The European Journal of Public Health Advance Access originally published online on May 4, 2006
The European Journal of Public Health 2006 16(5):509-512; doi:10.1093/eurpub/ckl043
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Smoking |
Exposure of pre-school children to passive cigarette and narghile smoke in Beirut
Hala Tamim1,2, Ghassan Akkary2, Abbas El-Zein2,3, Zana El-Roueiheb2 and Souheil El-Chemaly2
1 Department of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
2 Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
3 Department of Civil Engineering, University of Sydney, Australia
Correspondence: Hala Tamim, School of Kinesiology and Health Science, Bethune College, 4700 Keele street, Toronto, Ontario, Canada M3J 1P3, tel: +1 416 736 2100 ext 33338, fax: +1 416 736 5774, e-mail: htamim{at}yorku.ca
Received May 7, 2005, accepted February 7, 2006
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Abstract |
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Background: Narghile is a resurging smoking device. However, little research has been done to assess passive smoking exposure. The objective of the present study is to evaluate the exposure of pre-school age children in Beirut to parental passive smoking from cigarette and/or narghile. Methods: Data were collected from 1057 pre-school age children attending 16 day cares and 7 nursery schools in the city of Beirut. Results: The overall prevalence of parental smoking (cigarette and/or narghile) was 53.3%. Ten per cent of respondents reported smoking only narghile. Fathers were significantly more likely than mothers to smoke cigarettes. However, there was no significant difference between fathers and mothers with respect to smoking narghile only. Education was a significant predictor for smoking cigarettes but not for smoking narghile. Conclusion: Narghile smoking appears to follow different gender and social patterns than cigarette smoking. Further research is needed to establish the determinants of narghile smoking, in order to develop adequate prevention policies.
Keywords: narghile, passive smoking, pre-school age children
Smoking is a major cause of cancer,1 respiratory,2 and circulatory diseases.3,4 Despite various anti-smoking initiatives, estimates point to more than one billion smokers and four million annual deaths from tobacco worldwide.5 Non-smokers are also at risk when they are exposed to tobacco smoke. Passive tobacco smoking represents a main health hazard to children, possibly leading to otitis media, development or exacerbation of asthma, and other respiratory diseases.6
In Lebanon, there has been a revival of narghile smoking over the last decade. Narghile (also known as water-pipe, shisha, hookah, or hubble bubble) has been practiced for centuries in the Middle East. The main ingredient of narghile is the ‘tumbak’, a dark-paste tobacco lit by charcoal embers. The tumbak is piled on a tray atop a pipe connected to a glass bottle that is half-filled with water, and a burning charcoal is placed directly on the tumbak (figure 1). When the smoker sucks on the pipe, emissions from the burning tobacco travel through the water before being inhaled into the lungs. A recent study found that the total particulate matter (TPM) that is inhaled by narghile smokers is 1.10 g/h.7 When compared with a range from 1 to 27 mg of TPM per single cigarette,8 this hourly inhalation of TPM with narghile would equate to a mean of five packs per day of cigarettes. A literature search yields no reports about amounts of passive TPM exposure from narghile.
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Whereas many studies have looked at children's exposure to passive cigarette smoking,9,10 no studies, to our knowledge, have investigated the exposure to passive narghile smoking of children less than 5 years of age. The objective of the present study is to evaluate the exposure of pre-school age children in Beirut to parental passive smoking from cigarette and/or narghile, and to identify its distribution between mothers and fathers and across the different education and occupation levels. This will help in assessing the magnitude of the problem so that adequate policies can be developed.
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Methods |
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The study was cross-sectional in design. Pre-school in Lebanon is mandatory from the age of 4 and the proportion of non-attending children is expected to be small. A convenient sample of 23 institutions including 16 day cares and 7 nursery schools were selected based on the phone directory. The schools were selected to include children from both east and west Beirut and from all socio-economic background and the country's two major sects (Christians and Moslems). No institution refused to participate. Consent was sought from the administrative boards of each institution. Questionnaires were sent home with the children for their parents to fill. The questionnaire included information on socio-demographic characteristics, smoking behaviour (including dose and frequency) of each parent at the household level, and type of tobacco smoked (cigarettes or narghile). Response rate of filled questionnaires was above 90%. Collected data were analysed using the Statistical Package for Social Sciences (SPSS) Software version 11.
2 statistics were calculated to determine the association between the gender and the smoking methods of the parents. The t-test statistics were calculated to determine the relation between the dose of cigarette and the rate of narghile smoking across both genders. Three stepwise logistic regression models were performed separately for mothers and fathers; where the dependent variables were smoking either cigarettes or narghile, smoking cigarettes only, and smoking narghile only. The independent variables were education, occupation, and the smoking status of the spouse. Odds ratios (OR) and 95% confidence intervals (CI) for the variables selected in these models were reported. |
Results |
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The total number of children recruited in the study was 1057, of which 53% were boys and 47% were girls. Their age ranged from a few months to 6.5 years (mean ± SD: 3.97 ± 1.49 years). table 1 shows the overall prevalence of different types of smoking at the household level and among fathers and mothers. The overall prevalence of household smoking (either cigarette and/or narghile) in the sample was 53.3%. Fathers were significantly more likely than mothers to smoke only cigarettes, or both cigarettes and narghile. However, there was no significant difference between fathers and mothers with respect to smoking narghile only. A total of 17.2% of the households had both mothers and fathers smoking cigarette and/or narghile. Fathers were found to be significantly more likely to smoke a higher dose of cigarettes than mothers (respectively, 17.7 versus 15.3 cigarettes per day; P = 0.01) but no similar significance was observed for the difference in rates of narghile between fathers and mothers (respectively, 3.7 versus 3.5 narghile smoking times per week; P = 0.67).
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Stepwise regression analyses revealed a significant inverse relationship between both father and mother educational level and smoking cigarette but not narghile (table 2). Adjusting for the education, the parent (mother or father) was three times at higher odds of smoking cigarettes if his (her) spouse smoked cigarettes, whereas the parent was 20 times at higher odds of smoking narghile if his (her) spouse smoked narghile; OR = 19.7, 95% CI = 10.8–35.9.
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Discussion |
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More than 53% of the pre-school age children in this study are exposed to parental passive smoking of either cigarette and/or narghile. To our knowledge this is the first study to address the issue of exposure of children less than 6 years of age to passive smoking of narghile, hence making comparison with other countries difficult. The study does not address exposure of children from other sources and at other locations, including smoking household members other than parents, cigarette smoking at school and in school buses, cigarette and narghile smoking in public places, and so on. Therefore, the figures reported here must be viewed as a minimum estimate of exposure of pre-school children to passive smoking.
The prevalence of passive exposure to cigarettes among pre-school children in the present study (36%) is markedly higher than that reported by the National Health Interview Survey in the United States in 2000, which estimates that children's passive smoking exposure at homes declined from 36% to 25% between 1992 and 2000.10 One study form Iran looks specifically at cigarette-smoking fathers and finds that 41% of 622 children aged 6 months to 5 years live in houses where fathers smoke, compared to 31.6% of smoking fathers in our study.9
Male gender is positively associated with parental cigarette smoking. This is consistent with other surveys conducted in Syria which report a smoking rate of 48% among adult males, compared to 9% among adult females.11 The gender difference in parental cigarette smoking rates in Lebanon (31.6% versus 16.6%) is not as pronounced. Maziak11 attributes the rate of female smoking in Syria to conservative social attitudes and a low level of social liberalization. Accordingly, a higher degree of Westernization in Beirut, compared to other cities in the Arab world, could also explain the higher rates of parental female smoking. On the other hand, narghile smoking does not seem to follow a gendered pattern. Even the rates of narghile smoking among both sexes are very close: 3.5 times/week for mothers and 3.7 for fathers. This may be due to the fact that, despite relaxed attitudes to female cigarette smoking, female narghile smoking is still more socially acceptable.
In line with other reports we found that educational level of parents was significantly related to cigarette smoking.12 However, this relationship was not present for narghile smoking. The strong relationship between smoking narghile of both parents observed in the study suggests the socially encouraged habit practiced by different family members.
Narghile smoking is a culturally-specific practice that is intimately linked to social patterns of sociability and hospitality. Therefore, socio-cultural dimensions, such as age, religious beliefs, and cultural affiliations, must be explored to develop a better understanding of the determinants of prevalence. Most importantly, the gendered patterns of cigarette smoking cannot be extrapolated to narghile unless empirical evidence to the contrary is established.
Key points
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Acknowledgments |
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This work was carried out with the aid of a grant from Research for International Tobacco Control (RITC), an international secretariat housed at the International Development Research Center (IDRC), in Ottawa.
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References |
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