Prevalence of Tobacco use and Predictors: A Cross-Sectional Analysis of Baseline Data from Kong Cohort Study in the South of Iran

Background: Tobacco use (TU) has been increasing in Iran and turned into a major national healthcare concern. Thus, the present research aimed to explore the prevalence of TU and its predictors in Bandar-e-Kong in the south of Iran. Methods: The baseline data from Kong cohort study (KCS) were used in a prospective study of 4,035, 40-70 year old subjects in Bandar Abbas in Hormozgan Province between 2016 and 2018. Adjusted and crude odds ratios (OR) were used at 95% condence interval (CI) to measure the predictors of TU. Results: Hookah smoking (HS) showed to be the most prevalent type of smoking (17.60%, 95% CI: 16.41-18.78%). Only next was second-hand smoking (17%, 95% CI: 15.81-18.14%) followed by cigarette smoking (9%, 95% CI: 8.11-9.89%). Age, gender, education, alcohol consumption and environmental tobacco smoke (ETS) were the main predictors of cigarette and hookah smoking. Marital status, place of residence and psychological problems were the only predictors of HS (OR=.1.65, 95% CI: 1.11, 2.45, p=.01), BMI (OR=.95, 95% CI: .93, .98, p=.002) and drug abuse (OR=4.52, 95% CI: 3.11, 6.55, p<.001) were the only predictors of cigarette smoking. Conclusions: Masculinity, higher age, rural residence, low education, alcohol consumption, drugs, second-hand smoking and history of depression were among the main risk factors of smoking behavior. The results indicated a considerable need for more educational and preventive programs for each risk factor involved in smoking behavior especially for HS, exposure to ETS and its consequences in Kong population.


Introduction
Tobacco use (TU) is a key general health issue globally and a key risk factor involved in increasing the burden of diseases in the world especially in the case of chronic and non-contagious diseases such as cardiovascular diseases, respiratory diseases, cancer and brain attack [1]. Annually, TU accounts for more than 8 million mortalities worldwide [2]. About 80% of these mortalities occur in low to average income countries [3] .
In Iran, TU behaviors are ever growing among adults [4] Despite preventive measures, cigarette smoking trend has not reduced among adult population in Iran within the past two decades [5]. According to the CASPAIN study (2011-12), 5.9% of Iranian adults used tobacco in their lifetime, and this rate is higher than western countries and other middle-eastern countries [6]. HS is another traditional form of TU of an unknown origin. It involves the passage of smoke above water before inhaling. It is termed differently in different countries, including hookah, water-pipe, hubble-bubble, goza and nargile [7,8]. A body of research has shown that the adverse effects of HS are signi cantly more than cigarette smoking [9,10].
Iran has also witnessed an increase in the trend of HS for the past two decades especially in the south of the country [11]. In fact, Hormozgan Province ranks third in terms of the rate of HS [12] .
In Iran, TU is considered a main healthcare issue which requires major planning with the aim of controlling its use [13,14]. There is a considerable need for lowering the burden of HS-related diseases [15], as the current prevalence rate of the behavior is signi cantly high in Iran [4]. An effective measure before any intervention is the prevention and management of TS through identifying and concentrating on the prevalence of the issue and its correlates. This can help better know the risk factors involved in TS.
Before developing any effective intervention, there is a need for epidemiological investigations aiming to identify the risky behaviors associated with TU [16]. Moreover, there are certain intra-and intergeographical differences in terms of the prevalence of TU [17]. It is essential to conduct independent research in each geographic area marked by idiosyncratic cultural features. In Iran, geographical diversity should be considered carefully in policy-making and preventive TU measures [12].
The present research used baseline data from KCS with the aim of determining the predictors of TU in the target area in Hormozgan province in Iran. In this research, local health staff and policy-makers were provided with the required information to prevent and cut down on TU. Lowering the costs of TU-related chronic diseases and promoting the level of public health and quality of life in the target population were among the long-term goals of the present research.

Design and setting
The present cross-sectional research used the KCS baseline data in the south of Iran to explore the prevalence of TU and its associated risk factors. Bandar-e-Kong is located in '53 °54 to '57 °54 to the east and '35 °26 to '37 °26 to the north at the altitude of 5 meters above Persian Gulf. KCS design and protocol will be described later [18] In short, KCS is a prospective cohort study already conducted in 2016 with the aim of an epidemiological exploration and identi cation of the risk factors of noncontagious diseases in Kong in the south of Iran.
The present research was conducted on 4,063 adults, 40-70 years of age who had entered KCS in 2016-18. The participants were urban residents selected through a multi-strati ed sampling (cluster and systematic randomization) among 14 different regions in Bandar-e-Kong. The sampling scope was participants' home. The rst building on the right hand side of the nearest street to the center of cohort was selected as the rst cluster. Then, from each cluster one region, one street and an alley were selected respectively and, afterwards, the participants were selected from each cluster through systematic randomization (list of families). In rural regions, the sampling was done in two stages, the rst being a public announcement to invite in uential well-reputed neighbors to familiarize them with the bene ts and procedures of research. This was done through lecturing in public places such as mosques, distributing pamphlets to introduce the research and putting up posters and banners in villages. The second stage was done by visiting the eligible participants' houses one by one for the interview.
Each interview was held using a questionnaire presented by a well-trained KCS interviewer enquiring about demographic information, several socio-economic indices, history of TU, drug abuse and medical history. The inclusion criteria were explained completely. The participants were supposed to provide a written informed consent to take part in the research. This research was approved by the ethics committee of Hormozgan University of medical sciences (IR.HUMS.REC.159)

Inclusion and exclusion criteria
The primary inclusion criterion was 40-70 years of age. Only those residing to the target region were included in the study. Immigrants or foreigners could only participate if they had lived in the region for at least a year. For non-immigrants, it was necessary that they resided in the region for at least 9 months.
Those who were unwilling to participate despite being told about the research design and bene ts as well as those unable to respond to interview questions were excluded.

Instrumentation
The data collection instrument was a questionnaire developed in the light of the related literature and existing instrument and experiences gained from KCS in Iran or foreign similar works. The reliability and validity of the questionnaire was already approved [18].
The covariates used in this research were as following:

Hookah smoking (HS)
To nd out if the participants had experienced HS, the following question was asked: Have you ever smoked hookahs in your life?
The responses was supposed to be either yes or no.

Cigarette smoking
Whether the participants smoked cigarettes or not was checked using the National Health Interview Survey (NHIS). Smokers were de ned as those smoking for more than 100 cigarettes during their life. Those who had already ceased smoking were taken as ex-smokers.

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The following question was asked to see whether the participants experienced alcohol consumption or not: Have you drunk alcohol more than once in your life?" This question was to be answered as either yes or no.

Drug abuse
The following question was asked in order to see whether them participants ever experienced drug abuse (e.g. heroin, amphetamine, barbiturates, cannabis, cocaine, hallucinogen, opioid): Have you ever consumed illicit drugs more than once in life?
This question was to be answered as either yes or no.

Exposure to environmental tobacco smoke (ETS)
This variable was investigated with 2 questions: Have you been exposed to ETS at home or at work? How many hours a day have you been exposed to ETS?"

History of depression
Participants were asked whether they had ever been told by a specialist that they suffered from depression, again to be answered as yes or no.

Demographic variables
These variables included gender, age, BMI, place of residence, education, occupation, marital status, socio-economic status (possession of accommodation, area of accommodation, number of rooms in accommodation), family size, cigarette smoking by other family members. These were lled out within a questionnaire.

Statistical analysis
A complete range of information on participants' age, gender, marital status, education, socio-economic status (SES), BMI, place of residence (rural/urban), occupation, spouse's occupation, alcohol consumption, drug abuse, family members' smoking, exposure to ETS at home or work, physical activity, history of depression and psychiatric disorder was collected.
Concerning the low frequency of some levels of independent variables and the high collinearity between the history of depression and other psychiatric disorders, nally, 15 variables were included: age, gender, marital status, education, SES, family size, BMI, place of residence, occupation, alcohol consumption, drug abuse, exposure to ETS at home/work, family members' smoking and a history of psychiatric disorders correlating with cigarette smoking and HS.
Chi-squared test was run to test the correlation between two nominal variables. Simple logistic regression was used to estimate crude odds ratio (OR) and independent variables. The signi cance level was set at .25 in the nal model (multiple logistic regression) to calculate ORs.

Results
A total number of 4,035 people residing in Bandar-e-Kong participated in this study. Their average age was 48.2 years; the majority of the sample was female (n = 2,315, 57.4%). Moreover, 60% of the sample were illiterate or of a low level of literacy. The majority of women participants were housewives (n = 1,925, 83.2%) and their husbands were mostly drivers (n = 210, 9.1%), sailors (n = 178, 7.7%) or unemployed (n-186, 8%). The majority of men in this study were drivers (n = 189, 11%), shermen (n = 175, 10.2%) or sailors (n = 157, 9.2%). In this sample, 1,092 (27.1%) used at least one type of tobacco. HS was the most prevalent (17.60%) (95% CI: 16.41-18.78%). The next was cigarette smoking (9% of the sample) (95% CI: 8.11-9.89%). Table 1 presents a summary of the baseline participants' demographic information. Though more than 75% of the sample did not report any experience of smoking cigarettes or hookahs, 6.9% and 15.5%, respectively, reported smoking cigarettes and hookahs ( Table 2).    Table 5 indicate that the odds of hookah intake is .65 as high for participants with psychiatric disorders as others (OR = 1.65, 95% CI: 1.11, 2.45, p = .01).

Discussions
The KCS data helped to conclude that HS was the most prevalent tobacco type (17.6%) compared to cigarettes (9%). Age, gender, education, alcohol consumption and ETS showed to be the main predictors of hookah and cigarette smoking. Marital status, place of residence and psychiatric disorders were predictors of HS only and BMI and drug abuse showed to be predictors of cigarette smoking only.
In the present research, the prevalence of cigarette smoking was .30% and 20.80%, respectively, among women and men. The overall prevalence was 9%. In their research, Abdollahpour et al. reported the rate of cigarette smoking to be 41.07% and 32.68% among women and men, respectively [4]. This reported rate was higher than the present ndings. Drope et al. found that 14.2% of men and .4% of women were cigarette smokers. This rate among men showed to be lower than the present research, but about women it was consistent with the present ndings [19]. The prevalence of HS in the present research showed to be 13.70% and 23% among women and men, respectively. The overall rate of HS was found to be 17%. It seems that in the south of Iran, HS is more prevalent than cigarettes, which is consistent with their local culture. Thus, hookah showed to be the commonest tobacco type consumed in this region. It is socially accepted especially among women [20]. In a cross-sectional study in Tehran, the prevalence of HS showed to be 17.6% among 1,830 participants, which is consistent with the present ndings [21]. This is a higher rate than that of adults in the U.S. (.6%) [22]. and lower than a similar research in Kuwait which reported the prevalence of HS 79.9% and 21.1% among women and men, respectively [23]. Different geographical contexts and demographic information makes the comparison of information di cult. Yet, the prevalence of hookah and cigarette smoking in the present research was higher than the Iranian national report by Nemati [24]. These divergences can be explained partly by the different national rules and regulations in different countries and demographic features.
The logistic regression analysis in the present research showed that masculinity increased the risk of HS for about 1.83 times as high. These ndings are similar to the results of other studies in Iran and foreign countries [25][26][27]. Contrary to the present ndings, a body of research showed that the prevalence of HS among women was higher than men [28,29]. Another study showed to gender-based difference in the prevalence of HS [30]. These divergent ndings can be partly attributed to the idiosyncratic cultural, geographical differences, gender distribution, features of the target population and sample size. It is noteworthy that though in the present research the prevalence of HS is higher among men than women, among women, HS is signi cantly more prevalent than consuming cigarettes, alcohol or drugs. The difference showed to be statistically signi cant. This would point to the fact that HS is more socially acceptable in Bandar-e-Kong population. The results of an extensive survey in 2007 in Iran showed that from among tobacco types (hookah, pipe and cigarette), more than half of women (1.9% out of 3.2%) consumed hookahs among all tobacco types [31]. It seems that HS is rooted in public culture for long in the south of Iran especially in Hormozgan, and has turned into a local cultural value. It is a socially accepted behavior [19]. Thus, public awareness-raising through mass media and enculturation of the adverse effects of HS seems to be essential. HS needs to be considered as a detrimental social behavior as cigarettes and other addictive drugs are.
The present ndings showed that tobacco consumption, alcohol consumption and drug abuse are more prevalent among men than women and this divergence showed to be statistically signi cant. A body of research also reported the higher prevalence among men [4,[32][33][34]. Internalization of gender roles in participants and sociocultural acceptance of cigarettes and drugs among men can be part of the reason for the higher prevalence of smoking by male population [35]. Contrary to the present ndings, another study no difference was found across genders in terms of alcohol consumption and drug abuse [36]. This difference can be partly due to the age range and other idiosyncrasies of the target population and cultural and ethnic differences even within the country. It is further noteworthy that overall at the global scale, men are more prone to detrimental habits than women. The former tend to underestimate the detriments of drug abuse more than the latter [37]. Particularly in more conservative communities, where women are more controlled than men, access to cigarettes, alcohol and drugs is harder for women, and consuming such stuff is deemed culturally unacceptable for women in Islamic countries [38] .
The present research showed that women are more exposed to ETS at home, than men. In some other research, Al-Zabadi et al. in Palestine observed that more than half of the participants admitted that a family member or a spouse also consumed tobacco and they, thus, were exposed to ETS [39]. Contrary to the present ndings, Skorge et al [40]., Alamgir Kabir et al [41]. showed that men are more exposed to ETS than women. This divergence can be explained by the fact that Skorge et al. and Alamgir Kabir explored ETS at work and public places. Women are mostly housewives and are, thus, less exposed to ETS.
Besides, different social and cultural features of different countries can account for such divergences. These ndings can be explained by the fact that the sociocultural idiosyncrasies of Iran has led to the higher prevalence of cigarette smoking in men than women [4]. Consequently, those in the vicinity of smokers, primarily women and children, are more exposed to ETS. Raising smokers' and non-smokers' awareness of the adverse effects of ETS at home can be an effective strategy with this concern.
In the present research, men are signi cantly more exposed to ETS at work than women. This nding is consistent with a body of research by Skorge et al [40]., Alamgir Kabir et al [41]. and Akansha Singh [42].
This would point to the gender-related differences in occupation. Probably a higher percentage of men are employed than women. Thus, it is not far from expectation that men are more exposed to ETS at work. It seems that there is a strong need for smoke-free rules and regulations at work, as it is essential to optimally take care of smokers and non-smokers by providing a smoke-free environment [42].
The present research revealed that the beginning age of smoking cigarettes was lower among men than women. A body of research also reported the same nding [4,43]. This nding can be explained by men's more freedom of action in family and society and their more active social role. During adolescence and adulthood, the male enjoy more social presence under less supervision. However, the female are more controlled in family, which can be part of the reason for this gender-based difference. A relevant study showed that stricter family control over men is less effective than on women in ceasing alcohol or tobacco consumption and other illicit drugs [44].
Furthermore, the present ndings revealed that an increase in age is followed by a decrease in tendency to smoke cigarettes and hookahs. In other words, the young showed a stronger tendency to smoke [25,45,46]. Contrary to the present research, another study reported a higher rate of TU at a higher age [4,47,48]. This divergence might be explained by different features of the target populations and the age ranges. Moreover, probably the emergence of diseases following an increase in age and prohibited use and a better understanding of risks associated with drug abuse or other forms of TU lowered the rate of consumption.
As the present ndings showed, HS showed to prevail more among widows and divorcees than the single. Some other studies reported similar ndings too (49,50). As reported in some work of research, perceived family norms among the married can be effective in intention to cease TU (51). Similarly, in another study, married women showed to be encouraged to cease TU more than the single [20]. This nding can be explained by the fact that widows and divorcees might suffer more emotional and social de ciencies due to their loss than others. Thus, they might have appealed to smoking drugs to relieve their mind.
Another nding was that a higher level of education was associated with less cigarette or hookah smoking. In a similar vein, a body of research showed that lower level of education was a key reason for tendency to illicit drugs [49,50]. Contrary to this nding, in some other works of research, higher education showed no protective effect on the rate of TU [26,51]. These differences can be partly explained by the quality of items within the questionnaire, participants' education level and different sociocultural features. In addition, lower level of education can lower health literacy and then result in unawareness of consequences and actual risks of drug abuse which pave the way for the occurrence and continuation of addictive behaviors [52].
The results also showed that rural residence was a predictor of HS. Another study reported that more than half of rural residents accepted TU at home [53]. Still, some other research reported that rural residence was marked by a twofold rate of cigarette smoking [54]. This higher prevalence can be partly attributed to the existing gap of knowledge in rural areas in comparison to urban counterparts. Another reason might be that tobacco control and regulatory efforts are not implemented as strictly as cities in rural areas [55].
This nding points to the essentiality of greater attention to rural communities as a vulnerable population whole exploring the effective and fair tobacco control and other health-related policies.
The present ndings showed that alcohol consumption was a predictor of cigarette and hookah smoking. Other investigations also reported higher chances of hookah and cigarette smoking among alcohol consumers [4,56]. Occasionally, alcohol consumption and cigarette smoking develop simultaneously. In other words, it seems that alcohol consumption expose people more to cigarette and hookah consumption. As it was expected, lifetime drug abuse correlated with cigarette smoking [4]. Concerning this, a number of studies pointed to the strong association of the history of cigarette smoking and illicit drugs [57,58]. Moreover, exposure to ETS correlated with hookah or cigarette smoking. Probably, those exposed to ETS showed a stronger tendency to TU. In a similar vein, some investigations found exposure to ETS as a factor involved in TU [18,56]. Another explanation might be that those exposed to ETS might become more curious to try smoking [59]. Still, another nding was that psychiatric disorders could predict HS among the participants. Similarly, some other researchers reported the prevalence of HS among people of psychiatric disorders such as depression and stress [4,60]. Furthermore, an increase in BMI was followed by a decrease in the rate of cigarette smoking. Similarly, a body of related research showed that cigarette smokers had a lower BMI than non-smokers. In other words, BMI and cigarette smoking correlated negatively and this correlation was statistically signi cant [61,62]. Contrary to the present ndings, some other research indicated that a higher BMI was accompanied by more chances of beginning to smoke earlier and more frequently [63]. Yet, the cross-sectional nature of the research limits a causal relation claim among drug abuse, alcohol consumption, ETS, psychiatric disorders, BMI and hookah and cigarette smoking. These interrelations still need more longitudinal and in-depth investigations.

Limitations And Strengths
One limitation of the present research was the self-reporting nature of data collection. Thus, the validity of the data depended to a great extent on the accuracy of participants' responses. However, interviewers tried to emphasize the con dentiality of information and reduce this bias as far as possible. Moreover, this research was conducted on Kong population, which further limits the generalizability of the results.
Another key limitation lies in the information about alcohol consumption, drug abuse and TU. In information retrieval revealing such information might be faced with the feeling of embarrassment, undervaluation and crime consideration due to the cultural context. Moreover, the present research was population based. No similar research was found to explore the prevalence of TU and its correlates in the target region. The results can provide useful practical information to evaluate and reform tobacco control planning and policy-making in Iran and more speci cally in the target region.

Conclusions
The prevalence of HS and exposure to ETS showed to be above average in the present research. Masculinity, older age, rural residence, low education, alcohol consumption, drug abuse, ETS and history of depression were among the risk factors of smoking behavior. The present ndings revealed a great need for more systematic education and preventive measures for each risk factor especially HS, exposure to ETS and its consequences in Bandar-e-Kong. Considering the present contradictions in these ndings and the related literature, it seems that more specialized investigations are required to reveal whether any other similar factor accounts for smoking behavior in Iran.