1. INTRODUCTION
Worldwide, tobacco kills more men than women as historically smoking prevalence has been higher among men in many countries. However, because smoking rates are increasing among women in different countries, particularly among young females, the gap in tobacco death rates between men and women is closing [1]. The Eastern Mediterranean Region (EMR) faces a great challenge regarding tobacco epidemic due to the high rates of tobacco consumption. About half of the region’s adult men and about 10% of adult women are current smokers, and the situation among youth of both sexes is even more serious. WHO report (2009) on the global tobacco epidemic documented that the prevalence of current tobacco use among adult men ranged from 24% - 61%, as compared to 2% - 31% among women in EMR nations [2].
A national household study carried out by the Global Adult Tobacco Survey (GATS) in Egypt in the year 2009 reported that 19.7% of the Egyptian population aged 15 years and older used some form of tobacco product [3]. The prevalence of current tobacco smoking was 59.3% among adult males and 2.7% among adult females [2]. A cross sectional survey on tobacco use in Alexandria, Egypt (2002) revealed that the prevalence of current smokers was 27.2% with prevalence of smoking among men was 48.5%, as compared to only 1.5% among women [4].
Water-pipe smoking is now spreading to many countries in the EMR; particularly among young men and women [5]. The authors anticipated major differences between males and females, among different age and population groups in Alexandria, Egypt, when it comes to awareness about, perceptions towards and consumption of tobacco products. We also needed to objectively confirm the observed popularity of water-pipe smoking among women, as compared to men. Thus, this study aimed at analytically comparing knowledge, attitudes, and practices of tobacco use, by gender, among 4 subpopulations in Alexandria
2. MATERIAL & METHODS
A cross sectional design was used to detect magnitude and study consumption pattern (type and frequency), knowledge, attitude and behavioral factors of tobaccouse in Alexandria The study was conducted in selected settings in Alexandria involving different population subgroups (i.e. governmental high schools; university colleges; hospitals and clinics of University of Alexandria; two sporting and social clubs and two main shopping malls in Alexandria).
Sample size was estimated to be (≈4000), using 95% confidence level and 2% degree of precision [6]. The required sample size was equally divided between the 4 previously mentioned population subgroups i.e. 1000 for each sub group, with equal distribution between males and females. Details for each of the 4 sub-groups’ sample selection are provided below.
A multi-stage stratified random sampling technique was utilized for high school students’ selection, from the 7 educational zones of Alexandria. Two general high school schools (one for boys, one for girls) were randomly selected from each zone, by blind paper picking method. Two classes were randomly chosen from each school (one from grade one and one from grade 3) as to fulfill the required sample size of 144 students within a period of 2 months (thus 72 males and 72 females from each school in each educational zone were chosen randomly).
Regarding the university (undergraduate students) sample, two humanities colleges were chosen (arts and commerce) by blind paper picking method from the main campus of colleges for humanities’ studies in Alexandria; two health related faculties (medicine and dentistry) were randomly chosen (same method) from the main campus of colleges for health studies in Alexandria, during 2008. An equal number of male and female students were included from each selected college.
Five hundred attendees from two Alexandria sporting clubs were selected for this study. Similarly, 500 visitors to two shopping malls were included in this study. An equal number of male and female participants (i.e. 250 from each club and 250 from each mall) were selected.
All health professionals, including physicians and nurses, as well all non health related employees who were working at Alexandria University Students’ Hospital and clinics to fulfill the required sample size over a period of one month (500 health professionals and 500 non health related employees with equal distribution of males and females in both groups).
A modified version of the WHO-GYTS [7] and ESPRI [8] questionnaires were used for data collection, using self administrated method. The questionnaire was divided into four sections: demographic data; knowledge about tobacco use; attitude towards tobacco use as well as laws and rules governing its sales and advertising and behaveioral patterns, including risk factors and cessation attempts. Thus, the tool included questions on: 1) demographic data: age; gender; marital status; occupation, education, income; 2) knowledge about tobacco use: knowledge about smoking hazards and complications; knowledge about methods for smoking cessation, etc.; 3) attitude towards tobacco use and regulations: attitude towards friends smoking; parents smoking (as appropriate, for school-age children); attitude towards smokers; reasons that make people start smoking; attitude towards smoking advertisements; attitude towards cigarette sale age restriction; attitude towards (cigarette and water-pipe) smoking in front of parents (for school-age children); 4) behavioral patterns with respect to tobacco use: smoking frequency; age of initiation of smoking; intention for cessation of smoking.
Definitions [9]:
- Current Smoker: someone who, at the time of the survey, smokes any tobacco product either daily or occasionally.
- Never Smoker: someone who has never smoked at all.
- Non Smoker: someone who was not a smoker at the time of the survey, whether because of being a never smoker or ex daily or ex occasional smoker.
SPSS and Microsoft Office Excel 2003 were used for data analysis. Descriptive statistics were used, as appropriate, in addition to chi-squared test for testing associations between categorical variables. Odds Ratio, with 95% confidence interval, was calculated to estimate the strength of association between potential risk factors and smoking status (outcome variable). Z-test was used for comparison of 2 sample proportions [10,11].
3. RESULTS
The age of the participants (in all sub-groups) ranged from 11 to 78 years. Mean age (±SD) of participating employees was 34.5 ± 10.3 years, as compared to 16.2 ± 0.98 (high school students); 19.97 ± 1.7 and 30.9 ± 12.7 in university students and clubs and malls attendees, respectively.
3.1. Prevalence of Smoking
The prevalence of current smoking among employees was 17.6% (33.6% among males, but only 1.6% among females), (p £ 0.05). In addition, the prevalence of current smoking among males was 25.2% versus 9% among females among high school students’ sample; 29.2% among university students’ males as compared to 5% among university students’ females (p £ 0.05); 34.6% among malls/clubs’ males compared to only 8.2% among females in the same population subgroups (p £ 0.05) Table 1.
Table 2 reflects on type of smoking in our studied groups, where cigarettes represented the pattern of smoking in 48% - 68%; and water pipe was the type in 8% - 49%, with higher preponderance of water-pipe smoking among female smokers, in general.