Smoking Pattern among Attendants at the Family Medicine Clinics of Cairo University , Egypt

Background: Cigarette smoking is the prime cause of preventable disease and death worldwide. Objective: study the smoking pattern among the attendants at the family medicine outpatient clinics of Kasr Al-Ainy Teaching Hospitals, Cairo University. Methods: A cross-sectional study investigated the smoking pattern in a systematic random sample of 200(199 males + one female) smokers aging 16-79 years. After verbal consent, the participants were inquired about their demographic features, smoking motives (Horn questionnaire) and nicotine dependence (Fagerström questionnaire). Results: Most of participants were male (99.5%), married (79%), attracted to smoking by peer pressure (68%) & craving(93.5%) below the age of 18 years and for an average duration of 25 years (59%), highly nicotine dependent(59%) and referred to medication as the main method of smoking cessation (64.5%). Nicotine dependence was significantly associated with presence of smokers among family members or friends, previous attempt to quit smoking and addiction (p< 0.05). 73% of smokers tried, mostly self-motivated (98%), because of existing health problems (44.9%) and coping with stress from social & work problems (35.4%) to quit smoking 3 times before for an average duration of 5 months (73%). Conclusion: smoking seems peculiar to males, particularly married ones who often get motivated by craving and start smoking below 18 years. Starting smoking early in teenage might explain their high nicotine dependence and failure of quitting smoking. Therefore, smoking cessation program should be a top priority and targeted to prevent smoking in adolescence.


INTRODUCTION
Tobacco use is recognized as a major epidemic worldwide.It is estimated that there are over 1.3 billion smokers worldwide. (1)obal predictions indicate that by 2025, smokers will consume 9 trillion cigarettes annually, rising from 5,530,474 million in 2004. (2,3)Over the past 20 years, tobacco consumption has fallen in most high income, also known as developed, countries. (3)On the other hand, developing countries have shown Bull High Inst Public Health Vol.42 No. 2 [2012]   an increase of 3.4% per year. (4)It is estimated that over 80% of smokers currently reside in low and middle income countries. (5)In the Eastern Mediterranean Region the prevalence among males ranges between 25% -62% while among females from 1.0% to nearly 8%. (6)bacco smoking is one of the leading causes of preventable disease worldwide.It is associated with chronic diseases, economic losses to society, and a substantial burden on the health-care system.Tobacco smoking is a risk factor for over 25 diseases.It harms nearly every organ of the body, causing many diseases and reducing the health of the smokers in general.It is well established that smoking is a major modifiable risk factor for cardiovascular diseases as coronary heart disease and myocardial infarction, respiratory diseases and development of chronic obstructive pulmonary disease (COPD), asthma, as well as adverse reproductive effects and many others. (7)Tobacco use also represents the single greatest preventable cause of death worldwide.Tobacco-related diseases are expected to account for 11% of all deaths in developing countries by 2025. (8)Each year, nearly 5 million deaths occur due to tobacco related illnesses, and this is expected to more than double by 2030. (9)Smoking is identified as the primary causal factor for at least 30% of all cancer deaths, nearly 80% of deaths from COPD, and early cardiovascular disease deaths. (10,11) Egypt, smoking prevalence has become a major public health problem.
Over the past three decades, the number of smokers in Egypt has increased over twice as fast as the population. (12)cording to findings of the Global Adult  . (13)gypt is considered the biggest consumer of cigarettes in the Arab world.
There is evidence of increasing prevalence of smoking, especially among the younger generations and females.Given the numerous diseases caused by tobacco use, the health care cost of treating these diseases is substantial.Estimates indicate that about 3.4 billion EGP were spent annually in Egypt to treat the diseases caused by tobacco use. (14)nce this study was conducted to determine the characteristics and smoking tendency patterns of smokers among attendants of the family medicine outpatient clinics at Kasr El Ainy Teaching Hospitals, Cairo University, to be used in the formulation of a smoking cessation program that could be implemented in these clinics.

2.
The second part included the Fagerstrom Questionnaire (15) ; the 6-item questionnaire was used to determine participants' level of nicotine dependence.questionnaire. (15) The Horn Questionnaire. (16) The initial language for all questionnaires was English.All questionnaires were then translated into the local Arabic language and then back translated.The Arabic versions were used to collect the study data.

Data management and statistical analysis:
All collected data were revised for completeness and logical consistency.

DISCUSSION
In the current study, smoking seemed peculiar to male gender; 99.5% of our smokers were male.This greatly matches the study of the Egyptian Smoking Prevention Research Institute (ESPRI) in 5 villages in Egypt where 938 smokers were interviewed of which 935 (99.7%) were males and only 3 (0.3%) were females. (17)is may be related to the Egyptian culture which considers that female smoking is inappropriate.When assessing the age at which the participants started smoking, it was found that slightly over half of participants reported that they started smoking below 18 years (59%), although 18 years is the legal age for purchasing tobacco in Egypt.Similarly, the Global Adult Tobacco Survey (GATS) done in Egypt in 2009 found that over half (57.6%) of ever daily smokers initiated daily smoking before age 18 years. (13) this study it was found that the presence of smoker friends and peer pressure were the main reason for because their parents smoked. (18)The difference in the percent of youth who started smoking due to the presence of a smoking father between the participants (3%) and the Canadians (10%) may be becausethe families of our participants, including their fathers, were against their smoking habit and they even tried to stop them from smoking.
Additionally, many of the participants admitted that when they started smoking, they smoked away from their parents to avoid punishment if they were seen smoking.It is evident from our study that the strongest smoking motives among the participants as assessed by Horn's questionnaire were craving (93.5%) and tension reduction (82%) this was followed by social motives (61%) and relaxation (50%).This result is quite different from what one would have expected as most Egyptians when being asked directly what the reasons they continue to smoke were their answer would be because it is a habit.
In a study done in the University of Missouri, Columbia it was found that a desire to reduce craving (62.8%) and habit/automatic processes (42.8%) were the most frequent motives. (19) another study in England, enjoyment and stress relief were the most commonly reported motives (51% and 47%, respectively). (20)From the above, it is clear that the motives that cause smokers to continue smoking varies greatly from one population to another and even in different groups within the same population.This result compares with another study that suggested that nicotine dependence plays a role in quitting behaviors among young adult daily smokers. (21)e quitting attempts carried out by the participants were mostly unaided and occurred because the participants were self-motivated to quit (98.0%).This is similar to a study conducted in Canada which was done on 146 participants and concluded that most quit attempts were unaided (64%). (20)These results show that The main reasons that made the participants return to smoking were coping with stress (35.4%) due to social and work problems mainly and socializing (33.3%)This is similar to studies which showed that persons who quit smoking and subsequently relapse often report that returning to smoking was triggered by a stressful experience or negative affective state. (22)en studying the other forms of tobacco used by the participants it was found that 46.5% of the participants smoked shisha.This was higher than the results of the WHO reporting water pipe smoking to represent 24%-30%of all smoking patterns in all age groups. (23)The Each question is followed by a number of answers and an appointed score is given to each answer.The final score of the questionnaire is calculated by adding the scores of the six questions where the minimum score of the questionnaire is 0 and the maximum score is 10.Scores are divided into three categories; low level of addiction (between 0 -3 points), medium level of addiction (between 4 -6 points), and high level of addiction (between 7 -10 points).For comparison of study groups, the results of the questionnaire were further divided into two groups as follows; High dependence (scores between 7 and 10) and Low/Intermediate dependence (scores below 7)based on scoring and classification of the original

is a 21 -
item questionnaire that assesses smoking motives.Participants indicate the extent to which they agree with statements pertaining to their reasons for smoking (e.g., "I find cigarettes pleasurable") using a 5-point Likert scale where; Always = 5, Frequently = 4, Occasionally = 3, Seldom = 2, Never = The questionnaire identifies seven motives namely; stimulation, handling, pleasurable relaxation, tension reduction, craving, habit and social motives.To calculate the score for each motive, the scores given to each of the three questions representing that motive are added.The score of each motive ranges from a minimum of 3 to a maximum of 15 points.The final score, as described in the original questionnaire, is categorized in three categories; scores 11 or above represent a strong motive, scores between 7 and 10 represent a moderate motive, scores 6 and below represents a weak motive.The scores of the participants were further categorized into two groups for ease of comparison between study groups as follows; High motives (scores equal to and above 11), Low motives (scores below 11).

Figure 1 :
Figure 1: Awareness of smoking cessation methods among studied participants.
participants to start smoking (68%).The other reasons of significance included: Bull High Inst Public Health Vol.42 No.2 [2012] curiosity, experimentation and the pressure of a smoking brother (23.5%).These results were similar to the results of a survey done in Canada (year) to determine the reasons of smoking among Canadian youth, where they found that the presence of a smoker friend led 70% of their participants aged 15 -19 years to start smoking and 22% started smoking due to curiosity while 10% started smoking most of the smokers who try to quit do this on their own without help and without continuous exterior motivation which may be the reason most of these Bull High Inst Public Health Vol.42 No.2 [2012] attempts fail.This shows the importance of having well formulated smoking cessation programs to aid these smokers and it also shows that smoking cessation programs should place greater emphasis on the dynamic nature of motivation in the attempts to quit.
difference in the results may be due to the difference in the sample size or the sampled population, but what is evident from both studies is that shisha smoking is the second most commonly used form of tobacco among Egyptians which is considered by the majority of its users as less harmful to health and as a means to aid in cigarette smoking cessation since it is not as available as cigarettes.Thus, in any smoking cessation program in Egypt, asking about shisha smoking is important for proper cessation of all forms of tobacco smoking.In conclusion, formulating a smoking cessation program is a priority health issue, especially in view of the current situation where over half of participants started smoking before reaching 18 years.Furthermore, the greater majority of smokers included in our study (147 participants) have previously tried to quit by themselves due to suffering from an already existing health problem (44.9%) or due to fear of being ill in the future (27.9%)

Refer to the methods section for grouping definitions
The Statistical Program for Social Sciences (SPSS) version 15 was used for data analysis.Analysis included simple frequencies and descriptive analysis (Mean and Standard Deviations).According to the educational level, the participants were divided into basic educational level which included primary education or less and above basic educational level which included preparatory level or more.

Table ( 3): The relation between nicotine dependence of smokers and some variables
† Smoking other forms of tobacco such as shisha, cigar, and pipe ¥ Addiction to hashish, or alcohol and tablets e.g.Tramadol ‡ Health problems included chronic cough, hypertension, diabetes and ischemic heart diseases.•P-value is calculated by the chi square test * significant at P< 0.05