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Smoking among adolescents in a developing country

Smoking among adolescents in a developing country Department of Epidemiology and Biostatistics, Faculty of Health Sciences, American University of Beirut, Lebanon Umayya Musharrafieh Department of Family Medicine, American University of Beirut Medical Centre, Beirut, Lebanon Wassim Y. Almawi College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain In Lebanon, the general impression prevailing is that the society is still conservative and the impact of the family remains predominantly protective of youth. However, the 1975-90 war period that was experienced by Lebanese youth of the time on one hand, and the rapid invading globalisation on the other, have contributed to the introduction of new, open and less-inhibited changes, both in behaviours and attitudes. The purpose of this study was to assess smoking among Lebanese adolescents through determination of the prevalence of smokers among a representative sample of university students belonging to different social strata in Lebanon. In addition, the study addressed differences in smoking prevalence rates as they related to gender, residence with parents and study characteristics. Between February and June 2000, a random sample of 553 students was selected from four universities in Lebanon (Lebanese University, American University of Beirut, Lebanese American University and Beirut Arab University). The students recruited were representative of the two major religious sects (Christians and Moslems), of both sexes, and from different socio-economic levels. Participants were asked to fill a questionnaire, which included demographics, residence with parents, study characteristics and health behavioural aspects. Despite societies’ growing awareness and strong efforts to focus on anti-smoking campaigns, results obtained revealed a higher percentage of smokers as compared with previously reported rates in Lebanon.1 The overall proportion of students who smoked (cigarettes or nargileh) was 52.8%, which was significantly higher than those reported for North American or European studies, as exemplified by the Center for Disease Control (CDC) study in 1997, where smoking prevalence rates of 13.8% and 30.7% were reported for Utah and Kentucky, respectively.2 The average number of cigarettes smoked per day was 16 (SD=12), whereas the average number of nargileh smoked per week was 2.2 (SD=2.4). (Nargileh smoking is common in many non-Western countries. It consists of dark paste tabacco lit by charcoal embers. Users smoke it via a long, flexible tube, through which the smoke bubbles through a water bowl, also known as a waterpipe, shiska or hookah.) Table 1 shows the proportion of students who smoke (cigarettes and/or nargileh) distributed by gender, residence and study Table 1: The distribution of smoking by gender, residence, and study characteristics of university students. Smoke cigarettes/nargileh Yes No Number % Number % Total Gender Male Female University Private Public Major Health Arts and Sciences Engineering Law Enrolment year First Other Residence Home Other Notes: (a) OR = Odds Ratio (b) CI = Confidence Interval ORa (95%CIb) Smoke nargileh Number % Smoke cigarettes Number % 46.7 38.3 58.1 43.1 56.3 59.6 44.3 44.8 48.1 44.1 47.4 48.7 38.4 1 0.45(0.32-0.63) 1 0.59(0.41-0.85) 1 1.86(1.05-3.31) 1.82(0.95-3.51) 1.60(0.80-3.18) 1 0.88(0.62-1.24) 1 1.52(0.97-2.38) 2001 VOL. 25 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Letters to the Editors characteristics. A clear trend towards higher prevalence rates of cigarette smoking is seen among males (61.7%) compared with females (41.9%). This was reminiscent of an earlier study, which concluded that males were more associated with smoking than females.1 Moreover, the proportion of students who smoked was significantly higher among students enrolled in private (56.9%) versus public (43.7%) universities, a possible consequence of higher socio-economic status. This was in agreement with a previous study by Papazian,3 where 60% of young Lebanese university women who smoked belonged to the upper middle class, while only 22.5% belonged to the lower socio-economic strata. A major difference from previous studies found there was a decline of smoking in health science majors with respect to other majors, which was due to more awareness and knowledge about the consequences of smoking among this group of students.1 Moreover, the results of the present study showed that nonsmokers were more likely to reside with parents than their counterparts (48.7% versus 38.4%). Newman et al. similarly suggested that parental education and attitude towards smoking must be considered when targeting risk behaviour.4 The high percentage of smoking noted in this study seemed to stabilise during university years. This showed that a considerable number of smokers begin smoking prior to university, suggesting the need to target this group at the school level rather than later.5 In terms of the behaviour of smokers and non-smokers, our study showed that even though 52% of the smokers smoke without being sensitive to the people sitting next to them, 57% of non-smokers either ask the smoker to stop smoking or simply leave the immediate vicinity. In conclusion, smoking remains a serious health problem among youths in Lebanon and smoking campaigns should target school students. Since increasing the awareness of parents about health issues may have a positive impact on the students, the study recommends that they be included in smoking campaigns. Reply to Richard M. Smith’s response Dorothy Mackerras and Susan Sayers Menzies School of Health Research, Northern Territory In response to our comments,1 Smith asserts that the z-scores we calculated using the interim WHO breast-fed reference3 and plotted in the figure are incorrect.2 In both the text and the title of the figure, it is clear that we plotted data for the pre-intervention phase1 whereas the numbers Smith presents2 are calculated on the intervention phase data, which had a smaller sample. The tables for calculating z-scores in the breastfeeding report3 do not contain information for some of the age groups in the paper.4 To allow for this, we obtained the equations from which the tables were derived from one of the committee members.3 However, we were advised to cite the report3 rather than a personal communication as the reference. In the paper4 and subsequent reply,2 it is clear that failure to thrive is largely classified according to a child’s location on the growth chart. Progress in growth cannot be assessed by a single measurement, it can only be assessed by comparing the slope of the child’s growth to the slope shown on the reference. Smith comments that several large studies show that the majority of low birthweights in the infants of Aboriginal women is due to preterm birth.2,4 However, these are analyses of routine data collections, not research studies conducted with tightly defined methods of measurement. The results indicate consistency, but do not necessarily indicate validity. It would be preferable to discuss weight-for-gestational age rather than low birthweight if gestational ages are valid. Athough it is expected that preterm rates are higher in the Aboriginal population, the relative impacts of factors such as maternal smoking and infections and misclassification cannot be deduced from the studies referred to. References 1. Nassar N, Zurayk H, Salem P. Smoking patterns among university students in Lebanon. College Health 1980;28:283-285. 2. Holtzman D, Griner EP, Bolen JC, Rhodes L. State and Sex-Specific Prevalence of Selected Characteristics – Behavioral Risk Factor Surveillance System, 1996 and 1997. MMWR 2000;46(ss-6): 1-14. 3. Papazian T. Smoking and Health: Young Lebanese University Women. [Institute for Women. Studies in the Arab World, BUC]. Al Raide 1993; 10:62. 4. Newman I, Ward J. The influence of parental attitudes and behavior on early adolescents cigarette smoking. J Sch Health 1989; 59:150-53. 5. Coogan P, Adams M, Geller A et al. Factors associated with smoking children and adolescents in Connecticut. Am J Prev Med 1998; 15:17-24. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Smoking among adolescents in a developing country

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References (14)

Publisher
Wiley
Copyright
2001 The Public Health Association of Australia Inc
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1753-6405.2001.tb01843.x
Publisher site
See Article on Publisher Site

Abstract

Department of Epidemiology and Biostatistics, Faculty of Health Sciences, American University of Beirut, Lebanon Umayya Musharrafieh Department of Family Medicine, American University of Beirut Medical Centre, Beirut, Lebanon Wassim Y. Almawi College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain In Lebanon, the general impression prevailing is that the society is still conservative and the impact of the family remains predominantly protective of youth. However, the 1975-90 war period that was experienced by Lebanese youth of the time on one hand, and the rapid invading globalisation on the other, have contributed to the introduction of new, open and less-inhibited changes, both in behaviours and attitudes. The purpose of this study was to assess smoking among Lebanese adolescents through determination of the prevalence of smokers among a representative sample of university students belonging to different social strata in Lebanon. In addition, the study addressed differences in smoking prevalence rates as they related to gender, residence with parents and study characteristics. Between February and June 2000, a random sample of 553 students was selected from four universities in Lebanon (Lebanese University, American University of Beirut, Lebanese American University and Beirut Arab University). The students recruited were representative of the two major religious sects (Christians and Moslems), of both sexes, and from different socio-economic levels. Participants were asked to fill a questionnaire, which included demographics, residence with parents, study characteristics and health behavioural aspects. Despite societies’ growing awareness and strong efforts to focus on anti-smoking campaigns, results obtained revealed a higher percentage of smokers as compared with previously reported rates in Lebanon.1 The overall proportion of students who smoked (cigarettes or nargileh) was 52.8%, which was significantly higher than those reported for North American or European studies, as exemplified by the Center for Disease Control (CDC) study in 1997, where smoking prevalence rates of 13.8% and 30.7% were reported for Utah and Kentucky, respectively.2 The average number of cigarettes smoked per day was 16 (SD=12), whereas the average number of nargileh smoked per week was 2.2 (SD=2.4). (Nargileh smoking is common in many non-Western countries. It consists of dark paste tabacco lit by charcoal embers. Users smoke it via a long, flexible tube, through which the smoke bubbles through a water bowl, also known as a waterpipe, shiska or hookah.) Table 1 shows the proportion of students who smoke (cigarettes and/or nargileh) distributed by gender, residence and study Table 1: The distribution of smoking by gender, residence, and study characteristics of university students. Smoke cigarettes/nargileh Yes No Number % Number % Total Gender Male Female University Private Public Major Health Arts and Sciences Engineering Law Enrolment year First Other Residence Home Other Notes: (a) OR = Odds Ratio (b) CI = Confidence Interval ORa (95%CIb) Smoke nargileh Number % Smoke cigarettes Number % 46.7 38.3 58.1 43.1 56.3 59.6 44.3 44.8 48.1 44.1 47.4 48.7 38.4 1 0.45(0.32-0.63) 1 0.59(0.41-0.85) 1 1.86(1.05-3.31) 1.82(0.95-3.51) 1.60(0.80-3.18) 1 0.88(0.62-1.24) 1 1.52(0.97-2.38) 2001 VOL. 25 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Letters to the Editors characteristics. A clear trend towards higher prevalence rates of cigarette smoking is seen among males (61.7%) compared with females (41.9%). This was reminiscent of an earlier study, which concluded that males were more associated with smoking than females.1 Moreover, the proportion of students who smoked was significantly higher among students enrolled in private (56.9%) versus public (43.7%) universities, a possible consequence of higher socio-economic status. This was in agreement with a previous study by Papazian,3 where 60% of young Lebanese university women who smoked belonged to the upper middle class, while only 22.5% belonged to the lower socio-economic strata. A major difference from previous studies found there was a decline of smoking in health science majors with respect to other majors, which was due to more awareness and knowledge about the consequences of smoking among this group of students.1 Moreover, the results of the present study showed that nonsmokers were more likely to reside with parents than their counterparts (48.7% versus 38.4%). Newman et al. similarly suggested that parental education and attitude towards smoking must be considered when targeting risk behaviour.4 The high percentage of smoking noted in this study seemed to stabilise during university years. This showed that a considerable number of smokers begin smoking prior to university, suggesting the need to target this group at the school level rather than later.5 In terms of the behaviour of smokers and non-smokers, our study showed that even though 52% of the smokers smoke without being sensitive to the people sitting next to them, 57% of non-smokers either ask the smoker to stop smoking or simply leave the immediate vicinity. In conclusion, smoking remains a serious health problem among youths in Lebanon and smoking campaigns should target school students. Since increasing the awareness of parents about health issues may have a positive impact on the students, the study recommends that they be included in smoking campaigns. Reply to Richard M. Smith’s response Dorothy Mackerras and Susan Sayers Menzies School of Health Research, Northern Territory In response to our comments,1 Smith asserts that the z-scores we calculated using the interim WHO breast-fed reference3 and plotted in the figure are incorrect.2 In both the text and the title of the figure, it is clear that we plotted data for the pre-intervention phase1 whereas the numbers Smith presents2 are calculated on the intervention phase data, which had a smaller sample. The tables for calculating z-scores in the breastfeeding report3 do not contain information for some of the age groups in the paper.4 To allow for this, we obtained the equations from which the tables were derived from one of the committee members.3 However, we were advised to cite the report3 rather than a personal communication as the reference. In the paper4 and subsequent reply,2 it is clear that failure to thrive is largely classified according to a child’s location on the growth chart. Progress in growth cannot be assessed by a single measurement, it can only be assessed by comparing the slope of the child’s growth to the slope shown on the reference. Smith comments that several large studies show that the majority of low birthweights in the infants of Aboriginal women is due to preterm birth.2,4 However, these are analyses of routine data collections, not research studies conducted with tightly defined methods of measurement. The results indicate consistency, but do not necessarily indicate validity. It would be preferable to discuss weight-for-gestational age rather than low birthweight if gestational ages are valid. Athough it is expected that preterm rates are higher in the Aboriginal population, the relative impacts of factors such as maternal smoking and infections and misclassification cannot be deduced from the studies referred to. References 1. Nassar N, Zurayk H, Salem P. Smoking patterns among university students in Lebanon. College Health 1980;28:283-285. 2. Holtzman D, Griner EP, Bolen JC, Rhodes L. State and Sex-Specific Prevalence of Selected Characteristics – Behavioral Risk Factor Surveillance System, 1996 and 1997. MMWR 2000;46(ss-6): 1-14. 3. Papazian T. Smoking and Health: Young Lebanese University Women. [Institute for Women. Studies in the Arab World, BUC]. Al Raide 1993; 10:62. 4. Newman I, Ward J. The influence of parental attitudes and behavior on early adolescents cigarette smoking. J Sch Health 1989; 59:150-53. 5. Coogan P, Adams M, Geller A et al. Factors associated with smoking children and adolescents in Connecticut. Am J Prev Med 1998; 15:17-24.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Apr 1, 2001

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