Rizwan Nadim1, Sarosh Mahdi2, Hoshang Rumi Sukhia3
1. Assistant Professor, Department of Community Dentistry, Dow Dental College, DUHS.
2. Assistant Professor & Head of Department of Community Dentistry Jinnah Medical & Dental College, Karachi.
3. Vice Principal & HoD Dental Section / Professor, Orthodontics Department Sir Syed College of Medical Sciences Karachi.
Correspondance :“Dr. Rizwan Nadim”
How to CITE:
Nadim R, Mahdi S, Sukhia HR. Reasons for smoking and its socio-cultural perceptions in a migrant south asian community of wolverhampton/UK. J Pak Dent Assoc.2013; 22(3): 212-218
To identify reasons for smoking and its socio-cultural perceptions in a immigrant South East Asian community living in United Kingdom.
Thirty two healthy adult smokers were chosen through purposive sampling.The studywas set at Wolverhampton Mosque Trust. Personal interviews were conducted using a structured performaand a phenomenological approach was applied for data collection. Frequency and onset of smoking, knowledge of participants of disease caused by smoking, social, emotional and psychological factors promoting smoking, and how they perceive cultural and social barriers regarding smoking were analysed by using SPSS 13.
The average age of initiation of smoking was 15 years (SD±4) (table 2),while the most common factors promoting smoking were peer pressure (28%), poor self image (19%) and stress (19%) (Table 3). Cancer (53%) and heart diseases (32%) were the major diseases associated with smoking according to the study participants, while impact of religion (84%) and wide cultural acceptance for smoking (91%) came forward as the most common perceptions regarding quitting or initiating smoking(figure 2). Majority of participants (63%) expressed dissatisfaction with the existing smoking cessation programs.
Main reasons for initiating smoking were peer pressure, poor self image and stress while religion and cultural acceptance of smoking were most common perceptions.
‘perception, culture, social, religion, barriers, tobacco, smoking and South Asian Community’.
Smoking is the major known and widespread cause of non-communicable disease around the world 1. Tobacco smoke is attributed to nearly six million deaths each year, which includes more than six hundred thousand non-smokers who die from second hand exposure to tobacco smoke 2. If this current smoking patterns persists, it will result in about one billion deaths from tobacco related diseases3.
One fifth of the world’s population comprises of Muslims, and most of them live in areas where the prevalence of smoking is high and often increasing.4 In the United Kingdom South East Asian men have a higher prevalence of smoking than the general population. Prevalence of smoking was 49 % in Bangladeshi men and 29 % in Pakistani men in comparison to the national average of 24% in 200415.
In total, 29 percent of Adult women smoke of which less than 2 % women are of Indian origin , 5 percent are Pakistani and 2 percent are Bangladeshi women 5. On average, thirteen cigarettes per day are consumed in UK. From 1998-2006, the prevalence of smoking was stable among children aged 11-15, between 9 and 11 percent , displaying a reduction to 6 percent in 2007 while in 2012 overall prevalence had downward trend showing a similar proportion of regular smokers falling to 4 percent and to 10 percent, respectively6.
Smokers are at a higher risk of smoking related diseases such as angina, heart attack, stroke, diabetes, blood pressure, ischemic heart disease, myocardial infarction, chronic obstructive diseases, reproductive diseases in males and different types of cancer 7-12. Cancer, cardiovascular disease & non-insulin dependent diabetes are more prevalent in South Asian people living in the UK in comparison to the national average 13, 14, indicating the need for effective disease prevention initiatives for these communities. Health awareness and promotion campaigns in the South Asian communities have often tackled ethnicity-specific issues such as the risk of developing oral cancer due to tobacco and bidi smoking14-16.
Knowledge of religious beliefs and customs is important in understanding smoking behaviour among Muslims. Smoking in South East Asian Community is directly linked with age and sex, as well as socio-cultural factors which affect social acceptance of smoking according to few researches conducted on Pakistani, Bangladeshi and Indian community.5 Despite the fact that smoking has been recently declared haram (prohibited) by religious scholars and institutions in many countries, its prevalence is still unacceptably high among muslims communities all over the world, showing that South Asian religious authorities in UK need to follow the leadership shown by their Arab counterparts. 4.
Ethnicity is not only a question of language and discovering cultural differences, but also their experiences and health beliefs which reflect individual behaviours and are still limited among people of South Asian descent.17 Investigation of these variables by qualitative research provides deeper understanding of factors that may help in changing behaviour such as cultural and social norms to help stop smoking.18
The main interest here was how the participants give meaning to their experience on tobacco smoking and how they perceive cultural and social barriers in smoking cessation thus the phenomenological approach was selected as research method 19. Purposive sampling strategy was used for the study. The sample population was South Asians aged 18+, who currently smoke and live in Wolverhampton.
The participants for the study were selected from Wolverhampton Mosque Trust. Announcement about the study was made in the mosque with the help of Mosque Management before the Friday prayers. The participants were given the opportunity to readthe information sheet and ask any questions about the study before they confirmed their intention to participate. Those who agreed to participate were given consent form. It took 3-4 weeks to conduct interviews of 32 participants with average frequencyof 6-8 participants per week.
Approximately, 20-30 minutes were taken for an individual interview. A topic guide was made in advance, which contained a list of questions to be covered with each respondent. All interviews were tape recorded, and then transcribed before data analysis (discourse data analysis used) took place. The data was analysed using a thematic approach used by reorganizing distinct features of each type of smokers, and were continued until each subject could be placed in only one category or theme.
Participant demographic characteristics Table 1. The study was carried out on a total of thirty two participants with ages ranging from eighteen to thirty six years, out of which 84% were males and 16% were females.Educational background shows that 53% did graduation while 16% did post-graduation (Table 1).
1. SMOKING RELATION WITH CULTURE
Even though smoking by youth is not culturally acceptable but participants (table 3) agreed that in their culture tobacco smoking has become common(table 1). Negative perceptions and opinions regarding female smoking in South Asian community was alsopresent (25 participants, 78.1%, table 2).
2. RELIGIOUS POINT OF VIEW
2.1 Is smoking Mukruh or Haram: In our findings (table 1) we found that major religion was Islam and tobacco products were not considered good for one’s health and spiritual well being. The study also reveals that participants had different opinions on tobacco smoking whether it should be classified as ‘haram’ (forbidden) or ‘makruh’ (advised against). Most of the participants (69.2%) believed that smoking is acceptable as long as they are not addicted to it. While, remaining participants (30.7%) believe that tobacco smoking is ‘haram’
2.2 Religious influence on smoking cessation: During the study it was found that participants who tried to either quit or smoke less during Ramadan were occasional smokers (15.6%, table 2).
3. FACTORS PROMOTING SMOKING
3.1 Social: A majority of the participants (53.1%, table 3) took up smoking because of social reasons showing that they are ‘mature and independent’ (18.7%, table 3). Smoking behaviour of close friends and wider peer group (28.12%, table 3) is positively related to uptake.
3.2 Emotional: In our study we discovered that young boys and girls take up smoking at primary schools to show rebellion against parents due to communication gap between parent and child.
3.3 Psychological: Participants believed (15.6%, table 3) it was the cheapest way to enjoy as it helps them to relax and relieve stress (18.7%, table 3) of jobs and studies.
4.1 TYPOHOLOGY OF SMOKERS
Participants (15.6%) who smoked less than 1-5 cigarettes per week, were occasional smokers, regular smokers (46.8%) had 5-15 cigarettes per week,while (37.25%) heavy smoker smoked more than 15 cigarettes.
4.2 Initiation and frequency of smokers
The average age of onset of cigarette smoking, according to our study, among South Asian’s was 15 11-15. It was also found that friends smoking had both direct and indirect influences on adolescent’s initiation of smoking, but only indirect effects on escalation (28.1%, table3).20
5. SMOKERS PERCEPTION ON HEALTH SERVICES
Respondents generally agreed (63%, fig no. 2) that health services provided by the government were not sufficientand better service should be provided for ethnic minorities related to their social and cultural perspectives, when addressing smoking cessation programs
6. HEALTH ISSUES RELATED TO TOBACCO SMOKING
The most common disease (53 %, fig no.1) was cancer, second being (31.25%, fig no. 1) cardiovascular diseases. Researcher found that one participant smoked in addition to chewing paan (betel leaf) with tobacco in it ,which is very common in some South Asian communities. However, all participants (fig no.1) realized the damage smoking does to their mouth, gums and teeth.
We found in our study that smoking perceptions and opinions were same as the general population in UK but it also highlighted influential difference due to religion, culture and gender in South Asian Community.
It also came to our notice that smoking was common in teenagers while previous literature on smoking also showed similarities to our data. The average age of initiation of smoking is 17 years in Pakistan.21 Yuksel et al (2005) found that 83% of 10th graders (median age 16 years) in Turkey had tried smoking,which was an exceptionally high percentage, close to rates of the second- and third-ranked countries.22 According to Kaplan et al (2004) physicians were not asking about smoking at ages, typically ranging from 11-12 years, when children and adolescents are most likely to try their first cigarette.23 The prevalence of tobacco use among Muslim women compared to men is significantly low due to strong association with social values and norms. This is the opposite of the current pattern seen in white British community.
There was clear evidence in our study that smoking helps in socializing with people. Many researchers also shared the same opinion. It is seen as a manifestation of male identity in some cultures where as smoking by women of Muslim societies is a sign of rebellion against social stigma.24 Smoking may serve as a symbolic offering on occasions such as welcoming guests, paying homage, weddings, funerals, token of exchange and courtesy in social interactions25,26. When people from these countries migrate to other countries, they tend to keep their habit which can also been seen as an effort of preserving their cultural heritage. The dominant religion, in both Bangladesh and Pakistan, is Islam. Islamic scholars historically had mixed views about tobacco because cigarettes are a more recent invention , not existing at the time of revelation of the Qur’an in the 7th century A.D(27). Initially there were conflicting views on whether it was religiously acceptable for Muslims to smoke but recent research proved adverse effects of smoking, so in many Muslim countries the legal status of smoking was changed during recent years while numerous religious edicts or fatwa from notable authorities such as Al-Azhar University in Egypt, now declare smoking to be prohibited. In UK too, the government uses these Fatwa’s when targeting Muslim communities4, 28.
Our study has shown that social environment, emotional and psychological factors such as peer pressure, image, independence and rebellion greatly influence smoking of South Asian Community in UK.24, 26, 29 Islam et al 2005 explained similar findings in Egypt where smoking behaviour was positively associated with beliefs about smoking, sibling, parent and peer smoking, and social smoking norms, with sibling smoking and adult smoking norms having a stronger influence30. Stress also plays an important role in taking up tobacco smoking24,29, 31.One interesting fact was that many participants were students who smoked more due to boredom, to relax, stress of study or family issues, peer pressure and emotional support which was also found in previous research conducted on this topic.32,33 Most participants were aware that smoking is bad for health, can cause many different medical problems and in some cases fatal diseases. The most mentioned disease in the interview was cancer. In 2003, Bush et al. Reported that cancer was responsible for most deaths in South Asian Community 24.Similar study conducted by Kaplan et al in 2007 in USA and Netto et al 2007 in UK reported that smoking for many years could increase the chances of respiratory and cardiovascular diseases13,23. Other studies have shown a close relation between common health hazards associated with waterpipe and smoking.34,35 A study conducted in Pakistan showed that tobacco users believed that tobacco use could cause dental caries, oral cancer, oral submucosal fibrosis, chronic cough, and precipitation of asthma and lung cancer 36. Findings of the study clearly call for great integration of South Asian community within the United Kingdom. Changing behaviours & attitudes is a long term task while mainstreaming the South Asian community would be a good start. Health problems of ethnic minorities can only be dealt by understanding the culture and norms of these groups,hence it is important to engage elders of South East Asian communities and use their influence to alter attitudes regarding smoking and other socialmenaces amongst the Youth. Mosques and clerics also play a crucial role in “narrative building’ in Muslim societies that is why “Mosque” & other Muslim community centres can be used to propagate Anti Smoking & Pro-Life themes. In South Asian community more health promotion initiatives are need to create awareness about the harmful effects of smoking. Pakistanis and Bangladeshi have high rate of smoking tobacco as mentioned earlier than general population in UK, which indicates that ethnic minorities and their health problems should be discussed and addressed more appropriately.
The Conclusion of our study are as follow:
1. Main reason for initiating smoking were peer pressure, poor self image and stress.
2. Age of initiation of smoking was as early as 15 years.
3. Religion was strongest inhibitor while cultural acceptance of smoking was mostcommon factor promoting smoking.
4. Study participants had good knowledge about repercussions of smoking on health.
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