Beliefs and attitudes related to narghile (waterpipe) smoking among university students in Syria☆
Introduction
Although surveillance data about the spread and time trends of narghile (waterpipe) smoking is lacking in the Eastern Mediterranean region (EMR), anecdotal evidence suggests that this smoking method is witnessing a dramatic increase in popularity (1). This method of tobacco use is centuries old, originating in India and acquiring status during the Ottoman Empire. However, its popularity had been declining until recently in many Arab societies, with most users being older males 2., 3.. In recent years, however, this dying tobacco use method has become a universal phenomenon with café houses that serve narghile proliferating from Kiev to Paris and New York to Montréal 4., 5., 6.. Historically, tobacco use surveys in the EMR did not inquire about narghile because of its limited use (7), though recent youth surveys in this region indicate that about 10% of adolescents between 13 and 15 years of age use tobacco products other than cigarettes, most likely narghile (8). In some populations, such as university students and pregnant women, narghile smoking is practiced by a quarter of respondents 9., 10., 11., 12..
Unlike smoking cigarettes, traditional pipes, or cigars, smoking a narghile is a communal experience—more akin to the Native American tradition of passing a peace pipe. This communal experience is apparent in Syria: the majority of students who smoke narghile initiated smoking, currently smoke, and even share the same narghile with friends (11). People in the EMR seem to perceive narghile smoking as a cultural-bound ritual that characterizes the relaxed nature of people and their fondness of socialization with others. Offering guests a narghile or sharing narghile with sons or daughters is not unusual. In contrast, cigarette smoking represents the practical and stressful life of the West 2., 13. and, of course, sharing cigarettes with guests or children is unusual. An important component in the socio-anthropological equation of narghile according to Kamel Chaouachi of the University of Paris lies in the peculiar conviviality the artifact generates. He identifies three main elements related to this issue; the play with the smoking hose, the conversation of actors, and the nature of time within the created situation (13).
Our initial findings indicate that university students in Aleppo, especially females, tend to start smoking and share narghile with their family members (11). This sharing among family members is particularly important because, traditionally, families in Syria view cigarette smoking by their younger members, particularly girls, very negatively. Preliminary qualitative data from Arab-American adolescents suggest that they do not perceive using narghile as smoking, per se, and that this type of tobacco use is viewed by parents as acceptable family social activity (14). If narghile use among families, and particularly among young girls within families is a vector for increased narghile use, reliable information about family attitudes towards their young members' narghile (and cigarette) smoking is needed to advance our understanding of tobacco use patterns within the Syrian society and to help predict its future trends.
There is a general belief that, because narghile smoke is passed through water before it is inhaled, it is cleaner and thus less harmful than cigarettes (2). Very little research however, is available to address these beliefs, despite the increasing awareness of the critical need for tobacco control research in developing countries 1., 15.. Still, from the little available information, narghile is likely to be as harmful and addictive as cigarettes, and has the potential to become a major public health problem in the EMR 3., 16., 17., 18., 19..
Social cognitive theory (SCT) was used as a conceptual framework for this set of analyses (20). SCT has been used widely to understand the determinants of smoking initiation by adolescents and young adults 21., 22., 23. and posits that a number of personal, social, and environmental factors influence smoking behavior dynamically. Personal factors include physiological, affective, and cognitive responses to smoking (e.g., responsiveness to nicotine effects, perceived benefits of engaging in this behavior, perceived health risks). Social/environmental factors central to this framework include modeling and social support from peers and family, and access and opportunities to engage in the behavior.
The current study uses data from a cross-sectional survey of students at Aleppo University in Syria to examine beliefs and attitudes about narghile and cigarette smoking.
Section snippets
Methods
This study's target population was the 43,000 students (student population in 2001) of Aleppo University, the second largest university in Syria located in the most populated Aleppo province [about one quarter of the total Syrian population, estimated at 17,500,000 reside in Aleppo (24)]. This study was a cross-sectional survey of a randomly selected sample from this student population, using an interviewer-administered questionnaire. On the Aleppo University campus there are 12 men's and 7
Results
Despite the youth of the study population narghile use is quite popular, with about half of students reporting having ever used narghile and about one quarter of male students currently smoking it. Basic characteristics of the study population in relation to narghile smoking are shown in Table 1.
Responses to the three questions asked to all participants about what they like or dislike most about narghile, and about their opinion of what is the main reason behind the recent surge in narghile
Discussion
This study provides some of the first data regarding beliefs and attitudes about narghile smoking in the EMR. These data are relevant to an increased understanding of narghile's current surge in popularity, its future trends, and about possible ways to curb its spread. We believe that assessing practices and opinions related to narghile among university students represents an important starting point, because smoking habits in Syria typically begin around this age (28), and also because
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This work was supported by USPHS grants R01 TW05962, R21 TW006545, and DA11082.