Tobacco Smoking and Alcohol Drinking among Youth in Duhok, Iraq: A Cross-sectional Study

1. Student, Department of Community Medicine, College of Medicine, University of Duhok, Duhok, Iraq. 2. Assistant Professor,, Department of Community Medicine, College of Medicine, University of Duhok, Duhok, Iraq.

Abstract

Introduction: Tobacco smoking and alcohol drinking are among the high risk health behaviours that determine individual and community health, increasing risk of chronic diseases like cardiovascular diseases and cancer, and of early mortality.

Aim: To determine the prevalence and pattern of tobacco and alcohol use among youths in Duhok Province, Kurdistan Region of Iraq.

Materials and Methods: This community based cross-sectional study conducted from September 2020-January 2021 in Duhok Province, Iraq. Systematic random sampling was used to interview 729 youths (15-24 years) (366 males and 363 females), who visited the Premarital Screening and Counselling Health Clinic in Duhok city, Iraq. Data collection was done using questionnaire based on the World Health Organisation (WHO) STEPwise approach to Non Communicable Diseases (NCD) surveillance. Data were analysed by Statistical Package for the Social Sciences (SPSS) version 26.0, and association between variables was calculated using the Chi-squared test and logistic regression.

Results: Prevalence of tobacco smoking among youth was 20.3%, (25.4% in males and 15.2% in females). Males were 2.2 times more likely to smoke tobacco (OR: 2.2). Nargila/waterpipes was the most commonly used tobacco product (19.5%) followed by cigarettes (14.1%). Prevalence of alcohol drinking was 4.0%, (7.1% in males and 0.8% in females).

Conclusion: Tobacco smoking among youth in Duhok was high, especially among females, with more use of Nargila/waterpipes. Exposure to second hand smoking was very high. Alcohol drinking was higher than WHO estimate for Iraq.

Health risk behaviour, Nargila, Substance abuse, Waterpipes

Tobacco smoking and alcohol drinking are among the high risk health behaviours, with increased risk of chronic diseases like cardiovascular, cancer, and early mortality (1),(2). Globally in 2019, 64.2% of deaths from tracheal, bronchus, and lung cancer, were attributed to smoking (3). Tobacco use has negative health effects, with atleast 70 toxic compounds having carcinogenic effect on human (4),(5). The most known alkaloid’s component of tobacco is Nicotine which can affect the nervous system and is one of the highly addictive substances (6). Tobacco use is influenced by multiple factors with direct effect of the culture. In many communities, young boys still think tobacco smoking is part of growing and having authority (4). Peer groups have high influences on tobacco use among youth (7). Tobacco industries promotion has resulted in initiating smoking tobacco among many youths (8).

Smoking among Iraq adolescent and youth (13-18 years) is among the highest rate in the Middle East (21.8%) (9). In Erbil city, Iraq, 27.6% of youth (14-19 years) smoke cigarettes and 23.6% use waterpipe (Nargila/shisha) (10), and among Duhok universities’ students 23.5% smoke cigarettes (11). Stress and instability due to decades of wars in Iraq could have resulted in increasing tobacco use (12).

Alcohol use was the leading health risk factor globally in 2016, with 12.2% of deaths attributed to alcohol use among adult male (15-49) and 3.8% among females (13). Use of alcohol is associated with violent behaviours among youth (14) and increase risk of infectious diseases like Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and tuberculosis (15). Alcohol uses continue to be the most used psychoactive substance in Iraq 3.2% [16,17]; in Erbil city 3.7% (10); in Duhok, 5.4% of adult males reported consuming alcohol in 2004 (18); and there are no recent estimates specially among youth (15-24 years) in Duhok, Iraq.

Thus, the aim of this study was to determine the prevalence and pattern of tobacco and alcohol use among youths in Duhok Province, Kurdistan Region of Iraq.

Material and Methods

This was a community based cross-sectional study conducted in Duhok Province, Iraq, between September 2020-January 2021. Ethical approval was obtained from Research Ethical Committee of Directorate General of Health, Duhok, Iraq. (Reference no. 29052018-4).

Inclusion criteria: This study included youth aged 15-24 years old, both males and females, attending the Premarital Screening and Counselling Health Clinic in Duhok, gave consent and accepted to participate in this study.

Exclusion criteria: Those unwilling to participate in this study, and those not within the 15-24 years range, were excluded from this study.

Sample size calculation: Study sample size was calculated using {n=(Z² P(1-P))/E²} formula (19), where, Z=1.96, with anticipated prevalence (P) of 0.5 {the anticipated prevalence (p) of 0.5 was taken to get higher sample size}, and type one error (E) of 0.05. The sample size was increased, multiplied by the estimated design effect of 2, including 10% non response rate, to have a more representative sample size. Thus, the total sample size was calculated as 768.

Study Procedure

Systematic random sampling was used to select eligible and willing youth (15-24 years). Due to COVID-19 pandemic restrictions, data collection couldn’t be done in the community and instead done at the Premarital Screening and Counselling Health Clinic in Duhok city, Iraq. The clinic is the main health screening and counselling facility for young couples willing to marry, with the majority aged 18-30 years, and monthly around 450 couples visit this clinic.

Eligible youths, attending the clinic were randomly selected, based on systematic random sampling, where every third attendee was requested to participate in the study. Those accepted were interviewed in private and suitable place.

Verbal consent was obtained from each participant, the data were collected using standardised questionnaire, which comprised of 62 questions, based on the WHO STEP-wise approach to NCD surveillance (20). The questionnaire included, background and socio-demographic information (19 questions); tobacco (24 questions) products use, current and daily tobacco product smoking and use, exposure to second-hand smoking, attitude toward smoking, and tobacco product advertisement; and alcohol consumption, lifetime consumption of any alcohol, within the past 12 months, attitude toward smoking, and alcohol advertisement (19 questions) [Annexure-1].

Statistical Analysis

The study data were entered and scrutinised using Microsoft Excel spreadsheet, then analysed to measure the required frequencies, rates and proportions of the study variables using the SPSS version 26.0. Association between variables was calculated using the Chi-squared test and considered statistically significant if the p-value was <0.05. A logistic regression modelling was performed to examine the effects of gender, age groups, from Duhok district, sequence in the family, a friend offer a cigarette, someone smoke at home, seeing tobacco advertisement, university student, and lifetime use of alcohol, on the likelihood that participants currently smoke tobacco.

Results

A total of 729 (366 males and 363 females) youths were successfully interviewed, out of the 768 selected sample with 94.9% response rate, with mean age of 19.4 years, and 456 (62.6) were students. A total of 148 (20.3%) of youths were current tobacco smokers, 96 (13.2%) smoked daily, and 82 (11.2%) were past smokers, of them 17 (2.3%) smoked daily, and stopped at mean age of 17 years and no one used smokeless tobacco products. A total of 142 (19.5%) smoke Nargila/Shisha and 103 (14.1%) manufactured cigarettes, while hand rolled cigarette, pipes and cigars were not smoked at all. A total of 101 (13.8%) would definitely smoke a cigarette offered by a friend, while 24 (3.3%), think will definitely smoke a cigarette in the next 12 months, and 16 (2.2%) have noticed any health hazard notice on tobacco packs (Table/Fig 1). Sixty-one, (41.5%) of current tobacco smokers have tried to quit smoking, and 24.5% were advised to quit tobacco smoking during a visit to a medical doctor or other health workers. A total of 89 (60.5%) bought the tobacco they smoke while, 31 (21.1%) get it from a friend (Table/Fig 2).

The mean age for starting tobacco product smoking was 16.2 years. While the cost of tobacco product smoked in the past thirty days was 29,871 Iraq Dinars (Table/Fig 3).

Binary logistic regression model was statistically significant, χ²=27.583, p=0.004. The model explained 9.7% (Nagelkerke R²) of the variance in currently smoke tobacco and correctly classified 81.5% of cases, and shows that males were 2.21 times more likely to smoke tobacco than females, while not being the first child in the family, is less likely to smoke, (Odds Ratio [OR] 0.607, 95% Confidence Interval [CI] 0.417-0.883) (Table/Fig 4).

Twenty-nine (4.0%) participants reported lifetime alcohol drinking, with 16 (2.2%) in the last 12 months, while 11 (1.5%) have stopped drinking alcohol due to health reasons. Ten (1.4%) have had got into troubles once or twice with family or friends, missed school/work, or got into a fight as a result of drinking, while 7 (1.0%) have had trouble due to someone else drinking in the past 12 months. (Table/Fig 5). The mean number of times having at least one standard alcohol drink in the past one year and 30 days, was 3.81 and 11.56, respectively, with an average of 2.56 standard drinks on one occasion, and on 1.2 times have six or more drinks in a single occasion. The mean number of standard alcohol drinks on Thursday was 4.31, while on Sunday was 0.75 (Table/Fig 6).

Statistically significant associated was found between tobacco and alcohol use and being male (p<0.001) (Table/Fig 1),(Table/Fig 5).

Discussion

The current rate of 20.3% tobacco smoking among both sexes is close to Iraq adolescents’ national rate (21.8%) (9), and Duhok university students (11), but more than the 2018 WHO estimate of current tobacco use in Iraq (18.5%), the global prevalence among youth (17.0%) (21), and among secondary school students in Baghdad (16.1%) (22). Although, this should be taken cautiously, as each study have targeted different age cohort. Female tobacco smoking is higher than the national Iraqi rate, other studies in Iraq, and countries in the region, except Lebanon (Table/Fig 7) (9),(11),(21),(22). The social changes that have occurred as a result of a growing economy and a wide use of social media could have resulted in some cultural changes related to female tobacco smoking, as traditionally female smoking was culturally not acceptable in Iraq until recent years (12).

In this study, the daily cost of smoked tobacco was less than one dollar, which is consistent with the average cost of 0.78 USD for a pack of 20 cigarettes in 2015 (12). With the 2020 gross domestic product per capita of US$ 4,288.773 (23), the current tobacco smoking cost is affordable. WHO recommended 70% excise tax on cigarette retail costs, as a measure toward reducing tobacco usage through reducing tobacco affordability (6),(24), but this yet to be implemented in Iraq.

Nargila/shisha or waterpipe smoking was the most common type of tobacco smoked, followed by Cigarette’s, 19.5% and 14.1, respectively. Nargila/shisha smoking was less than university student in Lebanon 28% (25). But, among female, was higher than those reported in Duhok Universities 11.8% (11). This demonstrates a shift in the use of tobacco products among youth, as found among university students in Sulaymaniyah (26), and among Duhok universities students (11). While in Erbil city, cigarette smoking was the first most common type of tobacco product used followed by Nargila/waterpipes (27.6% compared to 23.6%) (10). Nargila/waterpipes smoking is increasing, especially among youth in Middle Eastern countries and among Arab-speaking communities in Western countries (25),(27). This needs further in-depth studies to reveal the social and cultural aspect related to this.

Among current smokers, less than half (41.5%), attempted to quit smoking, as less than one in four have been advised to quit smoking tobacco during any visit to a doctor or other health worker in the past 12 months. Frequent, simple, informative, culturally sensitive, and consistent advice on the health risks and hazards of smoking by medical doctors and other health staff are one of the most effective means to motivate tobacco smokers to quit (28). Medical doctors and health staff need to be encouraged to provide such advice.

Exposure to second-hand smoking was very high at home, and in enclosed places. This was much higher than among 6-18-year-old school children in Baghdad (34.2%) (29), the 55.9% average reported from 68 Low-Income and Middle-Income Countries (LMIC) including 53.7% in Eastern Mediterranean Region (EMR) (30). Smoking in closed spaces such as recreational, sport, public transport, indoor offices, educational and health facilities is common in the EMR countries as two third of recreational facilities and one third of health facilities show evidence of smoking (31). As per the applied Iraqi Anti-tobacco law 19 of 2012 and Kurdistan region of Iraq law 31 of 2007 (32),(33), tobacco smoking in indoor offices and public places is prohibited, yet this to be enforced due to ongoing security and political instability.

Lifetime alcohol use was low (4.0%), while alcohol drinker in the last 30 days was lower (2.2%). This was close to the reported 5.4% alcohol drinking among males in Duhok district (18), the 3.7% reported among high school students in Erbil (10); and the 3.2% among Iraqi adult (16). While, WHO estimate of current alcohol drinkers among 15-19-year-old in Iraq is lower (1.5%) especially among males (male 2.3% and female 0.7%) (15).

Limitation(s)

Due to Coronavirus Disease-2019 pandemic preventive measures, restricted access to schools and universities, youth attending premarital screening and counselling health clinic were selected to participant in this study.

Conclusion

Tobacco smoking was high, among youth in Duhok Governorate, and notably among females. There was a shift in the type of tobacco product smoked, with Nargila/shisha or waterpipe smoking being the most common type. Exposure to second-hand smoking was very high, at home, and in enclosed places. Tobacco products were accessible and affordable for youth. Lifetime use of alcohol was relatively low, but higher than the WHO estimate of current alcohol drinkers among the 15-19-year-old in Iraq. Further researches are required to better understand the motives, causes and other social aspects for tobacco product smoking and alcohol drinking.

Acknowledgement

The support provided by Dr. Sirwan Mohammed Aswad, Department of Community Medicine, College of Medicine, Duhok University, and the Directorate General of Health-Duhok is highly appreciated.

DOI and Others

DOI: 10.7860/JCDR/2022/52701.16268

Date of Submission: Oct 07, 2021
Date of Peer Review: Dec 10, 2021
Date of Acceptance: Feb 10, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 12, 2021
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ETYMOLOGY: Author Origin