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Mazidi Sharafabadi V. The Causes of Smoking and the Solutions to Control it in Tehran. JSBCH 2017; 1 (1) :49-59
URL: http://sbrh.ssu.ac.ir/article-1-29-en.html
URL: http://sbrh.ssu.ac.ir/article-1-29-en.html
School of Sociology, Tehran University, Tehran, Iran
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Discussion
The participants identified various causes for smoking. All of them expressed that somehow falling into the habit is the most important cause of smoking. They couldn’t quit this habit. Certainly, at least one time, each had decided to quit smoking. But none of them succeeded because getting accustomed to smoke builds a very strong habit. Onal et al. (2002) have mentioned in their research that 36% of students at the University of Istanbul, of them 46% male and 26% female, were accustomed to smoking.8 Certainly, since smoking makes a hard and strong habit for the smokers, and spreads quickly in society, day by day a larger part of resources is spent on smoking and the number of smokers keeps increasing. A person who begins to smoke can't give up easily. When we attempted to find people who had quit smoking for good, we could hardly find a person. It seems that smokers smoke because they smoked for the first time and got accustomed to it. A habit like this can be very difficult to quit because of severe physical and psychological addiction and dependence on it.
Approximately, all smokers stated that they have easy access to cigarettes. This issue can be considered as the most important cause of smoking. Now, the relation between access to cigarettes and smoking is very simple in Iran, especially when we combine the issue with the price factor. We can see that readily-available and cheap cigarettes help increase the number of smokers. In Iran, each store, shop and supermarket sell various brands of cigarettes and prices of these cigarettes are not higher than 4,500 Tomans for a pack. If the cigarettes were sold in certain places that were not easily accessible and there were some limitations for buying cigarettes, at least the number of smokers and the number of the cigarettes they smoke would have been much lower than it is at present. We must consider the fact that when a smoker is walking in the city and crave cigarettes, every 50 steps he faces a shop to buy it from. If there were only one seller in each neighbourhood or area of town and the smoker was forced to travel longer distances to obtain cigarettes, the number of cigarettes smoked would go down. When the smoker doesn’t have a cigarette, she or he postpones smoking to some extent. Saunders (2011) has concluded in his research that boys access cigarettes by stealing cigarettes from parents and girls by giving money to others to buy cigarettes for them easily.9 Therefore, based on the results of this study, if we limit sale and accessibility of cigarettes in Iran so that the smokers hardly have access to cigarettes, the extent of use, the number of cigarettes smoked, and the prevalence of smoking will be reduced automatically.
Another cause which the participants identified in relation with smoking is that smoking is a recreational tool. They turn to smoking when they need entertainment and recreation. But Hammal et al. (2008) in their research have mentioned that the users of hookah in Syria knew their action as an enjoyable social experience which has a root in culture, but they considered smoking cigarettes as a sign of a depressed individual and physical addiction.10 Certainly, entertainment is an important need for individuals and people turn to entertainment due to hardships, rigours of work, business or education, and to discharge their physical and mental pressures. If society provides cheap, healthy, interesting, and useful avenues of entertainments and encourages people to use them optimally, there will be very few users of harmful entertainment such as cigarettes and drugs.
Instead, in a society like ours where there are fewer recreational facilities that are interesting to the youth as well as being expensive, people turn to the cheapest and the most accessible entertainment. Cigarettes, as a cheap readily-available substance, can be the most important alternative. A young person may be exhausted by routine work, education or study, and yet recreation resources are not available or they are expensive, so, they can easily and cheaply buy a pack of cigarettes from a newsstand and derive the desired pleasure. Certainly, an entertainment with the price of 4500 Tomans available in any alley is cheaper and more accessible than the entertainment in the only water park with the ticket price of 50,000 Tomans located far away. So, everyone chooses the first one instead of the second. Unemployment and lack of income contribute to the problem and limits the youth’s options of more expensive entertainment. This makes them buy and smoke cigarettes more and more. Of course, it should be noted that smoking not only is not entertainment but also is a big self-deception and self-harming. But people perceive it as an entertainment and this is considered a big mistake. There should be more cultural awareness and people should be informed that the idea of entertainment by smoking is a big self-deception in reality.
Relaxation was another cause that participants identified as relevant to smoking. They acknowledged that they smoked in order to relax. Hammal et al. (2008) have mentioned in their results that unlike smokers who would smoke to manage stress, the consumers of hookah knew it as an entertainment.10 It should be noted that people have the misconception that if you light a cigarette when you are angry, your anger will be pacified. Even if this assumption is correct, why should the anger be pacified with smoking? Many measures can be considered to pacify anger such as study, exercise, and walking. Therefore, it can be said this is just an excuse to smoke. The smokers, who smoke a pack of cigarettes a day, definitely don’t become angry 20 times daily, and possibly there are days when they don’t become angry. This is a false and deceptive reason to smoke a harmful substance, which many smokers mentioned. In many movies, the important characters light a cigarette when they are angry and achieve outward and sham relaxation. For decades this has led to the false conception that when you become angry you can light a cigarette to pacify your anger. The youth are also being affected by these scenes since they imitate these actions and become dependent on cigarettes.
For some participants, their smoking was related to what they learnt and imbibed from friends and family. These people have friends, parents or siblings who smoke. They had learnt this behavior from others. They knew that the reason they took up smoking is because they were affected by others. Cremers et al. (2015) have mentioned in their results that among the boys who have never smoked, the positive attitude to cigarettes leads to smoking. But in girls who have never smoked, if they have the conception that smoking leads to very few complications, they smoke a lot. The intention of smoking for the boys who had never smoked is related to the perception of social norms. For the girls who had never smoked, their intention is strongly related to the smoking habit of people around them.11 Watanabe et al. (2013) have mentioned in their results that smoking among the participants have had a significant relation with the variable of having a smoker in the family.12 The youth are the worst-affected segment of the population in this regard. They learn, get socialized about, and initiate smoking and internalize the habit. Smoking in presence of the youth, adolescents and children, in addition to damage from secondary smoke, makes them vulnerable to learning and initiating smoking. Smoking is very contagious. Smoking in presence of others, especially the youth, leads them to smoke somehow. Therefore, special limitations must be imposed to control smoking in the presence of others.
In this research, women emphasized that they smoke for revenge and self-injury. No male smoker stated that he smokes for self-injury. This claim was common only among the female participants. Those women and girls who have been oppressed or had difficulties forced on them have the tendency to smoke and they do it in their solitude. The empowerment of women can make them feel more in control of their lives and prevent their tendency to smoke. It is strange that a person smokes only for self-injury. To harm the self knowingly, not for pleasure or fun, can be a dangerous cause for smoking. This action can be mentioned as a type of gradual suicide. Psychologists and sociologists have to analyze why only women have known self-injury as an important cause of smoking while men consider other causes.
Another factor identified by the participants is a sense of pride and megalomania associated with smoking. Since smoking is a common behavior among adults, the youth consider themselves to be in the group of adults simply by the virtue of smoking and they feel important. The photographs and movies of some of the great artists and scientists taken while they smoked lend credence to this feeling and there is a tendency to smoke in order to show off. A 15-year-old likes to be accepted as an adult by the society and may decide to use cigarettes as a tool for achieving that goal quickly. It is obvious that not only smoking has no dignity and pride, but it also is shameful. Who can claim that entering 4,000 types of poison into the body deliberately is a kind of honour and pride? The proliferation of the idea that smoking not only causes no dignity and pride but also is a big shame and dishonour can be an important factor in controlling smoking.
But various answers have been received from the smokers regarding fighting against the spread of smoking and controlling it. They have emphasized that the creation of an anti-smoking culture, individual volition, legislation, and pricing are relevant solutions. The results of this research indicate that setting limitations on cigarette advertisements and increase in tax can reduce smoking; the difference is that limitations on advertisements lead to the decline in smoking indirectly, but an increase in tax reduces smoking directly.7 Lopez et al. (2010) have mentioned in their research that poor performance in school, having relation with a pre-smoker, and the failure to understand the serious concerns of smoking are directly associated with smoking.13
But all the mentioned factors are important in order to fight and control smoking. At an individual level, people should smoke less or quit and this needs a strong will. On a larger scale, the authorities are required to create an anti-smoking culture, spread information about the harms of smoking and prevent the spread of smoking among people. For pricing and legislations, the authorities should provide conditions in a way that smoking to be not so easy that all people are able to smoke. It seems that the effect of protection and surveillance is much higher than individual volition. One example of the authorities’ interference is the control on the smuggling of cigarettes into the country. Like other products, cigarettes are smuggled into the country in large quantities and its difference with other smuggled goods is that smuggled cigarettes not only ruin the national industry but also destroy people’s health.
The most important limitation of this research was that female smokers didn’t cooperate with the researcher most of the times and even male smokers didn’t allow the researcher to record their voice in some cases.
Conclusion
In this paper, the causes of smoking and the solutions for its control have been evaluated through deep interview with 12 male and female smokers. The smokers stated some causes for smoking: getting accustomed to smoking, easy access to cigarettes, having no alternative entertainment, getting relief through smoking, not paying enough attention to the damages caused by smoking, being affected by others and taking up smoking, megalomania and a sense of pride derived from smoking, considering smoking as a normal behavior, and self-injury through smoking. They suggested some solutions to control smoking: the importance of individual volition, the creation of an anti-smoking culture, making cigarettes scarce and expensive, preventing excessive imports of cigarettes into the country, preventing smoking in public places, and replacing it with healthy avenues of entertainment.
Among the findings, there was an especial emphasis on five factors. Among the causes of smoking; all 12 spoke about getting accustomed to smoking, 11 spoke about easy access to cigarettes and 9 spoke about being affected by friends and family members. Among the solutions suggested by smokers to control smoking, five participants spoke about the importance of the creation of an anti-smoking culture and four spoke about the importance of individual volition. These were the highest frequencies. Among the causes, somehow all participants mentioned the factor of habit and confessed to feeling dependent on cigarettes. They knew that this form of tobacco is very easily accessible and in introducing the factor of taking up smoking, they said they started smoking by being affected by others. It is obvious that if a substance so addictive is available easily and can be bought and smoked in the shortest amount of time and with minimal cost, it will spread rapidly. It is a grave problem in a young society such as Iran where peer influence and peer pressure are high.
Therefore, despite the present smokers in this research having emphasized on individual volition to quit smoking the creation of an anti-smoking culture, some other solutions can be suggested. For one, there can be interdictions that prevent people from starting smoking so that the habit (as the strongest factor of smoking based on the findings of this research) is not formed. Making cigarettes more expensive and limiting sale can limit access to cigarettes. The youth and teenagers must be trained about the dangers of smoking and how to refuse to take it up as a habit. Through heavy taxes for cigarettes and making laws to limit the distribution and sale of cigarettes, some countries like Australia and Turkey have succeeded in controlling the spread and consumption of tobacco. They have become ideal examples of fighting against smoking in the world and should be emulated.
Conflicts of Interest
The authors declare that there is no conflict of interest in this work.
Acknowledgements
This study was conducted with the support of Iran's Anti-smoking Association in the form of a research project with the number: 94/5955 and approval date: 2015/7/26.The authors would like to thank the participants for their sincere cooperation in this study.
Authors' Contribution
This article has one author.
Copyright: This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
Full-Text: (1863 Views)
The Causes of Smoking and the Solutions to Control it in Tehran
Vahid Mazidi Sharafabadi
School of Sociology, Tehran University, Tehran, Iran.
| A R T I C L E I N F O | A B S T R A C T | |
| ORIGINAL ARTICLE | Background: Smoking is one of the leading causes of disease and death in the world. There is a growing trend of smoking in Iran, especially among youth and women. This study has been conducted to identify the factors related to smoking and solutions that can lead to its control in Tehran. Methods: This study was conducted qualitatively from August 2015 to August 2016 in Tehran. The data collection tool included cognitive interviews and deep, semi-structured interviews. The participants consisted of 7 men and 5 women who smoked cigarettes; they were selected through purposive sampling with maximum diversity and snowball technique which continued until data saturation. The data was analyzed through qualitative conventional content analysis. Results: Two main classes with 15 subclasses were extracted from the participants’ responses. The causes of smoking and the solutions for its control are evaluated along these two classes. The subclasses include factors like being accustomed to smoking, considering smoking as a normal behavior, easy access to cigarettes, recreation and entertainment; lack of recreational facilities, way of relaxing, increasing the price of cigarettes, the importance of making cigarettes scarce, and cultural and individual volition. Conclusion: Being accustomed to smoking and considering it as an entertainment are the most important causes of smoking, and the importance of creating an anti-smoking culture and individual volition have been introduced as the most important solutions for controlling smoking in Tehran. Furthermore, it seems that reducing the public access to cigarette through various ways such as increasing the price, reducing the imports, the decline in production and supply, as well as creating a culture against smoking can reduce the amount of smoking considerably. Keywords: Cigarette, Qualitative Study, Cause of Consumption, Control Solution |
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| Article History: Received: 12 Jan 2017 Revised: 25 Feb 2017 Accepted: 6 May 2017 |
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| *Corresponding Author: Vahid Mazidi Sharafabadi Email: mazidi0784@gmail.com Tel: +98 9132564870 |
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| Citation: Mazidi Sharafabadi V. The Causes of Smoking and its Control Solutions in Tehran. Social Behavior Research & Health (SBRH). 2017; 1(1): 49-59. |
Introduction
Smoking is one of the leading causes of diseases and death.1 The World Health Organization has estimated that annually more than 4 million people die because of tobacco use and this value will be increased to 10 million people per year until 2030.2 Many of the deaths related to cigarette occur in countries with middle and low income.3
The prevalence of smoking in Iran has been reported to be approximately 12% in people over 15 years old and the average daily consumption is 13.2 cigarettes.4 67% of Iranian men smoke for the first time at 14 years of age5 and 80% of them begin smoking before 20 years of age.6 Almost 429 million dollars are spent each year on smoking in Iran.7
But to fight smoking, if policies of controlling tobacco are executed as a part of the comprehensive plan, tobacco use can be reduced effectively. The increase of cigarette price with the increase of tax and introducing laws prohibiting smoking indoors and banning smoking in public places have been the most effective factors to reduce total rate of smoking.8 The results of previous studies have indicated that in the long run, limitations on advertisement and increase of tax can reduce the rate of smoking. Although limitations on advertisement usually reduce smoking indirectly and affect market boom, the increase of cigarette tax reduces the rate of smoking directly and has no effect on the market boom.9
This research aims to identify the causes of smoking among users of this tobacco substance and the solutions for its control. The study has attempted to find the root of the spread of smoking in Iran and tried to introduce operational solutions to control tobacco use in the country. In the present study, unlike most previous research, it has been considered that if the causes of smoking and the solutions for its control are directly asked from the users and planned in accordance with them, the chance of success improves for finding the roots and controlling smoking.
Methods
The present study is an explorative, qualitative study which has been conducted in Tehran. The participants consisted of people who smoked at the time of study. The sampling was conducted purposively with maximum variation and through snowball technique. There were 12 participants who smoked cigarettes, of them 7 were male and 5 females.
Cognitive and deep semi-structured interviews were used to collect the data. Interviews were recorded with the permission of the participants. Before the beginning of an interview, testimonials containing an explanation about the purpose of the study, the complete introduction of the researcher, an explanation about the way of performing the research and the advantages and disadvantages of conducting the research were given to the participants. They were asked to study the testimonials and sign it if they wanted or orally say that they were ready to participate in the interview. Generally, the time of the interviews was variable from half an hour to an hour. Some samples of the questions in the interview guide which had been considered for the smokers are: Why do you smoke? How can smoking be controlled in the country in your opinion? The next questions were asked based on the initial answers by the participants and the interview guide. Also, based on the need in the interviews, probing questions such as “what do you mean?” or “could you please explain more?” were used. Sampling was continued until data saturation and the best semantic unit was selected.
The conventional qualitative content analysis was used to analyze the qualitative data. First, the audio files of the interviews were transcribed on paper and then, with the careful study of the texts which included in the analysis units, the researcher tried to achieve an overall sense from them. Then, the text of the interviews was organized through open coding. The extracted codes were managed through a software for organizing text data MAXQDA12. Frequent study of the extracted codes helped in the recognition of the similarities and differences between them and in classification. Eventually, with the development of the analysis process, the relation among the classes was determined and then hidden themes in the interviews were extracted. The data was validated through credibility and reliability. For the credibility of the findings, member checking and peer review were used. To evaluate the verifiability or the audit trail, the researcher tried to accurately record and report the research path and made decisions on this path in order to provide the possibility of follow-up studies by other researchers.
The average age of the smokers in this study was 34 years. There were 7 males and 5 females, 8 singles and 4 married, 9 Persian and 3 non-Persians. Their education levels ranged from illiterate to PhD. The average age of starting smoking in the participants was 21 years old, the average daily consumption of cigarettes was 11 cigarettes, and the average daily cost of cigarettes was 1,900 Tomans. Ten participants would bear the cost of their cigarettes by themselves and the two others would depend on their close relatives (spouse or parent) (Table1).
Results
Findings in the research can be placed under two main classes and 15 separate subclasses, each one of them is explained below.
The First Class: The Causes of Smoking
The First Subclass: Being Accustomed to Smoking
Being accustomed to smoking is the most important cause which both male and female smokers have announced for smoking. The smokers believed that being accustomed to smoking is the most important cause for the continuous use of the tobacco. “Cigarette is a habit for me; if I don’t smoke it seems I’ve lost something,” said one of the smokers (smoker 1). Another smoker (smoker 12) said: “I’ve got used to smoking and can’t quit.” Based on the experience of the participants, cigarette creates a great mental tension in people and in the time that a person is not smoking cigarettes, the smoker feels that she or he has lost something.
The Second Subclass: Considering Smoking as Normal Behavior
Two of the smokers believed that cigarette is a normal thing and smoking is considered a normal behavior too: “Smoking is a normal action,” they said (smokers 6 and 11). These people consider cigarette as an issue is neither good or positive nor bad or negative.
The Third Subclass: Easy Access to Cigarettes
Easy access to cigarettes in each time and place is a very important cause identified by the smokers. Except for one, all the smokers believed that they have easy access to cigarettes. “Nowadays finding cigarettes is easier than a piece of cake,” said one of them (smoker 4). “I’ve seen even high school girls buy cigarettes from a shop,” said another (smoker 2).
Among the 12 smokers that we interviewed, only one had no easy access to cigarettes, but only because he would smoke the contraband Marlboro cigarettes and he had to go to Enghelab Square to buy that brand from a specific store. Except for this one case, the interviewed people had super easy access to cigarettes. When the smokers were asked if they had easy access to cigarettes, they smiled meaningfully and looked surprised and then, responded yes, they do have very easy access to cigarettes.
The Fourth Subclass: Recreation and Entertainment; Lack of Recreational Facilities
Another cause, which the smokers expressed for their smoking, was using cigarettes for recreation and entertainment. Smoking is considered to be a fun behavior and also as an entertainment. Some of them knew that the lack of alternative healthy recreation caused their smoking. When they are sitting in a park, in the house or taking a short break at work, lighting a cigarette is an enough for them and makes them continue smoking. They know it as a hobby or means of entertainment. One of them (smoker 6), who had smoked cigarettes for more than 50 years, said: “the pleasure of smoking is as scratching the part of the leg which is itching and even more pleasure the smoker achieves when he is smoking and this event occurs in his throat.” Another participant (smoker 3) said: “smoking is a type of entertainment.” Four out of the 12 interviewed people would consider smoking as a recreation and entertainment.
The Fifth Subclass: To Relax
Another cause for smoking proffered by the participants was to achieve relaxation. Eight participants expressed that they smoke to relax. “Cigarette is a tool which makes humans relaxed,” said one (smoker 7). “When you are in mourning ceremony or a wedding ceremony, your body needs to smoke, when you become happy or sad, you want cigarette,” said another (smoker 3). Another smoker (smoker 1) said: “I smoke to become relaxed.” These words show that any fluctuation in person’s a mental state, including sadness and happiness, can cause smoking so that the smokers smoke both in sadness and in happiness in public or in solitude to relax. Some of them would smoke in order to pacify anger and again become relaxed. Of course, this cause is not justifiable sometimes and they had no answer when the participants were asked “do you become angry 20 times per day?” or “do you need to pacify it with 20 cigarettes?”
The Sixth Subclass: Disregard for information and known harm of smoking
Four smokers who participated in our research believed that cigarettes are harmful and smoking is equal to damaging health. They defined cigarette a harmful thing. Another elderly participant (smoker 10) said: “Smoking is nothing but loss and pain.” It is interesting that the participants know the harmfulness of cigarette but they use it.
Nine participants believed that smoking is inappropriate behavior and a bad action. These smokers considered their smoking behavior to be bad. One of the participants (smoker 10) said: “Smoking is an action in vain.” All those who believed smoking is an inappropriate action became sad while admitting that fact.
The Seventh Subclass: Being Affected by Friends and Family
Nine participants knew that their smoking behavior related to their friends and families. Many of the participants had fathers who smoked and had learnt to smoke from them. A participant (smoker 4) said: “My father use to smoke at home.” Some other participants had experienced smoking for the first time due to the encouragement from and the companionship of their friends. A participant (smoker 7) who was a young man said: “I smoked for the first time with my friends in university.” It is interesting that when we asked him to participate in the interview he was smoking with his friends.
Some female participants expressed that they have experienced smoking as an adventure with friends of the same age, the action which maybe never they would have dared to do alone. A participant (smoker 7) said: “Once we went to a party with friends and smoked to know how it feels.”
The Eighth Subclass: For Self-Injury
Self-injury was expressed as one of the causes of smoking by the interviewed women. In this regard, if someone becomes too upset and decides to avenge her/himself, community, or the family, she or he commits self-injury in the form of smoking. This is a type of intentional harm and injury to self. It is very interesting that only women and girls consider smoking as self-injury. A woman (smoker 10) who was smoking when we interviewed her said: “Once a person drove me extremely mad and since I couldn’t pacify my anger by direct retaliation, I went somewhere and smoked for the first time and through this I took revenge from and myself.” She added: “Someone pulls her hair when angry and another one beats his head against the wall and I’ve selected this way to pacify anger and for revenge.” Another participant (smoker 9) believed: “Being a smoker is nothing but harming yourself and your health.” This strange perception of smoking, which is a quite true perception, is a realistic admission. Another participant (smoker 12) added: “I smoke in order to damage myself.”
The Ninth Subclass: Sense of Dignity and Pride
A participant (smoker 7) believed that smoking can cause dignity and pride for the smoker. The action that can admit the person to a group of adults and be introduced is an action that makes him feel proud. “Some people will smoke in order to feel dignity,” he stated.
The Second Class: Solutions to Control Smoking from the Perspective of Smokers
This class evaluates solutions, which, from the perspective of the smokers, can help control smoking. This class has been formed from six subclasses.
The First Subclass: Importance of Individual Volition in Control of Smoking
In this regard, the smokers who participated in the research said that the smoker and her or his volition are the most important factors controlling smoking. A smoker (smoker 11) said: “Nothing can make a smoker to quit unless he has the will to do that, even if many legislations are made.” Another smoker (smoker 4) said: “The smoker must have the will to quit smoking.” The high amount of smokers’ vote for individual volition in controlling smoking shows the importance of will in withdrawal from cigarettes.
The Second Class: The Importance of Culture in Controlling Smoking
Five smokers believed that a culture should be made to control smoking in the society. In this regard, a smoker (smoker 4) said: “The best way to fight against smoking is by creating an anti-smoking culture.” Another smoker (smoker 3) stated: “If we want to control smoking, [the anti-smoking] culture should be made everywhere.”
The Third Subclass: The Importance of Making Cigarettes Rare and Scarce
A smoker (smoker 1) said: “Cigarettes should be expensive the price of each cigarette should be 10 thousands of Tomans and no one should be able to find and buy it.” He believed that cigarettes should become expensive, scarce and even rare, in order not to be so easily available for youth and adolescents.
The Fourth Subclass: The Importance of Reducing Excessive Imports to Control Smoking
One participant (smoker 6) said: “Illicit cigarettes should not be allowed to be imported and found in the market so easily.” He believed that excessive imports of cigarettes to the country whether legally or illegally increase accessibility to cigarettes and makes smoking somewhat an epidemic.
The Fifth Subclass: The Importance of Preventing Smoking in Public Places to Control Smoking
One participant (smoker 11) said: “People shouldn’t be allowed to smoke wherever they will.” He believed that places and time of smoking should be controlled and monitored.
The Sixth Subclass: The Importance of Making Alternative Entertainment to Control Smoking
One participant (smoker 12): “When there is no healthy entertainment in the country or they are expensive, people turn to cigarettes. If alternative entertainment is provided, people will smoke less.” (Table2).
The prevalence of smoking in Iran has been reported to be approximately 12% in people over 15 years old and the average daily consumption is 13.2 cigarettes.4 67% of Iranian men smoke for the first time at 14 years of age5 and 80% of them begin smoking before 20 years of age.6 Almost 429 million dollars are spent each year on smoking in Iran.7
But to fight smoking, if policies of controlling tobacco are executed as a part of the comprehensive plan, tobacco use can be reduced effectively. The increase of cigarette price with the increase of tax and introducing laws prohibiting smoking indoors and banning smoking in public places have been the most effective factors to reduce total rate of smoking.8 The results of previous studies have indicated that in the long run, limitations on advertisement and increase of tax can reduce the rate of smoking. Although limitations on advertisement usually reduce smoking indirectly and affect market boom, the increase of cigarette tax reduces the rate of smoking directly and has no effect on the market boom.9
This research aims to identify the causes of smoking among users of this tobacco substance and the solutions for its control. The study has attempted to find the root of the spread of smoking in Iran and tried to introduce operational solutions to control tobacco use in the country. In the present study, unlike most previous research, it has been considered that if the causes of smoking and the solutions for its control are directly asked from the users and planned in accordance with them, the chance of success improves for finding the roots and controlling smoking.
Methods
The present study is an explorative, qualitative study which has been conducted in Tehran. The participants consisted of people who smoked at the time of study. The sampling was conducted purposively with maximum variation and through snowball technique. There were 12 participants who smoked cigarettes, of them 7 were male and 5 females.
Cognitive and deep semi-structured interviews were used to collect the data. Interviews were recorded with the permission of the participants. Before the beginning of an interview, testimonials containing an explanation about the purpose of the study, the complete introduction of the researcher, an explanation about the way of performing the research and the advantages and disadvantages of conducting the research were given to the participants. They were asked to study the testimonials and sign it if they wanted or orally say that they were ready to participate in the interview. Generally, the time of the interviews was variable from half an hour to an hour. Some samples of the questions in the interview guide which had been considered for the smokers are: Why do you smoke? How can smoking be controlled in the country in your opinion? The next questions were asked based on the initial answers by the participants and the interview guide. Also, based on the need in the interviews, probing questions such as “what do you mean?” or “could you please explain more?” were used. Sampling was continued until data saturation and the best semantic unit was selected.
The conventional qualitative content analysis was used to analyze the qualitative data. First, the audio files of the interviews were transcribed on paper and then, with the careful study of the texts which included in the analysis units, the researcher tried to achieve an overall sense from them. Then, the text of the interviews was organized through open coding. The extracted codes were managed through a software for organizing text data MAXQDA12. Frequent study of the extracted codes helped in the recognition of the similarities and differences between them and in classification. Eventually, with the development of the analysis process, the relation among the classes was determined and then hidden themes in the interviews were extracted. The data was validated through credibility and reliability. For the credibility of the findings, member checking and peer review were used. To evaluate the verifiability or the audit trail, the researcher tried to accurately record and report the research path and made decisions on this path in order to provide the possibility of follow-up studies by other researchers.
The average age of the smokers in this study was 34 years. There were 7 males and 5 females, 8 singles and 4 married, 9 Persian and 3 non-Persians. Their education levels ranged from illiterate to PhD. The average age of starting smoking in the participants was 21 years old, the average daily consumption of cigarettes was 11 cigarettes, and the average daily cost of cigarettes was 1,900 Tomans. Ten participants would bear the cost of their cigarettes by themselves and the two others would depend on their close relatives (spouse or parent) (Table1).
Results
Findings in the research can be placed under two main classes and 15 separate subclasses, each one of them is explained below.
The First Class: The Causes of Smoking
The First Subclass: Being Accustomed to Smoking
Being accustomed to smoking is the most important cause which both male and female smokers have announced for smoking. The smokers believed that being accustomed to smoking is the most important cause for the continuous use of the tobacco. “Cigarette is a habit for me; if I don’t smoke it seems I’ve lost something,” said one of the smokers (smoker 1). Another smoker (smoker 12) said: “I’ve got used to smoking and can’t quit.” Based on the experience of the participants, cigarette creates a great mental tension in people and in the time that a person is not smoking cigarettes, the smoker feels that she or he has lost something.
The Second Subclass: Considering Smoking as Normal Behavior
Two of the smokers believed that cigarette is a normal thing and smoking is considered a normal behavior too: “Smoking is a normal action,” they said (smokers 6 and 11). These people consider cigarette as an issue is neither good or positive nor bad or negative.
The Third Subclass: Easy Access to Cigarettes
Easy access to cigarettes in each time and place is a very important cause identified by the smokers. Except for one, all the smokers believed that they have easy access to cigarettes. “Nowadays finding cigarettes is easier than a piece of cake,” said one of them (smoker 4). “I’ve seen even high school girls buy cigarettes from a shop,” said another (smoker 2).
Among the 12 smokers that we interviewed, only one had no easy access to cigarettes, but only because he would smoke the contraband Marlboro cigarettes and he had to go to Enghelab Square to buy that brand from a specific store. Except for this one case, the interviewed people had super easy access to cigarettes. When the smokers were asked if they had easy access to cigarettes, they smiled meaningfully and looked surprised and then, responded yes, they do have very easy access to cigarettes.
The Fourth Subclass: Recreation and Entertainment; Lack of Recreational Facilities
Another cause, which the smokers expressed for their smoking, was using cigarettes for recreation and entertainment. Smoking is considered to be a fun behavior and also as an entertainment. Some of them knew that the lack of alternative healthy recreation caused their smoking. When they are sitting in a park, in the house or taking a short break at work, lighting a cigarette is an enough for them and makes them continue smoking. They know it as a hobby or means of entertainment. One of them (smoker 6), who had smoked cigarettes for more than 50 years, said: “the pleasure of smoking is as scratching the part of the leg which is itching and even more pleasure the smoker achieves when he is smoking and this event occurs in his throat.” Another participant (smoker 3) said: “smoking is a type of entertainment.” Four out of the 12 interviewed people would consider smoking as a recreation and entertainment.
The Fifth Subclass: To Relax
Another cause for smoking proffered by the participants was to achieve relaxation. Eight participants expressed that they smoke to relax. “Cigarette is a tool which makes humans relaxed,” said one (smoker 7). “When you are in mourning ceremony or a wedding ceremony, your body needs to smoke, when you become happy or sad, you want cigarette,” said another (smoker 3). Another smoker (smoker 1) said: “I smoke to become relaxed.” These words show that any fluctuation in person’s a mental state, including sadness and happiness, can cause smoking so that the smokers smoke both in sadness and in happiness in public or in solitude to relax. Some of them would smoke in order to pacify anger and again become relaxed. Of course, this cause is not justifiable sometimes and they had no answer when the participants were asked “do you become angry 20 times per day?” or “do you need to pacify it with 20 cigarettes?”
The Sixth Subclass: Disregard for information and known harm of smoking
Four smokers who participated in our research believed that cigarettes are harmful and smoking is equal to damaging health. They defined cigarette a harmful thing. Another elderly participant (smoker 10) said: “Smoking is nothing but loss and pain.” It is interesting that the participants know the harmfulness of cigarette but they use it.
Nine participants believed that smoking is inappropriate behavior and a bad action. These smokers considered their smoking behavior to be bad. One of the participants (smoker 10) said: “Smoking is an action in vain.” All those who believed smoking is an inappropriate action became sad while admitting that fact.
The Seventh Subclass: Being Affected by Friends and Family
Nine participants knew that their smoking behavior related to their friends and families. Many of the participants had fathers who smoked and had learnt to smoke from them. A participant (smoker 4) said: “My father use to smoke at home.” Some other participants had experienced smoking for the first time due to the encouragement from and the companionship of their friends. A participant (smoker 7) who was a young man said: “I smoked for the first time with my friends in university.” It is interesting that when we asked him to participate in the interview he was smoking with his friends.
Some female participants expressed that they have experienced smoking as an adventure with friends of the same age, the action which maybe never they would have dared to do alone. A participant (smoker 7) said: “Once we went to a party with friends and smoked to know how it feels.”
The Eighth Subclass: For Self-Injury
Self-injury was expressed as one of the causes of smoking by the interviewed women. In this regard, if someone becomes too upset and decides to avenge her/himself, community, or the family, she or he commits self-injury in the form of smoking. This is a type of intentional harm and injury to self. It is very interesting that only women and girls consider smoking as self-injury. A woman (smoker 10) who was smoking when we interviewed her said: “Once a person drove me extremely mad and since I couldn’t pacify my anger by direct retaliation, I went somewhere and smoked for the first time and through this I took revenge from and myself.” She added: “Someone pulls her hair when angry and another one beats his head against the wall and I’ve selected this way to pacify anger and for revenge.” Another participant (smoker 9) believed: “Being a smoker is nothing but harming yourself and your health.” This strange perception of smoking, which is a quite true perception, is a realistic admission. Another participant (smoker 12) added: “I smoke in order to damage myself.”
The Ninth Subclass: Sense of Dignity and Pride
A participant (smoker 7) believed that smoking can cause dignity and pride for the smoker. The action that can admit the person to a group of adults and be introduced is an action that makes him feel proud. “Some people will smoke in order to feel dignity,” he stated.
The Second Class: Solutions to Control Smoking from the Perspective of Smokers
This class evaluates solutions, which, from the perspective of the smokers, can help control smoking. This class has been formed from six subclasses.
The First Subclass: Importance of Individual Volition in Control of Smoking
In this regard, the smokers who participated in the research said that the smoker and her or his volition are the most important factors controlling smoking. A smoker (smoker 11) said: “Nothing can make a smoker to quit unless he has the will to do that, even if many legislations are made.” Another smoker (smoker 4) said: “The smoker must have the will to quit smoking.” The high amount of smokers’ vote for individual volition in controlling smoking shows the importance of will in withdrawal from cigarettes.
The Second Class: The Importance of Culture in Controlling Smoking
Five smokers believed that a culture should be made to control smoking in the society. In this regard, a smoker (smoker 4) said: “The best way to fight against smoking is by creating an anti-smoking culture.” Another smoker (smoker 3) stated: “If we want to control smoking, [the anti-smoking] culture should be made everywhere.”
The Third Subclass: The Importance of Making Cigarettes Rare and Scarce
A smoker (smoker 1) said: “Cigarettes should be expensive the price of each cigarette should be 10 thousands of Tomans and no one should be able to find and buy it.” He believed that cigarettes should become expensive, scarce and even rare, in order not to be so easily available for youth and adolescents.
The Fourth Subclass: The Importance of Reducing Excessive Imports to Control Smoking
One participant (smoker 6) said: “Illicit cigarettes should not be allowed to be imported and found in the market so easily.” He believed that excessive imports of cigarettes to the country whether legally or illegally increase accessibility to cigarettes and makes smoking somewhat an epidemic.
The Fifth Subclass: The Importance of Preventing Smoking in Public Places to Control Smoking
One participant (smoker 11) said: “People shouldn’t be allowed to smoke wherever they will.” He believed that places and time of smoking should be controlled and monitored.
The Sixth Subclass: The Importance of Making Alternative Entertainment to Control Smoking
One participant (smoker 12): “When there is no healthy entertainment in the country or they are expensive, people turn to cigarettes. If alternative entertainment is provided, people will smoke less.” (Table2).
Table 1. A sample of coding and classification (The first class: Accustomed to smoking) |
||
| Obtained class | Extracted codes | The full text of consumers' response |
| Accustomed to smoking | It’s a habit. | First of all, it is relaxation and in order to achieve relaxation. But now it’s a habit. If I don’t smoke I become frustrated and it seems I’ve lost something. For example, a time I decided to not smoke and I endured a day or two but since the third day I became frustrated and nervous and I used to feel I’ve lost something and when I puffed a cigarette I felt now I’ve achieved the required relaxation. My nervousness decreased. Even it’s stated that cigarette is a kind of addiction and a type of narcotic substance. It is said that addiction to drugs can be withdrawn but cigarette withdrawal is very difficult. I know some people who have withdrawn drug use also they had been intravenous drug users and now they’ve become clean of drugs but say that aren’t able to quit cigarette. |
| It’s a habit. | It’s a habit. If you don’t smoke no special event will happen and you can tolerate because it’s not narcotic. | |
| I'm accustomed to. | It doesn’t know why smoke. When I’m puffing like its taste and I’m accustomed to it. It is as if a person likes a music genre but another one doesn’t like it. Person who likes that genre of course is enjoyable for him. Just like that certainly it is not pleasant for the smoker that doesn’t smoke or hates or despises like my father. | |
| It’s a habit. | More it’s because of nervousness or habit. If I want to say scientifically I’ve heard the body produces nicotine and when you smoke additional nicotine enters the body and the part which produces natural nicotine for the body become lazy and artificial nicotine should be entered the body and later the body should be let and accustomed to reform and return to the initial state. | |
| Table 2. Main classes and Subclasses of the research | ||
| Number | Topic of class | Topic of subclass |
| 1 | Causes of smoking | Accustomed to smoking |
| Easy access to cigarette | ||
| Considering smoking as a normal behavior | ||
| Recreation and entertainment; lack of recreational facilities | ||
| To relax | ||
| Inattention to knowledge and beliefs | ||
| Affected by friends and family | ||
| For self-injury | ||
| Sense of dignity and pride |
||
| 2 | Control solutions of smoking | Importance of individual volition in controlling smoking |
| Importance of making culture in controlling smoking | ||
| Importance of making cigarettes rare and scarce | ||
| Importance of decline in excessive imports in controlling smoking | ||
| Importance of preventing smoking in public places in controlling smoking | ||
| Importance of making alternative entertainment in controlling smoking | ||
Discussion
The participants identified various causes for smoking. All of them expressed that somehow falling into the habit is the most important cause of smoking. They couldn’t quit this habit. Certainly, at least one time, each had decided to quit smoking. But none of them succeeded because getting accustomed to smoke builds a very strong habit. Onal et al. (2002) have mentioned in their research that 36% of students at the University of Istanbul, of them 46% male and 26% female, were accustomed to smoking.8 Certainly, since smoking makes a hard and strong habit for the smokers, and spreads quickly in society, day by day a larger part of resources is spent on smoking and the number of smokers keeps increasing. A person who begins to smoke can't give up easily. When we attempted to find people who had quit smoking for good, we could hardly find a person. It seems that smokers smoke because they smoked for the first time and got accustomed to it. A habit like this can be very difficult to quit because of severe physical and psychological addiction and dependence on it.
Approximately, all smokers stated that they have easy access to cigarettes. This issue can be considered as the most important cause of smoking. Now, the relation between access to cigarettes and smoking is very simple in Iran, especially when we combine the issue with the price factor. We can see that readily-available and cheap cigarettes help increase the number of smokers. In Iran, each store, shop and supermarket sell various brands of cigarettes and prices of these cigarettes are not higher than 4,500 Tomans for a pack. If the cigarettes were sold in certain places that were not easily accessible and there were some limitations for buying cigarettes, at least the number of smokers and the number of the cigarettes they smoke would have been much lower than it is at present. We must consider the fact that when a smoker is walking in the city and crave cigarettes, every 50 steps he faces a shop to buy it from. If there were only one seller in each neighbourhood or area of town and the smoker was forced to travel longer distances to obtain cigarettes, the number of cigarettes smoked would go down. When the smoker doesn’t have a cigarette, she or he postpones smoking to some extent. Saunders (2011) has concluded in his research that boys access cigarettes by stealing cigarettes from parents and girls by giving money to others to buy cigarettes for them easily.9 Therefore, based on the results of this study, if we limit sale and accessibility of cigarettes in Iran so that the smokers hardly have access to cigarettes, the extent of use, the number of cigarettes smoked, and the prevalence of smoking will be reduced automatically.
Another cause which the participants identified in relation with smoking is that smoking is a recreational tool. They turn to smoking when they need entertainment and recreation. But Hammal et al. (2008) in their research have mentioned that the users of hookah in Syria knew their action as an enjoyable social experience which has a root in culture, but they considered smoking cigarettes as a sign of a depressed individual and physical addiction.10 Certainly, entertainment is an important need for individuals and people turn to entertainment due to hardships, rigours of work, business or education, and to discharge their physical and mental pressures. If society provides cheap, healthy, interesting, and useful avenues of entertainments and encourages people to use them optimally, there will be very few users of harmful entertainment such as cigarettes and drugs.
Instead, in a society like ours where there are fewer recreational facilities that are interesting to the youth as well as being expensive, people turn to the cheapest and the most accessible entertainment. Cigarettes, as a cheap readily-available substance, can be the most important alternative. A young person may be exhausted by routine work, education or study, and yet recreation resources are not available or they are expensive, so, they can easily and cheaply buy a pack of cigarettes from a newsstand and derive the desired pleasure. Certainly, an entertainment with the price of 4500 Tomans available in any alley is cheaper and more accessible than the entertainment in the only water park with the ticket price of 50,000 Tomans located far away. So, everyone chooses the first one instead of the second. Unemployment and lack of income contribute to the problem and limits the youth’s options of more expensive entertainment. This makes them buy and smoke cigarettes more and more. Of course, it should be noted that smoking not only is not entertainment but also is a big self-deception and self-harming. But people perceive it as an entertainment and this is considered a big mistake. There should be more cultural awareness and people should be informed that the idea of entertainment by smoking is a big self-deception in reality.
Relaxation was another cause that participants identified as relevant to smoking. They acknowledged that they smoked in order to relax. Hammal et al. (2008) have mentioned in their results that unlike smokers who would smoke to manage stress, the consumers of hookah knew it as an entertainment.10 It should be noted that people have the misconception that if you light a cigarette when you are angry, your anger will be pacified. Even if this assumption is correct, why should the anger be pacified with smoking? Many measures can be considered to pacify anger such as study, exercise, and walking. Therefore, it can be said this is just an excuse to smoke. The smokers, who smoke a pack of cigarettes a day, definitely don’t become angry 20 times daily, and possibly there are days when they don’t become angry. This is a false and deceptive reason to smoke a harmful substance, which many smokers mentioned. In many movies, the important characters light a cigarette when they are angry and achieve outward and sham relaxation. For decades this has led to the false conception that when you become angry you can light a cigarette to pacify your anger. The youth are also being affected by these scenes since they imitate these actions and become dependent on cigarettes.
For some participants, their smoking was related to what they learnt and imbibed from friends and family. These people have friends, parents or siblings who smoke. They had learnt this behavior from others. They knew that the reason they took up smoking is because they were affected by others. Cremers et al. (2015) have mentioned in their results that among the boys who have never smoked, the positive attitude to cigarettes leads to smoking. But in girls who have never smoked, if they have the conception that smoking leads to very few complications, they smoke a lot. The intention of smoking for the boys who had never smoked is related to the perception of social norms. For the girls who had never smoked, their intention is strongly related to the smoking habit of people around them.11 Watanabe et al. (2013) have mentioned in their results that smoking among the participants have had a significant relation with the variable of having a smoker in the family.12 The youth are the worst-affected segment of the population in this regard. They learn, get socialized about, and initiate smoking and internalize the habit. Smoking in presence of the youth, adolescents and children, in addition to damage from secondary smoke, makes them vulnerable to learning and initiating smoking. Smoking is very contagious. Smoking in presence of others, especially the youth, leads them to smoke somehow. Therefore, special limitations must be imposed to control smoking in the presence of others.
In this research, women emphasized that they smoke for revenge and self-injury. No male smoker stated that he smokes for self-injury. This claim was common only among the female participants. Those women and girls who have been oppressed or had difficulties forced on them have the tendency to smoke and they do it in their solitude. The empowerment of women can make them feel more in control of their lives and prevent their tendency to smoke. It is strange that a person smokes only for self-injury. To harm the self knowingly, not for pleasure or fun, can be a dangerous cause for smoking. This action can be mentioned as a type of gradual suicide. Psychologists and sociologists have to analyze why only women have known self-injury as an important cause of smoking while men consider other causes.
Another factor identified by the participants is a sense of pride and megalomania associated with smoking. Since smoking is a common behavior among adults, the youth consider themselves to be in the group of adults simply by the virtue of smoking and they feel important. The photographs and movies of some of the great artists and scientists taken while they smoked lend credence to this feeling and there is a tendency to smoke in order to show off. A 15-year-old likes to be accepted as an adult by the society and may decide to use cigarettes as a tool for achieving that goal quickly. It is obvious that not only smoking has no dignity and pride, but it also is shameful. Who can claim that entering 4,000 types of poison into the body deliberately is a kind of honour and pride? The proliferation of the idea that smoking not only causes no dignity and pride but also is a big shame and dishonour can be an important factor in controlling smoking.
But various answers have been received from the smokers regarding fighting against the spread of smoking and controlling it. They have emphasized that the creation of an anti-smoking culture, individual volition, legislation, and pricing are relevant solutions. The results of this research indicate that setting limitations on cigarette advertisements and increase in tax can reduce smoking; the difference is that limitations on advertisements lead to the decline in smoking indirectly, but an increase in tax reduces smoking directly.7 Lopez et al. (2010) have mentioned in their research that poor performance in school, having relation with a pre-smoker, and the failure to understand the serious concerns of smoking are directly associated with smoking.13
But all the mentioned factors are important in order to fight and control smoking. At an individual level, people should smoke less or quit and this needs a strong will. On a larger scale, the authorities are required to create an anti-smoking culture, spread information about the harms of smoking and prevent the spread of smoking among people. For pricing and legislations, the authorities should provide conditions in a way that smoking to be not so easy that all people are able to smoke. It seems that the effect of protection and surveillance is much higher than individual volition. One example of the authorities’ interference is the control on the smuggling of cigarettes into the country. Like other products, cigarettes are smuggled into the country in large quantities and its difference with other smuggled goods is that smuggled cigarettes not only ruin the national industry but also destroy people’s health.
The most important limitation of this research was that female smokers didn’t cooperate with the researcher most of the times and even male smokers didn’t allow the researcher to record their voice in some cases.
Conclusion
In this paper, the causes of smoking and the solutions for its control have been evaluated through deep interview with 12 male and female smokers. The smokers stated some causes for smoking: getting accustomed to smoking, easy access to cigarettes, having no alternative entertainment, getting relief through smoking, not paying enough attention to the damages caused by smoking, being affected by others and taking up smoking, megalomania and a sense of pride derived from smoking, considering smoking as a normal behavior, and self-injury through smoking. They suggested some solutions to control smoking: the importance of individual volition, the creation of an anti-smoking culture, making cigarettes scarce and expensive, preventing excessive imports of cigarettes into the country, preventing smoking in public places, and replacing it with healthy avenues of entertainment.
Among the findings, there was an especial emphasis on five factors. Among the causes of smoking; all 12 spoke about getting accustomed to smoking, 11 spoke about easy access to cigarettes and 9 spoke about being affected by friends and family members. Among the solutions suggested by smokers to control smoking, five participants spoke about the importance of the creation of an anti-smoking culture and four spoke about the importance of individual volition. These were the highest frequencies. Among the causes, somehow all participants mentioned the factor of habit and confessed to feeling dependent on cigarettes. They knew that this form of tobacco is very easily accessible and in introducing the factor of taking up smoking, they said they started smoking by being affected by others. It is obvious that if a substance so addictive is available easily and can be bought and smoked in the shortest amount of time and with minimal cost, it will spread rapidly. It is a grave problem in a young society such as Iran where peer influence and peer pressure are high.
Therefore, despite the present smokers in this research having emphasized on individual volition to quit smoking the creation of an anti-smoking culture, some other solutions can be suggested. For one, there can be interdictions that prevent people from starting smoking so that the habit (as the strongest factor of smoking based on the findings of this research) is not formed. Making cigarettes more expensive and limiting sale can limit access to cigarettes. The youth and teenagers must be trained about the dangers of smoking and how to refuse to take it up as a habit. Through heavy taxes for cigarettes and making laws to limit the distribution and sale of cigarettes, some countries like Australia and Turkey have succeeded in controlling the spread and consumption of tobacco. They have become ideal examples of fighting against smoking in the world and should be emulated.
Conflicts of Interest
The authors declare that there is no conflict of interest in this work.
Acknowledgements
This study was conducted with the support of Iran's Anti-smoking Association in the form of a research project with the number: 94/5955 and approval date: 2015/7/26.The authors would like to thank the participants for their sincere cooperation in this study.
Authors' Contribution
This article has one author.
Copyright: This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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https://doi.org/10.1164/ajrccm/146.5_Pt_1.1345 - Baška T, Warren CW, Bašková M, Jones NR. Prevalence of youth cigarette smoking and selected social factors in 25 European countries: Findings from the Global Youth Tobacco Survey. International Journal of Public Health. 2009;54(6):439-445.
https://doi.org/10.1007/s00038-009-0051-9 - Moeini B, Poorolajal J, Gharlipour Gharghani Z. Prevalence of cigarette smoking and associated risk factors among adolescents in Hamadan City, west of Iran in 2010. Journal of Research in Health Sciences. 2012;12(1):31-37.
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5. Sarraf-Zadegan N, Boshtam M, Shahrokhi S, et al. Tobacco use among Iranian men, women and adolescents. European Journal of Public Health. 2004;14(1):76-78.
6. Regidor E, Pascual C, Giráldez-García C, Galindo S, Martínez D, Kunst AE. Impact of tobacco prices and smoke-free policy on smoking cessation, by gender and educational group: Spain, 1993-2012. International Journal of Drug Policy. 2015;26(12):1215-1221.
https://doi.org/10.1016/j.drugpo.2015.05.011
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http://doi.org/10.1080/1355621021000005982 - Saunders C. Access to cigarettes by daily smokers in Florida's public middle schools and high schools. Nicotine & Tobacco Research. 2011;13(7):589-98.
https://doi.org/10.1093/ntr/ntr047 - Hammal F, Mock J, Ward KD, Eissenberg T, Maziak W. A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria. Tobacco Control. 2008;17(2).
http://dx.doi.org/10.1136/tc.2007.020529 - Cremers HP, Mercken L, De Vries H, Oenema A. A longitudinal study on determinants of the intention to start smoking among Non-smoking boys and girls of high and low socioeconomic status. BMC Public Health. 2015;15(1):648.
http://doi.org/10.1186/s12889-015-1917-9 - Watanabe I, Shigeta M, Inoue K, et al. Personal Factors Associated with Smoking Among Marginalized and Disadvantaged Youth in Japan. International Journal of Behavioral Medicine. 2013;20(4):504-513.
- Lopez B, Huang S, Wang W, et al. Intrapersonal and ecodevelopmental factors associated with smoking in Hispanic adolescents. Journal of Child and Family Studies. 2010;19(4):492-503.
http://doi.org/10.1007/s10826-009-9321-7
Type of Study: Original Article |
Subject:
Special
Received: 2017/01/12 | Accepted: 2017/05/6 | Published: 2017/05/22
Received: 2017/01/12 | Accepted: 2017/05/6 | Published: 2017/05/22
References
1. Xu X, Dockery DW, Ware JH, Speizer FE, Ferris Jr BG. Effects of cigarette smoking on rate of loss of pulmonary function in adults: A longitudinal assessment. American Review of Respiratory Disease. 1992;146(5):1345-1348. [DOI:10.1164/ajrccm/146.5_Pt_1.1345]
2. Baška T, Warren CW, Bašková M, Jones NR. Prevalence of youth cigarette smoking and selected social factors in 25 European countries: Findings from the Global Youth Tobacco Survey. International Journal of Public Health. 2009;54(6):439-445. [DOI:10.1007/s00038-009-0051-9]
3. Moeini B, Poorolajal J, Gharlipour Gharghani Z. Prevalence of cigarette smoking and associated risk factors among adolescents in Hamadan City, west of Iran in 2010. Journal of Research in Health Sciences. 2012;12(1):31-37. [PMID]
4. Goli S, Mahjub H, Moghimbeigi A, Poorolajal J, Heidari Pahlavian A. Application of mixture models for estimating the prevalence of cigarette smoking in Hamadan, Iran. Journal of Research in Health Sciences. 2010;10(2):110-115. [PMID]
5. Sarraf-Zadegan N, Boshtam M, Shahrokhi S, et al. Tobacco use among Iranian men, women and adolescents. European Journal of Public Health. 2004;14(1):76-78. [DOI:10.1093/eurpub/14.1.76] [PMID]
6. Regidor E, Pascual C, Giráldez-García C, Galindo S, Martínez D, Kunst AE. Impact of tobacco prices and smoke-free policy on smoking cessation, by gender and educational group: Spain, 1993-2012. International Journal of Drug Policy. 2015;26(12):1215-1221. [DOI:10.1016/j.drugpo.2015.05.011]
7. Tan W. The effects of taxes and advertising restrictions on the market structure of the US cigarette market. Review of Industrial Organization. 2006;28(3):231-251. [DOI:10.1007/s11151-006-0015-7]
8. Onal AE, Tumerdem Y, Ozel S. Smoking addiction among university students in Istanbul. Addiction biology. 2002;7(4):397-402. [DOI:10.1080/1355621021000005982]
9. Saunders C. Access to cigarettes by daily smokers in Florida's public middle schools and high schools. Nicotine & Tobacco Research. 2011;13(7):589-98. [DOI:10.1093/ntr/ntr047]
10. Hammal F, Mock J, Ward KD, Eissenberg T, Maziak W. A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria. Tobacco Control. 2008;17(2). [DOI:10.1136/tc.2007.020529]
11. Cremers HP, Mercken L, De Vries H, Oenema A. A longitudinal study on determinants of the intention to start smoking among Non-smoking boys and girls of high and low socioeconomic status. BMC Public Health. 2015;15(1):648. [DOI:10.1186/s12889-015-1917-9]
12. Watanabe I, Shigeta M, Inoue K, et al. Personal Factors Associated with Smoking Among Marginalized and Disadvantaged Youth in Japan. International Journal of Behavioral Medicine. 2013;20(4):504-513. [DOI:10.1007/s12529-012-9268-8]
13. Lopez B, Huang S, Wang W, et al. Intrapersonal and ecodevelopmental factors associated with smoking in Hispanic adolescents. Journal of Child and Family Studies. 2010;19(4):492-503. [DOI:10.1007/s10826-009-9321-7]
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