Tobacco smoking is a worldwide leading cause of physical and psychological disorders and premature death (WHO Report on the Global Tobacco Epidemic & IGO., 2019). According to the latest reports, tobacco kills more than 8 million people each year. Ranked as second in 2015, smoking-attributed Disability-Adjusted Life Years (DALYs) were 148.6 million worldwide (Reitsma et al., 2017). National studies in Iran reported 25.2% and 4.0% of current tobacco smoking (including cigarettes and hookah) in men and women, respectively (Varmaghani et al., 2020). Over recent years, despite the declining trend of cigarette smoking, the cigarette intensity has increased in smokers, and the prevalence of hookah use had a constant trend in the adult population (Meysamie et al., 2017); therefore, smoking still remains a public health issue in the country.
The role of personal and socio-environmental factors in forming individuals' lifestyle behaviors, including smoking, have been well-documented. At the individual level, many factors such as genetic, depression, anxiety, low self-esteem, and deficits in emotion regulation are known to predict smoking behavior (Fluharty et al., 2016; Keenan, 2013; Mendelsohn, 2012; Verde et al., 2011; Wellman et al., 2016). Beyond the personal level, previous studies underline interpersonal and socio-environmental factors on smoking in different communities. Smoking parents and friends and low socioeconomic status (primarily due to low education and unemployment) play crucial roles in both the beginning and continuation of tobacco smoking (Rhodes et al., 2017; Wellman et al., 2016).
In addition to the personal and socio-environmental factors mentioned above that can motivate people to smoke, people's perception of their position in a society, which is mainly influenced by society's morphological and physiological characteristics, could also facilitate these behaviors. The concept that best describes this personal perception resulting from the psychosocial interaction is social well-being in the relevant literature. After the hedonic theory of well-being was gradually formed, (Flügel, 1925) the eudaimonic theory of well-being emphasized the outcome of positive goal pursuits. This model was constructed based on the assumption that individuals attempt to understand their unique talents to have the best function (Ryff & Keyes, 1995). Studying well-being through a socio-sensitive lens, Keyes developed a five-component model (social integration, social contribution, social coherence, social actualization, and social acceptance) by extending the eudaimonic theory and showing the extent to which individuals overcome social challenges and function well in society (Gallagher et al., 2009; Keyes, 1998).
The social well-being components and some other social indicators have been separately studied in relation to smoking behaviors previously. Social acceptance, social pressure, and social norms can form individuals' tobacco smoking (Saito et al., 2018). Regardless of sex, cigarette and hookah smoking have been associated with social isolation (Algren et al., 2020), social norms (Glenn et al., 2017), and integration to family, friends, or church, especially in youth (Lakon & Valente, 2012). In addition to mentioned dimensions of social well-being, some studies have focused on the social indicators, including deprivation of education (De Walque, 2007; Wang et al., 2018; Zeiher et al., 2017), unemployment (Montgomery et al., 1998; Novo et al., 2000; Wang et al., 2018), low income (Casetta et al., 2017; Sreeramareddy et al., 2018), and living in deprived residential areas (Glenn et al., 2017; Gorini et al., 2013). However, social well-being –as a comprehensive concept– rarely has been studied in relation to smoking.
The importance of sex differences has become more predominant in different cultural contexts. Valuing male cigarette smoking in Eastern-Asian communities (Tsai et al., 2008) or considering hookah smoking in Arab countries as a common traditional entertainment for men are examples of those societies where men could gain higher social acceptance with tobacco smoking (Jamil et al., 2014; Jamil et al., 2009). On the other hand, women's cigarette smoking is taboo in Eastern-Mediterranean cultures; therefore, lack of embarrassment, supportive social norms, and existing traditional roots could drive women to hookah rather than cigarette smoking (Afifi et al., 2013). Recently a systematic review revealed gaining social acceptance from peers as a strong motivator for women to consume hookah (Dadipoor et al., 2019). However, these tobacco-related sex disparities still need further in-depth investigations in different cultures.
Given the above-mentioned scientific gaps and the need for a deeper sex-specific study of this issue, we aimed to investigate the association between perceived social well-being and tobacco smoking (cigarette and hookah) among a large population of Iranian men and women.