Expert reports express concern over increasing or persistently high smoking prevalence in low- to middle Human Development Index (HDI) countries. Another major concern is an increase in smoking prevalence among youth, particularly among girls [1][2]. Although the lack of full implementation of tobacco control policies in many countries undermines global tobacco control efforts [1], the complex interplay of bio-social-environmental factors that promote smoking in subgroups of youth with different socioeconomic, cultural and contextual characteristics are not sufficiently understood. This gap in knowledge sets limits to the development of prevention tools with effectiveness in addressing diversity within and across countries.
Risk factors associated with youth smoking like peer and media influences, have been consistently identified across countries from varied HDI levels [3][4] [5][6][7][8][9]. Evidence supports the role of social norms that may influence substance use behavior, including smoking, with traditional gender roles usually acting as protectors especially among females [10][11][12]. However, the influence of stress inducing personal, family and contextual factors like exposure to violence is not sufficiently understood. The role of stress on substance use has been analyzed on the basis of several conceptual frameworks like the stress and coping theory [13], the social learning theory [14] and the tension reduction theory [15]. Youth in most countries are likely to be exposed to violent events either by interpersonal aggression, local gangs, organized crime, institutionalized violence and armed conflicts or wars, in addition to exposure to violence within the family and school settings [16] [17]. Violence refers to the intentional use of force or power, threatened or actual, against oneself, another person, or against a group or community that either result in or has a high likelihood of resulting in injury, death, or psychological harm [18]. Experiencing violent events has been shown to be associated with behavioral risk factors like substance use disorders and psychiatric morbidity [19][20].
Several studies have been conducted among school-based populations to assess the relationship between a reduced set of violent events and cigarette smoking. In these studies, from China, Malawi, the United States, Chile, and the Western Pacific, bullying or being involved in physical fights was significantly associated with cigarette use [21][22][23][24][25]. A cross-country school-based study showed a consistent association between physical fights and cigarette smoking in 6 countries within the Western Pacific [26]. Another cross-country study used a community-based sample of youth in five urban sites (Baltimore, New Delhi, Johannesburg, Ibadan, and Shanghai) to assess the association of neighborhood contextual factors with smoking behavior, and victimization measured as being pushed or shoved, hurt in a fight, verbally threatened, threatened with a weapon, or hurt with a weapon. Not all neighborhood-level factors were significant across sites. Witnessing community violence showed more consistency, being positively associated with ever smoking and victimization in New Delhi and Johannesburg [27]. Regarding gender differences, two school based population studies in the US reported inconsistent results [23][25].
Country level social, economic and/or political processes may modulate how youth experience and process exposure to violence at the personal level, conditioning behavioral responses to stress [28] [29][30]. This study examined the association of exposure to verbal and physical violence from family and non-family members with cigarette smoking, among middle school-age youth from the West Bank oPt and the Province of Jujuy, Argentina. The study adds to the scarce literature on cross-country studies of violence and smoking among school-age youth and adds a gender perspective to assess differences between girls and boys.
Study sites
Violence associated with economic crises, inequality, social conflicts and military dictatorships has been a chronic feature of many Latin Americans countries. Contributing local phenomena include state repression, impoverishment with social marginalization, and delinquency and crime linked to the illicit drug trade [31]. The Province of Jujuy in Argentina (population of 673,307) is socioeconomically disadvantaged with human development indicators significantly lower than national averages [32][33]. In Argentina the national average household poverty rate was 14,3% in 2001 with 26,5% for Jujuy where the rate reached 28.2% by 2019 [34][35].
The West Bank oPt presents unique features defined by regulatory and trade policies and Israeli control, including mobility restrictions within the territory [36][37]. Palestinians in the West Bank have coexisted with armed conflicts for more than 70 years witnessing wars, displacements and uprisings [38][39]. Of the West Bank, oPt governorates, Ramallah located in the central region with a population of 279,730 is the provisional site of the Palestine National Authority, as well as a hub for business and donor agencies. Jenin is an important governorate of the north, with a population of 256,619 and is located in the main agricultural region. Ramallah’s localities are predominantly much more prosperous compared to Jenin [36]. In 1997, the household poverty rate in the West Bank averaged 25.3% and had increased to 29.2% by 2017 [37][40]. Geographic variations showed that poverty rate was 53% around Jenin, and less than 10% in Ramallah [37].
Rates of ever smoking cigarettes among youth were similar in the West Bank and Argentina, 50% and 55% between 2000 and 2001, but current cigarette smoking was more prevalent in Argentina than in the West Bank (25% vs. 14%) [41]. The two research sites in the West Bank, oPt, Ramallah and Jenin, had similar current cigarette smoking rates among youth, 17% and 20% respectively in 2008 [42]. While current cigarette smoking rates by sex do not differ significantly in Argentina (20.2% vs. 21.7%) [43], rates are significantly lower among Palestinian girls than boys (4% vs. 32%) [42].
A study of exposure to violent events from military and settlers among 10th and 11th grade students in Ramallah in 2003, showed that 80% had seen shootings, 28% had seen a stranger killed, and 11% had seen a friend or neighbor killed [44]. In 2008 in Ramallah and Jenin, among 7th to 10th grade students, 58% were victims of violence related to actions from the armed forces, 67% witnessed violence, 56% were beaten by school personnel and 44% were beaten by parents [42]. Among Palestinian parents, support for physical punishment decreases with education and income level [45]. In Argentina, violent deaths among adolescents increase with increased poverty [46]. According to UNICEF, almost 70% of parents in Argentina reported the use of verbal or physical violence to discipline their children [47]. In a study among middle school students, 56% had witnessed or were subjects of more than 10 acts of violence, 58% witnessed someone being arrested with violence, and 50% knew someone who had been beaten by a non-family member [48] .