This study anonymously included a reasonable community-based sample from Syria which would remove the stigma of declaring smoking patterns for both genders and of declaring war distress among respondents.
In Syria in 2002-2003 according to WHO estimates, tobacco smoking in males was 48.0%, in females was 8.9% and in general was 24.7% (11), in 2006 cigarette smoking was 56.9% for males and 17.0% for females (12) while in 2014 cigarette smoking was 42.2% in total (13) compared with our study where we found that cigarette smoking among males was 34.7% and among females was 10% and in total was 16.4% (p<0.0001 when compared with the previous two studies for either gender or in total). The change in smoking habits in our study in 2019 indicates that tobacco smoking rates for males have decreased while it increased for females. This decrease might be due to war that made it harder to access smoking and increased living expenses which made it harder to smoke. However, we did not find an association between SES and smoking.
One study found the male-to-female ratio for cigarette smoking to be (5.33) in Syria which is lower than Jordan (9.53) (p<0.001) and Saudi Arabia (27) (p<0.0001) (14-16). In our study, the ratio was 3.46. Although cigarette and shisha smoking patterns among males were approximately the same, shisha smoking was more popular among females. We found that daily cigarette smoking and daily shisha smoking are more common among the male population. Shisha smoking habits in females are similar to what was found in one Iranian study (17). Males in both countries smoked cigarettes more than females, but the rates found in Syria for both cigarette and shisha smoking remains much higher than in Iran as cigarettes smoking prevalence in Iran was 12.5% (p=0.0022) and shisha smoking prevalence was 2.7% (p<0.0001) is lower than what we found in our study with cigarette smoking and shisha smoking being 16.4% and 29.3% respectively.
However, these numbers in Syria remain much lower than other countries such as Russia where tobacco smoking prevalence was 47% for males, and 15% for females (11), Lebanon had 48.7% prevalence for males and 29.4% for females, Jordan had 49.6% for males, but 5.7% for females which is lower than our findings, Iraq had 38.2% for males, but 1.9% for females which is lower than our findings, Turkey had 43.6% for males and 19.7% for females, China had 52.1% for males, but 2.7% for females which is lower than our findings, Greece had 35.0% for males and 41.0% for females (11).
Concerning Shisha smoking, in 2003 in Syria, it was found that among university students 25.5% of males and 4.9% of females smoked shisha with only 7.0% of males smoking shisha daily (18). Compared with our study where smoking shisha among university students was 34.3% for males (p>0.05) and 28% for females (p<0.0001), we found a significant difference from the previous study, suggesting that university student females smoke shisha more than in 2003. Not much is known about the dangers of second-hand shisha smoking although our study found that 72.5% of shisha smokers smoked shisha socially. Most people smoke shisha socially in indoor places where the quality of air is even worse and can have high levels of harmful substances such as particulate matter (PM2.5) and CO (19-21). Even when smoking shisha at home, these substances are found in the room where shisha is smoked and with higher levels than rooms where cigarettes were smoked (22). This high rate of social shisha smokers was also reported in 2004 in Aleppo (18).
Waterpipe/Shisha is considered as an element of the cultural identity and it grows a sense of togetherness while cigarette smoking is usually started in early adolescent life as males are becoming “real men”. Interestingly, cigarette smokers feel stigmatized while shisha smoking is looked at as socially acceptable (3), which can explain why we found that males smoked more packs for longer durations than females who prefer to smoke socially. This also can justify the lower rates of smoking reported previously among females in Syria and other nearby countries. However, we used anonymous online surveys which can let them express themselves without jeopardizing privacy. The male to female ratio in our study for shisha smoking was 1.24. This can be explained by females being able to smoke shisha without social stigma with friends when they go out while cigarette smoking is not considered a social activity and therefore more will avoid it as it is not very socially acceptable for women in Syria.
For shisha smoking, the most recent two studies conducted in Syria showed that the prevalence of smoking shisha was 20.2% for females and 4.8% for females in 2006 (12) and was 15.6% for males and 7.4% for females in 2014 (13) compared with our study of 34.3% for males and 27.6% for females (p<0.0001 with both studies compared with our study for either gender). In Egypt, 8.7% smoked shisha (11). However, shisha smoking was also studied among youth and adolescents and was 37.2% among youth in Lebanon and especially in Lebanese youth and university students reach 65.3%. Other studies also found shisha smoking to be more common in university students and youth as it reaches 16.3% in Iran for university students, and 10.4% in Egypt for Egyptian youth, 32.7% in West Bank while Jordan had an increase of 7.3% of shisha smokers among youth to 18.9 from 2008 and 2011, and shisha smoking was 20.1% in Syrian youth in 2010 (23). We also found that the people who smoked for more years tend to smoke larger quantities per day, smoke more shisha every week, and longer periods of shisha in each session.
Moreover, it was suggested that high-stress jobs have a higher risk for daily tobacco smoking, suggesting that adjustments to stressful work environments should be taken into account to help in quitting smoking (24, 25). Furthermore, smoking has a burden on work productivity, and quitting smoking could be beneficial for individuals and employers (26). We found an association between having a job, and certain types of work with smoking cigarettes and/or shisha with more years of smoking being also associated with the type of work. We found that being a laborer, working as a clerk or in a restaurant, or a technician was more frequently associated with smoking cigarettes. This was also found with shisha p=0.004 as working as a clerk or in a restaurant, or a technician smoked shisha more and with smoking shisha and cigarettes together p<0.001.
We did not find a correlation between having any medical condition with smoking although smoking was found to increase the odds for hospitalization, comorbidity, and burden on healthcare in the Middle East (27). Although marital status was found to affect smoking patterns (28), we found that being single was correlated with less frequent smoking, but it was statistically insignificant. This might require a larger sample with more participants being married or declaring if they were in a stable relationship for the past six months or not.
In addition, although the low educational level and SES were found by several studies to be correlated with smoking and more difficulties in quitting (29, 30), we did not find such a correlation; we found that shisha smoking and smoking both shisha and cigarettes together were significantly correlated with higher education, but not with SES. This might be explained as shisha is a social activity that would be widely practiced among university students and therefore, being enrolled in university encourages students to shisha smoke.
We also found a significant difference in smoking with the field of education; being a student in a medical field was associated with fewer cigarettes and shisha smoking but being a student in social studies was associated with smoking shisha and cigarettes more. This might be from medical students knowing the damage of smoking more. One study did not find such a difference between studying to be dentists and others (31). We found cigarette smoking to be positively correlated with being older, while shisha was more frequent in the younger age group (18-30) despite that shisha was found to be more common in ages of 33-52 years in Malaysia (32).
Soldiers deployed at wartimes have a higher risk for tobacco smoking (33), and patients with PTSD symptoms tend to be more dependent on nicotine and smoke more cigarettes per day (34, 35); we found such an association for a cigarette and/or shisha smoking with losing someone close due to war and being distressed from war noises. Cigarette smokers believe that smoking cigarette is harmful but is used to cope with stress, while shisha smokers believed that it is harmless and is used for entertainment and leisure (3).
Limitations
We acknowledge that our study has some limitations; 80% of the studied population were under the age of 45 years which indicates that caution should be taken when generalizing the results. Moreover, the distribution of population may seem unbalanced among provinces as most of them were in Damascus. However, most studies either electronically or not had the same distribution (7-9) which is attributed to the war effect which made Damascus even more populous as it is relatively safer than other provinces, had more jobs to offer, and the main universities were there. There is no validated method to measure SES in Syria due to differences with other countries and it is not socially acceptable to ask about income (7). A randomized sample is required to determine the prevalence more accurately. This study could not assess the events where people would smoke or whether they had stopped smoking. Furthermore, we could not assess if the social stigma or peer pressure affected smoking patterns. Moreover, recall bias might have affected recalling the amount and duration of smoking.