2847 people responded to our questionnaires, which were distributed through various Whatsapp groups whose members live in various parts of Syria. Only 51 participants (1.8 %) were excluded from the study because they were under the age of 18, which is the legal age in Syria to buy cigarettes or use tobacco products. As a result, a total of 2796 adults (aged 18 to 80 years) participated in the study, which lasted 30 days (01/06/2021-30/06/2021), with 1726 males (61.7 %) and 1070 females (38.3 %) as shown in (Figure 1).
When participants were asked where they smoked the majority of their cigarettes or where they smoked the most frequently, 41.1 % smoked primarily in their homes, followed by restaurants and coffee shops (20.2 % and 21.1 %, respectively). Parks received 11.4 % of the respondents, while university cafeterias received 6.2 %. The explanation for the high %age of smokers who smoked in their homes could be due to local municipality laws prohibiting smoking in public places, as well as the long hours they spent in their homes. The information is displayed in (figure 2).
The total number of smokers (cigarettes and other tobacco products) was 1630 individuals (males and females) in this study, and the overall prevalence of smoking among Syrians was 58.3 % ( CIs 57.1- 59.3). As shown in the table, the number of nonsmokers was 1166, accounting for 41.7 % (CIs 39.7-43.8) of the total (Table 1).
Table 1
The overall prevalence of smoking and the use of tobacco products among Syrians
Group
|
n
|
% (95% confidence intervals)
|
Smokers
|
1630
|
58.3 (57.1- 59.3)
|
Non-Smokers
|
1166
|
41.7 ( 39.7- 43,8)
|
Total
|
2796
|
100
|
Figure 3 showed that males had a higher prevalence of smoking than females. There were 1182 males (68.5 %) and 448 females (41.9 %) smokers in the male and female groups, respectively.
The findings of this study were very comparable to those of a Chinese study, which found that the prevalence of smoking among women was 5.34 % (16). In another study conducted in Iran, the prevalence of smoking among girls aged 12 to 17 years old was found to be 6%. (17). A study conducted in Central and Eastern Europe found that the prevalence of smoking among women was 64.7 %, which was fortunately very high when compared to the findings of this study (18). One of the reasons for female smoking has been the large number of tobacco companies that have promoted female smoking in both high and low-income countries over the last century.
According to the WHO report from 2018, the prevalence of cigarette smoking among women in Africa, America, the Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific was 1.4 %, 10.2 %, 1.5 %, 17.5 %, 0.9 %, and 2.5 %, respectively. The West Pacific and the African continent have the lowest prevalence, while Europe has the highest (19). According to the WHO report, the cigarette smoking rate among women in European countries is higher than in the rest of the world, which is consistent with the findings of this study. According to a World Bank report, the prevalence of smoking among women in high-income, upper-middle-income, lower-middle-income, and low-income countries was equal to 16.1 %, 4.4 %, 1.3 %, and 2%, indicating a high prevalence of consumption in high-income countries (20). The increased prevalence of smoking in adult women increases the risk of stroke, cardiovascular disease, asthma, decreased lung function, breast cancer, cervical cancer, and cervical cancer (21). Other factors that contribute to women starting to smoke include reduced stress, lower education levels, and lower cigarette prices (22).
The study looked at the percentage of pregnant women who smoke or use tobacco products of any kind. The findings of this study revealed a rising trend in smoking among women in general, and pregnant women in particular. Unfortunately, this included 150 female pregnant smokers (33.4 % CIs (30.2-36.9) of total female smokers. There were 298 non-pregnant smoker women, accounting for 66.6 % of the total ( CIs 62.9-70,3). Pregnant women have a higher smoking prevalence than other groups, owing to the negative effects of smoking on the health of pregnant women and their fetus, such as reduced fetal size, stillbirth, increased perinatal mortality, infant death, miscarriage, placental abruption, premature birth, premature lung aging, and chronic obstructive pulmonary disease (23), The effects of a mother's smoking on her fetus can be devastating, endangering future generations in any society. One reason for pregnant women's proclivity to smoke is a lack of knowledge about the effects of smoking on congenital anomalies (24). Other reasons include physiological changes during pregnancy. The Lange study published in 2018 found that the global prevalence of smoking during pregnancy is 1.7 %, which is lower than the prevalence found in this study (25). According to a study conducted by Kondracki in the United States, 9.5 % of pregnant women smoked, with 7 % smoking during pregnancy (26).
Table 2
The prevalence of smoking among pregnant women
Females
|
n
|
% (95% confidence intervals)
|
Pregnant
|
150
|
33.4 (30.2-36.9)
|
Non-Pregnant
|
298
|
66.6 (62.9-70,3)
|
Total
|
448
|
100
|
When smoking prevalence was compared to age groups, smokers were most prevalent in the age groups 18-30 and 51-60 years old (431 or 26.4 %) (374 or 22.9 %), respectively, followed by the age groups 31-40 years old (311 or 19.1 %) and 61-70 (206 or 12.6 %). Table 5 shows that the lowest smoking %ages were in the age groups over 70 years and 41-50 (90 smokers or 5.5 %) and (218 smokers or 13.4 %), respectively as shown in Table 3. The data obtained reveals an alarming trend in the youngest age group, which has the highest prevalence of smoking. The findings of this study are very similar to those of a 2011 study published in China, which found that among men, the prevalence was highest among those 45 to 64 years old (63.0 %) and lowest among those 15 to 24 years old (33.6 %) (9). Another study discovered that the majority of smokers began smoking during their adolescence (27).
Table 3
Comparison of the prevalence of smoking among age groups
Age (years)
|
n
|
% (95% confidence intervals)
|
18-30
|
431
|
26.4 ( 20.9- 32.4)
|
31-40
|
311
|
19,1 ( 18.2-20.1)
|
41-50
|
218
|
13.4 (11.6- 15,7)
|
51-60
|
374
|
22.9 ( 19.6- 25.4)
|
61-70
|
206
|
12.6 (11.1- 14.2)
|
>70
|
90
|
5.5 (4.8- 6.1)
|
Total
|
1630
|
100
|
According to the findings which are shown in Table 4, the prevalence of smoking in the countryside was higher than in the city (949 or 58.2 %) compared to (681 or 41.8 %) respectively.
Table 4
The %age of smokers residing in cities and country-sides
Residence
|
n
|
% (95% confidence intervals)
|
Cities (urban)
|
681
|
41.8 ( 37.5- 46.1)
|
Country-sides (Rural)
|
944
|
58.2 (52-7- 65,2
|
Total
|
1630
|
100
|
The prevalence of smoking in the Syrian countryside is higher than it was in China. According to a 2011 study published in the New England Journal of Medicine, the prevalence of smoking among men was significantly higher in rural residents (56.1 %) than in urban residents (49.2 %) (9).
Surprisingly, (Table 5) shows that university students, particularly undergraduate students, had the highest prevalence of smokers. The group with the lowest level of education (392 or 24.1 %) was followed by the group with the highest level of education (392 or 24.1 %) (389 or 23.9 % ). There were 17.4 % of smokers, or 284 smokers, among those who attended some college but did not complete college. Individuals who attended high schools, primary and preparatory schools had a smoking prevalence of (216 or 13.2 %), and (228 or 14.0 %) respectively.
Table 5
The relationship between smoking and educational level
Educational status
|
n
|
% (95% confidence interval)
|
No school
|
389
|
23.9 (21.3-25.4)
|
Primary and preparatory school
|
228
|
14.0 (12.6-16.2)
|
Secondary (High) school
|
216
|
13.2 (12.3-14.5)
|
Some collage
|
284
|
17.4 (15.2-19.5)
|
Under-graduate
|
392
|
24.1 (21.8-27.5)
|
Post-graduate
|
121
|
7.4 (5.5-9.5)
|
Total
|
1630
|
100
|
The study also looked at the prevalence of smoking and marital status. The difference between singles and married people was significant. The single group had the highest prevalence (637 or 39.1 %), followed by the widowed group (373 or 22.9 % ). While the prevalence among married people was (315 or 19.3 % ). As shown in, the divorced group had the lowest prevalence of smokers (305 or 18.7 %) as presented in Table 6.
Table 6
The prevalence of smoking according to the marital status
Social status
|
n
|
% (95% confidence interval)
|
Single
|
637
|
39.1 (31.9-46.6)
|
Married
|
315
|
19.3 (17.7- 21.4)
|
Divorced
|
305
|
18.7(16.6-21.5)
|
Widowed
|
373
|
22.9 ( 20.9-24.7)
|
Total
|
1630
|
100
|
The prevalence of smoking among professions is shown in Table 7. The highest prevalence was found among government employees (542 or 35.9 % ). The findings revealed a shocking fact: the prevalence of smoking among health care workers was (410 or 27.1 %), which should be concerning to policymakers in Syria's government. The self-employed had the highest smoking prevalence (340 or 22.5 %), followed by engineers and other professional groups (183 or 12.1 % and 36 or 2.4 % respectively).
Table 7
The prevalence of smoking among professional groups
Professional status
|
n
|
% (95% confidence intervals)
|
Self-employee
|
367
|
22.5 (20.1-24.8)
|
Government workers
|
585
|
35.9 (31.7- 39.9)
|
Health workers
|
442
|
27.1 (24.1- 30,7)
|
Engineers
|
197
|
12.1 (9.7-15.1)
|
Other professions
|
39
|
2.4 ( 1,9-3,2)
|
Total
|
1630
|
100
|
There was an inverse relationship between monthly earnings and smoking when it came to social status and smoking. The highest prevalence of smoking was found among those with a monthly income of less than 20,000 Syrian pounds (471 or 31.2 % ). This group could include both adolescents and those who did not receive an education. This was followed by the group earning 20,000-50,000 SP per month (337 or 22.3 %), the group earning 50,000-100,000 SP per month (201 or 13.2 %), and the group earning 100,000-150,000 SP per month (201 or 13.2 %) (261 or 17.3 %). The lowest prevalence was observed in both the 150,000-200,000 SP and the over 200,000 SP groups (181 or 12 % and 60 or 4 % respectively). These findings are illustrated in (Table 8).
Table 8
Smoking prevalence according to the monthly income
Monthly income (SP)
|
n
|
% (95% confidence intervals)
|
< 20,000
|
509
|
31.2 ( 30.6-32,4)
|
20,000-50,000
|
363
|
22.3 (20.5-24.9)
|
50,000- 100,000
|
215
|
13.2 (12.7-14.6)
|
100,000-150,000
|
282
|
17.3 (13.7-21.2)
|
150,000-200,000
|
196
|
12.0 (11.4-13.8)
|
> 200,000
|
65
|
4.0 (3,2-4,7)
|
Total
|
1630
|
100
|
According to the data in (Table 9), the highest prevalence of smoking was found among regular smokers who smoked at least one cigarette or one hookah (water - pipe) per day. In this group, the prevalence was 1491 or 91.5 % (CIs 87.4 - 95.6), while the prevalence among occasional smokers was 138 or 8.5 % (CIs 6.3-10.5). These findings are extremely concerning, given that the vast majority of those polled were regular smokers presented in (Table 9), showed that the highest prevalence of smoking was among the regular smokers who smoke at least one cigarette or one hookah ( water - pipe) per day. The prevalence in this group was 1491 or 91.5% (CIs 87.4 - 95.6) whereas the prevalence among occasional smokers was 138 or 8.5% (CIs 6.3-10.5). These results are very nerve-racking as the majority of individuals were regular smokers.
Table 9
Classification of smokers according to frequency of smoking
Type of smoker
|
n
|
% (95% confidence intervals)
|
Occasional
|
139
|
8.5 (6.3-10.5)
|
Regular
|
1491
|
91.5 (87.4 - 95.6)
|
Total
|
1630
|
100
|
Table 10 depicts the various types of smoking and tobacco products used by Syrians. Cigarette smoking has the highest %age (56.2 % or 916 (CIs 51.7-61.4) smokers, followed by hookah smoking (670 (41.1 %) (CIs 40.1- 42.5), which is on the rise among Syrians, particularly adolescents. Cigar and pipe smoking were very low among Syrians, accounting for 21 (1,3%) and 18 (1,1%), respectively. The reason for these low rates could be the high cost of cigars and pipe tobacco, as well as the time-consuming process of preparing the pipe for smoking. Vape or electronic cigarettes are becoming more popular among young people and the wealthy, but the prevalence of vape smoking remains low (28). The prevalence of vape smoking was 0.2 % in this study due to its high cost and scarcity. Sniffing tobacco is not as common in Syria as it once was. The prevalence of sniffing tobacco was 2 (0.1 %), which is extremely low. The outcomes are shown in (Table 10).
Table 10
The prevalence of Smoking and the use of other tobacco products among Syrians
Types of smokes
|
n
|
% (95% confidence intervals)
|
Cigarettes
|
916
|
56.2 (51.7-61.4)
|
Hookah (water pipe)
|
670
|
41.1 (40.1-42.5)
|
Cigar
|
21
|
1.3 (1.1-1.4)
|
Pipe
|
18
|
1.1 (1.0-1.1)
|
Vape or electronic cigarettes
|
3
|
0.2
|
Chewing Tabaco
|
0
|
0
|
Sniff
|
2
|
0.1
|
Total
|
1630
|
100
|
According to the findings of this study, Syrians smoked two types of cigarettes. 16.1%, or 147 participants, smoked hand-rolled or traditional cigarettes, while 769, or 83.9 %, smoked brand-name manufactured cigarettes (local and imported). Because of the higher prices of manufactured cigarettes, smokers prefer to smoke traditional or hand-rolled cigarettes, as seen in (Table 11).
Table 11
The different types of cigarettes smoked by Syrians
Types of cigarettes
|
n
|
% (95% confidence intervals)
|
Brand name manufactured
|
769
|
83.9 (80.7-86.4)
|
Hand rolled (Traditional)
|
144
|
16.1 (14.3- 18.8)
|
Total
|
|
100
|
According to the data in (Table 12), Syrians smoked more imported cigarettes. Syrians smoked more imported cigarette brands. 73.4 % of participants, or 672 people, smoked imported cigarettes, while 244 individuals, or 26.6 %, smoked locally produced cigarettes.
Table 12
The %age of imported and locally produced cigarettes smoked by Syrians
Cigarettes
|
n
|
% (95% confidence intervals)
|
Imported
|
672
|
73.4 (69.4 - 77.5)
|
Locally produced
|
244
|
26.6 ( 21.2 – 31. 8)
|
Total
|
916
|
100
|
According to the findings of this study, 720 participants, or 44.2 % (CIs 40-1-48.2), have been smoking or using tobacco products for less than 5 years, while 269 participants, or 16.5 % (CIs 12.3 – 20.2), have been smoking or using tobacco products for 5-10 years. 328 participants, or 20.1 % (CIs 18.1- 21.4), have smoked or used tobacco products for 10-15 years, while 145 participants or 8.9 % (CIs 8.1-8.8), have smoked or used tobacco products for 15-20 years. The number and %age of smokers were 148 or 9.1 % (CIs 7.4 – 11.3) and 20 or 1.2 % (CIs 0.1- 1.4) for a period of 20-25 years and more than 25 years of smoking, respectively.
Table 13
The duration of smoking practice among Syrians (years)
No. years of smoking
|
n
|
% (95% confidence intervals)
|
< 5 years
|
720
|
44.2 (40-1- 48.2)
|
5-10 years
|
269
|
16.5 ( 12.3 – 20.2)
|
10-15
|
328
|
20.1 ( 18.1- 21.4)
|
15-20
|
145
|
8.9 ( 8.1-8.8)
|
20-25
|
148
|
9.1 (7.4 – 11.3)
|
> 25
|
20
|
1.2 ( 0.1- 1.4)
|
Total
|
1630
|
100
|
This study also looked at the age of the first cigarette or use of tobacco products. The majority of smokers, 66.3 % (CIs 61.4 – 71.1), or 1081 participants, began using tobacco products when they were between the ages of 15 and 20. This result is consistent with the international trend. Increasing age has a negative correlation with using tobacco products or smoking cigarettes. 349 participants, or 21.4 % (CIs 19.9 – 23.2), used tobacco products for the first time when they were 20-30 years old, while 156 participants, or 9.6 % (CIs 5.3 – 13.9), used tobacco products for the first time when they were 30-40 years old. As shown in the table, only 37 participants (2.3 %) (CIs 1.6 -3.4) and 7 participants (0.4 %) used tobacco products or smoked their first cigarettes between the ages of 50 and 60, respectively (Table 14).
Table 14
Age of first cigarette smoking or the first use of tobacco products among Syrians
Age (years)
|
N
|
% (95% confidence interval)
|
15-20
|
1081
|
66.3 (61.4 – 71.1)
|
20-30
|
349
|
21.4 ( 19.9 – 23.2)
|
30-40
|
156
|
9.6 (5.3 – 13.9)
|
50-60
|
37
|
2.3
|
>60
|
7
|
0.4
|
Total
|
1630
|
100
|
According to the results of this study, 47 participants (5.1 %) (CIs 3.9-7.5) smoked fewer than 5 cigarettes per day. The highest %age of smokers was 277 participants (30.2 %) (CIs 28.7 – 32.5) who smoked 5-10 cigarettes per day. Only 176 smokers or 19.2 % (CIs 16,6 – 21.5) smoked more than 20 cigarettes (one pack) per day, while 193 smokers (21.1 %) (CIs 20.4 – 22.9) and 223 smokers (24.4 %) (CIs 21.4 - 27.6) smoked 10-15 and 15-20 cigarettes per day, respectively. The outcomes are shown in (Table 15).
Table 15
The %age of smokers and the number of cigarettes smoked daily
Number of cigarettes/day
|
n
|
% (95% confidence interval)
|
<5
|
47
|
5.1 (3.9-7.5)
|
5-10
|
277
|
30.2 (28.7 – 32.5)
|
10-15
|
193
|
21.1 (20.4 – 22.9)
|
15-20
|
223
|
24.4 (21.4 - 27.6)
|
>20
|
176
|
19.2 (16,6 – 21.5)
|
Total
|
916
|
100
|
The link between smoking and non-communicable diseases (NCD) is well explained and demonstrated in the literature. Only 50 people (3.1 %) were healthy and had no diseases or health problems to report. 530 people (32.5 %) (CIs 26.6 – 38.8) had respiratory diseases (i.e. emphysema, chronic bronchitis, and lung diseases). CVD was also common among the study's participants. 393 people, or 24.1% (CIs 21.6% – 26.4%), had some form of heart disease (CHD, Stroke, Aortic aneurysm and PAD). 329 participants, or 20.2 % (CIs 16.8 – 23.9), had diabetes, the majority of which was type 2 diabetes. The %ages of kidney and liver disease were nearly identical. As shown in the table, n= 176 (10.8 %) (CIs 16.8 – 23.9) had kidney diseases, while n= 152 (9.3 %) (CIs 7.3 – 11.2) had liver diseases (Table 16).
Table 16
the %ages of Non-communicable diseases (NCD) and health related issues among smokers.
Chronic diseases
|
n
|
% (95% confidence intervals)
|
CVD
|
393
|
24.1 (21..6 – 26.4)
|
Diabetes
|
329
|
20.2 ( 16.8 – 23.9)
|
Kidney diseases
|
176
|
10.8 ( 16.8 – 23.9)
|
Respiratory disease
|
530
|
32.5 ( 26.6 – 38.8)
|
Liver diseases
|
152
|
9.3 (7.3 – 11.2)
|
Healthy
|
50
|
3.1 (2.6- 4.7)
|
Total
|
1630
|
100
|
Smoking is not only a health issue, but it is also an economic one because smokers spend a portion of their income on cigarettes or other tobacco products, which can be financially burdensome for them and their families. 470 participants (28.8 %) (CIs 23.5 – 33.8) spent more than 5000 Syrian Pounds on smoking and other related products, with 23.7 % (CIs 20.8 – 26.5) or 386 participants spending between 3000 and 4000 SP daily. 295 participants, or 18.1 % (CIs 14.5 – 22.7), spent $4000-5000 SP, while 202 participants, or 12.4 % (CIs 10.7 – 14.6), spent 2000-3000 SP whereas 194 participants, or 11.9 % (CIs 10.1- 13.2) spent 1000-2000 SP on cigarettes and other tobacco products on a daily basis. Only 83 people (5.1 %) (CIs 4.6–6.5) spent less than 5000 SP per day.
Table 17
The amount of money spent on cigarettes and other tobacco products (SP/Day)
Money spent on smoking (SP/day)
|
n
|
% (95% confidence intervals)
|
< 1000
|
83
|
5.1 ( 4.6 – 6.5)
|
1000-2000
|
194
|
11.9 (10.1- 13.2)
|
2000-3000
|
202
|
12.4 ( 10.7 – 14.6)
|
3000-4000
|
386
|
23.7 (20.8 – 26.5)
|
4000-5000
|
295
|
18.1 (14.5 – 22.7)
|
>5000
|
470
|
28.8 (23.5 – 33.8)
|
Total
|
1630
|
100
|