Waterpipes are becoming increasingly popular throughout the Eastern Mediterranean region (EMR), and are spreading around the world.1^–3 There is growing evidence that waterpipe smokers have many of the adverse health effects seen in cigarette smokers, including pulmonary disease,4 5 lung cancer,6 7 coronary heart disease,8 and adverse birth outcomes.9

In Syria, little is known about why people start using narghile (Syrian waterpipes), if their patterns of use and perceptions about smoking are different from cigarette smokers, and whether they are interested in quitting. We undertook this study to begin to explore Syrian narghile smokers’ feelings, thoughts, perceptions, and experiences using narghile, and to compare them with those of cigarette smokers. Our objective was to begin to describe the cultural “landscape” of narghile smoking by exploring how smoking is embedded in the realities of smokers’ everyday lives.10 This study summarises our exploratory findings about narghile use and cigarette smoking from the perspectives of smokers in Aleppo, Syria.

The history of the narghile in Syria remains murky. However, Syrians are known to have used narghile for many generations, if not centuries.1 Contemporary Syrian narghile are handcrafted cultural objects with aesthetic as well as functional properties. The typical narghile forms a sinuous hourglass-like figure and is made of several parts (fig 1). The base of a narghile is a vase-like chamber made of coloured blown glass, often adorned with hand-painted decorations. Atop the chamber, which is filled partially with water, sits a decorative brass or wooden column with a long brass tube (stem) at its core. The bottom of the stem is submerged in the glass chamber. The rest of the stem rises up through the decorative column and is crowned with a small ceramic bowl and a brass disk for catching ash. Near the middle of the column is a fixture to which a smoking hose (approximately 1 m in length) is attached. Typically, the smoking hose has a wooden grip that forms the mouthpiece and is decorated with fabric and elegant tassels.

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Figure 1 A typical narghile.

A host in a café or a narghile smoker at home usually takes some time to prepare a narghile by placing rough-cut aromatic tobacco or maassel (fruit-flavoured, sweetened tobacco) into the bowl, covering the bowl with perforated aluminium foil, and placing a piece of hot charcoal on the foil to heat the tobacco or maassel. The smoker, typically seated in a comfortable place with other smokers, will hold the smoking hose and inhale through the mouthpiece. The smoker’s sucking action produces negative pressure inside the chamber, which in turn draws smoke from bowl down through the stem, bubbling through the water in the chamber, and out through the hose into the smoker’s mouth and lungs. Smoking sessions can last from 15 min up to several hours. Disposable plastic mouthpieces can be added, ostensibly to limit the spread of disease. The size of the narghile, number of hoses, and other features differ widely.

In Syria, we estimate that 20% of men and 5% of women smoke narghile regularly (ie, at least once per month), based on studies we have conducted in Aleppo (Halab), Syria’s second largest city (population 2.5 million).11 In Aleppo, narghile experimentation and occasional use have been especially common among young men (63%), and among young women (30%).12 Cigarette smoking is very common among Syrian men (57% reporting daily or occasional use during the past month), but much less common among women (17%).11 Mean (SD) daily consumption for the daily cigarette smokers was 20.8 (14.0) vs 1.4 (0.8) for narghile smokers.11 As is the case throughout the EMR, tobacco prevention and cessation support in Syria has been limited.

Although there have been social changes in Syria in recent years, Syrian society remains conservative and closed. Health generally, and tobacco use in particular, can be sensitive topics. In Syria, very few ethnographic or other types of qualitative studies have ever been conducted about health. Searches of databases on ethnographic research and PubMed using “Syria” and “health” show that only two qualitative health studies have been published since 1975. Ours is one of the first attempts to conduct such research in Syria.

METHODS

The Institutional Review Boards of the University of Memphis and the Syrian Society Against Cancer approved the following protocol for this exploratory study. We recruited adults (⩾18 years of age) in Aleppo through newspaper advertisements and word-of-mouth to participate voluntarily in a one-to-one interview about their tobacco use. We selected adults who identified themselves as currently being a “narghile smoker” or currently being a “cigarette smoker”. We focused primarily on recruiting respondents who smoked exclusively in one mode or the other, but we also included some individuals who did not smoke exclusively in one mode as long as they identified themselves as being a “cigarette smoker” or a “narghile smoker”, smoked predominantly in one mode, and smoked only occasionally in the other mode. In total, we interviewed 32 adults; 16 cigarette smokers and 16 narghile smokers. To conduct the interviews, we followed an interview guide that covered smoking initiation, current patterns of use, dependence, perceptions about health effects, interest in quitting, previous quitting experiences, and opinions about what might aid quitting. The interviews lasted 20–60 min, and we took notes and audiotaped the interviews. Additionally, we conducted some observations of narghile smoking and cigarette smoking in public settings.

We started this study with “explorer’s eyes” and without being driven by an a priori hypothesis. As we collected data, transcribing of the audiotapes occurred almost immediately, and then basic content analysis techniques were used to analyse the interviews to identify themes among the narghile smokers and among the cigarette smokers. This iterative approach allowed us to identify themes that were new, themes that were repeated, and questions that we needed to modify or include to enhance our understanding.13 We conducted our final analysis after conducting all 32 interviews.

This paper presents our findings about themes that emerged among cigarette smokers and narghile smokers. To show the comparison of these two groups, in the findings reported below we cover each topic, first presenting themes from our interviews with the cigarette smokers followed by themes from our interviews with the narghile smokers. Where appropriate, we have included quotations from the interviews to give the reader a clearer sense of common themes and patterns. We have also included quotations that reflect interesting but less common viewpoints and experiences.

RESULTS

The participants held varying occupations: 11 service employees, 8 self-employed, 5 students, 3 labourers, 3 housewives, a health worker, and a physician. The average age of the cigarette smokers was similar to the narghile smokers (table 1). In each group, we were able to recruit three women. A total of 12 of the cigarettes smokers and 11 of the narghile smokers smoked in one mode exclusively. On average, the cigarette smokers had smoked longer than the narghile smokers, had started earlier, and smoked more frequently. Whereas all of the cigarette smokers smoked multiple cigarettes daily, the narghile smokers smoked once or twice a day, or in some cases less than daily. All except one of the cigarette smokers felt that their family did not accept their smoking, but the narghile smokers varied in their sense of acceptance. Most of the cigarette smokers had tried to quit but relapsed for various reasons. Only three of the 16 narghile smokers had ever tried to quit.

Smoking initiation

Most cigarette smokers talked about starting smoking in their teens, usually with friends, with family members at home, or during military service. They talked about how cigarette smoking was normal and acceptable for males. Cigarette smokers gave different explanations about their motivations for starting, including peer pressure, social norms, curiosity, expressing masculinity, and aspiring to enter adulthood. For example, a male 19-year-old daily cigarette smoker reported:

I was 14. I was walking in the street with my friends. They offered me a cigarette. At the beginning I refused, then I caved in. Since my adolescence, my parents warned me giving advice about the harmful effects of smoking, but one cigarette after another, I got captured.

However, not all cigarette smokers started with others. A 25-year-old woman said:

At the beginning I started alone, then smoked with my friends. I was 16. I wanted to try it. It was kind of curiosity. I was at home. I took one of my mother’s cigarettes and I got started.

Most cigarette smokers initially had negative experiences, saying that in the beginning smoking cigarettes was awful, tasted bad, and caused them to feel dizzy and cough. Nevertheless, they persisted, often to avoid being embarrassed by friends.

By contrast, more of the narghile smokers started in their 20s. Many talked about starting narghile to share a “pleasure among friends”. Their motivations varied from curiosity to wanting to fill free time, seeking entertainment, being influenced by the atmosphere in a café and peer pressure. Many narghile smokers had a pleasant initial experience and found smoking maassel particularly pleasant. The physician, who was a daily narghile smoker said:

Due to the boredom of having free time, I used to go with my friends to a café. When they invited me to try narghile, I found it interesting and good. I felt some dizziness, but I enjoyed the taste and the smell. It was fun. And so I became a daily smoker.

Others reported that they enjoyed the feeling of smoking narghile, including extreme euphoria that made them relaxed. A few narghile smokers reported that they had started smoking narghile as a substitute for cigarettes because smoking narghile was widely available, socially acceptable, and based on the popular perception that the narghile is less harmful than the cigarette, particularly in the context of attempting to quit cigarette-smoking. A 30-year-old man who smoked narghile 5 times per week said:

When I quit cigarettes, I started smoking narghile in public places. I go out with my friends. They are all [narghile] smokers. I smoke [narghile] with them to entertain myself and because I do not want to be different. When I could not smoke cigarettes for a while I feel I need narghile. Why do I smoke [narghile]? Because it is an alternative, or a substitute for cigarettes.

Some also said they smoked narghile as a substitute for drinking alcohol. Two reasons were cited; narghile did not give them the side effects of drinking alcohol, and consuming alcohol is forbidden for Muslims while smoking tobacco is not. For example, a 41-year-old male daily smoker said:

Drinking alcohol has immediate effects, and could cause nausea and headache and so on. The narghile gives me the effects of alcohol, makes me relaxed and improves my mood, without side effects. I have only a good time and enjoy myself.

Perceptions about important effects of smoking

Cigarette smokers had varying perceptions about the effects of smoking. Several common themes emerged, namely that smoking cigarettes helped them to concentrate, to cope with their troubles, to calm down, and to vent (literally “to blow your anger with the smoke of the cigarette”). However, some felt no benefits such as a 26-year-old male cigarette smoker who had been smoking since age 14 who said:

I do not feel that smoking cigarette helps me. I just smoke as a habit or routine. It does not make me relaxed when I am nervous, but everyone around you when angry says smoke a cigarette and calm down. But in reality nothing happens.

By contrast, many narghile smokers used narghile as a leisure activity or to create a pleasurable ambiance for social gatherings or intimate conversations. At social gatherings, smoking the narghile made the event fun and festive. For more intimate occasions, they found that smoking narghile brought people to sit together and spend time in conversation. Others used narghile to create a sense of equanimity and happiness, to relax, or as a way to escape from life’s concerns. For example, a 41-year-old male daily narghile smoker said:

The narghile is good and fun. It helps me reduce tension. When we gather to smoke narghile, we know it is a gathering for serenity and joy. It helps me to feel cheerful and relaxed.

Similarly, a 33-year-old male health worker who smoked narghile daily said:

When I smoke narghile, I forget my thoughts and worries about the life and work problems and difficulties. It helps me fill my time. It gives me support and comfort.

Perceptions about addiction

The cigarette smokers talked about their smoking in terms of being addicted, ie, feeling cravings, feeling an inability to reduce their smoking, having difficulty trying to quit, and feeling withdrawal symptoms when attempting to quit. Some felt their addiction to cigarettes was oppressive, namely that it dominated them so completely that they had become a slave to their cigarettes. A few of the cigarette smokers used narghile as an occasional alternative or a “back up” to deal with their cigarette addiction when cigarettes were not available due to logistical reasons (eg, being in an isolated area or craving a cigarette after shops had closed).

Those who smoked narghile daily reported several signs and symptoms of nicotine dependence, including increasing the frequency and intensity of smoking over time, the perceived need to smoke narghile daily, smoking more than one narghile daily, difficulty quitting, and experiencing withdrawal symptoms during abstinence. We found that for daily narghile users, the intensity of addiction varied. For example, a 40-year-old woman expressed sentiments suggesting that she was highly addicted saying:

I like to dominate everything, but the narghile has completely dominated me. That bothers me. My happiness is related to the narghile. It is essential for having a good time. And if we cannot smoke, we feel bored. And for sure, I do not want to quit.

The 33-year-old male health worker described his use as being regular while being susceptible to contextual triggers explaining:

I usually smoke narghile once daily, but sometimes I smoke more. Because even when I have already smoked it, seeing or smelling narghile makes me feel that I need to smoke again, and I usually do smoke.

A daily female smoker described features of addiction yet felt that she could manage her use depending on the context saying:

If I cannot smoke, I feel restless and tired. I do not smoke narghile as a compulsive behaviour. It is not like drugs. I do not smoke when the ambiance is not suitable. When I travel to visit my parents, I do not smoke. Their home environment is not encouraging and I do not feel an urge to smoke. I crave the narghile from 7 till 10 in the evening, then this feeling goes and I forget the narghile.

Unlike daily narghile users, occasional users did not generally perceive narghile to be addictive. For example, a male narghile smoker who believed that he was not addicted said:

I do not go out very often, but when I go out for leisure time, smoking narghile has to be in my plan.

Individuals who smoked cigarettes daily but only occasionally used narghile described narghile as not being an adequate substitute for cigarettes. A 20-year-old man who was primarily a cigarette smoker said:

I don’t feel that the narghile fills my need like cigarettes. It is for spending time and entertainment. I don’t feel that I’m addicted to narghile, and I could quit narghile any time. I have thought about quitting cigarettes, but not the narghile, because our society is more tolerant to narghile than cigarettes.

Perceptions about the health effects of smoking

Nearly all of the cigarette smokers expressed concerns about the negative health effects of smoking, particularly that it caused cancer, heart disease, and lung disease. Most had become aware that cigarette smoking had affected their health, for example a 46-year-old male daily cigarette smoker said:

When I think about the cigarettes, I think about the cancer and the other serious diseases. This bothers me a lot but I ignore it, and I keep smoking.

A 32-year-old mole daily cigarette smoker mentioned:

The cigarette hurts the body. It causes atherosclerosis and heart disease. In addition, it has negative financial effects, and many social drawbacks.

Among cigarette smokers another common theme was the effects of second-hand smoke (SHS) on their family’s health. In the context of questions about SHS, a 22-year-old male daily cigarette smoker said:

I heard that when you smoke you hurt the people around you more than yourself.

By contrast, narghile smokers did not express concerns about the long-term health effects of smoking narghile. They tended to perceive smoking narghile as being much less harmful than smoking cigarettes, saying for example:

I do not worry about narghile. I do not feel it is harmful. It is not more than entertainment. We have not heard about anyone who had a health problem because of the narghile.

A few narghile smokers talked about the immediate effects on their physical functioning, citing chest distress, palpitations, or their inability to exert themselves. The narghile smokers did not mention concerns regarding SHS from narghile except for one woman. The limited knowledge about the poteneial hazarcly that several narghile smokers shared was similar to that of a 41-year-old female daily smoker, who said:

My husband smokes [narghile] and I’m waiting for my 4-year-old son to get older so that we can all smoke together.

The one narghile smoker who expressed some resentions about the effeds of SHS was a 40-year-old female daily smoker. She said:

I stopped smoking narghile at home for 6 months when I had new baby, and my husband wanted me to do that too. I’m sure narghile smoke is not good for newborn babies”.

Social implications of smoking

Cigarette smokers talked about the social drawbacks of smoking cigarettes, particularly the offensive odour. A common theme was about how attitudes towards smokers had changed in Aleppo. Young smokers were especially concerned about family disapproval and rejection, because cigarette smoking was unaccepted behaviour in their families due to the family perceptions and values. A 46-year-old cigarette smoker commented:

The society has developed, and as a smoker you are not always welcome with your cigarette.

Narghile smokers felt that narghile was generally socially accepted, but that non-smokers did not find it entirely acceptable. Among the eight younger narghile smokers, six said that their parents did not mind them smoking. Only two said that their parents did not know about their narghile use and would be upset if they found out because, based on their own experience, they were aware that narghile use produces adverse health effects. Some narghile smokers reported that their smoking restricted their friendships such that relationships with friends who did not smoke narghile grew worse. Narghile smokers found themselves socialising almost exclusively with other narghile smokers.

Motivations and attempts to quit

Among the cigarette smokers, the pervasive pattern was to attempt to quit and then relapse. A total of 13 had attempted to quit at least once, all without professional help. Most of the cigarette smokers had tried to quit because of health concerns. Other motivations for quitting included feeling stigmatised for being a smoker and shame for not having the willpower or ability to quit, and perceiving health benefits from quitting for their family. Perceived health benefits for family members included reducing the tobacco exposure of unborn children (for pregnant women) and infants and children in the home, and the desire to be a good role model for their children. Several cigarette smokers experienced benefits from attempting to quit such as being able to breathe better, having more stamina to work, and more happiness within their family. Most expressed some interest in trying to quit again, but few had any specific plans. Some were totally discouraged because they had lost confidence in their ability to quit. Others did not seem to be serious in their intention to quit, saying that they might try to quit at some undefined time in the future. A few had no interest whatsoever in quitting.

When cigarette smokers talked about relapsing, the negative influence of friends was a pervasive theme. A 36-year-old male who quit for 5 years said:

I was happy when I quit. My health improved. My body was more active and I did not feel tired. My appetite had increased…I relapsed because of my friends. They were all smokers. They kept offering me cigarettes. I would not have started again if they had not pushed me.

Another common theme that emerged among cigarette smokers was about how their relapse was triggered by arguments with family members such as a spouse, children, or parents. Several cigarette smokers cited narghile as a trigger for relapse. A 36-year-old daily cigarette smoker explained:

I quit smoking for more than 6 months. Then, I was invited to smoke narghile. After the second puff I asked for a cigarette and I started again.

By contrast, nearly all of the narghile smokers expressed no interest or motivation to quit. Only three had ever attempted to quit, and they had difficulty and experienced withdrawal symptoms. Some narghile smokers were enthusiastic, for example saying, “definitely I will keep smoking 5 years from now”. Most did not see anything bad about narghile, and did not feel any stigma or sense of shame. A few wanted to cut back on their smoking. Two narghile smokers who had attempted to quit did so because of health problems, and one had tried to quit because he was a health worker and knew about the health hazards of smoking narghile. A 32-year-old daily narghile smoker described his experience, saying:

I once tried to quit, but I could not manage without smoking narghile for more than 2 days. I felt the craving, and during those 2 days, I tried to fill my time with something else because as long as I had free time, I thought about the narghile”.

What might aid quitting?

Many cigarette smokers talked about “conviction” and “will” as the most important factors in quitting. Many mentioned that physicians could aid quitting. Beyond these two common themes, cigarette smokers had various other ideas about what might aid quitting. Some talked about broader approaches such as media campaigns designed to push smokers to think about quitting. Others were waiting for a health incident to force them to quit, or some new medication.

Although most narghile smokers expressed no interest in quitting, they had similar beliefs as the cigarette smokers about “will” being an important factor for quitting narghile. The narghile smokers were generally sceptical that smoking narghile caused significant health problems. The few who believed that smoking narghile was hazardous felt that most people were ignorant about the harms of narghile use. A few narghile narghile smokers even believed that quitting narghile was more difficult than quitting cigarettes. One who had smoked narghile for 10 years summed up this perception saying:

It is very difficult to stay away from the ambiance of narghile. Wherever you go for entertainment, there is always a narghile.

DISCUSSION

For many of the Syrians we interviewed, smoking narghile was in essence a pleasurable social experience. Smoking cigarettes was, by contrast, a mundane personal addiction. Based on the interviewees’ characterisations of their experiences, we found that smoking narghile had much greater social and cultural significance than smoking cigarettes. We found that narghile smokers considered narghile to be a cultural feature of life in Aleppo, in much the same way that hummus and tabuleh are served in social gatherings and quintessentially part of Syrian culture. This view is probably rooted in the long history of narghile use in Aleppo, and in its continued widespread use in contemporary Aleppo society.

By contrast, cigarette smokers told us that smoking cigarettes was just a repetitive activity in daily life with no particular connection to the culture of Aleppo, or to creating a culturally rich ambiance for socialising. We found that when most cigarette smokers started smoking, smoking cigarettes had an important social dimension, but this social dimension of smoking faded with time and as adults they no longer smoked to socialise with others. Rather, their cigarette smoking had become more a personal and private activity. Most narghile smokers started as part of socialising, but in contrast to cigarette smokers, the adult narghile smokers continued to find narghile smoking to be a social activity.

For male smokers, taking up cigarette smoking appeared to have stronger associations with projecting masculinity than did taking up smoking of narghile. The participants recalled that during their childhood, boys perceived smoking cigarettes as a symbolic rite of passage much more so than smoking narghile. For male cigarette smokers, the common pattern was to start in their early- to mid-teens to project their masculinity and keep in stride with other boys, or because other boys thrust cigarettes upon them. By contrast, narghile smokers started indulging in narghile as mature young men and women during the period when they were forming a sense of cultural identity. Narghile use has more to do with experiencing adult social life, and less to do with expressing masculinity. Sitting together in cafés around a narghile, young adults of both genders accepted friends’ invitations to join in smoking narghile as a way to enhance an ambiance of relaxation, and to pass time enjoying intimate friendships. Because narghile is a cultural fixture in Aleppo, narghile smokers did not feel a sense of shame about smoking. Generally, they perceived smoking narghile as being more acceptable socially than smoking cigarettes or drinking alcohol.

Narghile smokers talked about smoking narghile as an experience that appeals to all of the senses: sight, touch, hearing, smell, and taste. From the first experimental puff, the narghile smokers found narghile to be an aesthetic, and sometimes even ecstatic experience that can produce a sense of euphoria. Those who smoked narghile occasionally continued to find it pleasurable and seemed to avoid nicotine dependence.

In biomedical terms, the key components of nicotine dependence, or addiction, include tolerance (diminished effects with continued use of the same amount of nicotine, or need for increased amounts of nicotine to achieve psychoactive effects), greater use of nicotine than intended (in terms of either amount used or length of time of use), interruption of important social, occupational, or recreational activities because of amount of time spent using nicotine, continued use despite physical, psychological, or social problems that result, unsuccessful attempts to cut down or quit, and the occurrence of withdrawal symptoms during prolonged abstinence or use reduction.14 Tobacco dependence also has important social and cognitive factors such as pairing of tobacco use with social and emotional stimuli, having expectations about effects, and using tobacco as a coping response.15 16

The cigarette smokers we interviewed experienced most of the established physiological, social, and cognitive dimensions of tobacco addiction. Cigarette smoking was addictive and provided some relief from anxiety in exchange for a persistent, nagging sense of domination. Some of those who smoked narghile frequently also experienced intense cravings and felt that narghile had become a dominating addiction, like smoking cigarettes. However, among daily narghile smokers we found a range of addiction experiences. Some experienced moderate symptoms of addiction but were susceptible to contextual triggers. Others felt that they were capable of managing their addiction depending on the context.

Most cigarette smokers were concerned about the negative health effects of smoking cigarettes and had attempted to quit. Those we interviewed had failed primarily because they were around family and friends who still smoked and they could not resist the temptation. This experience is consistent with findings from other research in Syria.17 Cigarette smokers were also aware that cigarettes produce smoke that was harmful to family members and others around them. Some cigarette smokers were motivated to quit because of the changing values within their families and their desire to be good role models for children.

By contrast, narghile smokers said they were generally not interested in quitting because they believed that narghile was far less hazardous to health than cigarette smoking. This perception seems to have arisen because of the presumed water filtering properties of the narghile, smokers’ intermittent patterns of use, and the absence of health information based on scientific evidence about the effects of smoking narghile. Also, narghile smokers did not seem to have any concerns about whether the plumes of heavy narghile smoke might affect the health of others. The widespread availability and acceptance of narghile in social settings made it particularly difficult for narghile smokers to contemplate quitting. Another important pattern is that some narghile smokers intentionally switched to narghile after quitting cigarettes to satisfy their craving for nicotine. For some, smoking narghile led them back to smoking cigarettes.

Regardless of preferred mode of smoking, the participants believed that quitting is a matter of conviction and willpower. There was a general perception that physicians might be able to help smokers quit. Narghile smokers had no recommendations about quitting, largely because they continued to derive pleasure from smoking and did not experience burdensome negative effects such as stigma or ill health.

There are some limitations to this study. As is common with qualitative studies, the number of individuals in this study is relatively small and limited to one geographic area. Therefore, while the study provides insights into the range of themes within these two groups, we cannot make broad generalisations about the Syrian population as a whole. We found it difficult to recruit women, so women’s perceptions and experiences are not as well represented. We did not restrict the study to only those who smoked exclusively in one mode or the other. This introduced some variation in experience within groups. However, the incusion of non-exclusive smokers proved to be beneficial because they could compare their predominant mode of smoking to their experiences with the other mode. Additionally, the study does not suffer from a “misclassification bias”, because the participants classified themselves based on their perceptions of their own identities.

Overall, while the number of interviews is small, the volume of interview data was sufficient for this exploratory assessment. More in-depth interviews and observations will be necessary to fully understand the nature of narghile smoking and cigarette smoking in Syria, especially to understand addiction and compare men and women in each group to learn about their experiences with aspects of smoking such as initiation, family acceptance and things that would motivate them to quit.