Social norms and attitudes linked to waterpipe use in the Eastern Mediterranean Region
Introduction
The prevalence of waterpipe tobacco smoking (WTS) in the Eastern Mediterranean region (EMR) is alarmingly high and increasing, especially among youth populations where it is surpassing cigarette smoking (Akl et al., 2011, Maziak, 2008). The Global Youth Tobacco Survey measures tobacco use rates among 13–15 year olds and indicated that in all 17 countries of the region, use of other tobacco products (most likely referring to the waterpipe) was more common than use of cigarettes; with this trend increasing in seven countries and unchanging in 8 countries over time (Warren et al., 2009). Similarly, waterpipe use seems to be on the rise among women (Tamim et al., 2003) and is perceived to be more acceptable than cigarettes (Dar-Odeh and Abu-Hammad, 2011, Maziak, Eissenberg, et al., 2004, Maziak, Rastam, et al., 2004).
WTS is not a safe alternative to cigarettes; and research suggests health effects equal to or worse than those of cigarettes (Al Rashidi et al., 2008, Cobb et al., 2010, Maziak, Eissenberg, et al., 2004, Radwan et al., 2013, Sepetdjian et al., 2013, Shihadeh and Saleh, 2005). Studies using smoking machines to test toxicant yields in lab environments found that waterpipe tobacco smoke contains carbon monoxide, polyhydrocarbons, formaldehyde, nitrogen, nitric acid, nicotine (Rastam et al., 2004, Shihadeh and Saleh, 2005) and other toxicants such as arsenic, chromium, lead and volatile aldehydes (Al Rashidi et al., 2008), as well as phenols and phenol derivatives – chemicals that promote DNA mutations and cardiovascular diseases (Sepetdjian et al., 2013). Human laboratory studies have also indicated disease-related physiologic responses and carcinogens in body fluids as a result of WTS (Eissenberg and Shihadeh, 2009, Maziak et al., 2009, Radwan et al., 2013). Reviews have identified cancers and other chronic diseases as associated health risks, as well as the spread of infectious diseases, such as tuberculosis, due to sharing waterpipes (Akl et al., 2010, Maziak, Ward, et al., 2004, World Health Organization, 2005). The health risks of WTS remain largely unrecognized by the smokers (Cobb et al., 2010, Maziak, 2008). For example, a qualitative study in Syria reported people's views of waterpipe smoking as a pleasurable pastime among friends with no regard to health consequences (Hammal, Mock, Ward, Eissenberg, & Maziak, 2008). Increasing use may also be attributed to the misconception that the water in the waterpipe apparatus through which the smoke passes, cleans the toxic substances. In a study conducted with female university students recruited in waterpipe cafés in Cairo, Egypt, the majority preferred smoking waterpipe because it is perceived to be less harmful than cigarettes (Labib et al., 2007).
Other non-health related reasons, such as lack of social constraints on waterpipe smoking, the introduction of new flavoured and aromatic waterpipe tobacco (Moassel), and the effect of media on marketing waterpipe as socially acceptable, are also provided for smoking the waterpipe (Chaaya et al., 2003, Dar-Odeh and Abu-Hammad, 2011, Hammal et al., 2008, Khalil et al., 2013, Labib et al., 2007, Maziak, Eissenberg, et al., 2004, Maziak, Rastam, et al., 2004, Yegenoglu et al., 2006). The rise in use of waterpipe may also be fuelled by economic motivations of business owners on one hand and lack of policy regulatory frameworks on the other (Nakkash, Khalil, & Afifi, 2011).
Our understanding of the reasons for using waterpipe comes mainly from quantitative surveys. Though these provide important information on prevalence and scope of use, as well as reasons for use, they often lack in-depth understanding of the emic nature of a particular experience. A more thorough understanding of patterns and reasons for use is important for the development of interventions to prevent use of waterpipe. The current research aims to expand our knowledge about the personal, social, and community factors contributing to the rise in WTS using qualitative methods, among four countries of the region.
Section snippets
Methods
The main research question was: what are the social norms and attitudes that lead to waterpipe being a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean Region? Both focus group discussions (FGD) and key informant interviews were used. Whenever possible, FGDs occurred in their natural setting (natural group discussions) allowing the researcher to capture the social and cultural dynamics of WTS such as waterpipe smokers' interaction with each other,
Results
The ten themes emerging from the data, along with related quotes are described below. Specific quotes from the interviews and FGDs are identified in terms of country, gender of the participant and smoking status.
Discussion
This research revealed a number of norms and attitudes linked to the increasing use of waterpipe tobacco smoking among all segments of the population in the Eastern Mediterranean region. Overall, economics, social and health attributes were identified.
Conclusion
Results of this research have implications for policy and practice. The Ecological Model of Health Promotion (McLeroy et al., 1988) suggests that interventions at the individual, interpersonal, organizational, community and policy levels are necessary for behaviour change. The range of themes suggested by participants confirms this approach.
Starting with the individual level of the Ecological model, curiosity, boredom and personal will were found, among others, to influence people's behaviour
Acknowledgements
The authors would like to thank all those who participated openly in the interviews and focus group discussions and provided insight into the waterpipe tobacco smoking phenomenon.
This research was funded by a generous grant from the International Development Research Centre, Research for International Tobacco Control.
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