Radovanovic 1

Title:

Prevalence of Smoking among Currently Married Kuwaiti
Males and Females


Short title:
Smoking in Kuwait




Zoran Radovanovic *, Nasra Shah* & Jaafar Behbehani*

*Department of Community Medicine and Behavioural Sciences
Faculty of Medicine, Kuwait






_____________________________________________
Address for correspondence:
Professor Zoran Radovanovic
Department of Community Medicine and Behavioural Sciences
Faculty of Medicine
P.O.B. 24923, 13110 Safat, Kuwait
Tel. (965) 5319485
Fax: (965) 5338948
E-mail: zoran@hsc.kuniv.edu.kw


Radovanovic 2




Prevalence of Smoking among Currently Married Kuwaiti Males and Females



Abstract

A structured questionnaire was administered to a random sample of 608 Kuwaiti
couples through a household face-to-face interview. Both spouses were non-smokers
in more than half (50.8%) of all the couples, and there was a single couple (0.2%) with
both spouses currently smoking. Only 0.5% of the wives reported current smoking.
The prevalence of smoking was 3.2% among divorced/widowed women from the same
households. The difference between the two groups of women remained significant
upon controlling for the confounding effect of age. Among the husbands, frequencies
of current and ex-smokers were 37% and 11%, respectively. Younger respondents
consumed more tobacco and were initiated to smoking at an earlier age. Logistic
regression showed that age and educational level were inversely associated with the
current smoking. In particular, limited education (1-11 years) was an important
determinant of smoking. Reasons for the observed findings have been discussed.



Key words: Age - Education - Kuwait - Prevalence - Smoking - Social factors

Radovanovic 3
Introduction
There are no published data on the prevalence of smoking in Kuwait that might
be generalised to the population as a whole. Mimeographed results of two attempts to
assess the extent of tobacco use in the general population of the country are the only
available sources of reference [1,2]. Published studies were restricted to physicians
[3,4] or different categories of patients [5,6] and their controls [5]. Unpublished
studies, other than the two mentioned ones [1,2], were also related only to selected
groups of people, such as university teachers [7], young nargila (water-pipe) smokers
[8] and medical students [9].
The objectives of our study were: a) to assess the prevalence of tobacco
smoking in the representative samples of Kuwaiti couples from two selected
governorates, and b) to identify basic social, economic and demographic variables
associated with smoking.

Methods
The target population consisted of Kuwaiti couples residing in the Capital and
Jahra governorates, the most and the least developed of the five basic administrative
units in the country. The rationale for such an approach was our assumption that
findings in these two governorates, representing opposite poles of the Kuwaiti
society, would reflect the range of the smoking pattern in the country as a whole.
Five districts (mantaqas) were selected from each governorate. In the Capital,
they were sampled randomly from 19 districts inhabited by the Kuwaiti families.
Since there were only five such districts in Jahra, all of them were included in the
further sampling procedure.
One sub-district (qitaa) was randomly selected from each of these 10 districts,
and a 25% random sample of households was finally obtained.
Lists of districts, sub-districts and households in the two governorates were
obtained through the Public Authority for Civil Information, the most reliable source
of population data in the country.
Radovanovic 4
In the Capital, 263 households were selected but for 16 of them (6.1%) the
interviews were not accomplished because either the house was not inhabited at the
time of the visit (leased, abandoned, under reconstruction) or the head of the
household did not wish to participate in the study. A total of 242 households was
selected in Jahra and for seven of them (2.9%) data were not obtained.
During January 1996, Arab-speaking interviewers with a Kuwaiti accent used a
structured questionnaire to collect data through a household face-to-face interview.
The study was preceded by one week of training of the interviewers.
The basic unit of observation in this study was a couple. It was defined as any
current marriage involving the existing household members. There were 608 couples
in the sample, consisting of 578 husbands and 608 wives. The difference was due to
multiple marriages: 22 men had two wives and four of them three wives. Data were
also obtained for 221 separated, divorced and widowed individuals. Most of them
(189 or 86%) were females.
A smoker was defined as a person who smoked at least one cigarette per day
for at least a month. The cut-off point of the operational definition of smoking was
not critical, since all interviewees either did not smoke at all or were active smokers
for much more than a month. Respondents who gave up smoking more than a month
prior to the interview were considered as ex-smokers.
For nargila (hubble-bubble, sheesha, hooka, water-pipe) smokers, one large
head equalling to 6 grams of pure tobacco was considered equivalent to 6
cigarettes. Interviewers were instructed to have a similar approach for pipe smokers
(1 ounce of pipe tobacco = 28 grams = 28 cigarettes), but none of the respondents
used this form of tobacco smoking.
PC and VAX computer facilities were used to analyse the data by Excel,
EpiInfo and SPSS packages. Initial statistical analyses involved computation of
measures of central tendency, as well as the chi-square test, Mann-Whitney test, and
odds ratio with the 95% confidence limits. Mantel-Haenszel summary chi-square and
logistic regression were used for controlling the confounding effects.
Radovanovic 5

Results
More than half of all the couples (50.8%) consisted of both spouses without a
history of smoking, and there was a single couple (0.2%) with both spouses currently
smoking (Table 1). The chances of having a smoking husband and a non-smoking wife
were more than 100-fold higher than an opposite combination (odds ratio = 114.5;
95% confidence limits = 61.8-497.8).
Table 1
A negligible proportion of women (0.7%) reported to be previous or current
active smokers (Table 1). Since the number of wives equalled the number of couples,
horizontal marginal subtotals in Table 1 reflect the prevalence of female smoking.
Due to polygamy, however (see Methods), such an approach does not apply to
husbands. Among 578 of them, 64 (11.1%) were ex-smokers and 216 (37.4%) were
current smokers.
Low prevalence of reported smoking among the currently married females
prompted us to look at the smoking habit of 189 separated, divorced or widowed
women from the same households. Frequencies of current and ex-smoking in this
group were 3.2% and 3.7%, respectively. Proportions of smokers in the two groups of
women were not directly comparable due to different mean age of the currently
married (x = 35.5 years) and separated/divorced/widowed women (x = 50.5 years).
However, the difference in prevalence rates of current smoking remained at a
statistically significant level even when the confounding effect of age was controlled
(Mantel-Haenszel summary chi-square = 4.49, p = 0.034).
The existence of only three self-declared female current smokers among 608
couples did not allow for any meaningful statistics. Further analysis was therefore
restricted to 578 male spouses.
Smoking among male spouses
Nearly a half (45.4%) of the current smokers smoked 15-24 cigarettes a day (or
an equivalent amount of other tobacco) at the time of the interview, while 25.0%
Radovanovic 6
exceeded that range. The largest number of cigarettes ever regularly smoked by the
current or ex-smokers was most frequently between 25 and 90 (59.6% of all
responses), and almost one-third of them (30.7%) smoked 15-24 cigarettes a day as a
maximum. Age when smoking was initiated ranged between 10 and 35 years. More
than half of the ever-smokers (52.1%) began to smoke when they were 17-20 years
old, and four-fifths of the current or ex-smokers (80.4%) were initiated to smoking by
the age of 22.
The proportion of current/ex-smokers was higher among younger (up to 35
years) than among the older (36+ years) respondents (chi-square = 7.21; d.f. = 1; p =
0.007). Moreover, the quantity of tobacco that younger respondents consumed was
significantly higher (Table 2). Younger people were also earlier initiated to smoking
(Mann-Whitney U test: z = 4.11, p = 0.000).
Table 2
In Tables 3 and 4, the current smoking status of the husbands was cross-
tabulated with a number of socio-demographic variables. All quantitative variables
were negatively associated with current smoking, but the difference reached the level
of statistical significance only for the number of bathrooms and domestics, both per
household member, and for age (Table 3).
Table 3
Years of education were the only quantitative variable whose relationship to
smoking did not have an apparent linear pattern. As shown in Table 4, frequency of
smoking was lower than expected among illiterate respondents and those who had 12
or more years of education.
Table 4
Due to its non-linear association with smoking, education was reduced to two
categories, 1-11 years of education vs. the two extremes lumped together, i.e., none
and 12 or more years of education. Cross-tabulated this way, as a dichotomous
variable, limited education (1-11 years) was highly significantly associated with the
current smoking. There was almost no difference between current smokers and non-
Radovanovic 7
smokers in terms of two other categorical variables - the place of residence and
Bedouin affiliation (Table 5).
Table 5
Seven numerical variables (all but education from Table 3) and three
categorical variables (Table 5) were entered into a logistic regression model as
independent variables and current smoking as a dependent variable. Statistically
highly significant result was obtained for only one variable: people with one to 11
years of formal education were more likely to be current smokers as compared to the
rest of the respondents. Also, younger age was associated with the current smoking
but the upper confidence bound reached (though it did not exceed) unity, implying a
borderline significance (Table 6).
Table 6
Logistic regression analysis was repeated with education entered as a
numerical, rather than a categorical variable, i.e., the original 23 categories of
education, from zero to 22 years, have been retained. Age was slightly affected by
this change, gaining in significance as a predictor of smoking (odds ratio = 0.96, 95%
confidence limits = 0.94-0.98), while the impact of education appeared less
convincing, though still statistically significant (odds ratio = 0.91, 95% confidence
limits = 0.86-0.95).

Discussion
The prevalence of female smoking may be very high in some developed
countries of the West, e.g., 88% of young adult females in Greenland are smokers
[10]. In the developing world, it is considered that between 2% and 10% of women
smoke cigarettes [11]. Our data on the frequency of smoking among divorced and
widowed women (3.2%) fit within this range but the prevalence of smoking among
the currently married women was lower (0.5%).
Kuwait Health Survey [1], as the only available study addressing the issue of
Kuwaiti female smoking in the general population, pointed to the prevalence rate of
Radovanovic 8
cigarette smoking of 1.3%. If, for the sake of comparison, our own findings were
lumped together, the overall prevalence of cigarette smoking among women
comprised by our study would reach 1.1%. Exactly the same percentage was reported
by authors who restricted their research to Kuwaiti female medical students [9].
Studies that dealt with medical doctors could not be used for any comparison because
data on females were not presented separately [4,7] or nationality was ignored [3],
although a vast majority of doctors in the country are foreigners.
Apart from cigarette smokers, Kuwait Health Survey [1] identified 0.8%
women who smoked nargila. There were no female nargila smokers in our sample. In
spite of this difference, both our own and previous [1,9] data are fairly consistent,
pointing to a very low self-reported frequency of tobacco smoking among Kuwaiti
females, ranging between 1.1% [9; our study] and 2.2% [1].
These findings are in sharp contrast with the statement [12] that as much as
12% of women in Kuwait are smokers. Tracing back the origin of this assertion leads
to a review article [13] and, eventually, to a report of the Director-General of the
World Health Organisation (WHO) [14]. This unpublished report is not available [15]
but does not seem to have been based on any survey of a representative sample of the
population. Prevalence of smoking among non-Kuwaiti females is only 4.4% [1] so
that taking into account all rather than only Kuwaiti females still fails to explain such
a high frequency of smoking as indicated in the WHO report.
There is an assumed consensus among the experts that Kuwaiti women tend to
hide their smoking as a socially defined undesirable behaviour. The implication is
that self-reporting of smoking may be a reliable methodological approach, as shown
elsewhere [16], but not in Kuwait. Underreporting has been undoubtedly present
here, but its extent will remain to be guessed until an objective methodological
approach, e.g., reliance on saliva crotinine, is employed.
In a traditional society, peers approval is a major determinant of smoking [17].
Our data also point to the relevance of a peer (for married Kuwaiti females, it is a
husband) since, upon controlling for the confounding effect of age, currently married
Radovanovic 9
women admitted smoking significantly less frequently than those who were not
married any more. A question that this study did not address was whether currently
married women did not dare to smoke as frequently as their divorced and widowed
counterparts, simply hesitated to admit their habit, or differed in terms of some
psychological and other factors associated with the risk of smoking.
The prevalence of male current smoking in this study (37.4%) falls between the
Kuwait Health Survey estimate of 27.3% [1] and the frequency of 53% mentioned in
the report of the Director-General of the WHO [14]. There are two apparent reasons
why the percentage obtained by the Kuwait Health Survey is lower. First, it
comprised all males above the age of 12, while in our study only two respondents
were less than 20 years old. When the comparison is restricted to the age groups 30-
59 years, the difference between the Kuwait Health Survey (44.5%) and our study
(49.9%) is halved. Second, a period of 13 years has elapsed between the two surveys
and, as indicated in the Results, the prevalence of male smoking in Kuwait has been
increasing over time. This trend is likely to be responsible for the remaining
difference observed when the truncated samples are compared.
It is much more difficult to explain the prevalence of male smoking as high as
53% [14]. The report of the Director-General of the WHO [14] referred to all
residents of the State of Kuwait, but the frequency of tobacco smoking among the
non-Kuwaiti males (34.4%) is not much higher than among the Kuwaiti males
(27.3%) [1]. Since there is no indication that the report [14] was based on the results
of any published survey, the likely source might be either anecdotal evidence or a
non-random, ad hoc sample.
The overall prevalence of male current (37.4%) and ex-smoking (11.1%) in our
survey is not high when compared with population groups in some other parts of the
world. Thus, in a US study, virtually all low-educated white men (92.5%) were
either current or former daily smokers [18]. However, it is the trend of smoking in
Kuwait that is alarming.
Radovanovic 10
An unpublished report [2] already pointed to an increasing prevalence of
tobacco use among the adult Kuwaiti males. This study showed that, when
controlling for several possible confounding variables, age had an inverse net effect
on the prevalence of smoking. Moreover, younger respondents were initiated to
smoking at an earlier age and smoked more heavily.
Neither income nor any of several indicators of material well-being were
associated with smoking. Such a finding might have been expected in a welfare state
like Kuwait, with one of the highest per capita income in the world and relatively low
price of cigarettes (about 1 US dollar per pack).
An inverse relationship between the prevalence of smoking and education is
also no surprise, since low educational attainment has been a well-established risk
factor for smoking, both among males and females [18,19,20,21]. This general rule
applies to Kuwaiti nationals as well, but a peculiarity of the Kuwaiti situation is that
the relationship is not linear, i.e. people with a limited, rather without any education,
were most likely to be smokers.
Though not addressed in this study, it may be assumed that traditional values
were most deeply rooted among non-educated Kuwaitis, rendering them resistant to
Western influences, including cigarette smoking. Indirect evidence pointing to this
direction is the finding that older and less educated people in Kuwait were less
sympathetic towards substance abusers [22]. Heavily exposed to non-impeded
influence of commercials through media that are not available (newspapers) or less
attractive to illiterate individuals (cinema, TV channels targeting young generation),
and unaware of adverse effects of smoking, people with limited education may thus
turn to be the most vulnerable population group.
Our results indicate that an urgent public health action is needed for halting the
further increase of the prevalence of smoking. Two years ago, the Kuwaiti Parliament
sanctioned a law aimed at controlling the smoking epidemic in the country. Some of
the measures were fairly strict, provoking the public outcry. The fierce reaction of the
smokers was probably a major reason that the law was never implemented. This
Radovanovic 11
experience shows that it is better to proceed gradually with an ever-stiffening anti-
smoking campaign rather than to envisage a radical set of measures that cannot be
rendered operational at all.



Acknowledgement
Ms. Jyoti Nayar and Ms. Indu Menon Gopalakrishnan entered the data into computer
and helped in data analysis. The research was funded by Kuwait University (Grant
MC 038).


Literature
1. Ministry of Public Health. The Kuwait Health Survey. First Report (Draft), Vol. 1-
2. Department of Planning and Follow-Up, MPH, Kuwait, 1987 (mimeographed).
2. Al-Harbi AM, Al-Aradi IK, Al-Ghareeb MA: Smoking among adult Kuwaiti males.
Department of Community Medicine, Faculty of Medicine, Kuwait, 1994 (mimeo).
3. Bener A, Gomes J, Anderson JA. Smoking habits among physicians in two Gulf
countries. J R Soc Health 1993; 298-301.
4. Al-Shatti A, Moody PM, Moussa MAA, Memon A. A pilot study of cigarette
smoking behaviour among physicians in Kuwait. J Kuw Med Assoc 1995; 27: 36-
41.
5. Al-Owaish RA, Zack M. Risk factors associated with acute myocardial infarction in
Kuwait, 1978. Int J Epidemiol 1982; 11:368-371.
6. Omu AE, Makhseed M, Mohammed AT, Munim RA. Characteristics of men and
women with circulating antisperm antibodies in a combined infertility clinic in
Kuwait. Arch Androl 1997; 39: 55-64.
Radovanovic 12
7. Al-Anezi F, Al-Kandari F, Al-Qahtanni M. Prevalence of smoking among the
academic staff of Kuwait University. Department of Community Medicine, Faculty
of Medicine, Kuwait, 1993 (mimeo).
8. Al-Muzaini AF, Hayati AY, Al-Harbish ZM. Factors affecting the decision to
smoke sheesha among Kuwaiti youth. Department of Community Medicine,
Faculty of Medicine, Kuwait, 1997 (mimeo).
9. Al-Khaldy AA, Al-Mutairi N, Al-Hashem M, Al-Daihani F. Smoking among
medical students. Department of Community Medicine, Faculty of Medicine,
Kuwait, 1997 (mimeo).
10. Osler M, Kjaer SK. Determinants of smoking behaviour in random samples of
Greenlandic and Danish women 20-39 years of age. Arctic Med Res 1996;55:62-8.
11. Mackay J. Women and tobacco: international issues. J Am Med Women Assoc
1996;51:48-51.
12. Moody P. International use and marketing of cigarettes and proposed interventions.
Med Princ Pract 1992-3;3:174-180.
13. Crofton J. Tobacco and the third world. Thorax 1990;45:164-9.
14. Director-General of WHO. Tobacco or health. Report of the Forty-First World
Health Assembly. Geneva: WHO, 1988 (as cited by Crofton [13]).
15. Netscape address: unicorn.who.uhtbin/cgis. Document WHA41/DIV/4.
Unpublished.
16. Parazzini F, Davoli E, Rabaiotti M, Restelli S, Stramare L, Dindelli M, La Vecchia
C, Fanelli R. Validity of self-reporting smoking habits in pregnancy: a saliva
cotinine analysis. Acta Obstet Gynecol Scand 1996;75:352-4.
17. Otero-Sabogal R, Sabogal F, Perez-Stable EJ. Psychological correlates of smoking
among immigrant Latina adolescents. J Natl Cancer Inst Monogr 1995;18:65-71.
18. Winkleby MA, Schooler C, Kraemer HC, Lin J, Fortman SP. Hispanic versus
white smoking patterns by sex and level of education. Am J Epidemiol 1995;142:
410-8.
Radovanovic 13
19. Graham H. Smoking prevalence among women in the European community 1950-
1990. Soc Sci Med 1996;43:243-54.
20. Narayan KM, Chadha SL, Hanson RL, Tandon R, Shekhawat S, Fernandes RJ,
Gopinath N. Prevalence and patterns of smoking in Delhi: cross sectional study.
BMJ 1996;312:1576-9.
21. Escobedo LG, Peddicord JP. Smoking prevalence in US birth cohorts: the
influence of gender and education. Am J Public Health 1996;86:231-6.
22. Bilal AM, Makhawi B, Al-Fayez G, Shaltout AF. Attitudes of a sector of the Arab-
Moslem population in Kuwait towards alcohol and drug misuse: an objective
appraisal. Drug Alcohol Depend 1990;26(1):55-62.