Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon

Abstract

Background: Currently, little is known about argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in the Arab world, despite emerging evidence on the adverse health effects of argileh smoking and well-established knowledge about the health risks of cigarette smoking during pregnancy. Objectives: The present study assesses pregnant Arab women's knowledge of chemical contents and related harmful effects of argileh and cigarettes, their attitudes towards smoking argileh and cigarettes, and their actual smoking of argileh and cigarettes, both before and during pregnancy. Methods: A stratified sample of 864 women from 23 health care centers in Lebanon completed a structured, interviewer-administered questionnaire. Information was collected on basic demographic variables, women's knowledge, attitudes, and cigarette and argileh smoking. Results: Women were partially knowledgeable about the health risks of cigarette smoking, knew little about the harmful ingredients of argileh smoking, and had many misconceptions regarding how argileh worked or how it can produce harm. Attitudes were permissive towards all forms of smoking. Almost one quarter (23%) of participants reported smoking during pregnancy, with 17% smoking only cigarettes, 4% smoking only argileh, and 1.5% smoking both cigarette and argileh. Conclusion: A significant and growing percentage of pregnant Arab women are smoking in Lebanon, with four cigarette smokers for every argileh smoker. Smoking behaviors are empirically linked with important gaps in knowledge and with permissive attitudes. These data may be used to design more effective prevention programs targeting this vulnerable population.

Introduction

Lebanon has one of the highest smoking rates in the Arab region in general, and the highest rate of women smokers in particular (World Health Organization: Regional Office for the Eastern Mediterranean, 2002). An estimated 52.6% of individuals 19 years and above are current smokers (National Tobacco Information Online System of CDC, 2003).

Of particular concern are the estimated 21% of women in Lebanon who smoke during pregnancy (Chaaya, Awwad, Campbell, Sibai, & Kaddour, 2003), a proportion similar to that of other Arab countries, such as Jordan with 19% of women smoking during pregnancy (Najdawi & Faouri, 1999). Smoking among these pregnant women includes cigarettes and the argileh (water pipe or hubble-bubble), another locally popular, even “trendy” form of smoking that has ancient roots in the Middle East. The popularity of argileh smoking has risen in the last decade, among both genders and among practically all age groups. In Lebanon, argileh is commonly viewed as “healthy” compared with cigarette smoking.

There is, however, increasing evidence of the harmful health effects of argileh smoking. Most notable are the pulmonary effects with increased blood carboxyhemoglobin levels, reduced ventilatory capacity, and increased risk of developing obstructive airway disease Al-Fayez et al., 1988, Zahran et al., 1982. Other harmful health effects of argileh include cancer (El Hakim & Uthman, 1999) and coronary heart disease (Radwan, 1999). Argileh smoke has the same harmful components found in cigarette smoke, including carbon monoxide, heavy metals, potentially cancerous tar fractions, and nicotine (Shihadeh, 2003). Unlike popular belief, nicotine is present in considerable amount in argileh smoke as water filtration of nicotine is incomplete. Tar compounds, which are not water soluble, are present in higher concentrations in argileh smoke than in cigarette smoke (Shihadeh, 2003). During pregnancy, argileh smoking is associated with low birthweight, low Apgar score, presence of pulmonary problems, and other fetal problems, much like cigarette smoking (Nuwayhid, Yamout, Azar, & Kambris, 1998).

Pregnancy is an opportune time to address smoking and other unhealthy habits, as contact with the health care system increases the likelihood that expectant mothers will change behaviors to protect their fetuses. However, there are no studies of pregnant Arab women that can inform the design and/or selection of optimal interventions. Given this important gap in the literature, the present study was undertaken to assess the knowledge and attitudes of pregnant Arab women concerning common forms of smoking, and the associations between these factors and smoking practice.