shaw-Hegwer, A. Thrailkill, F. D. Gusman and J. I. Sheikh (2003). "The primary care PTSD screen (PC- PTSD): development and operating characteristics." Primary Care Psychiatry 9(1): 9-14. Schoonenboom, J. and R. B. Johnson (2017). "How to Construct a Mixed Methods Research Design." Kolner Zeitschrift fur Soziologie und Sozialpsychologie 69(Suppl 2): 107-131. UNDESA (2013). Definition of Youth.

Chapter 3: Alcohol: From Mesopotamia to Modern Iraq

Chapters 1 and 2 introduced the overall objectives and methods of this thesis. Those chapters pointed out the scarcity of alcohol research in Iraq. No literature review provides a background to the context of alcohol in that country. This chapter aims to fill this gap by providing a socio-historic context to the place of alcohol in Iraqi cultures. We set out with an overview of the diverse groups of ethnicities, religions and cultures present within the borders of modern Iraq. Many minority groups in Iraq identify with pre-Islamic indigenous ethno-religious identities that have been in Iraq for millennia.

This chapter also notes the position of Islam, the majority religion in Iraq, on alcohol and describes how alcohol’s place in Iraqi society shifted in the post-Islamic era and during the past century. By acknowledging these histories, a clearer insight on alcohol’s place in Iraq’s current diverse society can be established. This chapter explains the challenges that Iraqi society has faced in the recent decades and how these experiences may impact the attitudes and choices of young Iraqis today. By providing an overview of existing alcohol research and policies in Iraq, this chapter also aims to set out the challenges and sensitivities of alcohol research, policy, and treatment in the country.

The following article has been published in the Journal of Ethnicity in Substance Abuse:

Al Ansari M, Dawson A and Conigrave K (2019) Alcohol: from Mesopotamia to modern Iraq. Journal

of Ethnicity in Substance Abuse, 1-23 DOI: 10.1080/15332640.2019.1657541

51 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE https://doi.org/10.1080/15332640.2019.1657541

REVIEW Alcohol: from Mesopotamia to Modern Iraq

Mustafa Al Ansaria , Angela Dawsonb , and Kate Conigravea,c aThe University of Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; bFaculty of Health, University of Technology, Sydney, Australia; cDrug Health Services, Royal Prince Alfred Hospital, Sydney, Australia

ABSTRACT KEYWORDS An understanding of alcohol’s place in Iraq’s history and soci- Alcohol; Iraq; Muslim ety can help inform alcohol policy responses in that country majority countries; Islam; and other Muslim majority countries. This article describes the history; youth history of alcohol in Iraq from ancient to modern times, with reflection on the challenges facing Iraqi youth today. A search was undertaken to identify peer-reviewed and gray literature that describes alcohol-related practices, norms, and values across the millennia in Iraq. A historical overview is provided of alcohol’s use and context, with more detail on recent times. Alcohol was an important commodity in Iraq until the rise of Islam in the seventh century CE. Despite the subsequent Islamic restrictions on alcohol, alcohol remained present in Iraq’s society and cultures. Recent studies provide varying descriptions of the prevalence of alcohol consumption, and there are challenges in researching this sensitive topic. External forces shaping alcohol use in Iraq include direct and indirect alcohol promotion, globalized media, and conflict and violence with its associated stress and trauma. Alcohol research and policy development in Iraq must consider the country’sunique cultural, religious, historical, and political context. Iraq’syouth may be subject to pressures to increase consumption, and thus policies must be informed by an understanding of the complex set of current perspectives and pressures.

Introduction The fertile lands of Mesopotamia, between the Tigris and Euphrates rivers, are the probable hosts of the first permanent human settlements from around 10,000 BCE (Potts, 2012). The desire to brew beer has been cited as a possible trigger for the establishment of grain farming and such settlements (Hanson, 2013; Hornsey, 2003). Today, alcohol is linked to 3.3 million deaths or 5.9% of deaths worldwide (World Health Organization, 2014). Most alcohol consumption occurs in high-income countries. In response, these countries are increasingly regulating alcohol use by restricting availability, limiting marketing, and increasing taxation (Babor, 2010).

CONTACT Mustafa Al Ansari [email protected] Drug Health Services, Lvl 6, King George V Building, Royal Prince Alfred Hospital C39, University of Sydney, 2006, NSW, Australia. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wesa. ß 2019 Taylor & Francis Group, LLC

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To maintain income and productivity, the global alcohol industry is now growing its investments in low- and middle-income countries (Alcohol Public Policy Group, 2010). This is where the largest increase in alcohol use exposure has occurred (Gakidou et al., 2017). The highest proportional increase in drinking is in countries with low baseline levels of alcohol consumption (Alcohol Public Policy Group, 2010). Young people are particularly vulnerable to both alcohol marketing and alcohol-related harm (World Health Organization (WHO), 2014) and are most at risk from drinking. Alcohol is the leading risk factor globally for burden of disease in people aged 15–49 years (Gakidou et al., 2017). Accordingly, low- and middle-income countries with young populations and high rates of abstinence may be especially susceptible to emerging alcohol marketing and alcohol-related harm (WHO, 2014). While Muslim majority countries (MMCs) may be protected by strong religious and cultural taboos in relation to alcohol, their population is unlikely to be totally immune. Indeed, MMCs have seen some recent increases in alcohol consumption (WHO, 2011). Iraq is an upper-middle-income country with an estimated population of over 38 million, of which three out of five are younger than 24 years of age (United Nations Department of Economic and Social Affairs [UNDESA], 2017). While only 3.4% of Iraqi adults report current alcohol consumption (U.S. Department of State, Bureau of International Narcotics & Law Enforcement Affairs, Iraqi Society of Addiction Medicine, University of California LA, & Center for Human Services, 2015), there are many pressures on young Iraqis that may increase alcohol misuse. These include exposure to global media, alcohol promotion, and violent conflict with its associated political and economic instability, stress, and trauma. Insights into the social, cultural, and historical context of alcohol use in Iraq can help inform an appropriate policy response. In Iraq, the majority population of Muslim Arabs and the minority religious and ethnic groups continue to identify with religions and cultures dating back centuries or millennia. An examination of these traditions can contribute to improved understanding of contemporary Iraqi attitudes and practices related to alcohol. This article provides a chrono- logical overview of the history of alcohol in Iraq and of available data on current attitudes and consumption, including among young people. Finally, it considers the challenges faced by researchers and policy makers in Iraq and other MMCs in close geographical proximity that share similar cultures and sensitivities.

Methods A search of databases and websites was undertaken to identify peer- reviewed and gray literature that describes alcohol-related practices, norms, and values across the millennia in Iraq. This search was not exhaustive,

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particularly for periods up to the 20th century, but was undertaken to reveal the range and nature of available material. This research used primary and secondary sources in English, Arabic, and Persian (Farsi) languages. For the pre-Islamic era, reference books and articles about the origins of human alcohol consumption were consulted to gather information about alcohol in Iraq’s early history. These were identified through Google Scholar, library database searches, and searching through hard-copy books in relevant sections of the university library. Arabic primary sources such as Qur’an exegesis (tafsir) and jurisprudential (fiqh) books were consulted to identify the development of the Islamic jurisprudential position on alcohol. Some of these findings have also previously been published in the English literature (Al-Ansari, Thow, Day, & Conigrave, 2016; Enes, n.d.; Feins, 1997; Michalak & Trocki, 2006). Where there were commonalities in findings between peer-reviewed papers and the primary Arabic literature, the English sources were cited as they are more accessible to non-Arabic readers. A similar approach was undertaken for the brief overview of alcohol use during the Islamic era. An extensive search of Arabic and English publications on the social position of alcohol in Iraq during the 20th century was also conducted online and in the University of Sydney Library. Peer-reviewed literature relating to the place of alcohol in Iraq’s society and culture and prevalence of its use were identified using the search terms “alcohol” and “Iraq” on Scopus. The search identified almost 400 studies, but most were on alcohol use among U.S. servicemen returning from Iraq. After excluding the search terms “military or veterans or duty or soldiers or armed” and excluding irrelevant articles (e.g., relating to laboratory studies of ethanol), there were only three articles specifically about alcohol. In addition, eight articles on other topics included information about alcohol (three about other drugs [benzhexol and corticosteroids], three on mental health [e.g., schizophre- nia], one on driving behaviors, and one on health management). Other databases revealed even fewer results. These international academic sources were complemented with articles from local unindexed academic journals (some accessed through Research Gate) or gray literature and from conference presentations. Iraq’s alcohol policies were identified using primary legal sources (in Arabic) from legal databases (e.g., the Iraqi Local Governance Law Library). Information about implementation of these policies was mostly gath- ered from gray literature such as online media reports (in Arabic and English).

Findings Iraq has been home to and influenced by many ethnicities, cultures, religions, and civilizations. This is in part due to Iraq’s location at the crossroads between Central Asia, West Asia, Arabia, Africa, and Europe (Figure 1).

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Figure 1. Locations of the major historical capitals within Iraq’s modern borders.

The country’s evolving attitude toward alcohol (summarized in Figure 2) provides a lens to better understand the modern Iraqi society.

Alcohol and Iraq in pre-Islamic history Beer played a central role in ancient Mesopotamia; it provided the necessary calories to carry out daily work and was clear of the fecal matter that often polluted freshwater sources (Wolf, Bray, & Popkin, 2008). Accordingly, beer is said to have replaced water as the most consumed beverage (Corfield, 2015), and it acted as a form of currency (Corfield, 2015; Sinclair & Sinclair, 2010). Beer was socially consumed from a large vat using straws (Hornsey, 2003; Sinclair & Sinclair, 2010). The straws were sometimes made from gold and silver and measured approximately 1 cm in diameter and 93 cm in length (Sinclair & Sinclair, 2010). The first brewing recipe spread from southern Iraq as a hymn to the Sumerian Goddess of brewing, Ninkasi (Corfield, 2015; Hornsey, 2003).

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Figure 2. Timeline of alcohol in Iraq’s history.

Wine making similarly originated near the borders of Iraq in modern- day Iran in the fifth millennium BCE (Wolf et al., 2008). In southern Mesopotamia, Babylonians worshiped wine deities and used both beer and wine for ceremonial purposes (Hanson, 2013). This region is where the first evidence of alcohol policy can be found, in the 18th century BCE Babylonian code of Hammurabi. The engraved stone tablet set out legislation on tavern trade and restricted priestesses from opening, operating, or consuming publicly in taverns (Hammurabi, 1904). Jews in southern Iraq were also known to have written rules around wine as early as the fifth century BCE (Feins, 1997). They continued to produce and consume alcohol into the Islamic era (Feins, 1997). In northern Iraq, wine was seen as a luxury for the Assyrians, given as a reward to the men and women who were under the service of the king (Joffe, 1998). This region was also home to the first Christian state, the Oshoene Kingdom (Rassam, 2005). Wine was seen as a gift from God, an inherently good substance, but its excessive consumption was frowned upon (Hanson, 2013). In neighboring Arabia, consumption of alcoholic beverages was com- monplace and had cultural and religious importance until the rise of Islam (Feins, 1997; Maraqten, 1993). Indeed, the significance of alcohol is demonstrated by the hundreds of words that exist for alcoholic beverages in classical Arabic (Maraqten, 1993). The word alcohol is thought to be derived from the Arabic al-kohl, a black powder used in cosmetics for the eye (Matthee, 2014; Michalak & Trocki, 2006; Wiedemann & Allan, 2012). Kohl described any substance that cannot be pulverized any further (Wiedemann & Allan, 2012). In Arabic, alcoholic beverages are also referred to as khamr (literally: grape wine). The word khamr is the root of takhmeer (fermentation). The root kh-m-r is also the root of Arabic terms, including covering, clouding, hatred, or enslaving (Enes, n.d.; Ibn Manẓ ur, 2003). For this reason, the term khamr is widely believed to be inclusive of all intoxicants and not just grape wine (Enes, n.d.; Feins, 1997; Ibn Manẓur, 2003).

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Alcohol and Islam Islam began in western Arabia in the early seventh century, at a time when alcohol consumption was widespread (Gately, 2008; Maraqten, 1993). The advance of Islam, with its teaching of abstinence from alcohol, reduced alcohol production in the region (Wolf et al., 2008). Islam remains the religion of most of Iraq’s population (Pew Forum on Religion & Public Life, 2009). Shia Muslims constitute 65%–70% of the Iraqi population, while 29%–34% of the population are Sunni (Pew Forum on Religion & Public Life, 2009). There is a consensus on the prohibition of alcohol in both schools of thought. However, Abu Hanifa al-Nu’man, one of the main four Sunni jurisprudential authorities, argued that absolute khamr prohibition only applies to grape wine (Abbu Zahu, 2012; Feins, 1997). Substances from other sources are prohibited if consumed in amounts that cause intoxication (Abbu Zahu, 2012; Feins, 1997).

Alcohol in the Qur’an The Qur’an and the Sunnah form the main basis of Islamic law. The Qur’an is believed to be the word of God, revealed to Prophet Muhammad during his life. According to some interpretations, the Qur’anic prohibition of alcohol was gradually revealed via three stages (Figure 3). This was to create an environment that can accommodate the introduction of absolute prohibition (Al-Ansari et al., 2016; Baasher, 1981; Feins, 1997; Michalak & Trocki, 2006). Chronologically, the first verse warned that the harm from intoxicants outweighs their benefits: They ask you [Prophet] about intoxicants and gambling: say, “there is great sin in both, and some benefit for people: the sin is greater than the benefit.”(Abdel Haleem, 2005) Some scholars have interpreted the “benefits” of khamr in the above verse to be the temporary pleasure intoxicants provide (Al-Ṭ abat: aba)ī , 1997). This is consistent with other verses of the Qur’an that speak of harmless and pure goblets [of wine] in heaven as a reward for good-doers (Qur’an 37:45) (Abdel Haleem, 2005).

Figure 3. Stages of alcohol prohibition in Islam.

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Despite the warnings about the harms of alcohol in this verse, some Muslims continued to drink and even prayed in a state of intoxication (Michalak & Trocki, 2006). Accordingly, the second verse was revealed: You who believe, do not come anywhere near prayer if you are intoxicated, not until you know what you are saying. (Abdel Haleem, 2005) As Muslims needed to pray five times a day, the verse greatly limited the possibility of consuming alcohol, but it was not explicitly forbidden until the final verse was revealed: You who believe: intoxicants and gambling, idolatrous practices, and [divining] arrows are repugnant acts of Satan’sdoing—shun them so that you may prosper. With intoxicants and gambling, Satan seeks only to incite enmity and hatred among you, and to stop you remembering God and prayer. Will you not give them up? (Abdel Haleem, 2005) While some scholars argue these verses represent three steps toward the prohibition of alcohol, others say khamr was prohibited from the first verse and the latter verses only elaborate on the prohibition (Al-Ṭ abat: aba)ī , 1997). Although the Qur’anic prohibition may have been initially gradual, this did not mean that alcohol prohibition was implemented gradually in new areas Islam spread to, such as Iraq.

Alcohol in the Sunnah The Sunnah is the life, sayings, and teachings of the Prophet Muhammad (relayed via hadith, which were initially verbal accounts). In Shia thought, the life and teachings of the 12 Imams are also considered an accurate interpretation of Islam (Lindsay, 2005). Statements attributed to the Prophet indicate that khamr is anything that befogs the mind and that whatever intoxicates in large amounts is prohibited in small amounts (Feins, 1997; Michalak & Trocki, 2006). It is also narrated that God will reward abstainers, regardless of their intention, for protecting themselves. This is because consumption of khamr is considered a gateway to every evil (Al-Qummī Al-S: aduq, 1984; Enes, n.d.). Hadith literature indicates that in addition to consumption, this prohibition encompassed any association, production, sale, purchase, transport, profit, or service of alcohol or any other intoxicant (Al-Ansari et al., 2016;Enes,n.d.; Michalak & Trocki, 2006).

Brief history of alcohol during the Islamic era (seventh–20th centuries) in Iraq Although the Qur’an and Sunnah prohibit alcohol consumption, there is evidence that some Muslims continued to drink well into the Islamic era (Feins, 1997; Matthee, 2014). There are even examples of Muslim rulers

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consuming alcohol from the first century after hijra (Islamic calendar, circa seventh century CE) onward (Feins, 1997). Some Umayyad (661–750 CE in Syria) and Abbasid (750–1258 CE in Iraq) Caliphs were well known for their excessive drinking (Abbu Zahu, 2012; Feins, 1997; Matthee, 2014). This continued even beyond these empires, when Ibn Battuta, the famous 14th-century traveler and chronicler, spoke of a king who was whipped in his own palace as a punishment for his drinking (Ibn Bat: t: ut: a, 1987). Public consumption was also present, and taverns could be found across the Muslim world, although their reputation was negative (Matthee, 2014). It is also evident that non-Muslims remained free to produce, trade, and consume alcohol (Feins, 1997; Matthee, 2014). Strict religious prohibition and punishment only took place periodically and temporarily, depending on the ruler (Feins, 1997; Matthee, 2014). Another indicator that drinking did occur in some circles during this era is the rise of the pre-Islamic genre of wine poetry (khamriyyat) (Kennedy, 1997, 2012). Unlike mystic poetry, khamriyyat speak of the love of wine and of intoxication. This style of poetry was mastered by Abu Nawas: If I count my years I find no excuse for grayness to descend upon my head, They say, “You have become old and gray,” yet my hand is not so old that it cannot hold a cup to my lips! (Kennedy, 1997) Abu Nawas is still celebrated in Iraq, and a street named after him, fittingly, has become the center of Baghdad’s nightlife and drinking (Raad, 2017). Alcohol was( also used in Islamic medicine, including in antidotes (Ibn Abi Us: aybi a, 1996). Ibn Sina (Avicenna) dedicated a portion of his Canon of Medicine to “rules concerning the use of water and wines.” He explained some benefits from wine before prescribing alcohol mixed with moss as a sedative. He also prescribed cures for alcohol overdose while advising against youth intoxication: To give wine to youths is like adding fire to a fire already prepared with matchwood. Young adults should take it in moderation. But elderly persons may take as much as they can tolerate. (Avicenna, 1973). Although public Muslim consumption of alcohol was banned, there is evidence that alcohol continued to be consumed throughout the Muslims lands, including by the Ottomans, Safavids, Mughals, and Qajar, until the 20th century (Matthee, 2014; Matthee, 2005). The last caliphate was abolished on March 3, 1924.

Alcohol and modern Iraq Brief history of modern Iraq Between the 1500s and early 1900s, Iraq comprised three provinces of the former Ottoman Empire: Baghdad, Basra, and Mosul (Fontana, 2010;

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Zubaida, 2002). Despite strong resistance, the British occupied Iraq after the First World War. The newly created mandate of Iraq, typically labeled “artificial,” included borders with no historic, cultural, or geographic significance (Fontana, 2010). This Iraqi monarchy became independent from the British in 1932 (Zubaida, 2002). In 1958, following an uprising, the country became a socialist republic, and soon afterward the Baathist party overthrew the government to rule Iraq for the next few decades. Despite this political volatility, Iraq remained one of the most developed nations in the region, with an annual per capita income of US$3,510 in 1989, and 97% of the urban population had access to health care (Ali & Shah, 2000). However, in August 1990, prior to the First Gulf War, international sanctions reduced Iraq’s oil production by 85% and resulted in the decline of the per capita income to US$450 by 1996 (Ali & Shah, 2000). These sanctions contributed to the death and disability of many Iraqis, especially children (Ali & Shah, 2000; Rowat, 2000). Mortality rates soared by more than 100% in the space of a few years (Ali & Shah, 2000; Rowat, 2000; The United Nations Children’s Fund, 1999). Since 1980 (except for 1989), Iraq has been exposed to either war, sanctions, or terrorism.

Alcohol in Iraq in the 20th century CE There is only limited published work describing alcohol use in Iraq between 1932 and the present. From accounts, we know that alcohol production and consumption was present in the 1940s and 1950s, especially among Iraq’s non-Muslim population (Zubaida, 2014). Zubaida (2014)alsospeaksofa Jewish cooperative of households making their own alcohol for special occasions. Alcohol consumption among non-Muslims and in the middle and upper sectors of society was typically in private households or “casinos” and associated with enjoyment, sociability, and music (Zubaida, 2014). There was, however, another side to drinking in the common pubs (may- khanas) that were available around Baghdad. These establishments, where intoxication and fights were not uncommon, were frequented by poorer classes (Zubaida, 2014). In the 1960s, al-Wardi in his Study of the Nature of Iraqi Society mentioned this heavy presence of alcohol in urban environments. He relayed that men in urban settings drink to prove their masculinity and it is usual to see a drinker trying to engage in physical fights, even if he has not consumed enough to be particularly intoxicated (Al-Wardī, 1965). This helps “ ’ ” explain why araq( (distilled spirit) was colloquially known as the lion smilk (h: alībal-Sab)(Zubaida,2014). It is postulated that heavy social responsibil- ities and lack of opportunities for self-expression may have contributed to heavy drinking among Iraqi men (Al-Wardī, 1965; Khayyat, 1990). In 1990, when alcohol was consumed in Iraq at a rate of 0.8 L of pure alcohol per capita (WHO, 1999), Sana Khayyat (1990) interviewed Iraqi

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women (n ¼ 50) across the ethnic, religious, and professional spectra. The women reported their husbands typically drank excessively outside the home and often returned with financial difficulties and an increased chance of family conflict and domestic violence. Most of the women described their father, husband, or both as “alcoholics” and expressed that men use alcohol to express their adoption of modern attitudes as opposed to traditional customs (Khayyat, 1990). Iraq’s alcohol industry produced both beer and araq and lasted until the fall of Saddam in 2003 (Jansen, 2006). The Gulf War, international sanctions, and his permissive attitude toward alcohol and nightlife had made Saddam unpopular in religious spheres (Lewis, 1994;Rohde,2010). As a response, in 1994, Saddam introduced the al-H: amla al-Imanīyya (faith campaign), which banned public alcohol consumption (H: usayn, 1994). Alcohol played such a role in establishments on Abu Nawas Street (Baghdad’s main entertainment quarter) that the space was deemed “dead” following the ban (Raad, 2014). The faith campaign was disputed, including by Saddam’ssonUday (Lewis, 1994), who later oversaw Iraq’s largest brewery until the Second Gulf War in 2003 (Jansen, 2006).

Alcohol in contemporary Iraq (21st century) Iraqi legislation allowed the sale and consumption of alcohol within regulations until late 2016. Laws enacted in 2001 (Tables 1 and 2) allowed premises with an annual alcohol license to operate. These premises could not be situated in Iraq’s sacred cities or near a mosque, religious establishment, hospital, or school (Makkī, 2001). Such premises were required to be closed during special religious occasions, including Ramadhan. Individuals had to be over 21 years of age to work for an alcohol store, and the law permitted alcohol to be sold to anyone over the age of 18 (Makkī, 2001). Most alcohol sales in Baghdad were reported to be conducted by Christians and Yezidi minorities in Iraq, although some customers were Muslim (Alive in Baghdad, 2009). Alcohol businesses ceased sales during the Islamic holy months of Ramadhan and Muharram (Alive in Baghdad, 2009). According to alcohol shop owners, all types of alcoholic beverages were readily available in their Baghdad stores but were difficult to transport to other provinces for private sale due to the increased presence of police and security checkpoints (Alive in Baghdad, 2009). These 2001 national regulations remain the most detailed recent laws regarding alcohol in Iraq. After the 2003 war, alcohol sales declined due to violent attacks on bottle shops and nightclubs by a mix of government forces, militia, and terrorists (Russia Today, 2014). However, reports from coalition forces in Iraq suggest that “moonshine,” home-distilled spirit with high alcohol content, was available in Iraq during this time (Von Zielbauer, 2008).

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Table 1. Laws Regarding Application for a License to Sell Alcohol. Applicant One applicant (license cannot be under two or more names) Iraqi citizen Non-Muslim Female or male (males must have completed military service) Over the age of 21 Not have an existing license for another store for the same purpose Zoning and location Not be located in the holy cities (Najaf, Karbala(,Samura(,Kadhumiyya, and A)dhamiyya) Not be located on freeways, highways, or any other roads connecting towns or cities To be at a minimum distance of (from the boundaries, in all directions): 500 meters from Holy Shrines 200 meters from Mosques or Islamic centers 100 meters from schools or hospitals In the correct zoning within the Baghdad council or other municipal councils Approval from local People’sCouncil The relevant department will assess whether the location meets all terms and conditions Size and facilities Wholesale stores: Minimum size of 150 m2, must include rooms for management, budgeting, and to accommodate other staff. Storage facilities or shelters must be included with access available for large vehicles. Sanitary facilities must be included. Retail stores: Minimum size of 20 m2. Other required documents Ownership or lease documents of the potential store Valid business name approved by the Department of Trade Permission from the local representative (Mukhtar) License to import alcoholic beverages or primary ingredients for the making of alcoholic beverages Contract with an alcoholic beverage import or production company License renewal and conditions The license is annual and must be renewed annually in person before April 1. The Department of Tourism has the authority to limit the number of licenses given within a district.

Following the introduction of the new Iraqi constitution in 2005, some provincial governments passed their own laws regarding alcohol. A few provinces across Iraq, including the port city of Basra, prohibited alcohol production, sale, consumption, and import (Agence France-Presse [AFP], 2010). Alcohol prohibition in Basra caused anger among the province’s non-Muslim population, who argued that this would drive people to pro- cure their alcohol from illicit sources (AFP, 2009). A number of Christians also accused authorities of using the fight against alcohol to drive them out of the country (Leland, 2011). In 2016, the Iraqi parliament introduced a ban on alcohol import, production, and sale in all Iraqi provinces other than the Kurdistan autonomous region (Article( 14, Municipal Revenue Laws, passed 22 October, 2016) (Al-H: ukuma al- iraqiyya [Iraqi Government], 2016). Some analysts have argued that this ban was initiated by some members of Iraq’s parliament who had a conflict of interest. They believe that these members used their political power to establish a monopoly on the black-market trade of alcohol in Iraq (Salloum, 2016). Others argue that alcohol has become a political commodity. It is used to differentiate those in support of a secular, pluralist government from those working on the Islamization of the state (Salloum, 2016).

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Table 2. Laws Regarding the Operation of Licensed Stores. Marketing Alcoholic beverages are not to be displayed in a provocative manner inside or outside the store. All marketing for alcoholic beverages in any media (visual, readable, or audio) is banned. Age limits Alcohol cannot be sold to those less than 18 years of age. Employees are all to be over the age of 21. Closing dates All alcohol shops are to shut for the following occasions: Holy month of Ramadhan Islamic New Year (1st of Muharram ) Day of Ashura (10th of Muharram) Birth of the holy Prophet Muhammad Night of ascent and descent All other religious occasions Operating hours Wholesale stores: Saturday to Thursday 9 a.m. to 6 p.m. Retail stores: Saturday to Thursday from 10 a.m. to 10 p.m. and Friday, 3 p.m. to 10 p.m. Safety measures It is not permitted to amend the type or the label on any alcohol container. Wholesale stores must meet the relevant regulations for the storage of alcoholic beverages (depending on type). Wholesale stores are not permitted to sell individual containers. Retail stores are not permitted to sell wholesale or any alcohol that is not sealed into individual containers. Representation or transfer of license If the licensee is away for international travel, he or she must apply prior to travel for a representative to take all responsibility for the store during the entire period of the licensee’s absence. A licensee may surrender or transfer the license with the permission of the Department of Tourism to a family member or a shareholder in the company, given that they meet the requirements to hold a license. Muharram is the first month of the Islamic lunar calendar. Commemorates the Ascent of the Prophet Muhammad to heaven.

Despite this law’s publicity in local and international media, on the ground, the alcohol ban was not implemented, and alcohol is still available in Iraq—mostly in areas famous for their nightlife in Baghdad and Erbil.

Data on the prevalence of alcohol use in Iraq Alcohol is an understudied issue in the Muslim world, including in Iraq, where over half of the alcohol consumed is believed to be unrecorded (WHO, 2014). There have been attempts to fill in this gap by national household studies, such as the Iraqi Mental Health Survey (IMHS) (WHO, 2009) or Survey of Substance Abuse in Iraq (SSAI) (U.S. Department of State et al., 2015). However, the results have been limited due to cultural sensitivities in reporting alcohol use in interviews (Al-Hemiery et al., 2017;WHO,2009). In the available literature, underreporting of alcohol consumption is also indicated by a clear discrepancy between prevalence of self-reported drinking and the prevalence of knowing someone who has used alcohol (Al-Hemiery et al., 2017). Despite these limitations, anecdotal evidence from the 1980s (Maghazaji & Zaidan, 1982) and from present-day Iraq (Al-Diwan, Al-Hemiary, & Hashim, 2015) suggests that alcohol consumption in Iraq is increasing.

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Reported lifetime alcohol use by male Iraqis has risen from 6.8% to 16.7% in the nine years between the 2006 IMHS and 2016 SSAI. Past 12-month consumption has also increased from 2.9% to 6.7% in the same studies. However, it is unclear whether this increase is real or a result of different sampling and data collection methods. Reported lifetime alcohol use by female Iraqis is negligible at 0.6% in both studies, with past 12-month use at 0.4% and 0.1%, respectively. In terms of alcohol abuse, the 2006 IMHS indicated that only 0.1% of participants met the criteria for DSM-IV alcohol abuse (WHO, 2009). By contrast, the 2015 SSAI found that over 70% of current drinkers scored within the dependence range on the Severity of Substance Dependence Scale (SDS) (U.S. Department of State et al., 2015). In other smaller samples, Al-Hemiary and colleagues (2015) interviewed 2,678 people in youth centers across Baghdad and found 17% of the male sample met DSM-IV criteria for alcohol abuse using the Composite International Diagnostic Interview second edition (CIDI-2). In this study, alcohol abuse was most common among those who were illiterate (73.7%) (Al-Hemiary, Hashim, Al-Diwan, & Abdul Razzaq, 2015). Data from Ibn Rushd Alcohol and Substance Center in 2004 revealed that alcohol use disorders accounted for 41% (n ¼ 74) of admissions among unemployed male patients between the ages of 21 and 30 years (Aqrawi & Hussain, 2010).Similarly,overathirdofasampleofmedical residents and general practitioners (GPs) reported alcohol as the most abused substance in Iraq (Al-Hasnawi, 2006).

The next generation: Alcohol and Iraqi youth Iraqi youth are increasingly exposed to alcohol via international media and culture while facing a challenging political, social, and economic situation at home. In 2014, young Iraqis from Anbar province indicated that some youth boast about their drinking and see drug and alcohol use as a way to escape from despair, limited rights, and restricted freedoms (United Nations Development Program [UNDP], Ministry of Planning, & Baytul Hikma, 2014). They also see intoxication as a way to imitate celebrities. The interviewees focused on ease of access and lack of governmental control as factors in drinking (UNDP et al., 2014). During the ISIS (“Islamic State” of Iraq and Syria) crisis, Iraqi youth lived under the constant threat of war and violence. Many young Iraqis joined the ranks of the military to fight against ISIS. Universities also introduced voluntary training courses( to prepare students to defend against potential ISIS advances (Al-Jami a( al-Mustans(: iriya [University( of ī ī ī al-Mustansiriya], 2015; Al-Rimah: , (2015;Ilam al-ta l m al- al [Higher Education Media Office], 2015;Jami at al-Kufa [University of Kufa], 2015). Despite the subsequent decline of ISIS in Iraq, almost nine million Iraqis

64 14 M. AL ANSARI ET AL. still require humanitarian assistance. These include two million internally displaced persons (IDPs) (United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA)), 2018) and four million children (The United Nations Children’s Fund [UNICEF], 2018). Mental health issues are a concern among young Iraqis, with a study revealing that nearly half (47%) of a sample of 600 primary school children in Baghdad had been exposed to a major traumatic event in the past two years and 14% of the sample had symptoms of posttraumatic stress disorder (PTSD) (Razokhi, Taha, Taib, Sadik, & Gasseer, 2006). In Mosul, before the ISIS occupation, 30% of a secondary school student sample suffered PTSD with the majority (92%) not receiving any treatment (Razokhi et al., 2006). Previous research has drawn an association between conflict exposure and alcohol abuse among veterans (Browne et al., 2008; Kelsall et al., 2015; Wilk et al., 2010) and civilian (Weaver & Roberts, 2010) populations in other settings. However, there has been no research about alcohol and war on any Iraqi sample and very limited research on alcohol and internally displaced populations (Ezard et al., 2011; Roberts & Ezard, 2015).

Discussion Alcohol’splaceinIraq’s history is as volatile as the political, security, and economic tides that continue to affect the country. The relationship between Iraq and alcohol is a geopolitical one because alcohol as a commodity in Iraq is more than just another beverage or substance that might have negative health effects. Due to the long history of alcohol in Iraq and the expanding external cultural, economic, and political influences, alcohol is a commodity that is often seen to demarcate the “traditional” and the “modern,” the “basic” and the “sophisticated,” the “religious” and the “secular.” The conversation about alcohol throughout Iraq’s history has typically centered on culture and religion more than on health and medicine. Many of Iraq’s minorities are indigenous to the country and have had a culture of drinking that has lasted for millennia, even under Muslim rule. Some Muslims, including royalty, consumed alcohol despite the abstinence of the majority (Matthee, 2014; Nahas, 1982). For centuries, Iraq and neighboring countries have seen more stigma toward alcohol than toward other drugs. This is due to the lack of certainty about the prohibition of other intoxicating substance such as cannabis (hashish) among rulers, scholars, and lay persons (Nahas, 1982; Rosenthal, 2015). Similarly, use of other drugs and treatment seeking for problems with those drugs are less stigmatized than for alcohol in Iraq (Al-Hasnawi, Aqrawi, Sadik, & Humphreys, 2009;Brandt,2005;White,2011). Historically, there have been several policy interventions in the Islamic era. For example, Al-Mansur Qalawun, the 13th century Mamluk ruler of

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Egypt and Syria, allowed alcohol and cannabis production and trade but imposed excise taxes on the sale of both substances (Nahas, 1982). In other times, consumers of alcohol were punished (Ibn Bat: t: ut: a, 1987) and the trade outlawed (Nahas, 1982). This is similar to what occurred on a mass scale post-2003 when reportedly 95% of alcohol stores closed due to threats despite all being owned and operated by non-Muslim minorities (Taneja, 2007). This has driven non-Muslim minorities in Iraq to argue that alcohol trade and use is their “right” (AFP, 2009). This tension about the right to consume or trade alcohol among non-Muslims is juxtaposed with the religious and cultural conviction of Iraq’s majority Muslim population that typically abstains from alcohol and frowns upon any alcohol consumption. These contrasting viewpoints set unique challenges for policy makers and researchers. It also makes it difficult to discuss alcohol without being perceived as advocating either “prohibition” or “normalization” of alcohol use. Due to the Islamic prohibition and social stigma around alcohol, reported prevalence of alcohol use in Iraq is currently low compared to countries where alcohol consumption is culturally accepted. However, the rate of alcohol abuse and dependence among those who do drink is a concern. More than 70% of current drinkers in the Iraqi nationwide household survey reported symptoms of dependence (2.4% of the total population, with SDS 3þ) (U.S. Department of State et al., 2015). This prevalence of dependence among drinkers is strikingly high. By comparison, in Australia, 1.7% of current drinkers (1.4% of the total population) were dependent (using WMH-CIDI v3.0, DSM-IV criteria) (Teesson et al., 2010). However, SDS includes items about “worry about drinking” and the respondent’s desire to stop drinking. Some positive responses could be the result of cultural/religious prohibition of alcohol use. Nonetheless, any increase in consumption could be associated with an increased demand on treatment services. Currently, there are very limited facilities for alcohol and drug treatment in Iraq. Al-Rashad Hospital and Ibn Rushd Hospital were reportedly the only psychiatric hospitals in Baghdad, with only the latter hosting a special- ized alcohol and drug dependence unit (Al-Hasnawi, 2005). There is also reportedly a 40-bed center for alcohol and drug treatment currently being established in Basra (Salaheddin, 2018). The shortage of specialists and treatment facilities in Iraq means that often only those who can afford medical care in other countries are able to seek treatment (Salaheddin, 2018). Although no published information is available on alcohol-specific treatment, literature on mental health access in Iraq indicates the barriers of stigma and shortage of services and staff (Bolton, 2013; Sadik, Bradley, Al-Hasoon, & Jenkins, 2010). There have been efforts to incorporate mental health in primary health care (Sadik, Abdulrahman, Bradley, & Jenkins, 2011) and to train general practitioners in mental health (Al Hilfi, Lafta, &

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Burnham, 2013). However, most Iraqis do not feel comfortable speaking about mental health with primary care health providers or even with family and friends (Sadik et al., 2010). Anecdotally, primary health care in Iraq has limited confidentiality guarantees, especially within the public health system, and it is usual for multiple patients to see a practitioner in the same consultation room at the same time. Although steps such as alcohol or drug treatment integration into primary health care may increase treatment access, there is a long way to go until the Iraqi health system can cope with such pressure. This includes having adequate resources to allow confidentiality and availability of non-local health professionals, so locals are more at ease to share their alcohol-related concerns without fear of losing face or being outcast by their community. Religious bodies and scholars may also help with easing the path to treatment, even in areas with alcohol prohibition. An example of this is the issuance of a fatwa (ruling) in neighboring Iran that decriminalized treatment access (Al-Ansari, Thow, Mirzaie, Day, & Conigrave, 2019). Alternative avenues for treatment may also in the future be provided by religious or cultural organizations who may integrate their own teachings with evidence-based approaches such as brief interventions or Alcoholics Anonymous’s 12-step program. However, success will rely on guaranteed confidentiality and reduced stigma around alcohol treatment access. Available studies, albeit limited, indicate a possible increase in alcohol consumption since the 2003 war in Iraq. Reasons for this are multifaceted but may include war and media exposure. Although an association between exposure to trauma by civilian populations and increased alcohol misuse has been found, studies in this field are scarce (Weaver & Roberts, 2010). However, a systematic review of longitudinal studies concluded that exposure to alcohol in the media increases the likelihood of adolescents’ onset and/or increase of alcohol consumption (Anderson, de Bruijn, Angus, Gordon, & Hastings, 2009). Lebanon, an MMC with some similarities to Iraq, has also experienced increased alcohol use in the past few decades. Like Iraq, Lebanon has several other religious and ethnic minorities, although Lebanon’s non-Muslim population is proportionally larger. There was marked increase in alcohol consumption in the postwar period between 1991 and 1999, especially among females (40.7% to 67.7%) (Karam, Maalouf, & Ghandour, 2004). Similarly, in Egypt, where half of the population is younger than 20, alcohol consumption has increased in large community samples from 2.2% in 2005/2006 (Emad Hamdi et al., 2013) to 5.9% in a study conducted over the years 2007 to 2014 (E Hamdi, Sabry, Sedrak, Khowailed, & Loza, 2016). In neighboring Iran, an increase in youth drinking is also indicated (S: iramī, Qurbanī,&Mīnun ī, 2013). In the MMC context, younger people are at higher risk to initiate or increase their alcohol consumption as they have increased

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exposure to direct and indirect alcohol marketing across traditional and social media platforms (Anderson et al., 2009;Ghandouretal.,2016).

Conclusion Despite the limited prevalence of alcohol consumption, the Iraqi environment is potentially conducive for increased drinking, especially among its youth population. Young people in Iraq are exposed to many stressors as well as to global alcohol marketing. Iraqi governments, organizations, and families are likely to be preoccupied with basic survival needs such as safety, security, and access to electricity. Currently, due to the lack of developed mental health or alcohol-related policy or strategies in Iraq, the only protective factors are religious prohibition and the cultural stigma that has developed over the centuries. A well-developed alcohol policy that provides adequate strategies, regulations, and treatment facilities to prevent and treat alcohol misuse is needed. Any such policy development needs to make use of the modern evidence base as well as a sensitive approach, founded on an in-depth understanding of Iraq’s long and diverse religious, social, and cultural traditions. This is also needed to shift the debate from purely a cultural or moral lens to include a focus on health, medical, and social needs; this multi-lensed approach may find consensus from the diverse ethnic, religious, and cultural groups of Iraq.

Acknowledgement We acknowledge Ayatollah Mohammad Hussein Al-Ansari for his help in identifying and explaining some of the Islamic literature used in this paper.

ORCID Mustafa Al Ansari http://orcid.org/0000-0003-4989-8686 Angela Dawson http://orcid.org/0000-0003-0926-2202

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74 Chapter 4: Alcohol among young people in Iraq: A systematic scoping review

Chapter 3 established the context of alcohol research in Iraq. It set out historical, social, cultural, and religious factors that may influence the attitudes towards alcohol among young people today. As established within that chapter, very little is known about the prevalence of alcohol use or the attitudes of young people towards alcohol in Iraq.

The current chapter will describe the scope and nature of available data about Iraqi youth drinking in peer-reviewed journals. A systematic scoping review was utilised to provide a complete picture of what is already known regarding alcohol use among young people in Iraq. Non-alcohol specific studies were included because of the scarcity of alcohol-specific research, as identified in Chapters 1 and 3. We also included a wider age range than our mixed-method study because we identified that most national and general studies categorised their participants in bands between 14 to 34 years. This chapter sets out to identify the gaps in knowledge about prevalence of alcohol use and attitudes towards alcohol among young people in Iraq.

The following manuscript has been submitted for publication.

75 Abstract

Introduction

Young people in Iraq are exposed to conflict and trauma, and also to uncensored international TV and media, with its references to alcohol. However previous regional reviews indicate that alcohol is the least studied substance in Arab countries and no data on young people in Iraq were identified.

Accordingly, we re-examined the scope of available literature on alcohol and Iraqi young people, including in studies where alcohol was not the primary focus.

Methods

Five major international databases (MEDLINE (OVID), Embase (OVID), PsycINFO (OVID),

Scopus, Web of Science) and one local Iraqi database (Iraqi Academic Scientific Journals (IASJ)) were systematically searched for published articles up to 16th of September 2019. Original articles that included any alcohol data on general Iraqi young or student samples were included.

Results

Thirteen articles met the inclusion criteria from a total of 3374 results. All studies were cross-sectional and quantitative. Most alcohol data were incidental rather than the focus of the studies. All but two studies used face-to-face or pen-and-paper surveys. Each study reported on alcohol differently – with most not using validated tools. A wide range of drinking prevalence was reported (2.2%-23.7%).

Studies reported a relatively high rate (12.2-56%) of alcohol misuse among those that drink. Alcohol was associated with risky behaviour in the two studies that reported on this measure.

Conclusion

Results suggest a low prevalence of drinking compared to non-MMCs, however relatively high prevalence of risk amongst drinkers. More research is needed using study methods and validated screening or diagnostic tools tailored for the local Iraqi context.

Summary

What is already known?

- Alcohol is the least studied substance in the Arab world

- Iraqi young people are exposed to trauma, conflict and change, and are exposed to the tension between their home cultures and religions and global culture on social and other media (Al Ansari et al., 2019).

- Studies on alcohol in Iraq can be hard to find and no review is available of such studies

What are the new findings?

- Thirteen studies presented data on alcohol, though for most alcohol was not their primary focus

- Studies reported a wide range of drinking prevalence: 2.2% to 23.7%.

- Among those who do drink, a high prevalence of risky drinking and risk behaviour was reported, at times more than samples in non-MMCs

What do the new findings imply?

- Due to variations in study approaches and reporting, no clear picture of the prevalence of drinking or attitudes towards alcohol among young Iraqis can be drawn

- The reported relatively high rates of risky behaviour and alcohol misuse among drinkers suggest a need for further research, including on prevention.

- Validated and tailored research methods, tools, and early interventions are needed, because of the sensitivity of alcohol as a topic in Iraq, as in many other Muslim majority countries.

Introduction

Globally, alcohol is the leading risk factor for people aged between 15 and 49 (GBD 2016 Alcohol

Collaborators, 2018). Harmful alcohol use has been associated with conflict exposure (Lo et al.,

2017; Roberts et al., 2015) and other mental health conditions such as PTSD (Debell et al., 2014).

Iraq is a nation that has been exposed to international and civil war for the past four decades. Most of

Iraq’s population is under the age of 24 (UNDESA, 2017), and exposed to civil war, directly or through family or community involvement (see: Al Ansari et al., 2019). In addition, Iraqi young people are influenced by conflicting principles and cultures – that of their home cultures and religions and that which they are exposed to with no censorship on television, social and mass media (Al Ansari et al., 2019). Although each of these challenges may be present in other MMCs, the combination of these factors in Iraq is unique – especially given the diversity inherent in its deep cultural tradition

(Al Ansari et al., 2019).

Little is known about alcohol use in Muslim Majority Countries (MMCs), especially within the

Eastern Mediterranean region. In Arab countries, research about alcohol was less than research about other substances including illicit and abused prescription drugs (Sweileh et al., 2014). Previous reviews have looked at alcohol policy approaches in MMCs (Al-Ansari et al., 2015) as well as prevalence of drinking in the Eastern Mediterranean (L. Ghandour et al., 2016) and Arab gulf region

(AlMarri & Oei, 2009). In Iraq specifically, a previous review has looked at alcohol’s place in Iraq’s history, cultures, and societies (Al Ansari et al., 2019). However, none of these reviews outline the scope of existing academic literature around alcohol use, misuse, and policy in Iraq – including in relation to young people. For example, L. Ghandour et al. (2016) found no study matching their inclusion criteria that describes alcohol use among young people or students in Iraq. This may be for several reasons – firstly, data about alcohol may be found in studies that focus on other research areas such as smoking, risky behaviours, and other mental health conditions. These articles may employ a general sample, not specified by age or student status. And finally, other studies may be published in local journals which may not always be identified in general academic searches.

To remedy these gaps, we conducted a systematic scoping review to identify all articles about alcohol use, misuse or attitudes among young people or students in Iraq. Our objective was to identify what is known about attitudes towards alcohol and prevalence of drinking among young people in Iraq. To meet this objective, this review will consider:

1. What studies on the prevalence of alcohol consumption or attitudes of young people towards

alcohol have been undertaken in Iraq?

2. What definitions, questionnaires, tests, diagnostic processes, and outcomes did the studies

employ?

3. When and if available, how were influencing factors (such as war, globalisation, etc) assessed

in relation to alcohol use?

4. What, and if available, when, preventative strategies have been implemented and evaluated

that address the issues related to alcohol in this population?

Methods

This systematic scoping review (Arksey et al., 2005) intends to describe the available literature about alcohol in young populations in Iraq. This will include any literature regarding alcohol – including quantitative and qualitative studies that explore alcohol awareness or attitudes to alcohol, and prevalence of use, misuse, and dependence. By selecting a wide scope, we aim to capture as much as possible of the scarce literature about this topic.

Because one of the study’s main objectives is to assess the prevalence of alcohol use and misuse – this review utilised the approach: condition, context, population (CoCoPop) instead of the traditional approach: population, intervention, condition, outcome (PICO) (Munn et al., 2018).

Condition: Prevalence of drinking/Attitude towards alcohol

Context: Iraq

Population: Young/Student populations in Iraq

Identifying the relevant studies

In keeping with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement (Moher et al., 2009), a systematic search of six major health and multi-discipline databases was undertaken (see appendix 2 for PRISMA checklist). Five major international databases and one local Iraqi database were searched for published articles up to 13th of September 2019. These databases were MEDLINE (OVID), Embase (OVID), PsycINFO (OVID), Scopus, Web of Science, and Iraqi Academic Scientific Journals (IASJ). No earliest year of publication was included in this search. The search terms were Iraq AND alcohol* OR substance *use OR drinking. A detailed search strategy is included in the appendix (Appendix 3). The breadth of this search was purposely selected to identify any literature that included alcohol data.

Further hand-searched articles, identified via consultation with academics and the reference lists of the included articles, were also screened for eligibility.

Only English literature was searched. This is because English is the main language of medical research and education in Iraq. Arabic and Kurdish sources either do not exist, are limited or not accessible.

Study selection

Original peer-reviewed journal articles conducted in Iraq with an Iraqi general or student sample containing alcohol-specific data provided by age or student status were included (table 1).

Table 3 Inclusion and exclusion criteria for study selection

Criterion Inclusion Exclusion

Context Iraq Studies conducted outside Iraq

Population Iraqis Non-Iraqi sample. Example: ➢ refugee camps ➢ soldiers/journalists from other countries Sample selection General and student samples (non-specialised Specialised sample (except students). Example: samples only) e.g. household studies, university ➢ only drinkers samples and primary health settings ➢ only cancer patients ➢ emergency (ED) patients (more likely to misuse alcohol than general population)

Alcohol data Must contain alcohol-specific data Not containing alcohol-specific data. Example: ➢ papers about addiction or substance use that do not provide alcohol-specific data Age or occupation Alcohol data is reported for young people aged Alcohol data is not reported separately for young 14-34 or for those who are students. people or students. Study type Peer reviewed original journal articles. Not original journal article in a peer reviewed journal. Example: ➢ grey literature (such as books, reports, etc.) ➢ conference proceedings and abstracts ➢ reviews, editorials, and commentaries

Charting the data

The aims, methods, and results of each included article were described in a spreadsheet. This included: the main focus, data collection year, sample identifiers (size, type, sampling method), setting (university, school, clinic, etc.), method of data-collection (online, pen-and-paper, etc), tools and any criterion (AUDIT, etc.), lifetime or past-year prevalence and any other relevant quantitative or qualitative results (if any).

Patient and public involvement statement

There was no patient or public involvement in this research.

Results

The search resulted in 3374 articles, of which 1668 were duplicates. None of the papers found in IASJ were indexed in the other databases. After a title and abstract screen, 64 articles remained and were included in the full-text screen. Eight of these studies met the inclusion criteria. Five hand-searched articles also met the criteria (Figure 1), resulting in a total of 13 included studies.

Figure 5 PRISMA flow chart for literature search 82

Study descriptions Research topics Descriptions of the studies are reported in Table 2. Of the included studies, only four were alcohol specific (Al-Ameri et al., 2016; Al-Qazzaz et al., 2017; Al Mousawi, 2015; S. Ali et al., 2009); two were about substance use (Al-Hemiary et al., 2015a; Rahim, 2010) and two about health risk behaviours (Baker et al., 2016; Saeed, 2016); one each was primarily focused on mental health disorders (Alhasnawi et al., 2009), smoking (Al Mousawi, 2014), novel psychoactive drugs (Al-Imam et al., 2017), risky driving (Shabila et al., 2015), and sleep disorders (Abdulah et al., 2018). No literature was found that related to preventative strategies in relation to alcohol.

Study years Although no earliest year limits were placed in the search, all the papers were published between

2009 and 2018 with data collected from 2005 to 2017.

Study settings and data collection Only one study recruited a sample from more than one province (Alhasnawi et al., 2009). Four studies recruited from Baghdad (Al-Ameri et al., 2016; Al-Hemiary et al., 2015a; Al-Imam et al., 2017; Al-

Qazzaz et al., 2017) and Erbil (S. Ali et al., 2009; Baker et al., 2016; Rahim, 2010; Shabila et al.,

2015). Two recruited students from Karbala (Al Mousawi, 2014, 2015). Kirkuk (Saeed, 2016) and

Dohuk (Abdulah et al., 2018) were the recruitment sites of one study. Figure 2 identifies provinces where recruitment occurred on the Iraqi map.

All studies were cross-sectional and quantitative. Nine studies were self-administered surveys

(Abdulah et al., 2018; Al-Ameri et al., 2016; Al-Imam et al., 2017; Al Mousawi, 2014, 2015; S. Ali et al., 2009; Baker et al., 2016; Saeed, 2016; Shabila et al., 2015) - eight of these were paper-and-pen and one online (Al-Imam et al., 2017). Three studies used face-to-face interviews (Al-Hemiary et al.,

2015a; Alhasnawi et al., 2009; Rahim, 2010) and one used autopsy blood samples (Al-Qazzaz et al.,

2017). Eight studies were conducted in school or college (Abdulah et al., 2018; Al-Ameri et al., 2016;

Al Mousawi, 2014, 2015; S. Ali et al., 2009; Baker et al., 2016; Saeed, 2016; Shabila et al., 2015),

83 two at home (Alhasnawi et al., 2009; Rahim, 2010), one each at a youth centre (Al-Hemiary et al.,

2015a), online (Al-Imam et al., 2017) and at a forensics laboratory (Al-Qazzaz et al., 2017).

Three of the four alcohol-specific studies were self-administered pen-and-paper surveys conducted in school/college and the fourth was a post-mortem blood alcohol concentration (BAC) study.

Figure 6 Provinces where student/youth specific alcohol data are reported in peer-reviewed original articles

Alcohol screening and diagnostic processes Only four of the eleven studies reporting alcohol prevalence or patterns data reported using validated alcohol screening or diagnostic tools. Two used the Composite International Diagnostic Interview

(Al-Hemiary et al., 2015a; Alhasnawi et al., 2009; Kessler et al., 2004), one used the Alcohol Use

Disorders Identification Test (AUDIT) (Al Mousawi, 2015; T. F. Babor et al., 2001), and one the

Mini International Neuropsychiatric Interview (MINI) (Rahim, 2010; Sheehan et al., 1998). One study utilised blood alcohol concentration at autopsy (Al-Qazzaz et al., 2017). The other studies did not report how alcohol questions were asked.

Samples Ten of the studies reported randomised recruitment with varying levels of detail. Ten studies included a student sample: four were general university samples (Al-Ameri et al., 2016; Al Mousawi, 2014,

2015; S. Ali et al., 2009), three were medical students (Abdulah et al., 2018; Al-Imam et al., 2017;

Shabila et al., 2015), two secondary school (Baker et al., 2016; Saeed, 2016) and one did not specify

(Rahim, 2010). Although S. Ali et al. (2009) defined their sample as medical college students, it included students studying medicine, dentistry, pharmacy and nursing. Similarly, Al-Ameri et al.

(2016) defined medical students as those studying medicine, dentistry or pharmacy. Of the other three studies, one was a general household sample (Alhasnawi et al., 2009), one a youth centre sample (Al-

Hemiary et al., 2015a) and the third a sample of general autopsies (Al-Qazzaz et al., 2017).

Two samples were male only (Baker et al., 2016; Saeed, 2016), two had a majority male sample (Al-

Hemiary et al., 2015a; S. Ali et al., 2009) and six a majority female sample (Abdulah et al., 2018; Al-

Ameri et al., 2016; Al-Imam et al., 2017; Al Mousawi, 2014, 2015; Shabila et al., 2015). The other three studies did not provide gender breakdown for young or student subsamples.

Prevalence and patterns of alcohol use Lifetime drinking Alcohol-related results of each study are reported in Table 3. There was a wide variation in reported prevalence of drinking between studies. Two studies reported prevalence of lifetime alcohol use at

7.6% and 9.7% (Al-Ameri et al., 2016; Saeed, 2016). Al-Ameri et al. (2016) provides a breakdown by gender, showing the vast majority of those that drink are males (19.7% vs 0.8%). On multivariable analysis, lifetime alcohol users more likely lived away from family (prevalence ratio [PR] 2.7; 95%

CI 1.8-4.1); p<0.001 vs. those who lived with family) and were non-medical students (PR 2.6; 95%

CI 1.4-4.7; p 0.002 vs. medical students (medicine, dentistry or pharmacy)) (Al-Ameri et al., 2016).

Baker et al. (2016) and Al-Imam et al. (2017) also provide alcohol use prevalence (6.6% and 0.9% respectively) without specifying if the figure is for current or lifetime drinking. Although Baker and

Al-Doski’s total sample is 500 students, they only provide the drinking prevalence for the 296 students who reported any risk behaviours. Age of onset of drinking for a student or age-specific sample was only reported by one secondary school study: 12 years old (unspecified if mode, median or mean) (Saeed, 2016).

Current drinking Similarly, the prevalence of current drinking varied widely, from 2.2% (Al Mousawi, 2015) to 23.7%

(S. Ali et al., 2009). Each study reporting current drinking recruited individuals from a different setting and used different methods for data collection. The two Kurdistan studies, conducted in Erbil and Dohuk, had the highest prevalence at 23.7% and 11.9%, respectively (Abdulah et al., 2018; S.

Ali et al., 2009). In contrast, the study in Karbala, a conservative Arab city in central Iraq, reported

2.2% (Al Mousawi, 2015). Al-Qazzaz et al. (2017) reported the post-mortem blood alcohol levels in

14-34-year-old Iraqis who were sent for autopsy in Baghdad. A twelfth (8.5%) of the sample had a blood alcohol concentration of more than 40mg/100mL (0.04 g/dL).

In their study about sleep , Abdulah et al. (2018) report that evening drinking was a predictor of emotional disturbance (p=0.034) and restless legs syndrome during the night (p=0.003).

Alcohol misuse including abuse and dependence Five studies reported data on alcohol misuse, with four using validated screening or diagnostic tools.

Al Mousawi (2015) reports that the majority (56%) of drinking students who completed AUDIT

86 scored above eight (0.8% of entire sample)1. A third (36%) of drinkers who completed AUDIT were hazardous drinkers (8-15), a tenth (10.7%) risky drinkers (16-19) and a tenth (9.3%) were high-risk or dependent (20+). Al Mousawi (2015) comments that items 7 (guilt) and 10 (others concerned about your drinking) of the AUDIT may be may be interpreted differently in the Iraqi context. This is because guilt is common as a reaction to breaking a religious or cultural taboo. Similarly, any drinking in this context will typically make other people worried about the drinker’s behaviour even if it does not necessarily represent high-risk or dependence.

Al-Ameri et al. (2016) reported that 1.2% (12.2% of drinkers) of the Baghdad student sample were heavy/high risk drinkers (consumed 3+ standard drinks [10g ethanol] per day/7+ per week for women;

4+ per day/14+ per week for men). Similarly, A fifth (19.8%) of the student drinkers in Karbala consumed more than 4 drinks per drinking day (Al Mousawi, 2015). Almost half (46%) of the fifty students who answered AUDIT question 3 in Karbala reported consuming 6+ drinks on a weekly or daily basis (Al Mousawi, 2015).

Despite the occurrence of episodic heavy drinking among drinkers, reported prevalence of alcohol use disorders is low. A national household study from 2006, the Iraqi Mental Health Survey (IMHS), showed only 0.7% of those aged 18-34 met DSM-IV lifetime criteria for alcohol abuse and 0.3% met criteria for dependence (Alhasnawi et al., 2009). Similarly, in Baghdad, Al-Imam et al. (2017) reported that 0.4% (50% of drinkers) had alcohol use disorder (criteria not provided). In contrast, in

Erbil, six students (6.2% of students) met the DSM-IV criteria for past-12-month alcohol abuse and two (2.5%) for dependence (Rahim, 2010). In a youth centre sample in Baghdad, 20.1% of 18-35- year-olds met DSM-IV criteria for lifetime alcohol abuse (no female reported drinking) (Al-Hemiary et al., 2015a). Although the article does not provide specific details about the nature of the youth centre attendees, this higher figure suggests that this was most likely a high-risk group, and not representative of the general population.

1 An AUDIT score above 8 indicates risky drinking. This could range from hazardous use through to high-risk or likely dependence (Babor, 2001). 87

Reliability and validity analysis of alcohol screening/survey tools

Al Mousawi (2015) is the only study that conducted an internal reliability test of its alcohol screening tool in an Iraqi sample. The AUDIT had a Cronbach’s α of 0.66. However, when the guilt question was removed, the reliability increased to α = 0.73.

The Shabila et al. (2015) survey showed good internal consistency (α = 0.78 to 0.82) for a broad range of risky driving behaviours. Abdulah et al. (2018) reported the internal consistency of SLEEP-50 (a survey in relation to sleep consisting of 50 items, that only includes one alcohol question) in previous non-Iraqi international studies. Other studies did not measure internal consistency of their survey tools.

Patterns/locations Frequency of drinking Drinkers in Iraq mostly reported consuming alcohol infrequently. Student drinkers mostly reported drinking ‘occasionally’ in Erbil (81.5%) (S. Ali et al., 2009) and Baghdad (64%) (Al-Ameri et al.,

2016). Neither study defined what is meant by ‘occasional’ drinking. Al Mousawi (2015) reports that

40.8% of drinking students in Karbala had alcohol once monthly or less often. A minority (5.8%) of students in Kirkuk reported regular drinking (frequency undefined) (Saeed, 2016).

Drinking locations The only study to report on drinking locations was from Erbil. Students most frequently consumed alcohol in bars or restaurant (44.5%) followed by outdoor settings (25.9%). Only 7.6% of current drinkers drank at home (S. Ali et al., 2009).

Attitudes, behaviours, and motives Attitudes Only one, smoking-focused study reported on attitudes to alcohol. Two percent of the students had positive attitudes to alcohol (compared with 2% to illicit drugs and 10% to smoking). Smokers had more positive attitudes to drinking (p<0.001) (Al Mousawi, 2014). An overall negative attitude

88 towards alcohol is also seen with half of student drinkers in Karbala reporting guilt about their drinking (54.4%) or that people expressed concern about their drinking (49.1%) (Al Mousawi, 2015).

Motives Only one study reported on the motive for drinking. Most students (51.9%) reported they drink for pleasure while 44.4% drink to get relief from stress (S. Ali et al., 2009).

Behaviours Alcohol-related risk behaviours were reported by two studies. The first reported that most students perceived either driving after ‘mild to moderate’ drinking (80.1%) or drunk driving (72.5%) to be the riskiest driving behaviours. Despite this, some students reported driving after drinking (after a ‘mild to moderate intake of alcohol’ 4.5%; or whilst drunk, 6.4%). Further, almost a tenth reported finding driving under the influence of alcohol enjoyable (Shabila et al., 2015). In Kirkuk, Saeed (2016) reports 6.5% of the student sample had ridden more than once in a car driven by someone who has consumed alcohol. About one third (30.6%) of the secondary school students have also driven a vehicle while drinking alcohol.

This latter statement however is internally inconsistent with the reported 7.6% lifetime use of alcohol in the same study. The abstract of this study also contains a statement that more than half (52.5%) of the students were in a vehicle driven by a drinking person. However, these results are not included in the paper itself. Saeed (2016) also reported that alcohol is associated with carrying a weapon (n=15, p 0.014) and physical fighting (n=20, p<0.001).

Table 4: Findings of systematic scoping review (studies are ordered by year of data collection) Sample Data collection Data Mean age; Male Tool; Reported Article Focus Location Random Size Description Setting Method year Age range % Criteria findings Al Mousawi Smoking 2005 Karbala ✓ 2298 Students 21.2 ± 2.7 48 Unspecified Lecture Self-administered survey Prevalence (2014) (university) - rooms Attitudes Alhasnawi et al. Mental health 2006- All Iraq ✓ - General - - CIDI 3.0 Home Face-to-face interview Prevalence (2009) disorders 07 household 18-34 DSM-IV S. Ali et al. Alcohol use 2007 Erbil X 342 Students 21.3 64 Tool unspecified Classroom Self-administered survey Prevalence (2009) (university) 17-29 Moderate/binge# Patterns Motives Rahim (2010) Substance use 2008 Erbil ✓ 81 Students - - MINI 5 Home Face-to-face interview Prevalence (unspecified) DSM-IV Al-Hemiary et Substance use 2009 Baghdad ✓ 1684 Youth centre - 79.2 CIDI-2 Youth centre Face-to-face interview Prevalence al. (2015a) attendees 18-35 DSM-IV Al Mousawi Alcohol use 2010 Karbala ✓ 5446 Students - 45.8 AUDIT Lecture Self-administered survey Prevalence (2015) (university) 17+ Score of 8+ rooms Patterns Attitudes Baker et al. Health risk 2012- Erbil ✓ 500 Students - 100 Unspecified Classroom Self-administered survey Prevalence (2016) behaviours 13 (secondary) Shabila et al. Risky driving 2014 Erbil ✓ 211 Students 21.37 ± 1.8 48.3 N/A In-college Self-administered survey Behaviour (2015) (medical) 17-26 Al-Ameri et al. Alcohol use 2015 Baghdad ✓ 1435 Students 19.8 ± 1.6 47 Tool not specified Lecture Self-administered survey Prevalence (2016) (university) 18-24 Moderate/heavy* rooms Al-Qazzaz et al. Alcohol 2015 Baghdad - 473 General - - Blood alcohol Forensics lab Blood alcohol Prevalence (2017) concentration autopsies 14-34 >40mg/100ml concentration Saeed (2016) Health risk 2016 Kirkuk ✓ 278 Students - 100 Unspecified Classroom Self-administered survey Prevalence behaviours (secondary) 16-18 Behaviour Abdulah et al. Sleep disorders 2017 Duhok ✓ 317 Students 20.4 ± 1.9 43.3 SLEEP-50 In-college Self-administered survey Prevalence (2018) (medical) 17-28 (evening use) Al-Imam et al. Novel 2017 Baghdad - 458 Students 19.7 ± 1.4 34.3 Unspecified Online Self-administered survey Prevalence (2017) psychoactive (medical) 17-24 drugs # Occasional/moderate/binge use not defined. * Moderate drinking = one standard drink (10g alcohol) for women, two standard drinks for men; heavy/high-risk drinking = 3+ drinks per day/7+ drinks per week for women, 4+ drinks per day/14+ drinks per week for men.

Table 5 Findings of the included studies

Article Relevant findings Prevalence and patterns Attitudes, behaviours, and motives Al Mousawi (2014) ➢ Alcohol abstinence was inversely associated with smoking (OR = 0.05, p<0.001). ➢ 2% had a positive attitude to alcohol (vs. 10% to smoking and (prevalence of drinking not reported) 2% to illicit drugs) ➢ Smokers had more positive attitudes to drinking (p<0.001) Alhasnawi et al. (2009) ➢ 0.7% of those aged 18-34 met criteria for alcohol abuse N/A ➢ 0.3% met criteria for dependence S. Ali et al. (2009) ➢ 23.7% (males: 34.7%; females: 4.1%) consumed alcohol in the past 6 months ➢ 51.9% reported they drink to get pleasure and 44.4% for relief ➢ Of the drinkers, 81.5% drank occasionally and 18.5% drank moderately or binged from stress (frequency undefined) ➢ Most frequent drinking in bars or restaurant (44.5%) and outdoor settings (25.9%). Only 7.6% of users drank at home Data contradiction: Abstract says moderate to binge drinking only among males while data tables show two of the five females that drink consume alcohol at moderate to binge levels. Rahim (2010) ➢ Five students (6.2%) met criteria for abuse and two (2.5%) for dependence N/A ➢ Alcohol dependence more common among unemployed/non-governmental employees than students/government employees (p <0.001) Al-Hemiary et al. ➢ 339 participants aged 18-35 (20.1%) met criteria for lifetime alcohol abuse N/A (2015a) ➢ No female reported alcohol/drug abuse Al Mousawi (2015) ➢ 2.2% (n=116; 4.1% males; 0.4% females) were current drinkers ➢ More than half reported guilt (54.4%) about their drinking ➢ Of the 75 drinkers who completed AUDIT, 56% scored 8+ (scores of: 8-15, 36%; ➢ Almost half said people were concerned about their drinking 16-19, 10.7%; 20+, 9.3%) (49.1%) ➢ Alcohol use associated with smoking (OR =7.16), male gender (OR=10.52), and Author reports possible cultural bias in these items of AUDIT. taking evening classes (OR for daytime students=0.51), trauma (data not provided) ➢ Most drinkers had 1-2 standard drinks per day (61.2%); 6% had 10+ ➢ Many drank once monthly (40.8%); 20.4% drank on >4 times per week ➢ 46% of the 50 drinkers who answered, reported 6+ drinks weekly or daily Baker et al. (2016) ➢ 20 (6.6% of those that reported risk behaviours) reported alcohol use (unspecified if N/A current or lifetime). Shabila et al. (2015) N/A ➢ 4.5% of students reported driving after ‘mild to moderate’ drinking (4.5%) and 6.4% reported drunk driving ➢ These behaviours were considered the riskiest by 80.1% and 72.5% of students, respectively ➢ A tenth of students (10.7%) thought that driving after a mild to moderate intake of alcohol was enjoyable. While 8.7% found

Article Relevant findings Prevalence and patterns Attitudes, behaviours, and motives drunk driving as an enjoyable activity. These were the least common reported enjoyable behaviours. Al-Ameri et al. (2016) ➢ 9.7% (n= 139; 19.7% males, 0.8% females) reported lifetime alcohol use N/A ➢ Of drinkers, 17 (12.2%) drank heavy, 23.7% moderate and 64% occasional* ➢ Alcohol use higher among those who are male (19.7% vs 0.8%; p<0.001), non- medical students^ (10.7% vs 5.1%; p=0.006), older (11.7% for 20-24 vs 7.8% for 18-20; p=0.013), rural (23.3% vs 8.3%; p<0.001), living away from family/relatives (25.1% vs 6.8%;p<0.001) ➢ Multivariable: only living away from family (PR 2.7 (95% CI 1.8-4.1); p<0.001) and non-medical faculty (PR 2.6 (95% CI 1.4-4.7); p 0.002) remained significant Al-Qazzaz et al. (2017) ➢ 8.5% (n = 40) of autopsies in those aged 14-34 had a blood alcohol >40mg/100mL N/A Saeed (2016) ➢ Lifetime use: 7.6% Results appear internally contradictory (maybe due to limitations in ➢ Association between drinking, and age/grade (p<0.001), carrying a weapon (n=15, English expression) p 0.014), physical fight (n=20, p<0.001) ➢ One third (30.6%) drove a vehicle while drinking alcohol ➢ Age of onset was 12 years ➢ 52.5% of the students were in a vehicle driven by alcohol drinking person (in abstract only) ➢ 6.5% rode in a car for 2-4 times with a driver who had consumed alcohol Abdulah et al. (2018) ➢ 11.9% (n= 37) reported consuming alcohol in the evening N/A ➢ Evening drinking was predictor of emotional disturbance (p=0.034) and restless legs syndrome during night (p=0.003) Al-Imam et al. (2017) ➢ Four students (0.9%) reported drinking (undisclosed if lifetime or current), two N/A (0.4%) had alcohol use disorder (criteria unspecified) ➢ Alcohol consumption increased as students progressed in medical college * Moderate drinking = one standard drink (10g alcohol) for women, two standard drinks for men; heavy/high-risk drinking = 3+ drinks per day/7+ drinks per week for women, 4+ drinks per day/14+ drinks per week for men. ^ Medical students in Al-Ameri et al are students studying medicine, dentistry, and pharmacy.

Discussion

This systematic scoping review is the first review on prevalence, patterns, and attitudes of alcohol use in Iraq and to our knowledge, is the first review of student or youth drinking in any MMC. The search methods employed identified alcohol-related data on young Iraqis in local and international peer-reviewed academic literature. Thirteen articles were included. Most had a non-alcohol focus and reported alcohol data incidentally.

A wide range of prevalence was reported for lifetime and current alcohol use and misuse. Less than half the studies employed validated tools to assess alcohol use. Most articles did not document how they asked about alcohol. Similarly, most authors either do not report whether they asked about lifetime or current drinking, or how they determined that participants had “alcohol use disorders” or were “heavy/binge” users and what pattern of drinking each of these terms represents. This makes these results harder to interpret. Accordingly, no clear pattern of drinking can be discerned in these

Iraqi young and student samples. However, generally, a higher prevalence of alcohol use was reported by samples from Kurdistan (North Iraq). This is consistent with data from Iraq’s 2015 household survey that found alcohol consumption is highest in the Northern governorates and lowest in the

South (US Department of State et al., 2015).

All included studies reporting prevalence of consumption by sex, showed a significantly higher prevalence of alcohol use or misuse by male participants – with two studies indicating no female use.

The prevalence of female consumption is also low in other Iraqi general population studies with self- report data including the national household surveys (Al-Hemiery et al., 2017; WHO, 2009). In contrast, the one study employing the objective measure of post-mortem blood alcohol concentration shows a higher percent of females overall with BAC of over 40mg/100mL (12.2% vs 8.4% males with BAC above 40mg/100mL) (Al-Qazzaz et al., 2017). In this sample, there were 1136 males and only 139 females, and 91.4% of the females had died from a traumatic event (vs 78.4% of males).

One explanation for this discrepancy could be that Iraqis, by observation, are more protective of their female relatives – and some may be less likely to consent for their female relatives to undergo post- 93 mortem examination except where it is legally required. It is possible that the study has an over- representation of females who have either been victims of abuse and trauma or who are no longer connected to their families. Nonetheless, it reveals that female consumption of alcohol exists in Iraq and is associated with harms including death. In the study, there was a significant relation between traumatic death and higher consumption (p = 0.007) (Al-Qazzaz et al., 2017).

Studies assessing drinking in this context to date have mostly used in-home or in-class self-reported pen-and-paper surveys or face-to-face interviews. The sensitivity of alcohol use in MMCs makes it particularly difficult for young people or females to disclose behaviours or attitudes that go against societal norms. Previous studies have indicated under-reporting of alcohol consumption in MMCs and particularly in Iraq (Al-Hemiery et al., 2017).

Although prevalence of alcohol use is low in Iraq compared to some other MMCs such as Lebanon

(E. G. Karam et al., 2004) and non-MMCs such as Australia (AIHW, 2020), the prevalence of alcohol misuse is high among those who drink. This is clear in all studies that report on both alcohol use and misuse. Most strikingly, the IMHS (Alhasnawi et al., 2009) showed only 0.7% of those aged 18-34 had an AUD and 0.3% had dependence. However, among drinkers of all ages, 45.7% met criteria for

ICD-11 alcohol use disorders, with 32.1% harmful use and 13.7% dependence (compared to 33.3%,

26.6% and 6.8% respectively in Australia) (Degenhardt et al., 2019). In keeping with these findings, the 2015 Survey of Substance Abuse in Iraq (SSAI) showed that 71% of current drinkers met criteria for dependence on the Severity of Dependence Scale (SDS) (US Department of State et al., 2015).

Interestingly, Iraq had the highest prevalence of AUDs among drinkers from all ten countries included in WHO’s World Mental Health Surveys (Degenhardt et al., 2019). These high prevalence of dependence among drinkers are worrying. However, Al Mousawi (2015) highlighted the potential for screening or diagnostic tools to be culturally biased. For example, items 7 (guilt) and 10 (worry of others about your drinking) of AUDIT may be more highly endorsed by Muslim respondents. This is most likely because of religious, social, and cultural prohibition. Drinkers may feel guilty and trigger the worry of family and friends even if they consume alcohol in only small amounts. Similarly, the

SDS includes items such as “How much did you worry about your use of the drug?” which may also provide false positive results for dependence. This illustrates the importance of tailoring tools and interventions for MMCs.

S. Ali et al. (2009) reported that students used alcohol for pleasure (51.9%) or to relieve stress (44.4%) and Al Mousawi (2014) reported 2% of students view alcohol positively (with no further details).

Other than these two studies, there is no data on influencing factors, attitudes towards alcohol or preventative strategies. Given Iraq’s history of exposure to globalisation and war, an understanding of factors influencing drinking is key to understand and predict trends among young Iraqis.

No study reported on harm-reduction or treatment initiatives and measures in Iraq. Iraq has no clear written or implemented alcohol policy, strategy or harm reduction initiatives (Al-Ansari et al., 2015;

Al Ansari et al., 2019). This is despite at least three studies from diverse cities showing young people dying or placing themselves and others at risk while under the influence of alcohol (Al-Qazzaz et al.,

2017; Saeed, 2016; Shabila et al., 2015). This is another area of need.

All studies other than the national IMHS (Alhasnawi et al., 2009) report no funding. This is because medical and health research only began after 2003 and there are no current major government grant cycles. Most funded research such as the IMHS or SSAI are either directly managed and funded by the Ministry of Health or externally funded by international organisations (Al-Hemiery et al., 2017;

Alhasnawi et al., 2009). However, because Iraq is now a high-middle income country, it is no longer eligible for most international government and non-governmental organisational funding initiatives.

In addition, recent wars in Iraq have had a major impact on the national burden of disease. These factors impede Iraq’s ability to further progress in health research especially in areas such as alcohol.

Limitations

This study was limited to only include studies in English. Although, to our knowledge, there are no alcohol-specific data published in the Arabic language because English is the main language of medical and scientific research in Iraq. A meta-analysis of the data could not be conducted because

95 each study reported on alcohol differently (most using their own measures). We were limited in our ability to compare figures for specific demographics because the studies did not describe their sample adequately. Because this is a scoping review, limited assessment was made on the quality of the included studies. Despite this, clear weakness of the methods and reporting of some studies were noted in this review. This study was limited to original journal articles published in peer-reviewed academic journals – this meant that age-specific data for the SSAI was not included as these had been published in a report, but not in refereed journals. Although the Al-Qazzaz et al. (2017) paper fits within our scope and was included, the sample differed from the other included studies as it was based on blood samples of autopsies.

Conclusion Alcohol research is limited in all MMCs, including Iraq. This review shows that most alcohol data is incidental rather than the focus of the studies. No clear picture of the prevalence of drinking or attitudes towards alcohol among young Iraqis can be drawn. However, the results indicate that Iraq is not immune to health concerns resulting from alcohol use. The high rates of heavy use and AUD among those who consume alcohol as well as the alcohol-related risk behaviour among students are cause for concern. More research is needed, particularly to understand the concerns, needs and experiences of young people and their relationship with alcohol, and ways to effectively prevent or intervene for AUDs. To achieve this effectively, study methods, screening or diagnostic tools, preventive and therapeutic interventions should be tailored for the local Iraqi context.

References:

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Chapter 5: Alcohol and university students in Iraq: attitudes, availability, and use

Chapter 3 established the historical and socio-cultural context for this research. Chapter 4 presented a systematic scoping review outlining the scarcity of available research on youth and student drinking in Iraq. These reviews allowed the contextual positioning of our research within existing alcohol literature. The gap in research was even wider when we set out on conducting this mixed-method study in 2015.

This chapter will present the quantitative component of our mixed-method study on attitudes towards alcohol and the prevalence of alcohol use among young university students in Iraq. As identified in

Chapter 2, we first intended to conduct this study using a “voting booth” style of set up, with confidential paper-and-pen surveys, before arriving at the current methodology - conducting this research via an anonymous online questionnaire.

As the design of this project included consultations with local collaborators in Iraq, we were able to tailor some items such as the socio-economic scale to the local context, and to include local names for certain psychoactive substances. In addition, internationally validated screening tools and items on potential influencers of alcohol consumption were included. The full 10-item AUDIT test was initially utilised. However, because of observed high attrition rate among the early participants, only the first three consumption questions (AUDIT-C) were later used. That was considered an acceptable abbreviation, given both the research on the validity of AUDIT-C compared to the full AUDIT, and concerns about the validity of items 7 and 10 from the full AUDIT on guilt and other’s concern about drinking in the MMC context.

This quantitative component of the thesis presents the prevalence and patterns of student drinking.

Students’ attitudes towards alcohol, perceptions about alcohol policies as well as media and trauma exposure are also presented in this chapter.

The following manuscript has been submitted for publication.

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Abstract

Introduction

Like other Muslim Majority Countries (MMCs), there is little data on alcohol use in Iraq. This study examines attitudes towards alcohol and its use among Iraqi university students. It considers the likely impact of the context of conflict and globalisation.

Methods

An online quantitative questionnaire was distributed to students at diverse universities in Iraq. The survey included questions on alcohol use (AUDIT-C) and availability, drug use, attitudes towards alcohol policy and a screen for post-traumatic stress disorder (PC-PTSD). Descriptive analysis was conducted, followed by multivariable logistic regression to determine independent predictors of drinking.

Results

Of the 468 students who provided alcohol-related data, a minority reported having ever consumed alcohol (5.3%; 1.6% females, 10% males). Only 21 participants consumed alcohol in the last 12 months, of whom six had an AUDIT-C score of 4+ (all males). Most students indicated that access to alcohol was “easy”. Of the 220 respondents who completed the PC-PTSD screen, 29.2% (n=63) had positive scores. Two in five (n=90, 41.7%) reported direct exposure to violent conflict.

Independent predictors of lifetime consumption were being a non-Muslim, male and living away from family.

Conclusion

While prevalence of drinking is low, 6/15 male current alcohol users in this convenience sample report drinking at risky levels. There are several challenges conducting research on this sensitive topic in a MMC. Further research could strive to obtain representative samples, and to ascertain appropriate prevention and early intervention approaches for the socio-cultural context of Iraq.

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Introduction

Globally, alcohol is the leading risk factor for burden of disease in people aged 15-49 years (GBD

2016 Risk Factors Collaborators, 2017). Muslim majority countries (MMCs) have the lowest prevalence of alcohol consumption globally because of the Islamic prohibition of alcohol (Alcohol

Public Policy Group, 2010). Despite this, the consumption pattern among drinkers in some Eastern

Mediterranean MMCs is the second-highest in risk globally (in terms of hazard per litre of alcohol consumed) (WHO, 2006a). Studies from the region suggest that youth in MMCs are exposed to alcohol despite their country’s discouragement of it. For example, there was a marked increase in student drinking in post-civil war Lebanon from 1991 to 1999, particularly among females (40.7% to

67.7%) (E. G. Karam et al., 2004). There is also evidence of youth exposure to alcohol in Iran (Ṣirāmī et al., 2013) and among Arabs in Israel, where even abstinent older people disclosed that they used to drink in their younger years (Baron-Epel et al., 2015; Yazbek et al., 2014). Furthermore, college students worldwide, including in MMCs, are a high-risk group for heavy drinking and alcohol-related problems (Hamdieh et al., 2008; E. Karam et al., 2007).

Iraq is an upper-middle-income country with an estimated population of over 38 million, of which the majority (60%) are younger than 24 years (UNDESA, 2017). Current alcohol policy in Iraq is inconsistent. The latest complete alcohol law passed in 2001. This policy provides clear regulations on consumption and sale of alcoholic beverages (Al Ansari et al., 2019). Several provinces have also initiated their own policies since the 2003 conflict. These policies are still in practice despite an apparent introduction of an alcohol ban in 2016. Alcohol remains available in Iraq and no clear alcohol policy or regulations are implemented.

Internationally, alcohol and drug use data for Iraq are based on expert estimates rather than surveys

(WHO, 2010a) and the majority of alcohol use in Iraq is believed to be unrecorded (WHO, 2014a).

Previous studies in Iraq have indicated differing figures regarding the prevalence of alcohol use. For example, in an unpublished study from 2014, the lifetime prevalence of alcohol use in Baghdad was reported to be 17.8% and increasing (Al-Hemiary et al., 2014). In the same year, the Survey of 102

Substance Abuse in Iraq (SSAI) suggests that half that number (8.6%; 16.7% male; 0.6% female) were lifetime consumers (US Department of State et al., 2015). Even this is a marked increase on an earlier national household study, the 2006 Iraqi Mental Health Survey (IMHS), which found only

3.7% (6.8% of males) consumed alcohol in their lifetime. However, both national household studies report negligible alcohol use prevalence among females (0.6% in both studies) (US Department of

State et al., 2015; WHO, 2009).

Despite the relatively low prevalence of alcohol use in the general population, risky drinking patterns are common among drinkers. For example, the SSAI indicates that, on average, current drinkers consume more than six drinks per day on 10.5 days a month. Two thirds (70%) of current drinkers in the general population scored within the dependence range on the Severity of Substance Dependence

Scale (SDS) (US Department of State et al., 2015). Interestingly, the Iraqi Mental Health Survey

(IMHS), part of the larger World Mental Health (WMH) Survey, from just ten years prior reported

Iraq as having the lowest overall prevalence of dependence (0.2%) but one of the highest prevalence of dependence among drinkers (5.4%) (using the Composite International Diagnostic Interview 3rd edition, CIDI-3) (Glantz et al., 2020; WHO, 2009). Although both national surveys show a high risk of dependence among drinkers, the difference (70% vs 5.4%) maybe in part due to the tools used and their validity in the MMC context. SDS is a five-item screen, specific for dependence while CIDI-3 is an in-depth diagnostic interview assessing all sorts of AUDs including dependence. We could not identify any study that specifically validated either tool in the Iraqi context. However, we identified that two items of the SDS that may be interpreted differently by participants in MMC contexts and result in ‘false positive’ scores. These are items 3 and 4 which ask if the drinker is worried about their drinking and wishes they could stop. We anticipate that most drinkers in MMCs, especially those adhering to Islam, would often or always worry about their drinking and wish they could stop. This is because the expected norm in this context is abstinence. In addition to these two surveys, a specialised sample from youth centres in Baghdad also found that 17% of over 2000 attendees met criteria for alcohol abuse (using CIDI-2) with an average onset age of 21.7 years (Al-Diwan et al.,

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2015; Al-Hemiary et al., 2015b). This study however did not report on prevalence of alcohol consumption among this specialised group.

Alcohol consumption among university students in Iraq

Worldwide, university students drinking is a major health concern, including in some MMCs such as

Lebanon and Egypt (E. Karam et al., 2007; E. G. Karam et al., 2004). However, a systematic review of alcohol literature in the Arab world identified a scarcity of literature about youth and student drinking in Iraq (L. Ghandour et al., 2016).

The 2014 household study (SSAI) included 230 students (not specified if university students) reported that fewer than one in 30 students had ever consumed alcohol (3.0%) and less than one in 50 were current drinkers (1.7%) (US Department of State et al., 2015). An earlier 2010 study in Karbala indicated a similarly low prevalence of current drinking among 5446 students (2.2%; male 4.1%; female 0.4%) (Al Mousawi, 2015).

By contrast, in the large metropolis of Baghdad, results differ across studies. The lifetime consumption of alcohol was over four times higher than the national or Karbala prevalence, among three Baghdadi universities (9.7%; 19.7% male; 0.8% female) (Al-Ameri et al., 2016). However, data collected at around the same time from medical students at Baghdad University indicated a far lower prevalence at 0.4% (the authors did not specify if this is lifetime or current drinking) (Al-Imam et al.,

2017).

In an earlier (2007) survey in Erbil, a city in Iraqi Kurdistan, the prevalence of drinking (in the past six months) was even higher - double the prevalence reported at the three Baghdadi universities

(23.7% among 342 students; 34.7% male; 4.1% female) (S. Ali et al., 2009). The tool used to collect the consumption data is not described. In keeping with this prevalence, a study about student risky behaviour seven years later at the same university indicated that over a tenth (10.9%) of a sample of

211 students reported having driven a vehicle under the influence of alcohol (Shabila et al., 2015).

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It is not clear why the prevalence of consumption has varied so greatly in previous studies among student populations in Iraq. Potential reasons for variability include the method of survey administration and degree of privacy. Surveys often use interviews or paper surveys in a controlled setting (e.g. classroom or in-home), where it can be challenging to guarantee confidentiality. Only one study (about novel psychoactive substances, but including self-report alcohol questions), used an online questionnaire (Al-Imam et al., 2017). The fact that samples are derived from single universities or single cities also makes it hard to generalise the findings.

Identifying alcohol use, attitudes, and perceived motives for drinking among students allows for an assessment of the vulnerability of young Iraqis to take up drinking or to misuse alcohol. We were only able to identify two studies in local journals that assessed attitudes towards ‘addiction’ in a general sample and in a sample of medical residents/professionals (Al-Hasnawi, 2006; Al-Hasnawi et al., 2007). To our knowledge, there is currently no literature about attitudes to alcohol consumption and alcohol policy in Iraq among Iraqi university students.

To address the challenges of social desirability bias, and collect data on alcohol more sensitively and accurately, we used online data-collection, designed to maximise anonymity and confidentiality. We recruited students from multiple universities around Iraq to increase generalisability. We also collected data on perceived motives for drinking, attitudes on drinking, drinkers, and various alcohol policies, and a possible connection between war or media exposure and alcohol use. Assessing these attitudes are important in understanding current behaviour, and potential trends. It is hoped that this study will help inform policy and preventative measures in Iraq and other MMCs.

Methods

An online cross-sectional survey of Iraqi university students was conducted as the quantitative component of a larger mixed-method study on attitudes of University students in Iraq towards alcohol.

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Ethics approval

Ethics approval was granted by the Medical Ethics Committee at the College of Medicine in the

University of Kufa, Iraq (MECCM-0028) (Appendix 1).

Quantitative survey

The survey (Appendix 4 and 5) included 42 questions that were derived from household and college surveys from other countries, mainly Australia and Sweden (Australian Institute of Health and

Welfare, 2013; Bullock, 2004). The Swedish instrument was designed to assess attitudes towards drugs in medical student. We considered that alcohol in Iraq shares a similar place to illicit drugs in the Swedish context, making this instrument relevant. The Australian National Drug Strategy

Household Survey (NDSHS) was used for demographic questions and to assess drinking behaviour, including drinking location and companions. These instruments were edited to suit the local context in consultation with local collaborators and international experts. A draft Arabic translation of the complete survey was produced and then finalised in consultation with local recently graduated medical doctors in a focus group. The survey was piloted in English and Arabic by members of this focus group and took 15-20 minutes to complete. The Arabic survey was also shared with religious and cultural elders for comment. Based on these comments, some minor changes to the Arabic translation of the survey were made in for cultural sensitivity.

Following a consent question, demographic items enquired into the student’s family and university background, including internal displacement status, and living situation. Participants were asked if they had ever consumed alcohol and were screened using the AUDIT-C tool (Bush et al., 1998). This three-item tool, comprised of the first three items of the AUDIT questionnaire (T. F. Babor et al.,

2001), asks about frequency, amount of usual drinking, and frequency of drinking six or more drinks

(Bradley et al., 1998; T. M. Kelly et al., 2009).

Past or current drinkers were then asked about their drinking location, source of alcohol, and who they consumed it with. Non-drinkers were asked about any desire to consume alcohol in the future.

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These alcohol questions were followed by questions regarding use of other substances. Common substances used in Iraq were identified using literature and in consultation with local collaborators.

Additional items in the survey inquired into attitudes towards alcohol and other drug consumption and policies. Participants were then asked about exposure to alcohol in the media, and about exposure to war and violent conflict, before being screened for post-traumatic stress disorder (PTSD) using the four-item primary care PTSD (PC-PTSD) screening tool. This tool was chosen due to its brevity

(Prins et al., 2003) and suitability for a general population.

To maximise anonymity and confidentiality, and to minimise social desirability bias, the questionnaire was delivered as an anonymous online survey using the SurveyGizmo platform. No identifying information or trackable IP addresses were collected. The survey could also be completed privately at any time of the day and in any location. SurveyGizmo encrypted all data at the disk level.

The data may only be accessed through a password protected site by the author. The data was then stored on University of Sydney servers after download.

Sampling and Recruitment

A mixture of convenience and snowball sampling was used to recruit participants. These approaches were chosen as viable approaches to online recruitment for such a sensitive topic. Furthermore, there were limited central databases of student emails within universities in Iraq, and so random online sampling would have been difficult. The survey was open for online participation from 5th of March to 1st of May 2017, although active recruitment only took place from the 8th to the 31st March 2017.

Senior academic representatives of three Iraqi universities gave permission for their students to be recruited. Initial recruitment took place online by posting the survey link on the e-learning platform of one of the universities, with lecturers encouraging their students to take part in the survey.

However, it was mentioned by students and staff that other faculties and universities often did not actively use their e-Learning platforms and that student communication online occurred via student- only social-media groups. Accordingly, further recruitment was carried out by posting the survey link

107 to these social media groups. As this study was conducted concurrently with the qualitative component of the larger mixed-method project, interview participants were also asked to distribute the survey link to their student networks. Initial recruitment was commenced within the Medical

Faculty at each university (via academics, students, and other consultants), and then expanded to other faculties via students and staff contacts. Names of the universities will not be reported because of the sensitivity of alcohol in an MMC setting.

The only inclusion criteria for the survey were to be a consenting current student of an Iraqi university and aged under 24 years. Students could choose to complete the survey in Arabic or English. No incentives or reimbursement for participation was provided, however, those participating in interviews received a certificate of participation (if they shared their email address).

Data Analysis

Data were downloaded from SurveyGizmo, then analysed using SPSS Statistics 25. The data was cleaned and participants who either reported themselves to be not current students at an Iraqi university, to be above the age of 24 or who had not provided any information regarding their alcohol consumption were excluded.

Several variables were recoded for the purposes of bivariate analysis. Age was recoded to younger

(17-20 years) and older (21-24 years). A dichotomous variable was created to indicate whether the student lived with any of parent, partner or relative. Similarly, a variable captured if the student lived either alone, with friends or in the dorm. All religions or ethnicities other than Islam or Arab were combined into ‘non-Muslim’ and ‘non-Arab’ respectively. Universities apart from Universities A, B,

C and D were combined to ‘other’ because of small numbers at participants at those institutions.

Similarly, faculties apart from than Medicine, Pharmacy and Engineering were combined to ‘other’.

Drinkers were classified as at risk if the sum of the AUDIT-C items was three or more for females and four or more for males (Dawson et al. 2012). Those that answered yes to three or more questions on the PC-PTSD tool were scored positive for this screen (Prins et al., 2003).

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Chi square tests were used to compare consumption patterns between different demographic groups

(e.g. by age, gender, religion and living location). Fisher’s exact test was used if expected cell values were less than four. Significance was tested based on p value of less than 0.05.

Predictors that were significant in the bivariate analysis were considered for inclusion in a multivariable logistic regression analysis to determine their independent predictive effect. The outcome variables in the two analyses are lifetime and current (past-year) drinking.

Results

Sample

A total of 652 participants accessed the survey link. Five hundred and twenty-five participants were eligible (students between the age of 17-24 years) and consented and started the survey. Of those, 468

(89%) answered at least one consumption question and were included in further analysis. The alcohol and drug consumption, availability and use section was completed in full by 448 participants.

However, only 192 students (36.6% of eligible participants) completed the entire survey (Figure 1).

Each table and figure only include the individuals who answered that specific question or section.

There was no association between ever drinking and failure to complete the full questionnaire.

Students responded in either Arabic (n=388) or English (n=80).

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Figure 7 Number of participants completing the different survey sections

600

450

300

150

0 Completed Provided any Completed Completed war Eligible alcohol/drug use alcohol data attitudes section & media section section Respondents (n) 525 468 448 220 192 Percent (%) 100% 89% 85% 42% 37%

Demographics

Students were aged between 17 and 24 (mean = 20.52 years, standard deviation [sd]= 1.43). Over half of the sample was female (n=258; 55.1%).

The participating students were from over ten Iraqi universities but most attended four large public universities from four different provinces in Iraq. Students were from a broad range of regions across

Iraq. However, despite repeated attempts at recruitment, no university from the Kurdistan region participated. The majority (n=368; 78.6%) of participants were students in faculties of medicine, followed by 9.6% (n=45) from faculties of pharmacy. Of the 468 students who provided alcohol data,

450 (96.2%) were undergraduate students, eight were postgraduate and ten did not specify.

Islam was the predominant religion (n=448, 95.7%) reported. The majority (76.9%; n=360) of respondents reported living with relatives, while 23.1% (n=108) lived alone, in dormitories, or with friends. Most (78%; n = 355) students reported their socio-economic level between steps 4 and 7 on a ten-step socio-economic ladder. Internally displaced people accounted for 15.8% of the sample

(n=74).

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Table 6 Prevalence of lifetime and past-year alcohol consumption by selected demographic data

Lifetime abstinence Lifetime use Past-year use Total n % n % p-value n % p-value^ Total n % Age 17-20 233 97.5 6 2.5 0.005* 4 1.7 0.003* 239 51.1 21-24 210 91.7 19 8.3 17 7.4 229 48.9 468 100 Gender Male 189 90.0 21 10 <0.001* 17 8.1 0.001* 210 44.9 Female 254 98.4 4 1.6 4 1.6 258 55.1 468 100 University University A 211 96.8 7 3.2 4 1.8 218 46.6 University B 42 100 0 0 0 0 42 9 University C 50 87.7 7 12.3 0.028* 6 10.5 0.011* 57 12.2 University D 90 92.8 7 7.2 7 7.2 97 20.7 Other 50 92.6 4 7.4 4 7.4 54 11.5 468 100 Faculty Medicine 346 94.0 22 6.0 18 4.9 368 78.6 Pharmacy 44 97.8 1 2.2 1 2.2 45 9.6 0.361 0.422 Engineering 23 92.0 2 8.0 2 8.0 25 5.3 Other 30 100 0 0 0 0 30 6.4 468 100 Step on socio-

economic ladder 1-3 32 97.0 1 3.0 0 0 33 7.3 4-7 336 94.6 19 5.4 0.638 16 4.5 0.242 355 78.0 8-10 62 92.5 5 7.5 5 7.5 67 14.7 Missing 13 2.8 468 100 Religion Muslim 438 97.8 10 2.2 8 1.8 448 95.7 <0.001* <0.001* Non-Muslim 5 25 15 75 13 65 20 4.3 468 100 Ethnicity Arab 415 95.6 19 4.4 15 3.5 434 92.7 0.001* <0.001* Non-Arab 28 82.4 6 17.6 6 17.6 34 7.3 468 100 Relationship status Single 393 95.2 20 4.8 16 3.9 413 89.6 Unmarried Couple 19 79.2 5 20.8 0.002* 5 20.8 <0.001* 24 5.2 Married or engaged 24 100 0 0 0 0 24 5.2 Missing 7 1.5 468 100 Internally

displaced? Yes 68 91.9 6 8.1 6 8.1 74 15.8 0.249 0.101 No 375 95.2 19 4.8 15 3.8 394 84.2 468 100 Living location With parent, partner 347 96.4 13 3.6 10 2.8 360 76.9 or relative 0.002* 0.001* Alone, dorms or 96 88.9 12 11.1 11 10.2 108 23.1 with friends 468 100 * p-value less than 0.05 ^ the p-statistics for past-year use are in comparison to past-year abstinence (not shown)

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Alcohol consumption

Just over one in twenty (5.3%) students had ever consumed alcohol (n=25); the majority of those were male (n=21) and non-Muslim (n=15). Consumption in the last 12 months was only slightly less common (4.5%; n=21 of students). However, three of these 21 students with recent consumption later indicated that they “never” consumed alcohol when asked, “How often do you have a drink containing alcohol” on AUDIT-1. Of the non-drinkers, 88% (n=373) reported not having any desire to try alcohol in the future.

Six of the 15 males who had consumed alcohol in the past year scored above four in the AUDIT-C

(40%). None of the four women scored above three. On average, the onset of drinking was at the age of 17.83 (sd = 3.96). Males, older students (21-24 years), non-Muslims, non-Arab respondents, and those in a relationship outside of marriage or living away from parents were more likely to have consumed alcohol (lifetime and past-year; Table 1).

Four of the five dichotomous variables that were significant in the bi-variate analysis were included in the multi-variate analysis (except non-Arab as closely correlated to non-Muslim). The multivariable logistic regression model confirmed that being a non-Muslim was the most significant independent predictor (p<0.001) for lifetime and past-year drinking. Living away from relatives was also an independent predictor for lifetime and past-year consumption (Table 2). However, being older was only a significant independent predictor for past-year consumption while being male was only significant for lifetime consumption.

Table 7 Independent predictors of consumption (using logistic regression)

7a Independent predictors of lifetime consumption

Odds B S.E. Wald df Sig. ratio Older (21-24 years) 1.206 0.673 3.214 1 0.073 3.34 (vs. 17-20 years) Male 1.986 0.774 6.586 1 0.010 7.29 (vs. female)

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Live alone, with friends or university dorm 1.415 0.603 5.504 1 0.019 4.12 (vs. live with parents, partner, or relatives) non-Muslim 5.310 0.784 45.838 1 < 0.001 202.43 (vs. Muslim)

Constant -6.488 0.964 45.271 1 < 0.001 0.002

7b Independent predictors of past-year consumption

B S.E. Wald df Sig. Exp(B)

Older (21-24 years) 1.607 0.748 4.613 1 0.032 4.986 (vs. 17-20 years) Male 1.349 0.728 3.431 1 0.064 3.852 (vs. female) Live alone, with friends or university dorm 1.675 0.654 6.565 1 0.010 5.339 (vs. live with parents, partner, or relatives) non-Muslim 4.945 0.746 43.929 1 < 0.001 140.513 (vs. Muslim)

Constant -6.670 1.002 44.282 1 < 0.001 0.001

A majority of students (54.9%) thought that it was easy or very easy for students to get alcohol if they wanted it, while only 15.3% reported it being very difficult or impossible; this perception was not significantly associated with lifetime or past-year consumption. Over half of the 20 respondents to the source of alcohol question (n=13; 65%) reported that they get their alcohol from bottle shops.

Over half (n=11) of the 21 past-year alcohol consumers reported that they drink with their university colleagues. A quarter of all participants (n=106/450) reported that they know of friends and/or family who use alcohol. However, of those, only 28 (6.2% of 450) reported that they know a university friend who consumes alcohol. Despite this, participants (n=459) on average estimated that over a fifth

(mean=21.1%; SD 17.3) of university students in Iraq drink alcohol. Lifetime and past-year drinkers estimated a higher prevalence of student drinking than did non-drinkers (p<0.001).

Consumption of other substances

A total of 34 out of 450 respondents (7.3%: 6.5% male, 8.4% female) reported taking prescription drugs for non-medical reasons. Only seven (1.6%) reported lifetime illicit drug use. One in five

113 participants (n=100; 22.2%) reported tobacco use, with males more than three times as likely as females to use it (36.8% and 10.4% respectively) (Figure 8)

Figure 8 Substance use by participants (respondents re alcohol n=468, re other substances n=450)

15 Lifetime use (%) use Lifetime

0 Prescription drug use Alcohol use Illicit drug use Tobacco use (non-medical purposes) Male 10 2 6.5 36.8 Female 1.6 1.2 8.4 10.4 Total 5.4 1.6 7.6 22.2

Attitudes towards alcohol, alcohol policy and alcohol/drug users

When asked about motives for drinking or abstinence on a four point Likert-scale (never, rare, sometimes and often), all students agreed that motives for drinking were sometimes/often perceived to be either a desire to try forbidden things (87.5%), experiences of trauma (85.7%), fun (82.7%) or peer pressure (81.2%). On the other hand, lack of religiosity was perceived as a motivating factor by

92.2% of non-drinkers compared to only two thirds (66.7%) of lifetime drinkers (p=0.006).

Participants also perceived that sometimes/often students abstained for religious (93.7%), family

(90.2%) and socio-cultural (89.7%) reasons. In comparison, less than half (44.4%) of lifetime drinkers and two thirds (69.2%) of non-drinkers perceived that abstinence was sometimes or often for health reasons (p=0.029). When students (n=257) were asked if alcohol is a moral issue, 67.7% agreed, while only 43% agreed that it is a medical issue.

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Of the participants (n=256) who responded to the question asking whether they agree with certain alcohol policy options, nearly two thirds (n=166; 65.1%) thought that alcohol should be prohibited entirely. However, 104 (40.8%) agreed with a policy that would allow alcohol production, trade, and consumption for non-Muslims in Iraq. A sixth of students (n=42; 16.5%) agreed with a policy that alcohol production, sale and consumption should be permitted for everyone.

Figure 9 Participants’ views on the right response to regular substance use by a friend

9a: If a friend was having alcohol/drugs daily, what would you do? (n=220)

10 Percentage of respondents of Percentage 5

0 Tell their Tell them Force them Tell them Report to Nothing Cut contact family or not to not to to get help police friends Alcohol 6 29 8 22 4 19 10 Drugs 3 24 17 16 7 14 17

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9b: What should happen to someone caught with small amount of alcohol/drugs? (n=231)

15 Percentage of respondents of Percentage 10

0 Advice, warning Prison or No action Treatment Fine or education punishment Alcohol 10 45 12 22 10 Drugs 1 28 23 19 26

Figure 9a shows that students reported that their most likely action if they encountered a friend using either alcohol or drugs daily would be to advise them to stop (29.1% and 24.1% respectively). More severe responses (force them not to; tell police, family, or friends) were more likely to be endorsed for drug use than for alcohol. A similar trend was observed when participants were asked what should happen if someone was caught with small amounts of alcohol or drugs (Figure 9b).

Media and war exposure and post-traumatic stress disorder

Of the 202 students that were asked if they had been exposed to direct alcohol marketing, more than half had been exposed on the internet (n=112;55.4%), two fifths on social media (n=84;41.6%) and satellite TV (n=72;35.6%). A third of the sample indicated they have never had any exposure to alcohol advertisement (n=74;36.6%). There was a significant association between drinking status and perception of mass (p=0.035) and social media (p=0.009) as factors contributing to drinking. Two thirds of non-drinkers perceived that mass or social media influences drinking (n=214,66.7% and n=212,67.3% respectively), only two-fifth (n=6,40%) and one-third (n=5,33.3%) of lifetime drinkers respectively agreed. 116

Of the 220 individuals who answered the questions on exposure to violent conflict and on PTSD symptoms, two in five (n=90; 41.7%) reported direct experience of war or violent military conflict.

Almost a third (n=63; 29.2%) of the respondents were positive on the PC-PTSD screening test. No significant association was found between PC-PTSD results and lifetime consumption. No past-year drinker (n=9) scored positive on the PC-PTSD test.

Reliability of the included instruments

The internal consistency of the 3-item AUDIT-C in this sample was Cronbach’s α 0.70. The PC-

PTSD screen had a Cronbach’s α of 0.73.

Discussion

To our knowledge, this is the first comprehensive study to examine the behaviours and attitudes of young Iraqi university students towards alcohol and alcohol policy. By doing so, this study addresses an important gap in the field of alcohol research. This research was conducted with greater anonymity than past alcohol studies in Iraq and included participants from more universities. This is also the most current data from university students across several regions in Iraq that provides insight into student exposure to alcohol, consumption patterns and perceived availability. Our study also provides insights to improve data collection about sensitive topics such as alcohol in Iraq. Assessing alcohol use behaviours and attitudes together may help inform efforts to reduce risk factors for drinking in this context.

Almost one in twenty students in our sample had consumed alcohol (lifetime: 5.4%; past-year: 4.6%).

This is almost double the lifetime use reported by the 2014 national survey’s (SSAI) adult student sub-sample (3%) and thirteen times the prevalence (0.4%) among medical students surveyed at

Baghdad University in 2016 (Al-Imam et al., 2017). In contrast, students in our sample were only half as likely to report lifetime consumption of alcohol as respondents in a three-university study in

Baghdad (Al-Ameri et al., 2016). However, in this same study, a similar prevalence of drinking to our study was reported by medical students (6.0% vs 5.3%) (Al-Ameri et al., 2016).

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The different consumption rates identified in our research compared to those in other studies may be explained by contextual factors and the data collection methods. For example, Karbala is a conservative religious city while Erbil, the capital of Kurdistan, has a higher non-Muslim population, and is more modernised than the Arab majority regions of Iraq. Correspondingly, Mousawi (2015) reported the prevalence of past-year drinking in Karbala to be 2.2%, which is half the rate of consumption identified in our study. In contrast, in Erbil, Ali and Sabir (2009) found that almost half

(44%) of medical students living at colleges in Hawler Medical University had used alcohol in the past-six months. This is four times the past-year consumption of medical students living away from family in our sample (10.4%) that did not include students from this location.

In contrast to our study that used an online questionnaire tool, nearly all previous studies collecting alcohol data in Iraq have used pen-and-paper or face-to-face data collection methods. These approaches have been found to affect the accuracy of self-reported drinking in non-MMCs cultures with sensitivities to alcohol (Islam et al., 2012). Pen-and-paper or face-to-face data collection methods have also been identified as limitations in the two Iraqi national household studies (US

Department of State et al., 2015; WHO, 2009).

On average, students estimated the prevalence of drinking among their fellow students at four times the actual self-reported prevalence (21.1% vs 5.4%). A quarter of participants reported knowing a friend or family member that drinks (23.6%). Similar high reports of knowing someone who drinks have been reported previously in Iraq (US Department of State et al., 2015). Lifetime and current drinkers estimated a higher prevalence of peer drinking than did non-drinkers. This may indicate that students under-reported their personal consumption. Alternatively, it may indicate an overestimation of student drinking norms by drinking participants. The overestimation of drinking norms has been shown to influence consumption in non-MMCs. Interventions to correct individual misconceptions of drinking prevalence have been shown to be effective in reducing problem drinking among students

(Lewis et al., 2006; Ridout et al., 2014). These interventions normally require identifying the at-risk drinkers in the first place – an unlikely possibility in Iraq where alcohol is a sensitive topic. In

118 addition, due to the nature of the sensitivities, it is difficult to establish actual drinking norms.

Students are also unlikely to trust figures presented because they may have themselves underreported their drinking or know someone who has.

Two fifths (40%) of male drinkers in our sample met the criteria for risky drinking (AUDIT-C score of 4+). In a 2010 study at Karbala University using the full 10-item AUDIT more than half of drinking students (56%) reported consuming alcohol at risky levels (AUDIT score of 8+) (Al Mousawi, 2015).

We purposely did not use the full AUDIT because the authors noted possible inflated scores resulting from items 7 and 10 of the AUDIT (guilt and others’ concern about drinking). Despite that, the internal consistency of AUDIT-C in our sample was comparable to that of the full AUDIT in Al

Mousawi (2015) study (Cronbach’s α 0.70 vs 0.66). However, the Cronbach’s α score of 0.70 is more acceptable for a short 3-item instrument (Tavakol et al., 2011). This score inflation is consistent with the common anti-alcohol sentiment in MMCs. Further research is needed to identify culturally relevant ways to ask items relating to consequences of drinking – with consideration that guilt and social concern may be elevated in this setting.

The high prevalence of risky drinking patterns in Iraq is confirmed by two other studies: one in a national household study and the other in a specialised sample. Almost one in six males that attended youth centres in Baghdad met DSM-IV criteria for alcohol abuse using the Composite International

Diagnostic Interview (CIDI-2) (Al-Hemiary et al., 2015b). The SSAI reports that 71% of current drinkers met the criteria for dependence on the Severity of Substance Dependence Scale (SDS) (US

Department of State et al., 2015). This may reflect the over-reporting of guilt/shame in item 3 of the

SDS. WHO estimates show alcohol use patterns among drinkers in EMRO are second in risk to former soviet Eastern Europe (WHO, 2006b).

Our study is consistent with previous studies in reporting no risky drinking or alcohol misuse among females. However, sex was associated with lifetime drinking but was no longer significant for past- year consumption in our multi-variate analysis. A strong association of alcohol use with male sex was identified in the national household survey (US Department of State et al., 2015) and other studies 119

(Al-Ameri et al., 2016; Al Mousawi, 2015). However, female student in our study reported a higher consumption of alcohol (and other drugs). For example, compared to the SSAI, females in our sample provided higher reports of lifetime drinking (1.6% vs 0.6%) and current alcohol use (1.6% vs 0.11%).

They also reported a higher prevalence of lifetime illicit drug use (1.2% vs 0%) and licit drug misuse

(8.4% vs 0.7%) (US Department of State et al., 2015). This could be attributed to sampling differences or the greater anonymity of our data collection methods.

The gendered role that alcohol plays in Iraq and other MMCs may reflect socio-cultural norms. Haya’

(modesty or shyness) is a universal encouraged trait in Muslim societies particularly for females (M.

Ali, 2014). Drinking is considered an immodest act in Islam and local cultures. Observing haya’ may also reduce risk factors associated with alcohol consumption. For example, Iraqi females seldom live or travel alone or with friends – most would stay with relatives even if they study away from home.

Our data indicate that living alone, with friends or at university dormitory was significantly associated with being male (p = 0.01; data not shown) and in turn, significantly associated with drinking. The association of drinking and living away from home was also observed in students in Baghdad (Al-

Ameri et al., 2016) and in non-MMCs such as Sweden (Bullock, 2004). This indicates that there may be an opportunity to focus prevention interventions on males who live in dormitories or with friends.

Interactions between the two sexes are also limited in Iraqi society, especially in conservative areas.

In conservative settings, the university may be the only environment where females closely interact with their male peers. By observation, in some areas of Iraq, there can be a disparity between the student’s behaviour at the university and their life in the family home. It is possible that these different lifestyles, the stress of studies and the stigma around alcohol and illicit drug use may contribute to prescription drug use for non-medical reasons as observed in our female sample.

As indicated, two thirds (67.6%) of students agreed with the statement that alcohol is a moral issue

(vs 43% that agreed it was a medical issue). Similar observations have been made about attitudes towards “addiction” in Iraq (Al-Hasnawi, 2006; Al-Hasnawi et al., 2007). Students from our sample reported most abstain for religious, socio-cultural, and family purposes. They perceived that students 120 in general mostly drink due to lack of religiosity, trauma, for fun or because they find forbidden actions tempting. Student reactions to those who drink alcohol seem to also be driven by religious teachings or a sense of social and familial responsibility. For example, a fifth of the sample indicated they would cut off contact if a friend were using alcohol daily and more than half indicated they would either tell them to stop, or to get help. Muslims are taught to be a “mirror” for each other and to encourage good behaviour and discourage anti-social behaviour (amr bil ma’roof wal nahyi ‘an al-munkar) in their community. If their advice fails, individuals are instructed to avoid the perpetrator so that he/she may turn back once they realise their ‘bad’ actions have resulted in their isolation

(Dastghaib Shirazi, 1998). This moral worldview may also cause Muslims to underreport their own drinking. Muslims that drink still consider themselves sinners and Islam discourages confession or disclosing one’s sin to anyone (M. Ali, 2014). University or social-based interventions may need to be tailored for settings where alcohol is viewed from a moral (rather than medical) viewpoint. These may differ from approaches in non-MMCs (Stockings et al., 2016).

Considering that current mental health and substance treatment infrastructure is limited; contextual measures should be in place to prevent alcohol misuse in Iraq. This may help prevent an increase in the prevalence of drinking and associated risk behaviours as observed in other post-conflict MMC settings. For example, Risk behaviours such as drink driving, carrying weapon and physical fights associated with drinking are high in post-conflict Kirkuk and Erbil (Saeed, 2016; Shabila et al., 2015).

Figures from Lebanon also show an increase in alcohol abuse (DSM-III & DSM-IV) by Muslim university students within eight years after the end of the civil war (increasing from 3.8% to 6.1%, from 1991 to 1999) (E. G. Karam et al., 2004).

To prevent alcohol misuse and associated risky behaviours, a consistent and strong alcohol policy is needed in Iraq. Participants in our study reported a diversity of opinions on policy approaches

Currently, Iraq has a mix of these policies on a federal, provincial and local level (Al Ansari et al.,

2019). For example, currently active federal alcohol laws do not differentiate between faith groups except that alcohol sellers must be non-Muslim. Consumers, however, can be of any faith, including

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Muslim. The alcohol ban introduced in 2016 (but not enforced) also applied to all Iraqis, regardless of faith. In some provinces (e.g. Basra) and local areas (e.g. Khadimiyya in Baghdad), alcohol sales and drinking are totally prohibited for everyone at a provincial and local level. Consistent with previous evidence (Stockings et al., 2016), our findings did not suggest that local prohibition impacts upon reported drinking prevalence or access to alcohol (compared to sites with no alcohol prohibition). Further details of this analysis have been withheld to avoid identifying participating universities. These policies may be compromised by weak law enforcement including a lack of policing at provincial borders.

In addition to strong border control, taxation is known to be the single most impactful preventative intervention in non-MMCs (T. Babor, 2010; Stockings et al., 2016). Iraq, however, does not have a digitised tax system and has limited ability to implement import or sales tax on specific commodities such as alcohol (International Monetary Fund, 2017). Monitoring, controlling, and taxing alcohol will prove difficult in the current volatile political and economic situation.

Students suggested that advice, warning, or education would be their preferred method of responding to someone who is caught with alcohol on their person. Given the mixed perceived motives for the uptake of drinking, this advice could be provided by parents, religious and cultural leaders, or medical professionals. Such advice could constitute brief interventions or evidence-based approaches to encourage those already using alcohol in an ‘at-risk’ way to re-think their drinking. The introduction of brief interventions in primary health settings may help to address harmful drinking. There is currently an initiative in Iraq to integrate mental health care into primary health care to ease the associated stigma of seeking such care in specialised facilities (Sadik et al., 2011). This is key given that trauma is the second highest perceived motive of drinking and that two fifths reported direct experience of war or violent military conflict. However, mental health is stigmatised in Iraq (Bolton,

2013). In addition, most young people are less likely to visit a medical practitioner to discuss alcohol use (Humphreys, 2011). The Iraqi health system is struggling to integrate mental health care into

122 primary health care (Sadik et al., 2011). Additionally patient confidentiality is limited as primary health care practitioners rarely consult in private in Iraqi health settings (Al Ansari et al., 2019).

Information alone has been shown to be ineffective in curbing alcohol use and misuse, however, programs such as the positive youth development programs (PYDP) or family skill-based interventions have shown some promising results in curbing alcohol and other drug use (Stockings et al., 2016). These types of programs equip young people or their parents with psychosocial skills focusing on resilience, communication, and development without necessarily addressing alcohol exclusively.

Given that religious, sociocultural and family reasons are the main motives for abstinence and that drinking is associated with being non-Muslim and living away from family, in the absence of these protective factors, young people may be vulnerable to alcohol use and misuse. Globalisation has led to increasing exposure to alcohol advertisements on the internet, social media, and satellite TV. Iraq’s alcohol policy should therefore be cognisant of this changing contemporary landscape to safeguard the growing Iraqi youth population into the future. This policy should take into consideration Iraq’s diverse populace, cultures, and religions as well as evidence-based approaches, locally sourced or adapted from other MMC and non-MMC experiences.

Limitations

The study sample could not be randomly selected due to the lack of student email databases within universities. Most collaboration and recruitment occurred within the medical faculties. During visits to other colleges, we were informed by staff that the use of internet for educational purposes was relatively new except in faculties such as Medicine, Engineering and Pharmacy. This may have contributed to limited access from students of other faculties. Because of lack of external funding for this research, active recruitment at each site only lasted a few days while we were interviewing for the qualitative component of this study. Funding for further active recruitment could have increased

123 the sample size. Student status and age was self-reported and could not be verified as this was an anonymous online survey.

Despite our efforts, our sample did not include a University from Kurdistan – a region of Iraq where previous studies show a higher prevalence of drinking than other provinces. Although no significant difference was found in drinking based on faculty, our sample had an over-representation of Medicine and Pharmacy students. Students in Engineering had a higher prevalence of drinking than other faculties. However, this finding was not significant due to the small number of participants from the

Faculty of Engineering. Student drinking is likely underestimated in our sample and further attention needs to be paid in future studies to other faculties.

While 448 people (86% of eligible participants) completed the substance use section, less than half

(43.4%) completed the entire survey. We assume that this was because of the survey length (~15-20 minutes) as no association was observed between drinking patterns and the dropout rate. The largest drop-out rate was found in validation questions that explore similarly concepts in questions with deliberately reversed phrasing (e.g. motives for drinking). Accordingly, future studies should be shorter and avoid any perception of repetition. An alternative explanation is that the topic of the survey (alcohol and drugs) caused offence. There were also some internal contradictions in some sensitive questions. For example, some people said they have had alcohol in the past 12 months and then then answered “never” to the first question of the AUDIT (about frequency of drinking in the last year). This could be because people who do not see themselves as “usual” drinkers answer

“never”. As the PC-PTSD screen and the exposure to war question were placed towards the end of the survey, less than half of drinkers answered this question – so no conclusions can be drawn about alcohol use and war exposure.

Young Iraqis who are not university students were not the focus of this study. Drinking prevalence, patterns and motives may differ among this group. We did not include local laws and prohibition as an independent variable. However, we analysed by site (some sites had prohibition and others did not). The impact of policy on alcohol use and attitudes is an area worthy of future investigation. 124

Conclusion

The prevalence of self-reported drinking in Iraq is consistently lower than countries in the developed world or non-MMCs. However, this study and others have indicated that drinking occurs at risky levels among many drinkers in this setting. A decline in abstention may lead to an increase in alcohol- related harm. Iraq’s healthcare system is ill equipped to cope with such an increase and to implement evidence-based preventive approaches. This reflects an ongoing need to accurately and regularly measure alcohol use using appropriate tested and tailored tools.

Innovative, low cost evidence-based approaches are required to prevent alcohol-related harms, including skills-based youth and parental development programs. These initiatives should be tailored to and evaluated in the local settings. In addition, a clear and implementable alcohol policy that considers Iraq’s majority youth population and their experiences is needed.

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Chapter 6: Alcohol use in Iraq: Perceptions of students at three Iraqi universities

Chapter 5 presented quantitatively the perceptions of young university students in Iraq about the motives for and influencers of drinking in Iraq, and the prevalence of drinking. Prevalence of self- reported drinking was low among students, however two fifths of young male drinkers consumed at risky levels (AUDIT-C score of 4+). Drinkers and non-drinkers alike reported that coping and socialising were perceived as key motives for drinking. The diversity of views among students is noted in the quantitative sample. For example, while two-thirds of participants want a policy of total alcohol prohibition, two fifths prefer allowing alcohol to non-Muslims only, and a sixth want alcohol production, sale, and consumption to be universally permitted.

This qualitative chapter complements these findings with depth by drawing on personal experiences of young Iraqis at three Iraqi universities across Iraq. The semi-structured interviews focused on five guiding questions – these questions aim to chronologically ask about alcohol in Iraq – from the past, to the present and future. The interview guides were decided in consultation with local experts. As presented in Chapter 2, due to the sensitive nature of alcohol, no interviewee was asked about their own drinking behaviour. Students were instead asked about the behaviours and perspectives of other students.

By describing the experiences and perspectives of young Iraqis, we intend to investigate what lies behind the behaviours, attitudes, and perspectives of young Iraqis towards alcohol. This will ensure that perspectives are understood contextually. Preventative measures and alcohol policies can then be informed by combining quantitative findings from Chapter 5 with in-depth analysis present in this chapter.

The following manuscript has been submitted for publication.

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Abstract

Introduction

The people of Iraq have experienced conflict since 1980 and increased exposure to alcohol use in the media since the lifting of censorship in 2003. While the majority (60%) of Iraq’s population is under the age of 24, there is a lack of research examining the views of young Iraqis concerning alcohol use and related contextual factors that could provide insight into drinking behaviour and primary prevention. We undertook research to explore how the individual, interpersonal and social contexts of university students influence their experiences and perceptions of alcohol use.

Methods

We undertook a qualitative study underpinned by a socio-ecological framework and the alcohol use motivational model. Forty students, from eleven disciplines at three universities across Iraq were interviewed (45% female). Interviews were conducted in English (n = 3) or Arabic (n = 37). Template analysis was used to examine the data.

Results

Perceptions of the prevalence of alcohol use varied among participants. Perceived motives for drinking included using alcohol to cope with difficulties associated with grief, loss, poverty, and unemployment, as well as peer pressure, thrill seeking and social approval. Abstinence was associated with knowledge of the adverse effects of alcohol and a strong commitment to faith. Students reported alcohol use as a clandestine activity. Students suggested education, open communication, and employment opportunities as preventative strategies.

Conclusion

This is the first study to explore young Iraqi views and experiences of alcohol use in the current context of conflict, political instability, and globalisation. Young Iraqis are a vulnerable population who may be at risk of alcohol-related harm. Iraq should consider multidimensional preventive approaches that include evidence-based and culturally appropriate interventions that reflect young peoples’ real-life experiences and challenges.

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Summary

What is already known?

- Most Iraqis are under the age of 24 and have experienced conflict, terrorism, social, economic, and political unrest for all their lives.

- Iraqis have experienced friction between traditional and globalised culture since the second Gulf

War in 2003.

- There have been calls for qualitative alcohol studies in low- and middle-income countries, especially in the Arab world.

What are the new findings?

- Iraqi university students perceived that drinkers in Iraq always drink excessively; some shared stories of alcohol-related harm experienced by family or friends.

- Students associated drinking with bad parenting and peer pressure, and abstinence with religiosity or awareness of alcohol’s harms.

- Alcohol use is hidden - though students perceived that alcohol use is increasing, many (especially females) denied ever seeing a drinker.

What do the new findings imply?

- Iraq should establish and implement a clear alcohol policy based on a melding of evidence-based and traditional approaches.

- Research is needed on how best to support young Iraqis and reduce harms from alcohol use or mental health disorders

-Options that could be examined include tailored parenting and personal development programs to help prevent alcohol use or misuse.

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Introduction

Alcohol is linked to 5.3% of deaths globally (WHO, 2018a) and is the leading risk factor for burden of disease in people aged 15-49 years (GBD 2016 Risk Factors Collaborators, 2017). However, half of the world’s population is abstinent (in the past 12-months: 57%, lifetime: 44.5%). Muslim majority countries (MMCs) have the lowest per capita consumption and the largest prevalence of past-year abstinence that can largely be attributed to the Islamic prohibition of alcohol (WHO, 2018a). However increased globalisation and local changes in some MMCs may influence drinking.

Iraq is an upper-middle income MMC in the Eastern Mediterranean Region. The country has an estimated population of 38 million, with the majority (60%) under the age of 24 (UNDESA, 2017).

WHO estimates that 93.8% of Iraq’s population are lifetime abstainers and almost half of those who have ever consumed alcohol, abstained in the past year (WHO, 2018a). The legal situation regarding alcohol varies across the country. Although a ban on alcohol consumption and sale was imposed in

2016, this law was not implemented, and Iraq nationally recognises the 2001 laws regarding alcohol licensing and consumption (Al-Ḥukūma al-ʿirāqiyya [Iraqi Government], 2016; Al Ansari et al.,

2019). These civil laws allow for alcohol to be sold to adults by non-Muslims at a certain distance from religious and public places (Al Ansari et al., 2019). Despite this, some provincial governments have introduced local bans on the sale and consumption of alcohol (Al Ansari et al., 2019).

Despite the reported low use of alcohol, the unstable political and economic context in Iraq may place certain populations, such as young people at risk of substance use disorders. Iraq has been exposed to war and terrorism, as well as civil unrest since 1980. There are no studies that have examined the impact of conflict on the exposure to alcohol use and misuse in the Iraqi civilian population. However, the 2009 Iraqi Mental Health Survey (IMHS) identified that increased exposure to traumatic events was significantly associated with all mental disorders including substance misuse (WHO, 2009). In addition, an association between exposure to conflict and mental health conditions including substance and alcohol use disorders has been noted among coalition military personnel returning from the Iraq War (Levy et al., 2013). This association has also been noted in studies of conflict-affected 132 civilian populations, including displaced populations in MMCs (Ezard, 2012; Greene et al., 2018; E.

G. Karam et al., 2008; Lo et al., 2017).

Young Iraqis have access to all forms of media, including platforms that market alcohol directly or indirectly through content that depicts the common use of alcohol such as in film (Al Ansari et al.,

2019). Studies from several countries in the region have found that university students mainly consume English language media (Melki, 2010). Iraqi university students, who have a higher levels of English language competence than their non-student peers may be more exposed to alcohol use and marketing in media. There is strong evidence, mainly from non-MMCs, that alcohol promotion is linked to the initiation of drinking among young abstainers and increased consumption among drinkers. Such promotion includes exposure to indirect alcohol marketing present in movies

(Anderson et al., 2009).

While there are some, albeit limited, quantitative studies regarding alcohol consumption in Iraq, there is no peer-reviewed qualitative research that provides insight into the experiences, perceptions and views of Iraqi people concerning alcohol use. This lack of data has led to speculation regarding the factors that influence young people’s alcohol consumption and abstinence. Internationally, experts have called for research to explore the micro and macro characteristics of drinking in diverse cultures outside European and Anglophone countries (Kuntsche et al., 2017; Savic et al., 2016). A need for qualitative research to explore patterns of consumption and the factors influencing substance use within this cultural context has also been identified (Al Ghaferi et al., 2013).

The current study addresses aspects of this knowledge gap by exploring the attitudes and views of young Iraqi university students towards alcohol and their related experiences. We sought to understand why young people drink alcohol, how prevalent they perceive alcohol use to be and what perceptions they have concerning drinkers and alcohol-related harms. Finally, we aimed to understand students’ perspectives about the role of health policy in reducing alcohol-related health risks.

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Methods

There is a dearth of qualitative mental health research in Iraq, especially in the field of substance use.

Current alcohol policies are based on political and religious inclinations, and rarely account for the real experiences and circumstances of young Iraqis. Therefore, we applied a constructive descriptive approach to explore the factors that underpin current attitudes towards alcohol and how these may influence young people’s decisions to consume or abstain from alcohol. A constructivist approach allowed for assessing attitudes as constructed by the participants interactions with their environment.

We adopted a social ecological model (Bronfenbrenner, 1977) to explore the relationship between the individual student’s experiences, perceptions and views of alcohol use and that of the environment that hosts the individual, family, community, society and beyond. We complemented this framework with work by Kuntsche and colleagues that examines positive and negative internal and external factors influencing alcohol use (Kuntsche et al., 2005). Our model combines aspects of this model with the socio-ecological framework to assess current factors with socio-cultural and environmental dynamics. We adapted this model to the Iraqi context – assessing macro and micro antecedents to perceived attitudes and behaviours around alcohol use. In this way, the possible chain of influencing factors from the global to the individual level can be constructed. Previous literature in other contexts have shown that a larger number of students in non-MMC countries drink for social and enhancement motives (Kuntsche et al., 2005; Mackinnon et al., 2017; Wicki et al., 2017). We hypothesise that while this may also be the case in Iraq, a large proportion of drinkers would be perceived to drink for reasons of coping and conformity.

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Figure 10 Socio-ecological framework for alcohol use in Iraq complemented by aspects of the motivational model as presented in Kuntsche et al, 2005

Settings

To ensure a diversity of insights, four universities in different regions in Iraq were invited to participate in this study. Three universities were situated in Arabic speaking regions of Iraq and one in the autonomous region of Kurdistan. The University that was approached in Kurdistan did not respond to requests via phone, email and in-person and therefore was not included in the study. The universities who agreed to participate were in diverse Arabic speaking urban settings including a conservative religious city (University A), a large metropolitan city (University B) and a port city

(University C). The sites selected for this study have varied policies regarding alcohol (regulatory policy: University B; prohibition: University A and C).

Recruitment

The head of department or Dean in the faculty of medicine was first approached. The Dean then assigned a staff member or student representative to assist us with recruitment at their faculty as well as to help with recruitment in other faculties. The interviewer, assisting staff member or student

135 approached students in faculty buildings or university common areas to invite participants. The first author, a male Iraqi Australian PhD candidate who has been trained in qualitative research methods, conducted the interviews in Arabic or English according to the participant’s preference.

Due to the sensitive nature of alcohol in Iraq, we attempted to increase participant comfort by conducting the interviews in a casual relaxed environment, where no one could over-hear the interview. However, as the interviewer was a male, it was not possible for cultural reasons to interview a female in a closed area (such as a staff office) unless the door was kept open. Even when interviews took place in common spaces, some females requested the presence of a colleague or staff member. All interviews were conducted on campus except for one interview which was conducted after hours at a nearby café upon the request of the participant. The interview settings included the empty offices of staff (e.g. office of the Dean, head of school and ICT), University cafes and common outdoor spaces at the University. All interviews were audio recorded – when there was background noise the recording device (iPhone) was held up to the participant’s mouth to ensure all words were captured. Some field notes were taken following the interview to record non-verbal interactions or reflections of the interviewer. The interviewees and interviewer had not met before except for those students who had assisted the researcher with recruitment. The researcher engaged in general conversations with each participant at the beginning of every interview to build rapport and put the participant at ease.

Qualitative interviews

Qualitative interviewing was used to obtain descriptions of the lived experiences of the interviewees and how these impacted their attitudes (Brinkmann, 2013). The semi-structure provided flexibility and scope for the participant to answer freely and to direct the interview while still ensuring the interview remained on topic and some uniformity in questioning was maintained between participants

(Nathan et al., 2019). The semi-structured interviews were guided by five questions (Appendix 6).

Due to the sensitivity of the topic, no questions were asked about the participant’s own alcohol consumption or related behaviour. Instead, we enquired about University students as a collective 136 group.

Following verbal consent, the participants were first asked to narrate any story they had heard from their relatives or friends about alcohol use and attitudes in previous generations (1970’s to 1990’s).

Students were then asked to comment on the influence of sanctions, war and terrorism on attitudes towards alcohol among students. They were then asked about how common they thought alcohol use was in Iraqi. After this, participants were invited to comment on the "openness" of Iraq towards the outside world, including media, economy, culture, etc. and whether it had effects on students’ attitudes towards alcohol. Lastly, participants were asked about tolerance towards minorities and diverse views about alcohol in Iraq. This was followed by a question about the ideal alcohol policy that they would adopt in Iraq if they were a decision maker.

Translation and transcription

The transcripts were de-identified, and a pseudonym was assigned for each interview. All transcription and translation were carried out by the first author, who is fluent in Arabic and English, in a single step method (Arabic audio to English text). The first 12 recorded audio files were fully translated and transcribed verbatim. Due to the time-consuming nature of this exercise, only interviewee responses were transcribed for the remaining interviews (and not the interviewer’s questions and comments). Some notes and comments/codes were inserted at the translation stage to assist with analysis.

Analysis

The data was qualitatively analysed using King’s template analysis method (King, 1998). This method was used as the coding was derived from a priori themes informed by the conceptual framework (figure 1). Those were complemented and revised by new data-driven themes.

A preliminary template of codes was created a priori using the field exposure and the first eight transcripts by the first author. These transcripts were circulated to the other authors (AD and KC) for independent scrutiny. The authors jointly discussed and refined the template over several meetings.

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A revised template was then used to first analyse data from University A and C by the first author.

These findings were presented and discussed with the authors (AD and KC). The template was further revised. The further revised template was then used by the first author to analyse data from University

B. The findings were again discussed with the other authors (AD and KC). An audit trail was maintained of the analysis process.

A reflexivity statement is included in the discussion. Reflexivity places this research in context by identifying possible influence of the researcher on the study (Dodgson, 2019). This is especially important in such sensitive research where participants may feel discomfort speaking about the topic.

NVivo 12 software was used for coding and analysis of transcripts.

Patient and public involvement statement

No patients participated in this study. Local collaborators, young medical graduates and student representatives were consulted in the design, piloting and implementation of this study. We intend to share published findings from this with local universities and student organisations in Iraq. This process will also be done in consultation with local collaborators, graduates and students.

Ethics

Ethics approval was granted by the Medical Ethics Committee at the College of Medicine in the

University of Kufa, Iraq (MECCM-0028).

Results

Forty interviews between eight minutes and an hour were conducted. The gender and faculty mix of the participants are shown in Table 1.

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Table 8 Gender and faculty of participants (n = 40)

Uni. A (n) Uni. B (n) Uni. C (n) Total (n) Gender Male 10 3 9 22 Female 6 4 8 18 Faculty Medicine 4 2 6 12 Science* 7 2 4 13 Humanities# 2 0 1 3 Engineering^ 3 1 2 6 Social Sciences+ 0 2 4 6 Total (n) 16 7 17 40 *Science includes faculties of science, nursing, geography. #Humanities include faculties of languages and visual arts. ^Engineering includes faculties of engineering and planning. +Social Sciences include faculties of law, education, political science, and media.

The results are presented according to five key themes: perceptions of the prevalence of alcohol use, perceived motives for abstinence or drinking, attitudes towards those who drink, perceived harms associated with alcohol use and views of alcohol policy in Iraq. Although participants were specifically asked questions about student drinking, most students chose to answer with reference to the alcohol consumption among all young Iraqis. All students spoke about the alcohol use with reference to men and only one student mentioned drug use (not alcohol use) by females.

Perceived prevalence of drinking

Compared with the pre-war Iraq, students (n=14) reported that the prevalence of alcohol consumption has increased in Iraq. However, other students (n=7) reported drinking had reduced, and others didn’t report on prevalence but mentioned that patterns of drinking have become worse. Female students and those in University A described an increase in prevalence of alcohol use more often than those in other universities.

Students from all three sites agreed that alcohol use is a clandestine activity.

For example, here in our province, it’s not that alcohol is not present – it’s present, but it’s

hidden. In other provinces it’s present, it’s normal, people go, hang out and drink.

- Said, male, University A

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However, students in University B reported that alcohol consumption has become more visible in society:

Now, someone goes out and says publicly that this is me and I am doing this, and I am

drinking. It’s different, very different to before… I feel it’s much more public. Before, in all

honesty, there was none of this, now it’s public.

- Undisclosed, female, University B

Although some students (mainly males) described why they think alcohol use has increased, others

(mainly females) stated they felt that use has increased although they had never witnessed anyone drinking.

Why people drink: “It’s natural for there to be various views”

Participants reported diverse reasons for alcohol abstinence or consumption. Hisham, a young medical student from University A, summarised various underlying beliefs – interestingly, motives for drinking or abstinence were associated students’ world view rather than motives presented in

Figure 10 (such as social or coping, etc.):

It’s natural for there to be various views.

Firstly, those that outright reject it from a religious view.

…Secondly, those that see themselves free from religion, but refuse it for a personal belief.

…mostly, those that are known for alcohol are those that lean towards the secular view, mainly

present in Baghdad.

…I know some people that are secular… [or] Islam is not their faith – but they don’t drink

because they don’t find it suitable, it decreases a person’s aura or they don’t see it as a good

act that has health effects, etc. – so they leave it.

…But religion ensures that most people stay away from it – if they were religious.

- Hisham, Male, University A 140

The following results will be presented according to antecedents to individual perceptions of alcohol use, as presented in Figure 10. They will start from motives affected by the micro level (individual motives) to those associated with social, national or global influences.

Individual motives

Students reported perceived personal motives for drinking, one of which was curiosity to know what the possible effect might be. Participants thought that drinkers belonging to different socio-economic levels had different motives for drinking. For example, curiosity, and fun/adventure seeking

(enhancement) were particularly associated with young students who could afford to travel to other countries.

Even when they travel, they’re thinking ‘I am only going to enter this place to have a bit of

fun and while I am at it, might as well drink a bit’ – without a clear reason.

- Hasan, male, University C

Inquisitiveness about alcohol was also connected to a pre-conceived image of alcohol linked to appearing more sophisticated and cooler or reaching a side of one’s personality that he/she would not otherwise know.

I am a very curious person, and I tried it…as a joke we say, there are people that think ‘it adds

genius to you!’ Because, what is it? …Alcohol of course gives a strong relaxation to the body.

Through this relaxation, someone can reach their brain – how can I explain it? – how do I

explain it?

- Bilal, male, University C

Although trying alcohol out of curiosity and adventure was condoned, participants were fearful that drinking for enhancement purposes may lead to ongoing alcohol consumption. One participant,

Batoul (female, University A), described some students as having a “love of adventure, they want to try everything that is strange…When they try it out once, twice or thrice, they’ll fall for it.” Another

141 female student (Faiza, University C) stated that “they give it, alcohol, to the student without money, so that the student can get addicted to it”.

Several students argued that young Iraqis’ decisions to drink were the result of their “weak” personalities. Participants in all three settings explained that young Iraqis were naïve and drank to conform with others. They suggested that providing health information and education and improving critical thinking and informed decision making would help enable young people to make better decisions.

Before we can solve the problem of alcohol… we should focus on the weak and disjointed

personality of a young person here, so that…when they are told that alcohol is harmful to your

health or wrong religiously, then they can simply research it themselves, be convinced or ask

what’s your evidence? Not just accept what you say with a very simple mind of saying – “oh

this is a good guy and he told me [“alcohol is bad”], so it must be correct” – What we need to

do is to know ourselves. This is the main problem you will find among anyone that is addicted

to alcohol or drugs, or all these things [that their earlier abstinence relied on other people’s

opinions].

- Sandra, female, University A

Interpersonal motives

Students also mentioned that social relations with family and friends influenced a person’s alcohol- related behaviour. Students described “bad” friends and peer pressure as a source of alcohol use.

These encouraged of a mixture of social, enhancement and conformity motives for drinking. For example, Bilal (male, University C) said “What would my friends think if I rejected their invite?

They’d say, ‘I am not a man.’ I fear that.” Others indicated that young people would drink so that they can boast about it to their peers.

I have witnessed a lot of cases where people drink and then boast about their drinking saying “I drank in this place and this funny thing happened to me” – whether to friends, acquaintances or others.

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- Ibrahim, male, University C

Students also described the important role of families in the choices that young people make about alcohol use. Careless and strict parenting were both criticised by participants. Students preferred that parents and teachers educate and raise awareness of the harms of alcohol so that young people develop long-term “immunity” and are therefore protected from such harms. Current parenting practices, they argued, were either careless or authoritarian with high expectations that placed pressure on young people and did not necessarily impact long term behaviour or harm prevention. For example, one participant shared a story of a friend who had an alcohol problem that was linked to being raised in a very strict family and a lack of commitment to religion.

There was a student with us, in first year – unfortunately he is now dead…he went to study in

Russia. His religiosity wasn’t very strong, so…he was consuming alcohol… Maybe his

family, they were very strict …As you know, increased pressure eventually causes an

explosion. When he went abroad, naturally, as he was strangled [by strict parenting] at home,

he wanted to open to the world and see what it has to offer.

- Reda, male, University A

It was also indicated that young people found it difficult to talk to their parents about alcohol use. For example, a female student (University A) shared that students could not communicate with their parents about alcohol or other socially and religiously sensitive areas because they either did not want to disappoint their parents or were afraid to lose their parents’ financial support – alluding to the fact that they may be ‘kicked out’ if exposed. Other students argued that cultural differences affected the ability of parents to address their child’s drinking. For example, the mother would hide the son’s drinking in fear of punishment by the father if he found out – or to not reach out for help from others in fear of long-term social consequences for the child.

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He was led to this…[by] bad parenting, so for example, his mother might have seen some

things that are worrying about him but didn’t inform his father, so that was the wrong choice,

and so there was no discipline.

- Manal, female, University C

Three students described stories of personal friends who had experienced the death of parents and family members (some due to conflict), and who had used alcohol for coping purposes. Drinking within families was also reported by three students who disclosed that their father or close male relative was a drinker. Two of these participants suggested that they themselves had consumed alcohol in the past. A father’s regular drinking was also reported to influence the son’s alcohol-related behaviour. An indication that social motives also exist in Iraq.

[Some] families are strict and religious… he [the young drinker] fears them. So even if it’s

inconvenient, he only drinks when he sleeps over at his friends’ place... If [the son] drinks, he

drinks very little…to a limit where he can go back home, and his family will not find out. But

the person who has a father who drinks, he drinks as much as he wants and gets drunk.

- Ali, male, University B

Community-related motives

The local availability of alcohol was reported to influence the uptake of drinking. Participants from

University B and C reported that alcohol was easily available and some alleged that illegal alcohol trade was protected by security forces. Some participants said that alcohol (and other drugs) sale locations were commonly known. A student from University C, where alcohol is banned, offered to take the interviewer there in person.

Unemployment and lack of alternative recreational activities were also mentioned as possible reasons for increased alcohol consumption. The lack of activities to fulfil a young person’s social and enhancement needs encourages alcohol to fill the space.

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As soon as its sunset, go past the bars where they sell alcohol, you’ll see masses of people

there – it’s very busy (like this – hand gesture showing it’s crowded). Why? ... There is no

alternative. Where should a young person go? With his friends, go out, either to the cafés or

to drink.

- Ali, male, University B

Although many students stated that graduating students seldom find employment, some denied this was linked to increased alcohol consumption because they believed that education made them more resistant to alcohol use. However, participants shared their concern about alcohol use among unemployed young people with limited education for coping or social purposes.

It is not likely that a university student would uptake alcohol after graduating from university.

It’s impossible, because he has…intellectual immunity, he says, ‘I have learnt and struggled

and everything – why now would I destroy myself?’ But as for other young people out there,

there are a lot that went this way [towards alcohol] – even the smallest upset in life, for

example, a lover leaves him, or his father hits him or kicks him out of home, he will go

[towards alcohol]. There is no lack of bad friends [too].

- Mahmoud, male, University C

Society-related motives and influences

Several students (n=12) reported that the unstable political situation and corruption in Iraq led some to use alcohol as a coping mechanism. One student felt that although religion was currently the strongest deterrent of alcohol use, this was changing due to perceived corruption and hypocrisy.

They consider that terrorism… [and] limiting of freedoms is because of religion. Most of the

corrupt thieving politicians have a religious side and they scaled up using this side…The

student just wants to escape to anything, as long as it’s not Islam... Anything that is rejected

by Islam, they automatically start wavering towards…In their thinking, Islam has rejected

this, so it must be good. 145

- Hisham, male, University A

Other students stated that they believed that political parties and their militias have a financial interest in the alcohol and entertainment industries. They gave examples of venues that were attacked by

Islamist militias before later being protected by the same militia after the payment of bribes and loyalties.

Students spoke of Iraq’s post-war situation and how this had influenced young people’s decisions and beliefs around alcohol. While participants said that they had limited direct exposure to war, their words were heavy with allusions to the post-war situation.

They give up on life, or some, their father left them and separated, or as I said, some have

poverty, and others face social pressures. They are not in the same situation as young people

in other countries, especially Europe. That’s why we see they head towards [alcohol].

- Zaman, female, University C

Students in all three settings described alcohol use as a coping mechanism and some participants described personally knowing people who seek alcohol use for this purpose.

[I know] this person, before the fall of Saddam, he was from a higher socio-economic class.

After the fall, in 2004, there was killing by identity. They took his house and properties and

killed his wife…He started drinking daily under the bridge [homeless] to lessen his suffering.

- Adam, male, University A

Three students from University B and C denied that the Iraqi post-war situation resulted in some

Iraqis to uptake drinking. They argued that the situation might seem traumatic from an outsider’s perspective – but young Iraqis are familiar to this reality and have become resilient to the situation.

Interestingly, these students shared that their father or male relative used to drink.

People that haven’t lived in Iraq, when they look at us, they see that we live black and dark

lives…Yes, for as long as we know, there’s been war after war, problem after problem. But

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we are living fine, we are living. When I wake up in the morning, I am exactly like you... As

young people…we see the situation of Iraq as normal. When we come to drink, we don’t drink

because of the [negative] Iraqi situation, because…it is our reality. It is us.

- Sam, male, University B

Globalisation and greater/external society related motives: Globalisation or “openness” as referred to in Iraq was seen by students considering either “positive” or “negative” outcomes. All students acknowledged the benefits of media and social media – especially for facilitating interactions with other cultures and the outside world. In terms of its impact on alcohol consumption, there were diverse views but summarised in the statement below:

Maybe, it [openness] will increase [consumption]. Because people will see others seek

[alcohol], it will impact them…It could also increase awareness…It really depends on the

person, what side he leans and what his thoughts are.

- Huda, female, University A

Students feared that young people only absorbed “negative” influences such as alcohol use. They shared that young Iraqis were increasingly “mimicking” what they see on media – where they believed alcohol is presented in a positive manner.

We say that we like to see the outside world and we will progress through these things. We

will mimic them, and we will become the same as them. But no, this is not true, everything is

different here, we have religion, culture, traditions and for sure these are different from the

outside world.

- Ahlam, female, University B

Religious and social awareness about abstention was also reported to have increased since the 2003 war because of increased freedom of the press that allowed religious channels and media to broadcast messages to young Iraqis.

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In Iraq after the fall of the former regime in 2003, it opened to the outside world. This openness

wasn’t just cultural and technological – it was also religious openness. There were religious

lectures that addressed such issues. Permissible drinking now became something very rare

because people heard that [alcohol] is forbidden, and it’s a red line that no one should cross.

So even those who drink alcohol, started drinking secretly or at least started drinking in a way

that emphasises that it’s not permissible.

- Ibrahim, male, University C

Some students (n = 5) inferred that overseas travel was connected to alcohol consumption, with one describing a friend who returned with an alcohol problem and another narrating a personal story of colleagues who consumed alcohol for enhancement while travelling with him.

When I travelled, I had friends that would say “Why shouldn’t I try [alcohol], it’s once in a

lifetime. It won’t impact anything, so let me try and see”. Here in Iraq, obviously he can’t do

it, because he is afraid that his family see him, or someone else sees him. So where can he

drink? When he goes out of the country. I have seen over there, it’s easy, there’s nothing

restricting them. They don’t have a reason except wanting to try.

- Adam, male, University A

In contrast, other students did not believe that overseas travel would influence young Muslim Iraqis to try alcohol.

If they got a chance to travel outside and they saw a bar or something… I don’t think they

will [drink]… [although] it is easy to go there and buy alcohol. Because it’s kind of a stigma

and people think that it’s very hard to drink in public and you should be conservative about

it… and… most of us, as Muslims we are very convinced and… we don’t take these actions

easily.

- Mahdi, male, University A

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Perceptions of those who drink – “Not even Christian girls like drinkers”

As described earlier, students mentioned coping as a key motive for drinking. Students were sympathetic towards individuals who drank because they had suffered the loss of loved ones during the conflict. Others suggested that choices around alcohol use in Iraq weren’t made consciously and most drinkers (and abstainers) were “imitators” who followed other people. They blamed drinking on the “weak” personality of young Iraqis who consumed alcohol for conformity and did not make their own decisions.

In addition to being weak, students viewed drinkers as lacking religious conviction, education and/or wealth. Although students described alcoholics in a negative tone (“uneducated”, “poor”, etc.), they typically blamed the social, political and economic environment rather than the individuals themselves. One student, who shared that he and his relatives drink, praised young people that can stay away from alcohol, despite peer pressure.

Some students considered any drinker to be an “alcoholic”, while others only used this label for those who drank excessively, or were addicted to alcohol. Two students reported that if a male student tries alcohol for curiosity, this would be tolerated. However, according to these students, alcohol is rarely consumed in amounts that don’t cause intoxication.

In eastern societies…they don’t have a culture of drinking. Drinking of alcohol is a culture.

In the west, there are people that drink for a reason, there are people that stay awake all night

drinking, for a particular reason, but they drink little. But us, here, you won’t be called a

drinker of alcohol unless you’re intoxicated.

- Sam, male, University B

Students suggested that Iraq’s political instability was the primary reason for alcohol use in Iraq.

Students in University B and C stated that before the conflicts and sanctions, drinkers were more tolerated. However, the political instability and the introduction of religious militias has led to tension between Iraqis – especially towards minorities. For example, one student indicated that they were not

149 permitted to interact socially with non-Muslims whose religion allowed alcohol use: “our families don’t allow us to mix with people from other religions…Because they have more alcohol consumption. So, their assumption is that this will negatively impact us.” (Manal, female, University

Excluding drinkers from social interactions was a consistent theme. Students reported that drinkers were people that one would not want to associate with.

It’s impossible for a girl to say, “oh it’s okay, I will have a relationship with a drinker” and

same with boys, they’ll say, I will stay away from him and leave.

- Zahra, female, University B

Student differentiated between the attitudes of university students towards drinkers and the attitudes of young people in the wider society.

“[At] the university… they couldn’t…[have] a drinker of alcohol and put a tick on him. No,

there’s a big X on him. But if you walk outside the university…then yes, a drinker is seen as

normal and even accepted.

- Mahmoud, male, University C

Although many students relayed a negative view towards drinkers, some students mentioned that drinkers are increasingly perceived in a positive lens which may encourage drinking for social or enhancement purpose. Firstly, by traditional people who associate alcohol with masculinity and call it “the milk of lions” and secondly, by students who want to break free from current social and religious values and beliefs.

The person that drinks is considered a lion [strong, courageous] ... instead of people detesting

him, he became liked… bad things like fornication, drinking and all these things - they [young

people] grouped these and called them “galaat”. [“galaat” are] essentially negative [traits] that

are now used to praise someone.

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- Yacoub, Male, University A

Despite these differing views, students emphasised the need for young people to be more tolerant towards people that hold different views regarding alcohol.

We need people that don’t interfere in other people’s business…People must respect our

opinion, respect the differences among us, we aren’t all from the same religion, nor all have

a single opinion…someone must respect diversity. That’s the most important.”

- Naeema, female, University C

Consequences of drinking

Individual and intrapersonal alcohol-related harms were frequently mentioned. One person shared that his friend died from liver cirrhosis. Losing consciousness, or one’s memory or intellectual abilities were also mentioned.

At least one student in each of the settings reported that a friend or relative was either a perpetrator or victim of alcohol-related harms. Two female students from University A spoke about familiar cases of alcohol-related domestic violence. They both shared the limited ability of females to respond to any such violence due to a fear of losing their children or their children being left without a father.

“One of my relatives…it gets to the point of hitting her…all I know is he was addicted

to alcohol and he brings his friends home and one thing leads to another – and certainly

this involved girls and such things – she had no solution, she had children, so she

couldn’t do anything.”

- Zaman, female, University A

One girl in University C also shared that she has heard that females were the main target of alcohol- related violence, even in the streets. Two male students in University C shared specific stories of how drinking harmed their friends. One of them, Mahmoud, became tearful and expressed his guilt as he spoke of a friend who died in a fatal car crash: “I was his only friend that didn’t drink, so had

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I given up some of my time that night, he’d still be here.”

Students in University B did not share specific stories but said that alcohol-related street violence and car crashes were a daily occurrence in their setting – one narrated this directly from a friend who works as a police officer.

View of policies towards alcohol

Students were confused and unaware of Iraq’s policy towards alcohol, especially since the 2016 ban.

Students’ opinions of what an ideal alcohol policy in Iraq looks like differed greatly. Some students

(n=7) believed that if social harms are controlled, people should be free to drink by choice. They suggested regulations, like those in Europe, such as taxes and restricted alcohol hours and venues.

However, many students (n=12) stated that the implementation of immediate prohibition or a phased approach to this was the most appropriate policy for the Iraqi context.

Students that argued for prohibition did so either for religious reasons or because they believed prohibition protects health and ensures positive social outcomes. Some participants described alcohol use as a “right”, stating that people should make their own choices while others thought that regulation would be more successful in curbing actual alcohol use than a total prohibition policy because “that which is forbidden is attractive” (al-mamnüʿ marghüb).

Almost all students suggested preventative and health promotional efforts by the state – some directly blaming the State for the spread of drinking and the lack of awareness about alcohol-related harm. Students suggested introducing health-related educational programs, improving employment opportunities, and sport and recreational activities.

Discussion

This is the first qualitative study to explore alcohol consumption in Iraq. This study investigates the views of students in depth using interviews to shed light on the personal experiences of young Iraqis, including how exposure to war and to western culture through globalisation may have influenced perceptions of alcohol use. Drinking in Iraq is a clandestine activity and alcohol remains a sensitive 152 topic (AlMarri & Oei, 2009; L. Ghandour et al., 2016). Students had several views concerning the prevalence of alcohol use and the possible drinking motives of young Iraqis. A spectrum of opinions on future policies in Iraq were shared – ranging from complete prohibition to a free-for-all approach.

This diversity of attitudes is understandable in an evolving political, social and economic context and in light of the Islamic prohibition, local customs, religion and civil laws.

Despite the ban on alcohol marketing in Iraq, young Iraqis are exposed to alcohol advertisement and normalisation of drinking in international and social media platforms via posts from friends, celebrities and organisations. Such exposure to alcohol, though indirect via movies and shows, has been shown to increase young people’s likelihood of alcohol initiation in non-MMCs (Anderson et al., 2009).

Students in our study indicated that there is a visible increase in the availability and affordability of alcohol, even in provinces with alcohol prohibition and those affected by the war. The affordability of alcohol can be confirmed in the media. For example, the cost of a 500mL can of imported beer in post-ISIS Mosul is 2000 Dinars (~ $1.5 USD) and a 1L bottle of whisky (Alc. 43%) costs 12000

Dinars (~$10 USD) (AP, 2017), which is about the cost of a restaurant meal ($10-20 USD).

Students reported a diverse range of “internal” (coping/enhancement) and “external”

(social/conformity) motives for alcohol consumption. Participants perceived that alcohol use was linked to coping with exposure to war, grief, poverty, loss of loved ones, unemployment and rejection of culture and religion. Motives for drinking are important in this context as they are connected with initiation of drinking and with drinking outcomes (Kuntsche et al., 2005).

While social motives were shared by students, they were normally associated with drinking by previous generations, drinking in small friend groups or drinking outside of Iraq. Enhancement motives were associated with traditional and modern perspectives about alcohol. Traditionally, the feeling of invincibility or being a “lion” was a key factor and currently, the perceptions of sophistication and modernity. Some perceived that the underlying motive encouraging drinking for

153 social and enhancement purposes was conformity with the positive image of alcohol in global media and its association with sophistication and modernity.

Alcohol use for coping purposes has been associated with heavier drinking and more adverse personal and social outcomes for drinkers in our sample and internationally (Kuntsche et al., 2005; Wicki et al., 2017). Most Iraqis have been exposed to conflict due to the 2003 war, ongoing terrorism and the war against ISIS. At least 6.7 million Iraqis are currently displaced or in need of urgent assistance

(UNOCHA, 2019). Non-Iraqi displaced people and post-conflict populations have shown an increased likelihood to use and misuse substances (Greene et al., 2018). Post-traumatic stress disorder and exposure to trauma, both prevalent among young Iraqis, have also been associated with increased alcohol misuse (Debell et al., 2014). Iraqi refugees elsewhere have shared that alcohol they have used alcohol to cope with past experiences of trauma (Dupont et al., 2005).

Iraq is currently experiencing an economic crisis that coupled with the trauma experience could put young people at risk of harmful drinking (de Goeij et al., 2015). Nationally, one fifth of Iraqis (22%) and almost half of Iraqis from former ISIS controlled regions (44%) are experiencing poverty

(Bandiera et al., 2019). Over a third (36%) of Iraqi youth are currently unemployed with at least 2.5 million jobs urgently needed (Bandiera et al., 2019). There is evidence, albeit in non-MMCs, that alcohol use and misuse is associated with poverty (Allen et al., 2018) and long-term unemployment

(Henkel, 2011).

Although a normal outcome of years of conflict and political instability, the underlying social, economic, and political atmospheres that drive young people to seek alcohol as a coping strategy need addressing in the long term.

Preventing alcohol misuse in Iraq

By observation, public efforts to address alcohol in Iraq are generally expressed during religious sermons or during consultations with health professionals. To our knowledge, there is a paucity of research on alcohol policy in Iraq. Since the 2016 alcohol ban, there has been no clear or centralised

154 alcohol policy in Iraq (Al Ansari et al., 2019). Existing alcohol policy in the country is focused on the application for and operation of licensed commercial outlets (Al Ansari et al., 2019). These policies ban the marketing of alcohol, limit the operation hours of premises and regulate the labelling and bottling of products (Al Ansari et al., 2019).

Illegal sales and smuggling of alcohol make the implementation of a tax on alcohol complicated in

Iraq. While there is strong evidence of the effect of taxation on the reduction of alcohol use (Stockings et al., 2016), Iraq lacks the infrastructure to implement sale taxes or levies on retail products, including alcohol. The current taxation model works on a yearly schedule with no firm legal or financial structure. In 2016 the Government planned to charge a 300% levy on the importation and sale of alcohol, but this was not implemented. Even if import taxes are imposed, the Iraqi cash-based economy is not monitored adequately and smuggling is known to be widespread (Bureau for

International Narcotics and Law Enforcement Affairs, 2013).

Universal alcohol prevention efforts typically aim to either reduce overall use, problematic use or injury/harm (Stockings et al., 2016). Given that prevalence of alcohol use is reportedly low in Iraq

(US Department of State et al., 2015; WHO, 2009), the appropriateness of a universal alcohol prevention strategy has been questioned in this context (Dabbagh, 2017). However, the vulnerability of young people in Iraq to alcohol misuse indicates that a long term culturally sensitive strategy that maintains low levels of consumption while introducing harm reduction and treatment strategies may be required.

While prohibition with severe consequences for drinking was preferred by some students, they felt that banning alcohol will increase the desire for consumption among young Iraqis. Although national or local prohibition may decrease use, evidence on drug prohibition in non-MMCs have found such bans result in limited or no reduction of problematic use and harm and may result in adverse health and social effects including increased criminal activity in illegal drug markets (Stockings et al., 2016).

Students suggested alcohol use should be regulated and that a non-prohibition approaches would lead to increased ‘informed’ abstinence. 155

Iraqis view addiction as a moral rather than a medical issue (Al-Hasnawi et al., 2007; Dabbagh, 2017).

While there is a need to raise awareness of the health aspects of this issue, it is important that approaches to alcohol-related health promotion take into account this moral worldview (Stockings et al., 2016). Currently, the biggest deterrent of alcohol use in Iraq is the Islamic prohibition, which limits alcohol use across all MMCs worldwide (WHO, 2018a). For example, lifetime abstinence rate is 89.1% in Turkey (WHO, 2018a), despite being a secular nation with alcohol permissibility since

1924 (Evered et al., 2016). Despite the effectiveness of prohibition in other MMCs (WHO, 2018a), students in our study reported an increasing anti-Islamic sentiment among educated young Iraqis who blame Islam or the conservative and possibly fundamental Islamist governments for political and social issues. This negative sentiment is reportedly a reaction to the political, social and economic governance by Islamist parties leading Iraq since the 2003 conflict. For these reasons, despite keeping country-wide alcohol use prevalence low, religious intervention may not always be an effective form of drinking deterrence for the whole population.

Students in our study described the social stigma attached to alcohol use. While this may serve as a deterrent it may also limit access to treatment and re-integration into society for those affected by alcohol use disorders. Furthermore, students reported that families often hide an individual’s drinking in fear of life-long stigma. In some Iraqi settings, alcohol is stigmatised more than other illicit substances (Humphreys, 2011).

Community-based interventions may be useful in preventing alcohol misuse in the Iraqi setting where over half of Iraq’s population is under the age of 19 (Bandiera et al., 2019). However, overt conversations about alcohol might not be possible and substance-specific education programs have typically been shown to be ineffective (Stockings et al., 2016). Alternatively, conversations about alcohol could be incorporated into youth development approaches and health promotion efforts. There are some promising results from generic prevention programs that focus on psychosocial and life skills in reducing alcohol use, rather than on alcohol-related harm (Stockings et al., 2016).

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Positive youth development programs (PYDP) are an example of such programs that consist of training to strengthen young people in general character building and resilience– some also equip them with some health-related knowledge. Although limited studies found them effective in alcohol- and drug-related prevention, PYDP has been found effective in strengthening vulnerable populations and in altering knowledge, attitudes and risky behaviour among young people, including in MMC settings (Catalano et al., 2019). Accordingly, the use of PYDP in Iraq may strengthen the “weak” personalities, self-esteem and decision-making processes of young Iraqis that may in turn impact their attitudes and behaviours around alcohol.

Similar programs to PYDP exist in building parenting skills and parent-child communication. These programs have had promising results in diverse settings in high, middle and low income countries

(Bo et al., 2018; Giusto et al., 2018; Stockings et al., 2016). In addition to preventing anti-social behaviour, these interventions delay the child’s onset and frequency of alcohol use (Stockings et al.,

2016). Parenting interventions may be important in Iraq, because the age of transition to financial and social independence occurs later than other countries, with young people typically living at home until they are married in their mid-20s.

To reduce drinking for social and enhancement motives, students concern with lack of opportunities for entertainment and social interactions with other young people should be addressed. Alternative ways of addressing these social and enhancement needs should be studied and incorporated in future planning.

A holistic approach to preventing alcohol-related harm that supports young Iraqis to build resilience in challenging difficult times may be necessary in Iraq. It is important that approaches to addressing alcohol consider the diverse needs of young people and are sensitive to the socio-cultural context and

Iraq’s already stretched health system.

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Limitations

Lack of funding and the security situation in Iraq meant that recruitment for the interviews had to take place over a maximum of two days in each site. This limit in time and resources meant that participants from Iraqi minorities or internally displaced peoples could not be targeted for recruitment. It also meant that participants were spontaneously recruited, and the interviews took place wherever convenient, either in staff rooms or public spaces around campus. Care was taken that there were no people overhearing, but the lack of privacy may have hindered some participants from speaking freely. The interviews were all conducted by one male interviewer and thus most female recruitment was limited to those approached by university staff or interviewed in formal staff environments. The lack of a female interviewer was reflected in the ten rejections received from female participants compared to only two from men.

Lack of funding also meant that transcription and translation needed to be done in a one-step process by the first author. This could have impacted the accuracy of the transcripts and subsequent analysis.

Snippets of a few interviews were back translated to Arabic for verification by someone other than the first author as a random checking process.

Young Iraqis who are not university students were not the focus of this study. Drinking prevalence, patterns and motives may differ among this group.

Reflexivity

The first author who conducted, translated and transcribed the interviews is a non-drinking Australian

Iraqi male of the Muslim faith. Although this was not made explicit, interviewees would surmise this from his name. Being a young insider served positively in that people seemed to identify with the age and thoughts of the interviewer. However, this could have been perceived negatively as interviewees might have felt judged or restricted. An example of this is a participant who took a smoking break as soon as he found out (by accident) that the interviewer was related to one of the University staff.

Being an outsider was positive in that students felt more at ease to share their own opinions but may

158 have potentially influenced them to project a more modern approach. It was the author’s impression that some interviewees (and some other associates in Iraq) concluded that the author was either attempting to promote or prohibit alcohol use. This polarisation of views on alcohol policy is commonly observed in Iraq. At several points in the interviews, the interviewer formed the impression that students wanted to display what they thought the interviewer wants to hear.

In several interviews, once the participants’ personal view of alcohol became clear – this may have impacted the interviewer’s understanding of the remainder of the interview. For example, if a student appeared to be a devout Muslim the interviewer may have unintentionally understood what he said differently to the same words from a person that appears more liberal.

Conclusion

Alcohol's role in Iraq's youth is multi-dimensional. To some, it represents the difficulties, conflict and loss young Iraqis have endured and to others, it represents progression towards modern Iraq.

Predominantly, there is a negative perception towards alcohol consumption. Even those with a positive attitude to alcohol shared that heavy drinking and intoxication are common among drinkers in Iraq and stressed a need for preventative measures. Others expressed a desire for a staged long- term plan that gradually leads to an abstinent community.

The challenges that alcohol may present in the upcoming years are unpredictable, especially considering Iraq’s political, social and economic transition. Currently, prevention is centred on religious prohibition and social stigma. Increasingly, these preventive methods are becoming less relevant to some young Iraqis who reportedly choose to initiate or increase their drinking while in absence of social restraints. To future-proof the prevention of alcohol-related harms, Iraq’s economic and health infrastructure must be strengthened. This includes providing increased opportunities to young people, enforcing pricing and taxation policies and initiating youth and parenting development programs. These programs should consider young people’s lived experiences and attitudes as well as religion, culture, health (physical and mental), economics and recreation.

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Chapter 7 - Discussion

This thesis presented an account of the place of alcohol throughout Iraq’s socio-cultural history. It then focused on the attitudes to, and experience of alcohol among young people today, amidst Iraq’s political, social, and economic unrest. In keeping with previous studies, prevalence of alcohol consumption was relatively low in this Iraqi university student sample, but risky drinking was high among those who did drink. Corresponding to international and local research, being a non-Muslim male, and living away from family or relatives was associated with increased odds of consuming alcohol, even in this conservative country. Overall, our online survey presented a slightly higher prevalence of drinking among females than previous face-to-face and pen-and-paper surveys in Iraq.

Even in conservative areas, participants said that it was easy to access alcohol. Students in interviews shared many perceived motives for alcohol consumption among drinkers – chief among those was drinking for coping, socialising, and entertainment purposes. Young Iraqis either directly or indirectly connected experiences of unrest resulting from conflict and terrorism with alcohol use or misuse.

Most students perceived alcohol negatively and suggested a mix of regulatory, restrictive, or prohibitive policies towards alcohol.

This thesis presents the first analysis of factors influencing prevalence of alcohol use and attitudes towards alcohol among young Iraqis. Chapter 2 set out the special methodological challenges facing research on the sensitive topic of alcohol among Iraqi youth, and the ways these challenges were addressed in this setting. Chapter 3 provided the first review on the social, cultural, and historical context of alcohol in Iraq – an essential precursor to assessing the current perspectives of diverse young Iraqis. This was followed by the first systematic scoping review on alcohol in Iraq. Chapter 4 described the limited quantity and varying quality of past research on alcohol among young Iraqis.

Together, these two chapters set the base for the mixed-method study. Chapters 5 and 6 presented the first qualitative and mixed-method data on alcohol prevalence and attitudes towards alcohol among university students in Iraq.

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This discussion will synthesise the findings from the two reviews (Chapters 3 and 4) and the mixed- method studies (Chapters 5 and 6) to enable a clearer understanding of alcohol’s place among young university students in Iraq. Having both the quantitative and qualitative data enables a holistic analysis, including key individual and societal vulnerability factors (WHO, 2014a). We will also contextualise this research within the broader alcohol literature.

Diversity and alcohol in Iraq

Despite the impression sometimes conveyed by the media that MMCs are home to homogenous societies, our research indicated the existence of a diversity of views on alcohol consumption, how it is perceived, what leads to alcohol’s misuse and how this should be addressed. Each of our four studies revealed different dimensions contributing to this heterogeneity. The socio-historical study showed that many factors have influenced how alcohol is viewed including the presence of diverse religious, cultural, and family traditions over history.

The scoping review provide further evidence of this diversity by showing that distinct settings in Iraq have different prevalence of drinking. The quantitative survey showed that views towards drinking and alcohol policy also differ among students. Even estimation of the prevalence of student drinking varied widely among participants. The interviews shed further light on this diversity. Most students view alcohol in a negative light – reasons for this including religious, health and social. However, those who viewed alcohol in a less negative light also mentioned that alcohol is typically misused in

Iraq because of a lack of culture around drinking. They also expressed the importance for freedom, self-expression, and self-determination.

As described in Chapter 3, during colonisation by the British after World War I, Iraq’s current borders were drawn without cultural, religious, or ethnic considerations. This resulted in modern Iraq housing a multi-faceted population, formed over the millennia at the cross-roads of the East and West. Despite the Islamic prohibition of alcohol, parts of the Iraqi population have an imbedded historical or cultural connection with alcohol – sometimes dating to the pre-Islamic era (Al Ansari et al., 2019). Evidently, the majority Muslim population’s connection to alcohol is also not new. Chapter 3 presents tales of

164 excessive drinking noted throughout most of the post-Islamic era, including by Muslims. Iraq’s alcohol production and trade, however, has been almost solely in the control of minority religions over the course of Iraq’s history. Laws typically banned Muslims from participating in alcohol trade while there was no prohibition for communities of other faiths (Al Ansari et al., 2019; Zubaida, 2014).

Iraq’s main non-Muslim communities are ethno-religious groups that are connected to Iraq ethnically, culturally, and historically. However, in recent decades, the number of non-Muslim Iraqis declined rapidly. This displacement started with the persecution of the Jewish population following the creation of Israel in 1948 (Bashkin, 2012) as well as the displacement of Christian, Mandeans and

Yezidis during the former Baathist government, following the 2003 war (Hanish, 2009) and with the rise of Daesh (Office of International Religion Freedom, 2019). Iraq’s Christian population, for example, is estimated to have declined from over a million to only 250,000 in just the past two decades

(Office of International Religion Freedom, 2019). Although non-Muslims account only 3% of Iraq’s population, over half of the Iraqi-born population of Australia identify with a denomination of

Christianity (ABS, 2016) - a testimony to the grand scale of their displacement in recent years.

Our findings add to the growing literature on alcohol in MMCs showing that prevalence of alcohol use may be impacted by two key factors: primarily, the proportion of the Muslim population and secondly, the secularity of government and society. For example, Lebanon is known to have the highest alcohol use prevalence in the region – mainly due to its large non-Muslim population (44%) and relatively secular society (Rosentiel et al., 2006). Turkey, although secular, remains relatively protected from alcohol use because of its overwhelmingly Muslim majority – with more than 87% of its population lifetime abstainers (Gündüz et al., 2019). Drinking however is reportedly increasing among young people even in this setting (Gündüz et al., 2019). Our multivariable analysis in Chapter

5 confirmed that being a non-Muslim is a significant predictor of drinking in our Iraqi university student sample after controlling for other influences such as age and living away from relatives.

As presented in Chapter 6, interview participants also associated drinking behaviour with non-

Muslims – but they differed on whether non-Muslims should be allowed alcohol in Iraq. One 165 participant stated that her parents advised her against having non-Muslim friends, citing “bad influence” due to alcohol consumption as a primary concern. In extreme cases, such fears escalate to sectarian conflict centred around alcohol. There have been reports of threats and even actual attacks on bottle shops and their owners (BBC, 2013). Such sentiments however were not shared by students in either of our samples. Increasingly, alcohol bans and limitations are seen to infringe on minority rights in Iraq (UNHCR, 2018). Two fifths (40.8%) of survey participants suggested a policy that accommodates non-Muslim consumption of alcohol.

Although most traditional drinking in Iraq occurs within ethno-religious minorities, some Muslims also traditionally consumed alcohol (Zubaida, 2014). Participants in our interviews confirmed that consumption traditions exist within Muslim families. Consumption by past generations is also in line with descriptions of drinking araq in Iraq from the mid-20th century (al-Wardī, 1965; Zubaida, 2014).

All students that volunteered information on their drinking in the interviews shared that their father or other male relatives were drinkers. This is in line with our survey findings on non-drinkers, that following religion, family was the second most prominent protective factor. Interestingly, all the interviewees who shared that their older relatives consumed alcohol – stated they were ex-drinkers who have since ‘repented’. Sharing this detail could be associated with the participant’s desire to be socially accepted by the interviewer or may be indicative of the resurgence of religious influence in

Iraq following the 2003 conflict (Marr, 2018).

It is likely that as Iraq’s overall population rapidly increases due to high birth rates (UNDESA, 2017), and religious minorities decrease due to displacement (Office of International Religion Freedom,

2019), the demographics of alcohol use may change in Iraq. Similarly, as the impact of secular thought and society increases in Iraq, alcohol consumption may increase. However, as Islam remains the majority religion, it ensures an ongoing protective factor for most of the population – as in the case of Turkey. Nonetheless, ideally, preventative measures in Iraq should target Muslim and non-

Muslim populations alike.

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Alcohol availability, affordability, and taxation

Historical accounts relay that the 10th century Abbasid Caliph al-Qāhir ordered taverns shut, alcohol confiscated and drinkers prosecuted, yet, al-Qāhir himself was never seen sober (Al-Kirmalī, 1919).

In Iraq today, similar contradictions were perceived by students. Even in conservative areas where alcohol is prohibited, most respondents to the student survey shared that alcohol was easily accessible.

At least one student from a province with an alcohol ban offered to take me to observe places where alcohol and drugs are sold – apparently under the watch of security forces. Interview participants saw the mismatch they observed between official policy and the state conduct as hypocrisy. Students shared that while alcohol is publicly opposed by Islamist political entities and militias, these same groups were defending other nightclubs, alcohol sellers and bars. When I enquired why they believe this occurs, their answer was “corruption” and “bribery” – arguing that these same entities supported the alcohol ban in 2016. It is difficult to decipher between truth and speculation in such accounts.

Such sentiments were also shared in the media following the 2016 ban (Salloum, 2016). However, a general distrust of the government, political entities and policy makers was sensed from almost all interviewed students.

One of the arguments made by Islamist groups for alcohol’s ban in Iraq was that all proceeds (or taxes) resulting from the importation, production, or sale of alcohol were “unclean”. Therefore, they argued, it is unconstitutional for the government to collect or use such funds (UNHCR, 2018). Iraq’s constitution guarantees equal rights for minorities, it also sets out that laws cannot be opposed to

Islam – the majority religion. The jurisprudential ruling regarding the permissibility of alcohol proceeds is however irrelevant as Iraq is a secular state and not a theocracy. While Muslims are the majority, laws in Iraq are not based on Islamic jurisprudence or theology (The Republic of Iraq, 2005)

– and if they were, alcohol would be prohibited in the first place with no need for financial justifications. These arguments are also historically questionable considering that non-Muslims in

Iraq and elsewhere in MMCs, such as Iran, have been and are able to produce, sell and consume alcohol (Al-Ansari et al., 2019; Zubaida, 2014). There is evidence of tax on wine from the 10th

167 century CE (Kennedy, 2015). More recently, there have been customs duties and taxes on alcohol importation in modern Iraq as early as 1935 (Amīn Rayḥānī, 2015). The government had planned to increase the levy on alcohol importation to 300% in 2016, a step that was later backtracked

(International Monetary Fund, 2017).

In 1935, there were at least 35 non-Muslim alcohol sellers and 15 importers in Baghdad, most situated on one street – Shāriʿ al-Rashīd (Ḥarb, 2018). Despite the lower prevalence of non-Muslims, in 2011, the Russian news outlet, RT reported that there were around 100 licensed alcohol sellers in Baghdad

(RT Arabic, 2011). Today, the landscape seems similar – interviewed students seemed to identify certain streets with alcohol retailers, nightclubs and other establishments that sell alcohol. By observation, the presence of alcohol is clear in areas such as Ainkawa, a majority Christian area, in

Erbil. Even fruit shops and outdoor stands display visible alcohol branding. The laws described in

Chapter 3 ban any alcohol marketing and restrict hours of operation and location of alcohol shops to non-residential areas away from public facilities such as hospitals or schools (Al Ansari et al., 2019).

In theory, Iraq is enacting the enforcement of WHO’s “best buys” of restricted physical availability of alcohol. However, in practice, licensed stores are reportedly opening in residential areas throughout central Baghdad, with their hours of operation exceeding those permitted (Ultrasawt Editorial Team,

2019).

Excise taxes on alcohol is another of the WHO “best buys” and a leading preventative measure

(Stockings et al., 2016; WHO, 2018a). Apart from potential moral objections to collecting tax on alcohol, there is no infrastructure for excise and sales taxes in Iraq (Al-Awwad et al., 2017;

International Monetary Fund, 2017). Reportedly, a full-sized bottle of locally made spirits with over

40% alcohol content is sold for around $8 USD. This is compared to around $40 USD for imported spirits of the same type (NAS news, 2018). Interview participants in our study also indicate that alcohol smuggling into provinces with alcohol bans is common. At the time of writing, there were no publicly accessible data on alcohol smuggling, however, some public figures and news articles have reported smuggling attempts through domestic and international borders (Ultrasawt Editorial Team,

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2019). Similarly, The Bureau for International Narcotics and Law Enforcement Affairs (2013) reports that smuggling is endemic in Iraq, especially of petroleum products and cigarettes.

Market prices of other substances such as tobacco are also low. A packet of cigarettes, by personal observation, costs as little as half a dollar (USD) and can be bought with no restrictions at any convenience store. Very often, by observation and anecdotally, young children walk into grocery shops to buy packets of cigarettes for their parents. Anecdotally, alcohol seems to be similarly purchased by children. Although there is no data on underage purchase or consumption of alcohol, one study of secondary school students in Iraq shows the age of onset of drinking as 12 (Saeed, 2016).

In Lebanon, teenage school students reported that they easily purchase alcohol with no questions asked (Yassin et al., 2018). Similarly, while travelling through Erbil Airport, I enquired if age restrictions are enforced for alcohol sales – the cashier was unsure. When I asked if they would sell alcohol to a minor? They answered that they personally would not, however, they were not sure of any legal enforcement or consequences. A trending video reported on the BBC shows a three-year- old drinking from a bottle of spirits in a public celebration on 2019 New Year’s Eve in Iraq (BBC

News Arabic, 2019). It is unknown if these videos are real or represent what is more widely happening in Iraq – but they may impact how Iraqis view alcohol and its potential effect on children.

Conflict, social unrest, terrorism, and trauma

Two fifths (41.7%) of our survey sample reported direct experience of war or violent military conflict and almost a third (29.2%) scored positive on the PC-PTSD screen. Although no association was found between PTSD and drinking in our sample, most (85.7%) students attributed drinking motive to coping with experiences of trauma. Similarly, in the interviews several students shared stories of friends or people they know who used alcohol to this end. Iraqi refugees in Europe have similarly shared that drinking occurs for coping purposes (Dupont et al., 2005). Drinking for coping purposes has also been associated with heavier drinking and worse outcomes in previous international literature

(Wicki et al., 2017). As described in Chapters 1 and 3, Iraqis have experienced continuous war, sanctions, and terrorism since 1980 (Al Ansari et al., 2019). The biggest decline in living standards 169 was following the two Gulf Wars in 1990 and 2003 (Al Ansari et al., 2019; Marr, 2018). Young Iraqis born after this period have not seen an Iraq without economic, political, and social turmoil. Even basic needs such as electricity and running water are limited in Iraq (Marr, 2018). The full impact of this exposure to conflict and difficulty of living is yet to be established.

Despite these circumstances, some of our interview participants did not feel that war and terrorism will lead to drinking. They argued that Iraq’s intense circumstances have led to Iraqis becoming more resilient because terror has become a daily reality for young Iraqis. They perceived that only people from outside [of Iraq] think that conflict and terrorism are ‘strange to us’ and that ‘we need alcohol to cope’. By observation, Iraqis reminded of certain health measures or experiencing illnesses, including COVID-19, commonly make similar statements: “If we survived the bombs that fell on our houses and the bullets that flew through our walls – do you think we won’t survive a little microbe?”.

Another result of years of conflict in Iraq is the political unrest. Political entities in Iraq are often accused of contributing to the economic and social unrest. Most of these parties follow Islamist ideologies. A recurring theme in our interviews was that a large contributor to alcohol use was the frustration of young people with the perceived hypocrisy and control of Islamist parties. Participants shared that young people in Iraq are growing increasingly intolerant towards this control and many are leaving Islam altogether. The apparent contempt of political entities, according to participants, triggers a reaction among some young people that all things Islamic are wrong and limiting.

Globalisation, media, and social media

In our survey sample, a large portion of students reported seeing alcohol marketing on mainstream and social media. Although social and mass media were perceived as influencing factors for drinking by non-drinkers, most drinkers in our survey did not make this association. Students also reported that drinking was associated with the image of “sophistication”, associating uptake of drinking with

“blind following” of other cultures. They also shared examples of their friends’ consumption while

170 studying or travelling in other countries. Interviewees emphasised that young people should be wise in their use of the internet and social media.

The survey results also indicate that although students were exposed to pro-alcohol messaging, anti- alcohol messaging was also prevalent in the Iraqi media (data not shown). Interview participants also shared that media was a source of religious and health awareness which protected against alcohol use.

As discussed in Chapters 5 and 6, there is increasing evidence in non-MMCs that exposure to alcohol marketing, including in movies and TV shows, is associated with the earlier uptake of alcohol by non- drinking adolescents and more drinking by those who already drink (Anderson et al., 2009). Most young people in Middle Eastern Muslim countries consume English language media (Melki, 2010).

Students also reported that young people normally “imitated” the “negative” behaviours such as drinking from other cultures. The influence of this exposure is shown in previous media interview with alcohol sellers in Iraq. An alcohol seller reported that Iraqis often dislike Arabic branding and labels on their alcoholic beverages and prefer foreign brands and marketing (NAS news, 2018). This has encouraged local alcohol producers to also use foreign branding such as “Mr Chavez” for their whisky to appeal to consumers (NAS news, 2018). despite its marketing restrictions on alcohol, Iraq lacks measures to protect young people from alcohol content on the internet and or via satellite services. Promotion of alcohol in digital media and especially on the internet remains a global concern and public health interventions to restrict this promotion have been supported by consistent evidence

(Lobstein et al., 2017).

Alcohol – males and females

In line with these findings and previous studies presented in Chapter 4, our survey (Chapter 5) showed that males drink significantly more than their female counterparts. Similarly, in chapter 6, all interviewees consistently used male pronouns when they referred to or described a drinker. All the stories shared in the interviews were those of male drinkers. Only one female reported knowing a drinker personally, the other females who reported knowing drinkers connected this to either their

171 occupation or relaying stories they have heard from male relatives. These included stories of female victims of violence resulting from male alcohol use.

Although still negligible, a higher prevalence of females in our survey reported lifetime or past 12 months alcohol consumption than in other Iraqi studies. As discussed in Chapter 5, in Iraqi culture there is an additional hayāʾ (modesty) attached to females that is harder to regain if lost. Due to the sensitivity of alcohol consumption, it is possible that females felt more comfortable to share their drinking in a self-reported online survey than in past face-to-face interviews or paper-and-pen surveys.

As indicated in Chapter 3, culturally, alcohol has been associated with masculinity in Iraq (al-Wardī,

1965; Al Ansari et al., 2019). These findings are in line with research from other non-MMCs which links alcohol with masculinity (de Visser et al., 2007; Wells et al., 2014). Global trend also indicate alcohol use and misuse is more prevalent amongst males and that many low and middle income countries have vast differences in prevalence of male and female consumption (GBD 2016 Alcohol

Collaborators, 2018).

Overestimation or underreporting of student drinking?

In MMCs, alcohol is an extremely sensitive topic. This often results in underreporting of drinking by study participants as with previous studies in Iraq (Al-Hemiery et al., 2017). Previous literature, however, indicates that students often overestimate their peer consumption which impacts their own attitudes and behaviours around alcohol (Kypri et al., 2003). Because this study relies on student self- reported and estimated data – the findings must be viewed in light of this possible underreporting or overestimation.

Only one in every 20 participants (5.3%) reported lifetime consumption of alcohol. In contrast, one in four knew a family member or friend who drinks. On average, students estimated that over a fifth

(21.1%) of students drink alcohol. Similarly, interviewees, some of whom reported never having seen a drinker, shared that drinking is widespread and increasing. The over-estimation of the consumption

172 of others could be due to a perception, shared in the interviews, that young people are increasingly adapting to globalised western culture and neglecting religious and traditional values. Among drinkers, the over-estimation could be because drinkers associate more with other drinkers. Also, as discussed in Chapter 5, students’ perception of the drinking of others influences their own alcohol consumption in non-MMCs (Kypri et al., 2003). For this reason, norm-resetting interventions have been proposed but found to have a small long-term effect in university students in non-MMCs

(Foxcroft et al., 2015). The effect of such interventions in Iraq is unknown, especially as most people are abstainers. Students are also aware of the sensitivities of reporting alcohol use and may not trust drinking prevalence figures from self-reported studies.

Risky and harmful behaviour among drinkers

Our study reported a range of alcohol-related harms present among young Iraqis today. These included domestic and other interpersonal violence as well as impact of drinking on health, driving and other behaviours. These risks and harms may have severe consequences in a country with limited security, health, and legal infrastructure.

Domestic violence was one of the main alcohol-related harms reported in the interviews. Other studies in Iraq also associate domestic violence with excessive alcohol use (Abd Azeez et al., 2016; Abdul

Jabbar, 2007; Khayyat, 1990). Interviewees mentioned that women do not often report domestic violence related to alcohol so that their children do not become outcasts. We could not identify services that provide help for domestic violence while mitigating risks to the woman or her children.

Students also shared that alcohol-related violence and socially unacceptable behaviour is common in the city. One female indicated that women are the main victims of alcohol-related street violence and harassment. Reports of street violence are consistent with evidence from the early 1960s (al-Wardī,

1965; Zubaida, 2014) and with more recent studies described in Chapter 4, associating drinking with carrying a weapon and physical fights (Saeed, 2016). The association of alcohol with violent

173 behaviour has been demonstrated in many settings internationally (Graham et al., 2011; WHO,

2006a).

Drink driving has also been previously reported as a risk behaviour in North Iraq (Saeed, 2016;

Shabila et al., 2015). Interview participants reported on this phenomenon, with one sharing a personal account of attending a car accident site following his friend’s death. Although the 2015 Global

Alcohol Report indicates that the national maximum legal blood alcohol concentration (BAC) for driving in Iraq is 0.08% (WHO, 2015a), it is not clear that these limits are enforced. WHO (2018b) has scored the enforcement of drink-driving measures in Iraq at 2/10. For comparison, enforcement in neighbouring Iran is 7/10 and Australia 8/10. However, there are security checkpoints throughout the Iraqi capital and between cities, so it is likely that a driver who is visibly drunk may be easily detected in these checkpoints. We could not identify any generalised use of random breath testing or any active campaigns against drink driving.

Importance of tailoring measures and priorities to the Iraqi context

Iraq is a MMC with high prevalence of lifetime and past-12 months abstinence. Global evidence increasingly suggests that the only safe level of consumption is zero (GBD 2016 Alcohol

Collaborators, 2018). Internationally, prevention measures should focus on lowering overall population-level consumption (GBD 2016 Alcohol Collaborators, 2018). For this reason, public health measures in Iraq should have three priorities: 1. reduce uptake of alcohol use among non- drinkers, 2. reduce alcohol consumption among those who drink and 3. reduce alcohol-related harm among risky drinkers.

Tailoring of interventions and their priorities to the cultural context is important. The perception that a program is “foreign” may limit the program’s reach. For example, announcing “recommended” drinking guidelines in a MMC will not be seen positively (Al-Ansari et al., 2020). Such a measure would be interpreted as intending to encourage alcohol consumption. This is because the predominant social, religious, and cultural guideline is zero consumption. A more contextually sensitive model is

174 that of neighbouring Iran, where despite the legal limit of zero, recommended guidelines are provided as part of medical treatment for harm reduction (Al-Ansari et al., 2020). In Iraq, a similar approach may be implemented where general preventative programs campaign for abstinence, but targeted harm reduction programs advocate for safer limits in clinical settings.

Alcohol sensitivity in Iraq and other MMCs should be also considered contextually. The topic of alcohol in MMCs is not necessarily comparable to alcohol in non-MMCs, especially in western countries where alcohol drinking is culturally accepted and prevalent. A more relevant assessment would be to compare alcohol sensitivity in MMCs to that of illicit substances such as heroin in non-

MMCs. If one is to contextualise alcohol in this way, the perspectives, stigma, and sensitivity around alcohol in MMCs become easier to understand. In this light, one can also better empathise with the opposition of many Iraqis to relaxing alcohol restrictions in Iraq, including on its importation, production, sale, and consumption. Consequently, programs to prevent uptake or harms from illicit drug use in non-MMCs may provide relevant learnings for this setting.

An example of a tailored measure is the socio-ecological model (Figure 10) used in the qualitative analysis. This framework helps contextualise motives for alcohol use in the Iraqi context by considering the global, national, social, inter-personal and individual circumstances of young Iraqis.

The use of such models throws further light on perceptions and helps inform further tailored approaches for research, prevention, and intervention.

Prevention approaches

Although interviewees suggested a range of preventative measures including educational, sports and recreational programs, they perceived parenting as the key factor influencing drinking behaviour in

Iraq. Drinkers known to the interview participants were either away from their family, influenced by family members who drink, or had lost their loved ones during war or conflict. The survey also showed that living away from relatives was associated with higher prevalence of alcohol use. As discussed in Chapter 6, in non-MMCs there is mixed evidence for effectiveness of parental education

175 programs to reduce alcohol misuse in young people (Stockings et al., 2016). For parental education programs to be successful in Iraq they should consider local traditions, incorporate some religious material, and be tailored to the local context. Programs could emphasise the religious importance of parental responsibility and include religious and cultural references with every intervention.

Increasing connectedness is an evidence-based approach to prevent alcohol misuse (Bond et al.,

2007). The program could emphasise the importance of connectedness which is also a key principle in Iraq’s collective culture (Hofstede, 2020).

In addition to parental interventions, students in the interviews and the survey perceived that education was a key tool in alcohol prevention. Past literature in non-MMCs indicates that education about alcohol harms alone has limited influence on alcohol behaviours (Lee et al., 2016). However, as discussed in Chapter 6, literature from non-MMCs and some MMCs indicate programs that include social skills training, such as positive youth development programs, may be of some benefit.

Interview participants perceived that young Iraqis who drink have “weak personalities” and are

“imitators”, a reference to imitating other cultures and other young people instead of creating their own identity. Personal development programs could potentially promote the capacity of young Iraqi people to make informed decisions and create their own identity. Affective skill-based interventions have been shown to deter drug use in non-MMCs by improving decision-making skills, self-esteem and peer-pressure avoidance (Faggiano et al., 2008). The same three factors mentioned by our interviewees that when inadequate lead to “weakened” personalities and alcohol use.

Preventative programs targeted to young people should contain a mix of traditional and modern approaches. Tailored faith-based or secular approaches can be evaluated in the Iraqi context – this is so that religious and non-religious problem drinkers alike can have access to treatment facilities. By observation and through the interviews, some groups of young Iraqis may not follow guidelines unless they are religiously mandated. On the other hand, other Iraqis may not follow guidelines if they are perceived as religiously motivated. For this reason, alcohol should be framed in a way that considers a mixture of moral, health, and social perspectives.

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Such a “multi-angled” approach may be best to cater for all youth regardless of their attitudes to religiosity, secularism, traditionality or liberalism. For example, resilience and importance of keeping good company could include the use of traditional material and proverbs: “Tell me who your friends are, and I’ll tell you who you are” and “Where did you learn good manners? From the one that lacks them.” These proverbs emphasise the importance of good company, but also to learn from “bad company” for self-development. Such tailored programs may be easier to introduce and promote in

Iraq because they will be culturally relevant while not directly addressing sensitive matters such as alcohol.

Secular and religious aspects may complement each other. While religious programs may focus on moral and spiritual harms, secular measures may concentrate on the health and social harms of drinking. Combined, the measures may be relevant to a larger portion of Iraqis. The importance of including a health angle, even in conservative settings, is to equip young Iraqis even when they are away from their conservative home environments. Student interviewees emphasised that many young people do not drink only because it is socially unaccepted. They shared stories of young Iraqis from conservative areas who consume alcohol excessively when living or travelling away from their family.

Screening in a MMC context

An investment in culturally safe prevention, early intervention and treatment facilities would be of benefit in Iraq. However, to assess the need and function of such programs, research is needed to identify appropriate and tailored screening and diagnostic tools in MMC contexts.. For example, as presented in Chapter 2 and 4, the Alcohol Use Disorders Identification Test (AUDIT) and the SDS

(Severity of Dependence Scale) include items that may have a different meaning in a MMC. These items include guilt about using a substance (item 7) or worry of others about one’s use (item 10). An

AUDIT validity study among UAE prisoners identified that AUDIT was valid as a two-factor model among Arab Muslims, even though items 7 and 10 had a lower standardised factor loading (0.69) than most other items (Almarri, Oei, et al., 2009). 177

In our survey, we utilised the AUDIT-C screening tool that focuses only on alcohol consumption items. This removed the potential for the total score to be inflated because of guilt or concern over drinking. Despite this, there was discrepancy in the way some students answered questions on alcohol.

Some students stated they “consumed alcohol in the past 12 months” in an earlier question then answered “never” to the first item on AUDIT-C (frequency of drinking). The students may have interpreted the first item on AUDIT-C as relating to ongoing or regular drinking. They may have only had alcohol on one occasion in the past year and see their consumption closer to “never” than other available options. The internal consistency of the 3-item AUDIT-C in our sample was Cronbach’s α of 0.70. Although this is below the reliability of the AUDIT-C in an American sample (Barry et al.,

2015), it is higher than the Cronbach’s α reported by Al Mousawi (2015) for the full 10-item AUDIT.

Discrepancies on meaning may also impact qualitative results, legal proceedings, and clinical interviews from the region. For example, in the interviews, students described drinkers as

“alcoholics”, “addicts” or “intoxicated people”. Upon deeper enquiry, students shared that drinkers in Iraq normally drink excessively and are referred to by these labels.

Such results indicate that without further research and validation of screening and diagnostic tools, much data generated from the region may not be accurate enough to inform interventions and policy.

Treatment and harm-reduction

Treatment programs in Iraq could utilise evidence-based approaches such as Alcohol Anonymous’

12-step programs (J. F. Kelly et al., 2020) or alcohol relapse prevention pharmacotherapies. Such programs can be tailored to the local MMC context, as observed in Iran (Al-Ansari et al., 2020).

However, there are currently limited or no alcohol treatment facilities available in Iraq, especially outside Baghdad (Al Ansari et al., 2019). In Basra, the first rehabilitation facility with 40 beds, targeted at drug users, was built in 2018 (Ruptly, 2018). Even in MMCs with alcohol treatment services, sensitivity of alcohol makes providing accessible treatment difficult (Al-Ansari et al., 2020).

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Religious establishments may encourage treatment seeking. A fatwa in Iran, for example, ensures no punishment is given to an individual if they seek treatment to stop their consumption – a step that may likely expand access to alcohol and substance treatment in the country (Al-Ansari et al., 2020).

Religious groups may also support participants through post-treatment social reintegration programs aimed at re-establishing the ex-drinker’s connection to their family and community. This is likely to be important given the role of connectedness as a protective factor against youth drinking (Bond et al., 2007).

Sin, stigma, and punishment

As previously discussed, alcohol in Iraq is mainly viewed from a moral rather than a health perspective. Chapter 3, for example, presented that alcohol in the Islamic tradition is viewed as the gateway to other sins and immoralities. This is because in Islamic ethics, the mind is an important moral compass - and so when intoxicated or addicted, one risks falling into actions that one would otherwise avoid (Dastghaib Shirazi, 1998; Rizvi; Yaseen et al., 2017). Similarly, from a health- centred viewpoint, alcohol is increasingly being identified as a gateway drug, leading to the consumption of other substances (Barry et al., 2016; Kirby et al., 2012).

As presented in Chapter 3, public consumption and intoxication of alcohol has been illegal in Iraq since 1994. However, anecdotally, alcohol seems to be more socially than legally regulated.

Interviewees did not share any accounts of punitive deterrence taking place in Iraq and only a minority of survey respondents favoured the approach of physical punishment for drinkers.

Students from both the survey and the interviews reported avoidance as a likely reaction to a drinker.

Student interviewees reported that a drinker becomes “manbūẓ” (outcast) at university. Some Islamic teachings, presented in Chapters 3 and 5, encourage abstinence through ostracizing of drinkers until the drinker repents (Dastghaib Shirazi, 1998). Although religious prevention may be effective in this setting, heightened stigma is a double-edged sword. While isolation may theoretically encourage turning away from alcohol for reintegration into their social and family community, it may also push

179 the individual into a “rabbit hole”. Once the drinker becomes increasingly isolated from their family and friends, with their social reputation permanently stained, they may become more attached to their drinking and form new and more accepting social circles.

This avoidance strategy was especially reported by female interviewees, with several students emphasising that a female would never speak or be with a person that drinks. One participant added that avoidance of drinkers by females was not exclusive to Muslim girls.

In Basra, where alcohol is prohibited, drug use is on the rise and prison cells are reportedly crammed with substance users (Rubin, 2019). More than 1000 people are reportedly arrested each year for substance use or trade (Rubin, 2019). Although news reports speak of illicit drug and methamphetamine users, anecdotally, alcohol users may also be prosecuted. Criminalisation of substance use in non-MMCs has been shown to be largely ineffective in curbing substance misuse

(Hall, 2018). Although there are some Islamic traditions that speak of physical punishments for public drinking or intoxication as a social deterrent, these traditions forbid personal insults directed at the drinker (Yaseen et al., 2017) and are seldom carried out (Al Ansari et al., 2019)

Limitations

Limitations for each component of this thesis have been discussed in chapters 3-6. In this section we discuss limitations which are relevant to this research as a whole. As mentioned in the introduction to Chapter 4, most studies included in the scoping review were published after we set out on this research. Although care is given to reference peer-reviewed literature where available, the scarcity of data meant that media reports, observational and anecdotal data were also consulted in the socio- historical review (Chapter 3) and in this discussion (Chapter 7).

The sample for the quantitative online survey was not able to be randomly selected and so may not be representative. Most students were from the medical faculty because that is where recruitment was targeted. Also, because anecdotally, medical students are more versed in using the internet for non- social media purposes. The survey length was around 20 minutes. There was a high attrition rate from

180 about the half-way point of the survey. As this is the first paper attempting to record data online anonymously, there was no past academic literature to use as a guide for optimal length. The piloting and consultation of the survey did not alert us to this potential issue. Because of the need for anonymity, we could not follow-up with students with incomplete responses. Future surveys may consider shortening the time of the survey to a maximum of 10 minutes.

In the interviews, because of sensitivities, we intentionally did not record detailed demographic information of participants. This meant that we were unable to identify which sector of Iraqi society participants belonged to. There were 10 rejections from female participants compared to only two from males. Female participants were more likely to accept if recruited by university staff as opposed to the interviewee or students assigned by the faculty to assist him. Social conventions prevented the male interviewee from talking with all participating females in a setting where others could not overhear the interview. Despite these limitations, almost half (45%) of the interviewees were females.

To ensure greater confidentiality in the interviews, future research should employ both a male and female interviewer in the Iraqi setting.

As identified in chapter 6, as a researcher I am both an insider and outsider to the young MMC population being studied. This may have helped me more accurately interpret implied meanings.

However, it may also have made the participants afraid of judgement and so they may have held back from sharing their thoughts. I did introduce myself as a researcher from Australia and so, interviewees may have felt more comfortable expressing their opinions. On the other hand, they may have tried to ensure a correct image of Iraq is represented to the outside world. Despite my Muslim name, being

Australian-Iraqi meant that it was unknown if I was conservative or liberal towards alcohol. In either case, my personal demographics and characteristics may have impacted their evaluation of what to share.

Future directions

There is insufficient data to assess change of consumption prevalence since the pre-2003 Second Gulf

War era. However, the local context and the motives for drinking have certainly shifted. The post- 181

2003 era provided opportunities for both traditional conservatism and globalism to become mainstream. With the absence of a powerful central government, the debate about alcohol, like debates about other sensitive topics, may not lay to rest. However, if there were an increase in prevalence of alcohol use or misuse, the added disease burden would pose a challenge for Iraq’s limited health system. Because the prevalence of abstinence is high in Iraq, the most evidence-based and practical approach would be to strive to maintain this low prevalence of consumption which reduces the prospects of increased alcohol burden in Iraq. A mix of religious and secular preventative measures, such as contextually tailored skill-based personal development programs, may be utilised to this end. Improvements in infrastructure to support the implementation of WHO’s “best buys” such as excise sale taxes, restriction of physical availability of alcohol and restrictions on alcohol exposure in all types of media is important in the current socio-cultural environment.

Regardless of the policy approach to alcohol, clear regulatory guidelines need to be in place to ensure that minorities and others who choose to drink have a lower risk of harm to themselves and others.

This may include enforcement of policies on drink driving, alcohol licensing, underage sales, and hours of operation. Students shared, quantitatively and qualitatively, the society’s negative and unforgiving view towards drinkers. Because of this, a re-integration program would also be key to help people out of their alcohol-related problems and to connect back to their family and community.

This may require a re-calculated approach and advice by religious authorities to ensure that stigma does not drive young drinkers into further social and health problems.

Iraqis are still living in an evolving period of conflict, unrest, and lack of essential needs. This situation may impact their focus on mental and psychological wellbeing. The full extent of the impact of war and its resulting psycho-social effects will likely not be realised until Iraq approaches some sort of normality.

Because of increasing number of young Iraqis and the evolving nature of Iraqi society today, there is a need for ongoing research. Such research should employ culturally sensitive methods that ensure the confidentiality and anonymity of responders. Given the lack of existing infrastructure and the 182 priorities of local health agencies, the implementation of evidence-based prevention, early intervention and treatment programs would be challenging. There is a need for research to inform these processes, and international support from WHO and other agencies to help the overstretched

Iraqi health authorities implement those findings.

Conclusion

Alcohol has been present in Iraq for all recorded history. Over the years various views of alcohol have been dominant in Iraq and, as seen in this study, attitudes continue to evolve. In today’s Iraq,

Islamic prohibition and its resulting social and cultural stigma have ensured that prevalence of alcohol consumption remains low. However, given the social, political, and economic unrest in Iraq, these protective factors may not translate to a continuity of the current pattern of clear majority abstinence.

These factors also do not ensure harm reduction for drinkers in Iraq, who reportedly often drink for coping purposes and experience alcohol use disorders, including dependence at a higher rate than many in other countries.

The absence of a clear alcohol policy and strategy in Iraq is worrying. However, it also provides an opportunity for Iraq to draft new, clear, and consistent policies. These policies should consider Iraq’s traditional culture, minority groups, as well as secular evidence-based and religious approaches that relate to the lived experiences of its youthful population. The strategies would ideally maintain abstinence, prevent alcohol misuse, and provide harm reduction and treatment opportunities for harmful or dependent drinkers.

Breaking down barriers to targeted and open research among at-risk populations, such as this study, will ensure more knowledge generation about lived experiences of Iraqis. This will assist in tailoring preventative, therapeutic and harm reduction measures to the subgroups where they are most needed.

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Appendices

Appendix 1: Ethics approval

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Appendix 2: 194 PRISMA 2009 Checklist

Reported Section/topic # Checklist item on page # TITLE Title 1 Identify the report as a systematic review, meta-analysis, or both. 72 ABSTRACT Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, 73 participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. INTRODUCTION Rationale 3 Describe the rationale for the review in the context of what is already known. 75 Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, 76 outcomes, and study design (PICOS). METHODS Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide N/A registration information including registration number. Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, 76-77 language, publication status) used as criteria for eligibility, giving rationale. Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify 77 additional studies) in the search and date last searched. Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be 77 repeated. Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, 77-78 included in the meta-analysis). (table 3) Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes 78 for obtaining and confirming data from investigators. Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and 78 simplifications made. Risk of bias in individual 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was N/A studies done at the study or outcome level), and how this information is to be used in any data synthesis. Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). N/A Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency 78 2 (e.g., I ) for each meta-analysis.

195 PRISMA 2009 Checklist

Page 1 of 2 Reported Section/topic # Checklist item on page # Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective N/A reporting within studies). Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating N/A which were pre-specified. RESULTS Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at 79 each stage, ideally with a flow diagram. (figure 5) Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and 87 provide the citations. (table 4) Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). N/A Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each 88-89 intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. (table 5) Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. N/A Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). N/A Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). N/A DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to 90-92 key groups (e.g., healthcare providers, users, and policy makers). Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of 92 identified research, reporting bias). Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 93

FUNDING Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the N/A systematic review.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097 For more information, visit: www.prisma-statement.org. Page 2 of 2 Appendix 3: Search strategies

Scopus, Web of Science, and Iraqi Academic Scientific Journals (IASJ)

Search terms/strategy:

1. Iraq

2. alcohol* OR substance *use OR drinking

3. 1 and 2

196

Embase

Database: Embase Classic <1947 to 1973>, Embase <1974 to 2019 September 13>

Search Strategy:

------

1 alcohol liver disease/ or alcohol.mp. or alcohol test kit/ or drug alcohol interaction/ or alcohol abuse/ or breath alcohol analyzer/ or alcohol abstinence/ or fetal alcohol syndrome/ or alcohol/ or alcohol withdrawal seizure/ or fatty alcohol/ or alcohol intoxication/ or alcohol rehabilitation/ or alcohol rapid test/ or alcohol withdrawal syndrome/ or alcohol liver cirrhosis/ or "Alcohol Use

Disorders Identification Test"/ or alcohol consumption/ (565661)

2 alcoholism.mp. or experimental alcoholism/ or alcohol/ or alcoholism/ (351538)

3 substance abuse/ (52528)

4 drinking.mp. or drinking behavior/ or college drinking/ or drinking/ or binge drinking/ or underage drinking/ (183381)

5 iraq.mp. or Iraq/ (11433)

6 substance misuse.mp. or addiction/ (50595)

7 1 or 2 or 3 or 4 or 6 (789676)

8 5 and 7 (646)

***************************

197

MEDLINE

Database: Ovid MEDLINE(R) ALL <1946 to September 13, 2019>

Search Strategy:

------

1 Iraq War, 2003-2011/ or Iraq/ or iraq.mp. (9679)

2 Alcohols/ or alcohol.mp. (299510)

3 alcoholism.mp. or Alcoholism/ or Alcohol-Related Disorders/ or Alcohol Drinking/ (137116)

4 Underage Drinking/ or Alcohol Drinking in College/ or Alcohol Drinking/ or Drinking/ or drinking.mp. or Binge Drinking/ or Drinking Behavior/ (162100)

5 Substance Withdrawal Syndrome/ or Substance Abuse Detection/ or Substance-Related

Disorders/ (116889)

6 substance misuse.mp. (2347)

7 2 or 3 or 4 or 5 or 6 (504931)

8 1 and 7 (470)

***************************

198

PsycINFO

Database: PsycINFO <1806 to September Week 2 2019>

Search Strategy:

------

1 exp "Alcohol Use Disorder"/ or exp Alcohol Drinking Patterns/ or exp Alcohol Withdrawal/ or exp Fetal Alcohol Syndrome/ or exp Alcohol Drinking Attitudes/ or exp Blood Alcohol

Concentration/ or exp Alcohol Intoxication/ or exp Alcohol Abuse/ or Alcohol*.mp. or exp Alcohol

Treatment/ (140955)

2 alcoholism.mp. or exp Alcoholism/ (51384)

3 exp Underage Drinking/ or exp Alcohol Drinking Patterns/ or exp Drinking Behavior/ or exp

Alcohol Drinking Attitudes/ or exp Binge Drinking/ or drinking.mp. or exp Social Drinking/

(56616)

4 exp "Substance Use Treatment"/ or exp "Substance Abuse and Addiction Measures"/ or exp

"Substance Use Disorder"/ or exp "Substance Related and Addictive Disorders"/ (139153)

5 substance misuse.mp. (2960)

6 iraq.mp. (4054)

7 1 or 2 or 3 or 4 or 5 (221985)

8 6 and 7 (393)

***************************

199

Appendix 4: English survey You’re invited to participate in this public health survey about the attitudes of Iraqi university students towards alcohol.

The survey is part of a doctoral research project at the University of Sydney, Australia and is completely anonymous and will not record any information that can link back to you, so please answer honestly.

Your participation is voluntary and you can stop at any time.

Are you willing to participate in this study? *

Yes

Are you a university student? *

Yes

200 What university do you attend? *

University of Baghdad

University of Basra

University of Kufa

University of Babylon

Salahudin University

Hawler Medical University

University of Mustansiriya

University of Misan

University of Thi Qar

University of Wasit

Nahrain University

University of Technology, Iraq

University of Mosul (alternate campus)

University of Diyala

University of Qadisiya

University of Anbar

Other - please specify

201 Please select your faculty *

Agriculture

Arts

Business

Engineering

Law

Medicine

Nursing

Pharmacy

Science

Other - please specify *

What degree are you currently enrolled in? *

Bachelors degree

Graduate diploma

Masters degree

PhD - Doctorate degree

Other - please specify *

202 How old are you? *

What is your gender? *

Male

Female

What is your relationship status? *

Single

Cohabited (unmarried couple)

Engaged

Married

Divorced

Widowed

Other - please specify *

203 What is your religious affiliation? *

Muslim

Christian

Jew

Mandaean

Yezidi

Agnostic

Athiest

No religious affiliation

Other - please specify

What ethnicity do you identify as? (choose all that apply) *

Arab

Kurd

Assyrian

Chaldean

Turkmen

Armenian

Persian

Other - please specify

204 Imagine that this ladder represents social, economic and educational levels in Iraqi society.

Choose which step you’d place yourself relative to other people in Iraq. *

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 205 Are you a refugee or internally displaced person? *

Yes

Were you a student before becoming a refugee or an internally displaced person?

Yes

Are you living away from your home town during semester (study periods)? *

Yes

Where do you normally live during semester (study periods)? *

Live alone

At home with parents

At home with partner

Share accommodations with friends and others

University Dorms

Refugee camp/accommodation

Other - please specify *

206 Have you ever tried alcohol? *

Yes

Have you ever had a full serve of alcohol? (e.g. a glass of wine, a whole nip of spirits, a glass of beer, etc.) *

Yes

About what age were you when you had your first full serve of alcohol? *

Have you had an alcoholic drink of any kind in the last 12 months? *

Yes

About what age were you when you last had an alcoholic drink? *

AUDIT 1 *

Monthly or 2-4 times a 2-3 times a 4 or more times a Never less month week week

How often do you have a drink containing alcohol?

207 AUDIT 2 *

1 or 2 3 or 4 5 or 6 7 or 9 10 or more

How many drinks containing alcohol do you have on a typical day when you are drinking?

AUDIT 3 *

Never Less than monthly Monthly Weekly Daily or almost daily

How often do you have six or more drinks on one occasion?

AUDIT 4-8

Daily or Less than almost Never monthly Monthly Weekly daily

How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected of you because of drinking? How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because of your drinking?

208 AUDIT 9-10

Yes, but not in the Yes, during the No last year last year

Have you or someone else been injured because of your drinking? Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

Have you consumed alcohol in: *

Yes No

The city you study in Elsewhere in Iraq Another country

Where do you drink alcohol? (choose all that apply)

In my own home

At a friend’s house

At a social gathering or party

Hotels/clubs/bars

In public (e.g. parks, roadside)

At university

In a car or other vehicle

Out of town in orchards, farms or farm houses

Other - please specify * 209 Where do you get your alcohol from? (choose all that apply)

Friend or acquaintance

Brother or sister

Parent

Spouse or partner

Other relative

Steal it

Purchased it myself from a store

Purchase it illegally (black market seller/dealer)

Get stranger to get it (e.g. online)

Produce/make it myself

Other - please specify *

210 Who do you drink alcohol with? (choose all that apply)

Alone

Parents

Brother or sister

University friends/colleagues

Friends from outside of university

Strangers

Other - please specify *

Which type of alcoholic beverage do you drink? (choose all that apply)

Homemade spirits (e.g. araq)

Homemade beer

Homemade wine

Branded wine

Branded beer (e.g. Heineken, Farida, Corona)

Branded spirits (e.g. vodka, brandy, Chivas Regal whisky)

Other - please specify *

211 Have you used any of the following substances (for non-medical reasons)? (choose all that apply)

Tobacco

Marijuana/cannabis/hashish

Meth/amphetamines

Cocaine

Ecstasy

Heroin

Benzodiazepines (e.g. Valium, Clonazepam)

Benzhexol (e.g. Artane)

Anti-depressants/anti-psychotics

Pain-killers/Analgesics/Opioids (e.g. Morphine, Codeine)

Inhalants (e.g. paint thinners, glue)

Steroids

None

Other - please specify *

212 Do any of your family and/or friends use alcohol? (choose all that apply)

Parents

Brothers or sisters

Other relatives

University friends

Other friends

None

Do any of your family and/or friends use other drugs? (choose all that apply)

Parents

Brothers or sisters

Other relatives

University friends

Other friends

None

What percentage of university students in Iraq do you think use alcohol? *

0% 100% 50%

213 Do you have a desire to try alcohol?

Yes

I don't know

How difficult do you think it would be to get alcohol if a student wanted it? *

Very easy

Easy

Difficult

Very difficult

Impossible

214 Which of these reasons explain why students choose to NOT USE alcohol? *

Often Sometimes Rarely Never

Health reasons (alcohol isn’t good for their health) One can become addicted to alcohol They just don’t want to use alcohol Influence of mass media (e.g. television, satellite channels) Influence of social media (e.g. fb, instagram, twitter) They don’t like how alcohol would influence their behaviour Alcohol is illegal Religious reasons (alcohol is forbidden/haram) They are scared of getting caught Family reasons (family members think that they shouldn’t drink alcohol) Societal/cultural reasons (broader society frowns upon drinkers) Friends (friends don't drink alcohol or think badly of drinkers) It is not available for them to purchase or drink Alcohol doesn’t taste good

Enter another option

215 Which of these reasons explain why students choose to USE alcohol? *

Often Sometimes Rarely Never

Alcohol is available and easily accessible Influence of social media (e.g. fb, instagram, twitter) Influence of mass media (e.g. television, satellite channels) Lack of religiosity As a way to escape trauma, responsibility or stress Socialising Friends drink alcohol (peer pressure) To rebel against traditional values or show that they are 'modern' Practising their rights as a minority Family tradition ‘Forbidden things are always tempting’ For fun and entertainment Boredom Relaxation

Enter another option

216 What do you think of the following statements? *

Strongly Strongly agree Agree Disagree disagree

Drinking alcohol is normal for a young student at University Alcohol is a bigger problem for Iraq than drugs People who drink alcohol experiment more with drugs than those who do not drink Alcohol is not a problem in Iraq If a young person tries alcohol it is a sign of a much more serious problem If alcohol becomes available, there’d be an increase in its use More treatment facilities are needed in Iraq for people with alcohol problems Alcohol consumption is a moral issue Alcohol consumption is a medical issue Alcohol is a common problem in Iraq

What do you think of the following policy options in relation to Iraq? *

Strongly Strongly agree Agree Disagree disagree

Prohibit alcohol entirely including import and consumption Allow alcohol for production, sale and consumption by non-Muslims Alcohol trade and import should be banned, but consumption shouldn’t be criminalised Alcohol should be permitted to decrease black market trade Severe punishments for people found in possession of alcohol Permit alcohol production, sale and consumption for everyone

Enter another option

217 What do you think should happen to a person found to possess a small quantity of alcohol for personal use? *

No action

A warning only

Advice or brief discussion

Referral to seek counselling or treatment

Education about safety and possible harms

A small fine

A large fine

Short detention

Prison sentence

Physical punishment (e.g. lashes)

Other - please specify *

218 What do you think should happen to a person found to possess a small quantity of other drugs for personal use? *

No action

A warning only

Advice or brief discussion

Referral to seek counselling or treatment

Education about safety and possible harms

A small fine

A large fine

Short detention

Prison sentence

Physical punishment (e.g. lashes)

Other - please specify *

219 What would you do if you found out that someone you know is: *

Ask Try to to Try to Force persuade Report Tell their Cut contact Shame join persuade them them to get them to the family and with them them in them not to not to help police friends completely publicly Nothing

About to try alcohol for the first time Using alcohol daily Selling/supplying alcohol to others About to try other drugs for the first time Using other drugs daily Selling/supplying drugs to others

Have you had any direct experience of war or violent military conflict? (been in direct contact or close proximity from terrorist attacks and/or active military action) *

Yes

220 Have you undertaken military training in preparation for combat?

Yes, mandatory military service

Yes, at a training program at University

Yes, elsewhere with a militia or brigade

Yes, other - please specify *

No.

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: *

Yes No

Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings?

221 Have you seen an alcohol advertising on any of the following media? *

Satellite television

Newspapers or magazines

Hotels/clubs/bars

Billboards or posters

Internet

Social media

Promotional material

Other - please specify

222 Have been exposed to alcohol images or mentions in these forms of media? If so, how was alcohol portrayed? *

Associated Stylish, Addicting Associated with No Fashionable sophisticated Fun or Bonding or with death Associated immorality exposure or 'cool' or high class relaxing friendships controlling or disease with crime ('evil')

Movies TV Shows Novels Social media (fb, Instagram, twitter) Reality TV Advertisements Religious/cultural channels

Enter another option

223 How did you find out about this survey?

University eLearning (e.g. Moodle)

University only social media group

Student society or organisation (e.g. IFMSA-Iraq)

Social media (e.g. facebook, twitter)

Family or friends

During university lecture or tutorial

University Staff or Student

Other - please specify

224 ﻫﺬه دﻋﻮة ﻟﻚ ﻟﺘﺸﺎرك ﺑﺪراﺳﺔ اﺳﺘﻘﺼﺎﺋﻴﺔ ﺻﺤﻴﺔ ﺣﻮل ﻣﻮﻗﻒ ﻃﻠﺒﺔ اﻟﺠﺎﻣﻌﺔ اﻟﻌﺮاﻗﻴﻴﻦ ﻋﻦ اﻟﻜﺤﻮل (اﻟﺨﻤﻮر). Appendix 5: Arabic survey

ﻫﺬه اﻟﺪراﺳﺔ ﺟﺰء ﻣﻦ ﻣﺸﺮوع ﺑﺤﺚ دﻛﺘﻮراه ﻓﻲ ﺟﺎﻣﻌﺔ ﺳﺪﻧﻲ, اﺳﺘﺮاﻟﻴﺎ. ﺳﺘﻜﻮن ﻫﻮﻳﺘﻚ ﻣﺠﻬﻮﻟﺔ وﻟﻦ ﺗﺴﺠﻞ اي ﻣﻌﻠﻮﻣﺎت ﺗﺸﻴﺮ اﻟﻴﻚ، ﻓﺮﺟﺎءا اﺟﺐ ﺑﻜﻞ ﺻﺪق.

ﻣﺸﺎرﻛﺘﻚ ﺗﻄﻮﻋﻴﺔ وﺗﺴﺘﻄﻴﻊ اﻟﺘﻮﻗﻒ اي وﻗﺖ.

ﻫﻞ ﺗﺮﻏﺐ ﺑﺎﻟﻤﺸﺎرﻛﺔ ﻓﻲ ﻫﺬه اﻟﺪراﺳﺔ؟ *

ﻧﻌﻢ

ﻻ

ﻫﻞ اﻧﺖ ﻃﺎﻟﺐ ﺟﺎﻣﻌﻲ؟ *

ﻧﻌﻢ

ﻻ

225 ﻓﻲ أي ﺟﺎﻣﻌﺔ ﺗﺪرس؟ *

ﺟﺎﻣﻌﺔ ﺑﻐﺪاد

ﺟﺎﻣﻌﺔ اﻟﺒﺼﺮة

ﺟﺎﻣﻌﺔ اﻟﻜﻮﻓﺔ

ﺟﺎﻣﻌﺔ ﺑﺎﺑﻞ

ﺟﺎﻣﻌﺔ ﺻﻼح اﻟﺪﻳﻦ

ﺟﺎﻣﻌﺔ ﻫﺎوﻟﺮ اﻟﻄﺒﻴﺔ

ﺟﺎﻣﻌﺔ اﻟﻤﺴﺘﻨﺼﺮﻳﺔ

ﺟﺎﻣﻌﺔ ﻣﻴﺴﺎن

ﺟﺎﻣﻌﺔ ذي ﻗﺎر

ﺟﺎﻣﻌﺔ واﺳﻂ

ﺟﺎﻣﻌﺔ اﻟﻨﻬﺮﻳﻦ

اﻟﺠﺎﻣﻌﺔ اﻟﺘﻜﻨﻮﻟﻮﺟﻴﺔ

ﺟﺎﻣﻌﺔ اﻟﻤﻮﺻﻞ (اﻟﻤﻮﻗﻊ اﻟﺒﺪﻳﻞ)

ﺟﺎﻣﻌﺔ دﻳﺎﻟﻰ

ﺟﺎﻣﻌﺔ ﻗﺎدﺳﻴﺔ

ﺟﺎﻣﻌﺔ اﻻﻧﺒﺎر

أي ﺟﺎﻣﻌﺔ اﺧﺮى؟

226 رﺟﺎءا اﺧﺘﺮ ﻛﻠﻴﺘﻚ ﻣﻦ اﻟﺨﻴﺎرات اﻟﺘﺎﻟﻴﺔ؟ *

اﻟﺰراﻋﺔ

اﻵداب

اﻻدارة واﻻﻗﺘﺼﺎد

اﻟﻬﻨﺪﺳﺔ

اﻟﻘﺎﻧﻮن

اﻟﻄﺐ

اﻟﺘﻤﺮﻳﺾ

اﻟﺼﻴﺪﻟﺔ

اﻟﻌﻠﻮم

أي ﻛﻠﻴﺔ اﺧﺮى؟ *

ﻓﻲ أي ﻣﺮﺣﻠﺔ ﺗﺪرس؟ *

ﻣﺮﺣﻠﺔ اﻟﺒﻜﺎﻟﻮرﻳﻮس

ﻣﺮﺣﻠﺔ اﻟﺪﺑﻠﻮم اﻟﻌﺎﻟﻲ

ﻣﺮﺣﻠﺔ اﻟﻤﺎﺟﺴﺘﻴﺮ

ﻣﺮﺣﻠﺔ اﻟﺪﻛﺘﻮراه

أي ﻣﺮﺣﻠﺔ اﺧﺮى؟ *

227 ﻛﻢ ﻋﻤﺮك؟ *

ﻣﺎ ﻫﻮ ﺟﻨﺴﻚ؟ *

ذﻛﺮ

اﻧﺜﻰ

ﻣﺎ ﻫﻲ ﺣﺎﻟﺘﻚ اﻻﺟﺘﻤﺎﻋﻴﺔ؟ *

أﻋﺰب

ﻋﻼﻗﺔ ﻗﺒﻞ اﻟﺰواج (ﻣﻜﺒﻞ)

ﻣﺨﻄﻮب

ﻣﺘﺰوج

ﻣﻄﻠﻖ

أرﻣﻞ

أي ﺣﺎﻟﺔ اﺧﺮى؟ *

228 ﻣﺎ ﻫﻲ دﻳﺎﻧﺘﻚ؟ *

ﻣﺴﻠﻢ

ﻧﺼﺮاﻧﻲ

ﻳﻬﻮدي

ﺻﺎﺑﺌﻲ

أﻳﺰﻳﺪي

اﻏﻨﻮﺳﺘﻴﺔ (اﻟﻼادري)

ﻣﻠﺤﺪ

ﻻ دﻳﻨﻲ

أي دﻳﻦ آﺧﺮ؟

229 ﻣﺎ ﻫﻮ اﺻﻠﻚ اﻟﻌﺮﻗﻲ؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ) *

ﻋﺮﺑﻲ

ﻛﺮدي

آﺷﻮري

ﻛﻠﺪاﻧﻲ

ﺗﺮﻛﻤﺎﻧﻲ

أرﻣﻨﻲ

ﻓﺎرﺳﻲ

أي اﺻﻞ آﺧﺮ؟

230 ﺗﺼﻮر ان ﻫﺬا اﻟﺴﻠﻢ ﻳﻤﺜﻞ اﻟﻤﺴﺘﻮﻳﺎت اﻻﺟﺘﻤﺎﻋﻴﺔ, اﻟﻤﺎﻟﻴﺔ واﻟﻌﻠﻤﻴﺔ ﻓﻲ اﻟﻤﺠﺘﻤﻊ اﻟﻌﺮاﻗﻲ

اﺧﺘﺮ ﻓﻲ اي درﺟﺔ ﺗﻀﻊ ﺷﺨﺼﻚ اﻟﻜﺮﻳﻢ ﻧﺴﺒﺘﺎ ﻟﻠﻨﺎس اﻻﺧﺮﻳﻦ ﻓﻲ اﻟﻌﺮاق *

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10

231 ﻫﻞ اﻧﺖ ﻻﺟﻲء او ﻧﺎزح؟ *

ﻧﻌﻢ

ﻻ

ﻫﻞ ﻛﻨﺖ ﻃﺎﻟﺐ ﻗﺒﻞ ان ﺗﻜﻮن ﻻﺟﻲء او ﻧﺎزح؟

ﻧﻌﻢ

ﻻ

ﻫﻞ اﻧﺖ ﺗﻌﻴﺶ ﺧﺎرج ﺑﻠﺪﺗﻚ ﺧﻼل اﻟﻔﺼﻞ اﻟﺪراﺳﻲ؟ *

ﻧﻌﻢ

ﻻ

أﻳﻦ ﺗﻌﻴﺶ ﻋﺎدﺗﺎ ﺧﻼل اﻟﻔﺼﻞ اﻟﺪراﺳﻲ؟ *

أﻋﻴﺶ ﺑﻤﻔﺮدي

ﺑﺎﻟﺒﻴﺖ ﻣﻊ واﻟﺪي

ﺑﺎﻟﺒﻴﺖ ﻣﻊ ﺷﺮﻳﻜﺘﻲ

أﺷﺎرك ﻣﻜﺎن اﻻﻗﺎﻣﺔ ﻣﻊ اﺻﺪﻗﺎء او آﺧﺮﻳﻦ

اﻟﺴﻜﻦ اﻟﺠﺎﻣﻌﻲ

ﻣﺨﻴﻢ او ﺳﻜﻦ اﻟﻼﺟﺌﻴﻦ

أي ﻣﺴﻜﻦ آﺧﺮ؟ * 232 ﻫﻞ ﺳﺒﻖ ﻟﻚ ان ﺟﺮﺑﺖ ﺗﻨﺎول اﻟﻜﺤﻮل (اﻟﺨﻤﻮر )؟ *

ﻧﻌﻢ

ﻻ

ﻫﻞ ﺳﺒﻖ ﻟﻚ ان ﺗﻨﺎوﻟﺖ ﻛﺎﺳﺎ ﻛﺎﻣﻞ ﻣﻦ اﻟﻜﺤﻮل (اﻟﺨﻤﻮر)؟ (ﻣﺜﻼ: ﻛﻮب ﻣﻦ اﻟﻨﺒﻴﺬ, رﺷﻔﺔ ﻣﻦ اﻟﻤﺸﺮوﺑﺎت اﻟﺮوﺣﻴﺔ او ﻋﻠﺒﺔ ﻣﻦ اﻟﺒﻴﺮة) *

ﻧﻌﻢ

ﻻ

ﻛﻢ ﻛﺎن ﻋﻤﺮك ﻋﻨﺪﻣﺎ ﺗﻨﺎوﻟﺖ ﻛﺎﺳﺎ ﻛﺎﻣﻼ ﻣﻦ اﻟﻜﺤﻮل (اﻟﺨﻤﻮر) ﻻول ﻣﺮة؟ *

ﻫﻞ ﺗﻨﺎوﻟﺖ اي ﻣﺸﺮوب ﻛﺤﻮﻟﻲ ﻓﻲ ال 12 ﺷﻬﺮ اﻟﻤﺎﺿﻴﺔ؟ *

ﻧﻌﻢ

ﻻ

ﻛﻢ ﻛﺎن ﻋﻤﺮك ﻋﻨﺪﻣﺎ ﺗﻨﺎوﻟﺖ ﻣﺸﺮوﺑﺎ ﻛﺤﻮﻟﻲ ﻻﺧﺮ ﻣﺮة؟ *

233 * AUDIT 1

ﻻ اﺷﺮب ﺷﻬﺮﻳﺎ 2 اﻟﻰ 4 ﻣﺮات ﻓﻲ ﻣﺮﺗﻴﻦ اﻟﻰ ﺛﻼث ﻣﺮات ﻓﻲ 4 ﻣﺮات او اﻛﺜﺮ ﻓﻲ اﺑﺪا واﻗﻞ اﻟﺸﻬﺮ اﻻﺳﺒﻮع اﻻﺳﺒﻮع

ﻣﺎ ﻫﻮ ﻣﻌﺪل ﺗﻨﺎوﻟﻚ ﻟﻠﻤﺸﺮوﺑﺎت اﻟﺘﻲ ﺗﺤﺘﻮي ﻋﻠﻰ اﻟﻜﺤﻮل؟

* AUDIT 2

1 او 2 3 او 4 5 او 6 7,8 او 9 10 او اﻛﺜﺮ

ﻛﻢ ﻛﻮب ﻣﻦ اﻟﻤﺸﺮوﺑﺎت اﻟﻜﺤﻮﻟﻴﺔ ﺗﺘﻨﺎول ﻋﺎدة ﻓﻲ اﻟﻴﻮم اﻟﺬي ﺗﺸﺮب ﻓﻴﻪ؟

* AUDIT 3

ﻻ اﻓﻌﻞ ذﻟﻚ اﺑﺪا اﻗﻞ ﻣﻦ ﻣﺮة ﻓﻲ اﻟﺸﻬﺮ ﺷﻬﺮﻳﺎ اﺳﺒﻮﻋﻴﺎ ﻳﻮﻣﻴﺎ او ﺗﻘﺮﻳﺒﺎ ﻳﻮﻣﻴﺎ

ﻣﺎ ﻫﻮ ﻣﻌﺪل ﺗﻨﺎوﻟﻚ ﻟﻴﺘﺔ اﻛﻮاب او اﻛﺜﺮ ﻓﻲ ﻣﻨﺎﺳﺒﺔ واﺣﺪة؟

AUDIT 3-8

ﻳﻮﻣﻴﺎ او ﻟﻢ ﻳﺤﺼﻞ اﻗﻞ ﻣﻦ ﻣﺮة ﺗﻘﺮﻳﺒﺎ ذﻟﻚ ﻟﻲ اﺑﺪا ﻓﻲ اﻟﺸﻬﺮ ﺷﻬﺮﻳﺎ اﺳﺒﻮﻋﻴﺎ ﻳﻮﻣﻴﺎ

ﺧﻼل اﻟﻌﺎم اﻟﻤﺎﺿﻲ ﻛﻢ وﺟﺪت اﻧﻚ ﻣﺘﻰ ﺗﺒﺪا ﺑﺎﻟﺸﺮب ﻓﺎﻧﻚ ﻻ ﺗﺴﺘﻄﻴﻊ اﻟﺘﻮﻗﻒ؟ ﺧﻼل اﻟﻌﺎم اﻟﻤﺎﺿﻲ ﻛﻢ وﺟﺪت اﻧﻚ وﺑﺴﺒﺐ اﻟﺸﺮب ﻟﻢ ﺗﺘﻤﻜﻦ ﻣﻦ اﻟﻘﻴﺎم ﺑﻤﺎ ﻫﻮ ﻣﺘﻮﻗﻊ ﻣﻨﻚ؟ ﺧﻼل اﻟﻌﺎم اﻟﻤﺎﺿﻲ ﻛﻢ ﻛﻨﺖ ﺗﺤﺘﺎج اﻟﻰ ﻣﺸﺮوب ﻓﻲ اﻟﺼﺒﺎح ﻟﻜﻲ ﺗﺘﻤﻜﻦ ﻣﻦ اﻟﺸﺮاع ﺑﻬﺎرك ﺑﻌﺪ ﺟﻠﺴﺔ اﻛﺜﺮت ﻓﻴﻬﺎ ﻣﻦ اﻟﺸﺮب ؟ ﺧﻼل اﻟﻌﺎم اﻟﻤﺎﺿﻲ ﻛﻢ ﺣﺼﻞ اﻧﻚ ﺷﻌﺮت ﺑﺎﻟﺬﻧﺐ او اﻟﻨﺪم ﺑﻌﺪ اﻟﺸﺮب؟ ﺧﻼل اﻟﻌﺎم اﻟﻤﺎﺿﻲ ﻛﻢ ﺣﺼﻞ اﻧﻚ ﻟﻢ ﺗﺘﻤﻜﻦ ﻣﻦ ﺗﺬﻛﺮ ﻣﺎ ﺣﺼﻞ ﻓﻲ اﻟﻠﻴﻠﺔ اﻟﺴﺎﺑﻘﺔ ﻻﻧﻚ ﻛﻨﺖ ﺗﺸﺮب؟ 234 AUDIT 9-10

ﻧﻌﻢ و ﻟﻜﻦ ﻟﻴﺲ ﻓﻲ ﻧﻌﻢ ﺧﻼل ﻛﻼ اﻟﺴﻨﺔ اﻟﻤﺎﺿﻴﺔ اﻟﺴﻨﺔ اﻟﻤﺎﺿﻴﺔ

ﻫﻞ ﺣﺼﻞ ان ﺗﻌﺮﺿﺖ اﻧﺖ او ﺷﺨﺺ اﺧﺮ ﻻﺻﺎﺑﺔ ﺑﺴﺒﺐ ﺗﻨﺎوﻟﻚ ﻟﻠﻤﺸﺮوب؟ ﻫﻞ ﺳﺒﻖ ان اﺑﺪى اﺣﺪ اﻻﻗﺮﺑﺎء او اﻻﺻﺪﻗﺎء او اي ﻃﺒﻴﺐ او ﻣﻮﻇﻒ ﺻﺤﻲ ﻗﻠﻘﺎ ﺗﺠﺎه ﻋﺎدة اﻟﺸﺮب ﻟﺪﻳﻚ او ﻫﻞ اﻗﺘﺮح ﻋﻠﻴﻚ اﺣﺪﻫﻢ اﻟﺘﻘﻠﻴﻞ ﻣﻦ اﻟﺸﺮب؟

ﻫﻞ ﺗﻨﺎوﻟﺖ اﻟﻜﺤﻮل (اﻟﺨﻤﻮر) ﻓﻲ *

ﻧﻌﻢ ﻻ

اﻟﻤﺪﻳﻨﺔ اﻟﺘﻲ ﺗﺴﻜﻦ ﻓﻴﻬﺎ ﻣﻜﺎن اﺧﺮ ﻓﻲ اﻟﻌﺮاق دوﻟﺔ اﺧﺮى

235 اﻳﻦ ﺗﺘﻨﺎول اﻟﻜﺤﻮل (اﻟﺨﻤﻮر)؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

ﻓﻲ ﺑﻴﺘﻲ

ﻓﻲ ﺑﻴﺖ ﺻﺪﻳﻘﻲ

ﻓﻲ ﺗﺠﻤﻊ اﺟﻨﻤﺎﻋﻲ او ﺣﻔﻠﺔ

ﻓﻲ اﻟﻔﻨﺎدق اواﻟﻤﻼﻫﻲ واﻟﺤﺎﻧﺎت

ﻓﻲ ﻣﻜﺎن ﻋﺎم (ﻣﺜﻼ اﻟﺸﺎرع او اﻟﺒﺎرك)

ﻓﻲ اﻟﺠﺎﻣﻌﺔ

ﻓﻲ اﻟﺴﻴﺎرة او ﻣﺮﻛﺒﺔ اﺧﺮى

ﺧﺎرخ ﻣﻦ اﻟﻤﺪﻳﻨﺔ ﻓﻲ اﻟﺒﺴﺎﺗﻴﻦ, اﻟﻤﺰارع او اﻻﺳﺘﺮاﺣﺎت

اي ﻣﻜﺎن آﺧﺮ؟ *

236 ﻣﻦ اﻳﻦ ﺗﺤﺼﻞ ﻋﻠﻰ اﻟﺸﺮاب اﻟﻜﺤﻮﻟﻲ (اﻟﺨﻤﻮر)؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

ﻣﻦ اﻻﺻﺪﻗﺎء او اﻟﻤﻌﺎرف

ﻣﻦ اﺧﻲ او اﺧﺘﻲ

ﻣﻦ اﺑﻲ او اﻣﻲ

ﻣﻦ زوﺟﻲ او ﺷﺮﻳﻜﻲ

ﻣﻦ اﻗﺎرﺑﻲ اﻻﺧﺮﻳﻦ

اﺳﺮﻗﻪ

اﺷﺘﺮﻳﻪ ﻣﻦ اﻻﺳﻮاق

اﺷﺘﺮﻳﻪ ﺑﻄﺮﻳﻘﺔ ﻏﻴﺮ ﻗﺎﻧﻮﻧﻴﺔ (اﻻﺳﻮاق اﻟﺴﻮداء)

ﻣﻦ ﺷﺨﺺ ﻏﺮﻳﺐ (ﻣﺜﻼ ﻋﺒﺮ اﻻﻧﺘﺮﻧﻴﺖ)

اﻧﺎ اﺻﻨﻌﻪ

اي ﺷﺨﺺ اﺧﺮ؟ *

237 ﻣﻊ ﻣﻦ ﺗﺘﻨﺎول اﻟﺸﺮاب اﻟﻜﺤﻮﻟﻲ (اﻟﺨﻤﻮر)؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

ﺑﻤﻔﺮدي

ﻣﻊ اﺑﻲ او اﻣﻲ

ﻣﻊ اﺧﻲ او اﺧﺘﻲ

ﻣﻊ اﺻﺪﻗﺎﺋﻲ ﻣﻦ اﻟﺠﺎﻣﻌﺔ

ﻣﻊ اﺻﺪﻗﺎﺋﻲ ﻣﻦ ﺧﺎرج اﻟﺠﺎﻣﻌﺔ

ﻣﻊ اﻟﻐﺮﺑﺎء

اي ﺷﺨﺺ آﺧﺮ؟ *

اﺧﻨﺮاﻧﻮاع اﻟﻤﺸﺮوﺑﺎت اﻟﻜﺤﻮﻟﻴﺔ (اﻟﺨﻤﻮر) اﻟﺘﻲ ﺗﺘﻨﺎوﻟﻬﺎ؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

اﻟﻤﺸﺮوﺑﺎت اﻟﻤﻘﻄﺮة (اﻟﺮوﺣﻴﺔ) اﻟﻤﺼﻨﻮﻋﺔ ﻓﻲ اﻟﺒﻴﺖ

ﺑﻴﺮة ﻣﺼﻨﻮﻋﺔ ﻓﻲ اﻟﺒﻴﺖ

ﻧﺒﻴﺬ ﻣﺼﻨﻮع ﻓﻲ اﻟﺒﻴﺖ

اﻟﻨﺒﻴﺬ اﻟﻤﺼﺪر ﻣﻦ ﻗﺒﻞ ﺷﺮﻛﺎت

ﺑﻴﺮة اﻟﻤﺼﺪرة ﻣﻦ ﻗﺒﻞ ﺷﺮﻛﺎت (ﻣﺜﻼ ﻓﺮﻳﺪة, ﻣﻮروﻧﺎ او ﻫﺎﻳﻨﻴﻜﻴﻦ)

اﻟﻤﺸﺮوﺑﺎت اﻟﻤﻘﻄﺮة (اﻟﺮوﺣﻴﺔ) اﻟﻤﺼﺪرة ﻣﻦ ﺷﺮﻛﺎت (ﻣﺜﻼ ﻓﺮﻛﺎ, وﺳﻜﻲ, ﺗﺸﻴﻔﺎز)

اي ﻧﻮع آﺧﺮ؟ *

238 ﻫﻞ ﺗﻨﺎوﻟﺖ اي ﻣﻦ اﻟﻤﻮاد اﻻﺗﻴﺔ (ﻻﺳﺒﺎب ﻏﻴﺮ ﻃﺒﻴﺔ او ﻋﻼﺟﻴﺔ)؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

اﻟﺘﺒﻎ (اﻟﺴﻴﺠﺎر)

اﻟﺤﺸﻴﺶ (ﻣﺎرواﻧﺎﻛﺎﻧﻴﺒﺲ)

اﻟﻤﻴﺜﻤﻔﻴﺘﺎﻣﻴﻦ (اﻟﻜﺮﻳﺴﺘﺎل"اﻟﺘﻤﻦ")

اﻟﻜﻮﻛﺎﻳﻴﻦ

اﻛﺴﺘﺎﺳﻲ (اﻟﺤﺐ MDMA)

اﻟﻬﻴﺮوﻳﻦ

ﺑﻴﻨﺰودﻳﺎزاﺑﻴﻦ (ﻓﺎﻟﻴﻮم, ﻛﻠﻮﻧﺎزﻳﺒﺎم)

ﺑﻴﻨﺰﻳﻜﺴﻮل (ارﺗﺎﻳﻦ)

دواء ﻣﻀﺎدات اﻻﻛﺘﺌﺎب وﻣﻀﺎدات اﻟﻌﺼﺒﻴﺔ

ادوﻳﺔ اﻟﻤﻮاد اﻷﻓﻴﻮﻧﻴﺔ , ﻣﺴﻜﻨﺎت اﻻﻟﻢ (اﻟﻜﻮداﻳﻴﻦ, اﻟﻤﻮرﻓﻴﻦ)

اﻟﻤﺴﺘﻨﺸﻘﺎت (اﻟﺼﺒﻎ او اﻟﻼﺳﻖ)

اﻟﻤﻨﺸﻄﺎت (ﺳﺘﻴﺮوﻳﺪز)

ﻻ اﺳﺘﺨﺪم اي ﻣﻮاد اﺧﺮى (ﻣﺨﺪرات/ﻣﻨﺸﻄﺎت)

اي ﻣﻮاد اﺧﺮى؟ *

239 ﻫﻞ اي ﻣﻦ ﻋﺎﺋﻠﺘﻚ اواﺻﺪﻗﺎﺋﻚ ﻳﺘﻨﺎوﻟﻮن اﻟﻜﺤﻮل (اﻟﺨﻤﻮر)؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

اﺑﻲ او اﻣﻲ

اﺧﻲ او اﺧﺘﻲ

اﺧﺮﻳﻦ ﻣﻦ ﻋﺎﺋﻠﺘﻲ

اﺻﺪﻗﺎﺋﻲ ﻣﻦ اﻟﺠﺎﻣﻌﺔ

اﺻﺪﻗﺎﺋﻲ اﻻﺧﺮﻳﻦ

ﻻ اﺣﺪ ﻣﻦ ﻋﺎﺋﻠﺘﻲ او اﺻﺪﻗﺎﺋﻲ

ﻫﻞ اي ﻣﻦ ﻋﺎﺋﻠﺘﻚ اواﺻﺪﻗﺎﺋﻚ ﻳﺘﻨﺎوﻟﻮن اﻟﻤﻮاد اﻻﺧﺮى (ﻣﺨﺪرات/ﻣﻨﺸﻄﺎت) ؟ (اﺧﺘﺮ ﻛﻞ ﻣﺎ ﻳﻨﻄﺒﻖ)

اﺑﻲ او اﻣﻲ

اﺧﻲ او اﺧﺘﻲ

اﺧﺮﻳﻦ ﻣﻦ ﻋﺎﺋﻠﺘﻲ

اﺻﺪﻗﺎﺋﻲ ﻣﻦ اﻟﺠﺎﻣﻌﺔ

اﺻﺪﻗﺎﺋﻲ اﻻﺧﺮﻳﻦ

ﻻ اﺣﺪ ﻣﻦ ﻋﺎﺋﻠﺘﻲ او اﺻﺪﻗﺎﺋﻲ

ﻣﺎ ﻧﺴﺒﺔ اﻟﻄﻠﺒﺔ اﻟﺠﺎﻣﻌﻴﻴﻦ اﻟﺬي ﻳﺘﻨﺎوﻟﻮن اﻟﻜﺤﻮل (اﻟﺨﻤﻮر) ﻓﻲ اﻟﻌﺮاق؟ *

0% 100% 50%

240 ﻫﻞ ﻟﻚ رﻏﺒﺔ ان ﺗﺠﺮب ﺗﻨﺎول اﻟﻜﺤﻮل (اﻟﺨﻤﻮر )؟

ﻧﻌﻢ

ﻻ

ﻻ ادري

ﻣﺎ ﻣﺪى ﺻﻌﻮﺑﺔ اﻟﺤﺼﻮل ﻋﻠﻰ اﻟﻤﺸﺮوب اﻟﻜﺤﻮﻟﻲ (اﻟﺨﻤﻮر) ﻣﻦ ﻗﺒﻞ اﻟﻄﺎﻟﺐ اذا اراد ذﻟﻚ؟ *

ﺳﻬﻞ ﺟﺪا

ﺳﻬﻞ

ﺻﻌﺐ

ﺻﻌﺐ ﺟﺪا

ﻣﺴﺘﺤﻴﻞ

241 ﻣﺎ ﻫﻮ رأﻳﻚ ﻋﻦ اﻻﺳﺒﺎب اﻟﺘﺎﻟﻴﺔ اﻟﺘﻲ ﺗﺤﻔﺰ اﻟﻄﻼب ﻋﻠﻰ ﻋﺪم ﺷﺮب اﻟﻜﺤﻮل (اﻟﺨﻤﻮر) *

ﻏﺎﻟﺒﺎ أﺣﻴﺎﻧﺎ ﻧﺎدرا أﺑﺪا

اﺳﺒﺎب ﺻﺤﻴﺔ (اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻳﻀﺮ ﺻﺤﺘﻬﻢ) اﻟﺸﺨﺺ ﻣﻤﻜﻦ ان ﻳﻌﺘﺎد ﻋﻠﻰ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻫﻢ ﻻ ﻳﺮﻳﺪون اﺳﺘﺨﺪام اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﺗﺄﺛﻴﺮ اﻻﻋﻼم اﻟﻌﺎم (ﻣﺜﻼ اﻟﺘﻠﻔﺰﻳﻮن ، اﻟﻔﻀﺎﺋﻴﺎت) ﺗﺄﺛﻴﺮ ﻣﻮاﻗﻊ اﻟﺘﻮاﺻﻞ اﻻﺟﺘﻤﺎﻋﻲ (ﻣﺜﻼ ﻓﻴﺴﺒﻮك ، اﻧﺴﺘﻐﺮام ، ﺗﻮﻳﺘﺮ) ﻫﻢ ﻻ ﻳﺤﺒﻮن ﺗﺄﺛﻴﺮ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻋﻠﻰ ﺗﺼﺮﻓﺎﺗﻬﻢ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻣﻤﻨﻮع ﻗﺎﻧﻮﻧﻴﺎ اﺳﺒﺎب دﻳﻨﻴﺔ (اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻣﺤﺮم ﺷﺮﻋﺎ) ﻳﺨﺸﻮن ان ﻳﻜﺸﻒ ﺷﺮﺑﻬﻢ ﻟﻠﻜﺤﻮل (اﻟﺨﻤﺮ) اﺳﺒﺎب ﻋﺎﺋﻠﻴﺔ (اﻋﻀﺎء اﻟﻌﺎﺋﻠﺔ ﻳﻌﺘﻘﺪون ان ﻳﻨﺒﻐﻲ ﻟﻬﻢ اﻻ ﻳﺸﺮﺑﻮن اﻟﻜﺤﻮل (اﻟﺨﻤﺮ)) اﺳﺒﺎب اﺟﺘﻤﺎﻋﻴﺔ وﺛﻘﺎﻓﻴﺔ (اﻟﻤﺠﺘﻤﻊ اﻟﻌﺎم ﻳﻜﺮه ﺷﺎرﺑﻲ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ)) اﻻﺻﺪﻗﺎء (اﺻﺪﻗﺎؤﻫﻢ ﻳﻔﻜﺮون ﺑﺴﻮء ﻧﺤﻮ ﺷﺎرﺑﻲ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ)) اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻟﻴﺲ ﺑﻤﺘﻨﺎول اﻟﻴﺪ ﻟﻬﻢ ﻟﻴﺸﺘﺮوه او ﻳﺸﺮﻳﻮه ﻃﻌﻢ اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) ﻟﻴﺲ ﺟﻴﺪ

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242 ﻣﺎ ﻫﻮ رأﻳﻚ ﻋﻦ اﻻﺳﺒﺎب اﻟﺘﺎﻟﻴﺔ اﻟﺘﻲ ﺗﺤﻔﺰ اﻟﻄﻼب ﻋﻠﻰ ﺷﺮب اﻟﻜﺤﻮل (اﻟﺨﻤﻮر) *

ﻏﺎﻟﺒﺎ أﺣﻴﺎﻧﺎ ﻧﺎدرا أﺑﺪا

اﻟﺨﻤﺮ ﻣﺘﺪاول وﻣﻤﻜﻦ اﻟﻮﺻﻮل اﻟﻴﻪ ﺑﺴﻬﻮﻟﺔ ﺗﺄﺛﻴﺮ ﻣﻮاﻗﻊ اﻟﺘﻮاﺻﻞ اﻻﺟﺘﻤﺎﻋﻲ (ﻣﺜﻼ ﻓﻴﺴﺒﻮك ، اﻧﺴﺘﻐﺮام ، ﺗﻮﻳﺘﺮ) ﺗﺄﺛﻴﺮ اﻻﻋﻼم اﻟﻌﺎم (ﻣﺜﻼ اﻟﺘﻠﻔﺰﻳﻮن ، اﻟﻔﻀﺎﺋﻴﺎت) ﻗﻠﺔ اﻟﺪﻳﻦ ﻃﺮﻳﻘﺔ ﻟﻠﻬﺮوب ﻣﻦ اﻟﻮاﻗﻊ ﻣﺜﻞ اﻷذى او اﻟﻤﺴﺆوﻟﻴﺔ او اﻟﻘﻠﻖ ﻟﻠﻤﻌﺎﺷﺮة اﻻﺟﺘﻤﺎﻋﻴﺔ ﻻن اﺻﺪﻗﺎﺋﻬﻢ ﻳﺸﺮﺑﻮن (ﺿﻐﻂ اﻻﻗﺮان) ﻟﻠﺜﻮرة ﻋﻠﻰ اﻟﻘﻴﻢ اﻟﺘﻘﻠﻴﺪﻳﺔ واﻇﻬﺎر اﻧﻬﻢ "ﻋﺼﺮﻳﻮن" ﻟﻤﻤﺎرﺳﺔ ﺣﻘﻮﻗﻬﻢ ﻛﺎﻗﻠﻴﺎت ﺗﻘﻠﻴﺪ ﻋﺎﺋﻠﻲ اﻻﺷﻴﺎء اﻟﻤﻤﻨﻮﻋﺔ داﺋﻤﺎ ﻣﻐﺮﻳﺔ ﻟﻠﻤﺘﻌﺔ واﻟﺘﺮﻓﻴﻪ ﻣﻦ اﻟﻤﻠﻞ ﻟﻠﺮاﺣﺔ

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243 ﻣﺎ رأﻳﻚ ﺑﺎﻟﻌﺒﺎرات اﻟﺘﺎﻟﻴﺔ؟ *

ﻣﻮاﻓﻖ ﺑﻘﻮةﻣﻮاﻓﻖ ﻣﻌﺎرض ﻣﻌﺎرض ﺑﻘﻮة

ﺷﺮب اﻟﺨﻤﺮ ﻃﺒﻴﻌﻲ ﻟﻠﻄﺎﻟﺐ اﻟﺸﺎب اﻟﺠﺎﻣﻌﻲ اﻟﺨﻤﺮ ﻣﺸﻜﻠﺔ اﻛﺒﺮ ﻣﻦ اﻟﻤﺨﺪرات ﻓﻲ اﻟﻌﺮاق ﺷﺎرﺑﻲ اﻟﺨﻤﺮ ﻳﺠﺮﺑﻮن اﻟﻤﺨﺪرات اﻻﺧﺮى اﻛﺜﺮ ﻣﻦ ﻋﺪم ﺷﺎرﺑﻴﻪ اﻟﺨﻤﺮ ﻟﻴﺲ ﻣﺸﻜﻠﺔ ﺗﻮاﺟﻪ اﻟﻌﺮاق ﺗﺠﺮﺑﺔ اﻟﺸﺎب ﻟﻠﺨﻤﺮﻋﻼﻣﺔ ان اﻟﺸﺎب ﻋﻨﺪه ﻣﺸﻜﻠﺔ اﻛﺒﺮ اذا ﺗﺪاول اﻟﺨﻤﺮ ﻛﺜﺮ اﺳﺘﺨﺪاﻣﻪ اﻟﻌﺮاق ﻳﺤﺘﺎج ﻟﻤﺮاﻓﻖ ﻣﻌﺎﻟﺠﺔ اﻛﺜﺮ ﻟﺬوي اﻟﻤﺸﺎﻛﻞ ﻣﻊ اﻟﺨﻤﺮ ﻣﻮﺿﻮع ﺷﺮب اﻟﺨﻤﺮ أﻣﺮ اﺧﻼﻗﻲ ﻣﻮﺿﻮع ﺷﺮب اﻟﺨﻤﺮ أﻣﺮ ﻃﺒﻲ اﻟﺨﻤﺮ ﻣﺸﻜﻠﺔ ﺷﺎﺋﻌﺔ ﺑﺎﻟﻌﺮاق

ﻣﺎ رأﻳﻚ ﺑﺎﻟﺴﻴﺎﺳﺎت اﻟﺘﺎﻟﻴﺔ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻌﺮاق؟ *

ﻣﻮاﻓﻖ ﺑﻘﻮةﻣﻮاﻓﻖ ﻣﻌﺎرض ﻣﻌﺎرض ﺑﻘﻮة

ﻣﻨﻊ اﻟﺨﻤﺮ ﺑﺘﺎﺗﺎ ﺣﺘﻰ اﺳﺘﻴﺮاده او اﺳﺘﺨﺪاﻣﻪ اﻟﺴﻤﺎح ﺑﺼﻨﺎﻋﺔ اﻟﺨﻤﺮ وﺑﻴﻌﻪ واﺳﺘﺨﺪاﻣﻪ ﻟﻐﻴﺮ اﻟﻤﺴﻠﻤﻴﻦ اﻟﻤﺘﺎﺟﺮة ﺑﺎﻟﺨﻤﺮ واﺳﺘﻴﺮاده ﻳﺠﺐ ان ﺗﻤﻨﻊ وﻟﻜﻦ ﻻ ﻳﻨﺒﻐﻲ ﺗﺠﺮﻳﻢ اﺳﺘﻬﻼك اﻟﻜﺤﻮل ﻳﻨﺒﻐﻲ اﻟﺴﻤﺎح ﻟﻠﻜﺤﻮل ﻟﺘﻘﻠﻴﻞ اﻟﺘﻌﺎﻣﻼت ﻓﻲ اﻟﺴﻮق اﻟﺴﻮداء ﻋﻘﻮﺑﺎت ﺻﺎرﻣﺔ ﻟﻸﺷﺨﺎص اﻟﺬﻳﻦ وﺟﺪوا ﻣﻊ ﺣﻴﺎزة اﻟﻜﺤﻮل اﻟﺴﻤﺎح ﺑﺎﻧﺘﺎج اﻟﻜﺤﻮل (اﻟﺨﻤﺮ) واﺳﺘﻬﻼﻛﻪ وﺑﻴﻌﻪ ﻟﻠﺠﻤﻴﻊ

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244 ﺑﺮأﻳﻚ ﻣﺎذا ﻳﺠﺐ ان ﻳﻔﻌﻞ ﻟﻠﺸﺨﺺ اﻟﺬي وﺟﺪ ﻋﻨﺪه ﻗﻠﻴﻼ ﻣﻦ اﻟﻜﺤﻮل ﻟﻼﺳﺘﻌﻤﺎل اﻟﺸﺨﺼﻲ؟ *

ﻻ ﻳﻔﻌﻞ ﻟﻪ أي ﺷﻲء

ﻳﺠﺐ ان ﻳﺤﺬّر ﻓﻘﻂ

ﻳﻨﺼﺢ او ﻳﻨﺎﻗﺶ ﻗﻠﻴﻼ

ﻳﺤﺎل ﻟﻄﻠﺐ اﻟﻤﺸﻮره أو اﻟﻌﻼج اﻟﻼزم

ﺗﻮﻋﻴﺘﻪ ﺣﻮل اﻟﺴﻼﻣﻪ و اﺿﺮار اﻟﻤﺤﺘﻤﻠﻪ

ﻳﻐﺮم ﺑﻐﺮاﻣﻪ ﺻﻐﻴﺮه

ﻳﻐﺮم ﺑﻐﺮاﻣﻪ ﻛﺒﻴﺮه

ﻳﺤﺠﺰ ﻟﻤﺪة ﺻﻐﻴﺮة

ﻳﺤﻜﻢ ﺑﺎﻟﺴﺠﻦ

ﻳﻌﺰر - ﻳﻌﺎﻗﺐ ﺟﺴﺪﻳﺎ (ﻣﺜﻼ ﻳﺠﻠﺪ - ﻳﻀﺮب ﺑﺎﻟﺼﻮط)

أي ﺷﻲء آﺧﺮ؟ *

245 ﺑﺮأﻳﻚ ﻣﺎذا ﻳﺠﺐ ان ﻳﻔﻌﻞ ﻟﻠﺸﺨﺺ اﻟﺬي وﺟﺪ ﻋﻨﺪه ﻗﻠﻴﻼ ﻣﻦ اﻟﻤﻮاد اﻻﺧﺮى (اﻟﻤﺨﺪرات/اﻟﻤﻨﺸﻄﺎت) ﻟﻼﺳﺘﻌﻤﺎل اﻟﺸﺨﺼﻲ؟ *

ﻻ ﻳﻔﻌﻞ ﻟﻪ أي ﺷﻲء

ﻳﺠﺐ ان ﻳﺤﺬّر ﻓﻘﻂ

ﻳﻨﺼﺢ او ﻳﻨﺎﻗﺶ ﻗﻠﻴﻼ

ﻳﺤﺎل ﻟﻄﻠﺐ اﻟﻤﺸﻮره أو اﻟﻌﻼج اﻟﻼزم

ﺗﻮﻋﻴﺘﻪ ﺣﻮل اﻟﺴﻼﻣﻪ و اﺿﺮار اﻟﻤﺤﺘﻤﻠﻪ ﻟﻠﻜﺤﻮل

ﻳﻐﺮم ﺑﻐﺮاﻣﻪ ﺻﻐﻴﺮه

ﻳﻐﺮم ﺑﻐﺮاﻣﻪ ﻛﺒﻴﺮه

ﻳﺤﺠﺰ ﻟﻤﺪة ﺻﻐﻴﺮة

ﻳﺤﻜﻢ ﺑﺎﻟﺴﺠﻦ

ﻳﻌﺰر - ﻳﻌﺎﻗﺐ ﺟﺴﺪﻳﺎ (ﻣﺜﻼ ﻳﺠﻠﺪ - ﻳﻀﺮب ﺑﺎﻟﺼﻮط)

أي ﺷﻲء آﺧﺮ *

246 ﻣﺎذا ﺳﺘﻔﻌﻞ اذا ﺗﺒﻴﻦ ﻟﻚ ﺑﺎن ﺷﺨﺺ ﺗﻌﺮﻓﻪ: *

ﺗﻄﻠﺐ ﻻ ﻣﻨﻬﻢ ﺗﺤﺎول أن ﺗﺠﺒﺮﻫﻢ ﺗﺤﺎول أن ﺗﺒﻠﻎ ﺗﺨﺒﺮ ﺗﻘﻄﻊ أي ﺗﻔﻌﻞ أﻻﻟﺘﺤﺎق ﺗﻨﺼﺤﻬﻢ ﺑﺄن ﺑﺄن ﻻ ﺗﻨﺼﺤﻬﻢ ﺑﺄن ﻋﻨﻬﻢ ﻋﻮاﺋﻠﻬﻢ و اﺗﺼﺎل ﺗﻌﻴﺮﻫﻢ أي ﺑﻬﻢ ﻻ ﻳﻔﻌﻠﻮا ﻳﻔﻌﻠﻮا ﻳﻄﻠﺒﻮا ﻣﺴﺎﻋﺪة اﻟﺸﺮﻃﺔ أﺻﺪﻗﺌﻬﻢ ﻣﻌﻬﻢ ﻋﻠﻨﺎً ﺷﻴﺊ

ﻋﻠﻰ وﺷﻚ أن ﻳﺠﺮب اﻟﻜﺤﻮل ﻷول ﻣﺮة ﻳﺸﺮب اﻟﻜﺤﻮل ﻳﻮﻣﻴﺎ ﻳﺒﻴﻊ/ ﻳﻌﻄﻲ اﻟﺨﻤﺮ ﻟﻶﺧﺮﻳﻦ ﻋﻠﻰ وﺷﻚ أن ﻳﺠﺮب اﻟﻤﻮاد اﻷﺧﺮى (اﻟﻤﺨﺪرات/اﻟﻤﻨﺸﻄﺎت) ﻟﻠﻤﺮة اﻷوﻟﻰ ﻳﺸﺮب اﻟﻤﻮاد اﻷﺧﺮى (اﻟﻤﺨﺪرات/اﻟﻤﻨﺸﻄﺎت) ﻳﻮﻣﻴﺎ ً ﻳﺒﻴﻊ/ ﻳﻌﻄﻲ اﻟﻤﻮاد اﻷﺧﺮى (اﻟﻤﺨﺪرات/اﻟﻤﻨﺸﻄﺎت) ﻟﻶﺧﺮﻳﻦ

ﻫﻞ ﻛﺎن ﻟﺪﻳﻚ أي ﺗﺠﺮﺑﺔ ﻣﺒﺎﺷﺮة ﻣﻊ اﻟﺤﺮب أو اﻟﺼﺮاع اﻟﻌﺴﻜﺮي اﻟﻌﻨﻴﻒ؟ (ﻫﻞ ﻛﻨﺖ ﻓﻲ اﺗﺼﺎل ﻣﺒﺎﺷﺮ أو ﻗﺮﻳﺐ ﻣﻦ ﻫﺠﻮم ارﻫﺎﺑﻲ أو ﻣﻦ اﻟﻌﻤﻠﻴﺎت اﻟﻌﺴﻜﺮﻳﺔ اﻟﻔﻌﺎﻟﺔ) *

ﻧﻌﻢ

ﻻ

247 ﻫﻞ اﺗﺨﺬت أي ﺗﺪرﻳﺐ ﻋﺴﻜﺮي ﻟﻼﺳﺘﻌﺪاد ﻟﻠﻘﺘﺎل؟

ﻧﻌﻢ، ﻓﻲ اﻟﺨﺪﻣﺔ اﻟﻌﺴﻜﺮﻳﺔ اﻻﻟﺰاﻣﻴﺔ

ﻧﻌﻢ، ﻓﻲ ﺑﺮﻧﺎﻣﺞ ﺗﺪرﻳﺒﻲ ﺑﺎﻟﺠﺎﻣﻌﺔ

ﻧﻌﻢ، ﻣﻊ اﻟﻤﻠﻴﺸﻴﺎت أو أي ﻟﻮاء آﺧﺮ

ﻧﻌﻢ، وﻟﻜﻦ ﻓﻲ ﻣﻜﺎن آﺧﺮ (اﻟﺮﺟﺎء ﺗﻌﻴﻴﻦ ﻧﻮﻋﻪ): *

ﻻ ﻟﻢ اﺗﺪرب ﻋﺴﻜﺮﻳﺎ ﻗﻂ

ﻫﻞ ﻣﺮرت ﻓﻲ ﺣﻴﺎﺗﻚ ﺑﺄي ﺗﺠﺮﺑﺔ ﻣﺨﻴﻔﺔ، رﻫﻴﺒﺔ أو ﻣﺰﻋﺠﺔ، ﺑﺤﻴﺚ ﺟﻌﻠﺘﻚ ﻓﻲ اﻟﺸﻬﺮ اﻟﻤﺎﺿﻲ أن: *

ﻧﻌﻢ ﻻ

ﻛﺎﻧﺖ ﻟﺪﻳﻚ ﻛﻮاﺑﻴﺲ ﺣﻮﻟﻬﺎ و ﻛﻨﺖ ﺗﻔﻜﺮ ﺑﻬﺎ ﻓﻲ ﺣﻴﻦ اﻧﻚ ﻻ ﺗﺮﻳﺪ أن ﺗﺬﻛﺮﻫﺎ؟ ﺣﺎوﻟﺖ ﺑﻘﻮة ﺑﺄن ﻻ ﺗﺬﻛﺮﻫﺎ أو ﺧﺮﺟﺖ ﻋﻦ ﻃﺮﻳﻘﻚ اﻟﻤﺆﻟﻮف ﻛﻲ ﺗﺘﺠﻨﺐ اﻟﻤﻮاﻗﻒ اﻟﺘﻲ ﺗﺬﻛﺮك ﺑﻬﺎ؟ ﻛﻨﺖ ﻋﻠﻰ ﺣﺬر ﺑﺸﻜﻞ ﻣﺴﺘﻤﺮ، ﻟﺪﻳﻚ أرق و ﺗﻨﺪﻫﺶ ﺑﺴﻬﻮﻟﺔ؟ ﻛﻨﺖ ﺗﺸﻌﺮ ﺑﺎﻟﺨﺪر أو ﺑﻤﻌﺰل ﻋﻦ اﻵﺧﺮﻳﻦ، ﻋﻦ اﻷﻧﺸﻄﺔ، أو ﻋﻦ ﻣﺤﻴﻄﻚ؟

248 ﻫﻞ ﺷﺎﻫﺪت أي دﻋﺎﻳﺔ ﻋﻦ اﻟﻜﺤﻮل ﻓﻲ اي ﻣﻦ اﻟﻮﺳﺎﺋﻞ اﻻﻋﻼﻣﻴﺔ اﻟﺘﺎﻟﻴﺔ؟ *

اﻟﻔﻀﺎﺋﻴﺎت

اﻟﺠﺮاﺋﺪ أو اﻟﻤﺠﻼت

اﻟﻔﻨﺎدق، اﻟﻨﻮادي أو اﻟﺤﺎﻧﺎت

ﻟﻮﺣﺎت أو ﻣﻠﺼﻖ اﻹﻋﻼﻧﺎت

اﻹﻧﺘﺮﻧﺖ

ﻣﻮاﻗﻊ اﻟﺘﻮاﺻﻞ اﻹﺟﺘﻤﺎﻋﻲ

أدوات دﻋﺎﺋﻴﺔ ﺗﺮوﻳﺠﻴﺔ

أﺷﻴﺎء أﺧﺮى (اﻟﺮﺟﺎء ﺗﻌﻴﻴﻨﻬﺎ)

ﻫﻞ ﺗﻌﺮﺿﺖ ﻟﺼﻮرة أو ذﻛﺮ ﻟﻠﻜﺤﻮل ﻓﻲ أي ﻣﻦ اﻟﻮﺳﺎﺋﻞ اﻻﻋﻼم اﻟﺘﺎﻟﻴﻪ؟ إذا ﻫﻮ ﻛﺬﻟﻚ، ﻓﺒﺄي ﺻﻮرة ﻛﺎن ﻣﻄﺮوﺣﺎً؟ *

ﻣﻄﺎﺑﻖ ﻟﻪ ﻋﻼﻗﺔ ﻟﻢ ﻟﻠﻤﻮﺿﺔ أﻧﻴﻖ، راﻗﻲ ﻣﺴﻠﻲ، ﻳﺆدي إﻟﻰ ﻳﺴﺒﺐ اﻹدﻣﺎن و ﻟﻪ ﻋﻼﻗﺔ ﻟﻪ ﺑﺎﻟﻔﺠﻮر، أﺗﻌﺮض اﻟﺤﺪﻳﺜﺔ أو أو ذو درﺟﺔ ﻣﻤﺘﻊ أو ﺗﺮاﺑﻂ ﻳﺴﻴﻄﺮ ﻋﻠﻰ ﺑﺎﻟﻤﻮت أو ﻋﻼﻗﺔ اﻟﻔﺴﺎد ﻗﻂ راﺋﻊ ﻋﺎﻟﻴﺔ ﻣﺮﻳﺢ اﻟﺼﺪاﻗﺎت اﻷﻓﻌﺎل اﻟﻤﺮض ﺑﺎﻟﺠﺮاﺋﻢ واﻟﺸﺮ

اﻷﻓﻼم ﺑﺮاﻣﺞ اﻟﺘﻠﻔﺰﻳﻮﻧﻴﺔ اﻟﺮواﻳﺎت واﻟﻘﺼﺺ وﺳﺎﺋﻞ اﻹﻋﻼم اﻹﺟﺘﻤﺎﻋﻴﺔ (ﻓﻴﺲ ﺑﻮك، اﻹﻧﺴﺘﻘﺮام، ﺗﻐﺮﻳﺪ) ﺑﺮاﻣﺞ اﻟﺘﻠﻔﺰﻳﻮن اﻟﻮاﻗﻌﻴﺔ اﻹﻋﻼﻧﺎت واﻟﺪﻋﺎﻳﺎت اﻟﻘﻨﻮات اﻟﺪﻳﻨﻴﺔ/ اﻟﺜﻘﺎﻓﻴﺔ

Enter another option 249 ﻋﻦ أي ﻃﺮﻳﻖ ﺗﻮﺻﻠﺖ اﻟﻰ ﻫﺬه اﻟﺪراﺳﺔ اﻻﺳﺘﻘﺼﺎﺋﻴﺔ؟

اﻟﺘﻌﻠﻢ اﻹﻟﻜﺘﺮوﻧﻲ اﻟﺠﺎﻣﻌﻲ (ﻣﺜﻼ Moodle)

وﺳﺎﺋﻞ اﻟﺘﻮاﺻﻞ اﻹﺟﺘﻤﺎﻋﻴﺔ اﻟﻤﺨﺘﺼﺔ ﺑﺎﻟﺠﺎﻣﻌﺔ ﻓﻘﻂ

ﺟﻤﻌﻴﺔ أو ﻣﻨﻈﻤﺔ ﻟﻠﻄﻠﺒﺔ

وﺳﺎﺋﻞ اﻟﺘﻮاﺻﻞ اﻹﺟﺘﻤﺎﻋﻴﺔ (ﻓﻴﺲ ﺑﻮك، أو ﺗﻮﻳﺘﺮ)

اﻟﻌﺎﺋﻠﺔ اواﻷﺻﺪﻗﺎء

ﻋﻨﺪ ﺣﻀﻮرك ﻟﻤﺤﺎﺿﺮة أو دورة ﺗﻌﻠﻴﻤﻴﺔ ﻓﻲ اﻟﺠﺎﻣﻌﺔ

ﻣﻦ ﺧﻼل ﻃﻠﺒﺔ أو ﻣﻮﻇﻔﻲ اﻟﺠﺎﻣﻌﺔ

ﻋﻦ ﻃﺮﻳﻘﺔ أﺧﺮى ( اﻟﺮﺟﺎء ﺗﻌﻴﻴﻨﻬﺎ)

250 Appendix 6: Interview guide (English/Arabic)

Introduction As you know Iraq is a nation in a state of change. The country has experienced some difficult times. I would like to talk with you about the role of alcohol and possibly other drugs in Iraq and your experiences and views. كما تعلم ان العراق هو دولة في مرحلة التغيير. العراق واجه الكثير من المصاعب. انا اود ان اتكلم معك حول دور الكحول والمخدرات االخرى في العراق خالل تجاربك ووجهات نظرك. Question 1 Have attitudes changed towards alcohol in society over the generations? Can you give some examples of this i.e. in relation to your friends and family? What has changed and why do you think this is? هل تغيرت وجهات النظر نحو الكحول في العراق عبر االجيال؟ هل ممكن ان تعطيني بعض االمثلة. ما تغير ولماذا حدثت هذه التغيرات. Question 2 Iraq has suffered from sanctions, wars, terrorism and political instability. Do you have any stories to share where alcohol or other drugs have played a role in the lives of today’s university students who have lived most of their lives under these conditions? (start with alcohol, then ask about other drugs if no story) كما تعلم ان العراق عانى من عقوبات دولية، حروب، ارهاب وعدم استقرار الوضع السياسي. هل لديك اي قصة تحب ان تقولها حول كيف الكحول او المخدرات االخرى لعبت دور في حياة طلبة الجامعة الذي عاشوا أكثر وحتى جميع حياتهم تحت هذه الظروف ؟ Question 3 Since 2003, Iraq has been at increased exposure to the international world. How do you think Iraqi students have been influenced by this exposure and how are they conflicted with traditional values – with specific mention about attitudes towards alcohol. منذ 2003, العراق انفتح أكثر الى المجتمع الدولي. كيف؟ وهل تعتقد ان هذا االنفتاح أثر على طالب الجامعات في العراق – وخصوصا نسبتا الى وجهة نظرهم للكحول؟ Question 4 One interesting point about Iraq that is overlooked is the diversity that exists within this country – religious, ethnic, social, and cultural. Do the different groups in Iraq think about and use alcohol differently? Can you give me some examples? يتميز العراق بتعدد الثقافات واالجناس – فهل تعتقد ان هذا االمر يؤدي الى افكار مختلفة نحو الكحول في العراق. هل ممكن ان تعطيني اي امثلة؟ Question 5 Imagine an Iraq where there was the best public health policy related to alcohol; What would it look like? تخيل لو ان العراق دولة مثالية، ما هي السياسة التي سيتبعها تجاه الكحول؟ وكيف ستكون؟ Question 6 Would you like to add anything else? هل تحب ان تضيف شيئا اخر؟

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