Smokers and Marriage : Attitude of Youth in the United Arab Emirates

Consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper middle-income countries. More than six million people die from tobacco use and exposure to tobacco smoke, with one death occurring every six seconds. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030. The United Arab Emirates (UAE) is one of the most rapidly developing countries in this region. Smoking is one of the major issues that plagues the nation, with an increasing number dying each year from smoking-related diseases. Health officials are worried about the huge burden that this poses on the health care system (Mahmood, 2011). A family health survey in 1995 revealed that 18.3% of adult males and 0.4% of adult females were current smokers in the UAE (Fikri et al., 2002). Global Youth Tobacco Survey (GYTS) which reported that among 4178 schoolchildren aged 13–15 years, 14.3% of boys and 2.9% of girls were


Introduction
Consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper middle-income countries. More than six million people die from tobacco use and exposure to tobacco smoke, with one death occurring every six seconds. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030. The United Arab Emirates (UAE) is one of the most rapidly developing countries in this region. Smoking is one of the major issues that plagues the nation, with an increasing number dying each year from smoking-related diseases. Health officials are worried about the huge burden that this poses on the health care system (Mahmood, 2011). A family health survey in 1995 revealed that 18.3% of adult males and 0.4% of adult females were current smokers in the UAE (Fikri et al., 2002). Global Youth Tobacco Survey (GYTS) which reported that among 4178 schoolchildren aged 13-15 years, 14.3% of boys and 2.9% of girls were
A recent study in 2010 about prevalence and pattern of dokha use (an indigenous form of smoking typically seen in UAE and Iran) among medical and allied health students in Ajman, UAE showed that dokha use is common in this group and hence the development of an anti-smoking program for university students is recommended . There are several recommendations to overcome the menace of smoking, viz. mass media health education programs, ban on all forms of tobacco advertising and promotion, vivid health warnings on tobacco products, regular increases in tobacco taxation, restrictions on smoking in public places and workplaces, help for smokers who wish to quit and crop diversification where tobacco is grown .
Many studies have been done on the influence of partner in smoking initiation and cessation. However, no such study is done in the UAE. Two studies, both from India tried to examine the attitude of youths towards marrying a smoker. The first study, among 1800 unmarried female college students in south India found that 96.5% of the participants had negative attitude toward smokers. 99.3% expressed their unwillingness to marry a person with the habit of tobacco use, whereas the other 0.7% were willing to marry smokers but were doing so with the sole belief that they could affect a change in the person (Sreedharan J et al., 2011). The second study was conducted in Mumbai by Salaam Bombay Foundation among 524 males and 267 females aged 18-25 years. Over 80% of the participants did not find smokers attractive, 67% were not willing to date a smoker and about 75% were not willing to marry a smoker. The limitations for both the studies are that they are cross sectional studies and the sample consists of people largely from the same ethnic background. Another study with a similar focus, but slightly different from the first two is the longitudinal study carried out by Kennedy et al. in the United States. Results of this study indicate that, for close romantic relationships, cessation was more likely among smokers with more time in relationships with non-smoking partners. Greater exposure to smoking through partners significantly decreased the likelihood of cessation among initial smokers and increased the likelihood of initiation among initial non-smokers, Suggesting that peer-based smoking programs aimed at adolescents should incorporate a focus on romantic relationships (David PK et al., 2011).
In the present study an attempt has been made to assess the attitude of youth from diverse ethnicities towards marrying a smoker, attitude toward parents' and friends' tobacco use, and their willingness to participate in antismoking campaign. The information thus obtained can be used by policy makers in formulating tobacco control strategies and discouraging the adoption of the behavior.

Materials and Methods
This cross sectional survey was conducted among students from different Universities in the U.A.E. A total of 516 students from five universities participated in the study. The universities included were The UAE University, Al Ain (70), Ajman University of Science and Technology, Ajman (200), Gulf Medical University, Ajman (146), Sharjah University, Sharjah (80) and Middlesex University, Dubai (20). All individuals, males and females, smokers and non-smokers within the age group of 16 to 30 were included in the study. Incidental non-probability sampling was used. Based on the prevalence of smokers, the minimum required sample within a 95% confident interval was arrived at 400. Data were collected using a self-administered questionnaire with structured, mostly close-ended questions. The questionnaire was based on the standardized WHO Global Youth Tobacco Survey questionnaire. Due to cultural factors, a number of questions were removed and some questions had to be reworded. The questionnaire was validated by a panel of experts in the field. Data were collected after getting approval from the ethics committee of Gulf Medical University. After getting consent from the University coordinators, questionnaires were handed to students who were present on the day of data collection. Verbal consent was obtained from the participants willing to take part in the study before distributing the questionnaires, and the completed questionnaires were collected back on the same day. All the concerns raised by the students were addressed.
Data were analyzed using PASW 18.0 version. Chi-square test was performed to find the association between variables. A P-value less than 0.05 was taken as statistically significant.

Results
Of the 516 questionnaires collected, 101 had to be discarded due to incomplete entry and 415 were analyzed. The mean age was 20.41 years, with the youngest participant being 16 years of age and the oldest 29. Of the 413 participants who provided information on gender, 99 (24%) were males and 314(76%) were females. The majority of the participants were of Arab origin (32.8%) UAE nationals and 34% other Arabs, and 62% were unmarried (Table 1). On enquiry whether ever tried to smoke, 26.6% reported to have smoked at least once.

Discussion
The study explores the general opinion of college students on attitude toward parents' tobacco use and influence of tobacco use in selection of a spouse. Most of the participants (68%) had a negative attitude toward parents' tobacco use. Several studies have shown a significant association between parental smoking habits and subjects decision to smoke (Oie TP et al., 1990;Madan K et al., 2006). A study conducted by (Chassin et al.,2008) concluded that while having parents that are current smokers may influence children to smoke during the initial or trying phases, it appeared that there was no influence during the transition period. The results obtained from our study showed that a high proportion whose parents are smokers did not like it. This contradicts the finding of a study done by (Gilman et al.,2009) which indicates that the children whose parents are smokers are at a high risk of smoking adoption.
Most participants (83.5%) are not willing to marry smokers while 16.5% did not mind marrying smokers. Both males and females were equally unwilling to marry smokers. The majority of subjects that do not object to marrying smokers indicated that marriage was about love, rather than the partners' smoking habits. However, a small number did not object to marrying a smoker with the hope that can dissuade their partners from smoking. One study among female students in India found that only 0.7% was willing to marry smokers. Another study in India showed that over 80% of the participants did not find smokers attractive, 67% were not willing to date a smoker and about 75% were not willing to marry a smoker. A similar study in Florida found that 41% of the students agreed to the statement, "I would not date or marry a smoker" (Ganeshasundaram R et al., 2008). In another study, female participants indicated that being a smoker or being with a smoker could affect their marriage prospects and their social standing (Frank B et al., 2002). Tobacco is mostly advertised using imagery that depicts smokers as handsome/beautiful, with athletic prowess, sexual attractiveness, success, adult sophistication and adventure. But in reality, smokers are not any of the things that are depicted, and are also not viewed as such by others. In our study the general perception of males about smokers varied widely, with the majority holding the opinion that smokers are losers, stupid or even lacking in confidence while another subset 33.2% did not have an opinion. The perception of the females on smokers was essentially similar to that of the males, with only very slight differences in numbers.

. Opinion of Students About Parents' Smoking Habit
Significantly more males (74.7%) than females (26.6%) tried smoking p<0.005 (Table 2). Table 3 shows that 83.5% of the participants are not willing to marry, while 16.5% are willing to marry smokers. 76% of the males and 85% of the females were not willing to marry smokers. Of those willing, the majority (47.6%) said because they believed marriage was all about love, while the second major reason for willingness to marry smokers was because they felt they could change the person (23.8%). As regards the choice of a partner, 82.6% preferred to marry non-smokers, 14% believe there was no difference while 3.4% preferred to marry smokers.
All participants were asked to choose whether smokers were more attractive, less attractive or there was no difference. Figure 1 shows that 66.7% of females think boys that smoke are less attractive whereas 62.6% of males think girls who smoke are less attractive. 24.2% of all the participants think of male smokers as stupid, 13.6% think of them as lacking in confidence and 23.2% think of male smokers as losers. 33.2% have no opinion on this question. Only 2.2% suggested smokers as intelligent, another 2.2% consider them as successful and 1.5% thinks of them as macho. 37.9% of all the participants think of female smokers as stupid, 24.2% think of them as losers and 9.2% think of them as lacking in confidence. 22.2% have no opinion on this question. Only 2.4% think of them as intelligent, another 2.9% think of them as successful and 1.2% thinks they are macho. Figure 2 shows that of those whose parents smoke, 106 (68%) do not like it when their parents smoke, 13.6% Smoking used to hold a certain allure and was associated with status in the past. However, as this study shows this view has almost been completely eliminated. A very small number of participants perceive it to be cool or identify it with a certain level of social standing. In fact, many participants are keen to engage in anti-smoking campaigns. There is enough evidence in this study that fewer people are willing to marry a smoker. It could be for cultural or religious purposes or it may be that the detrimental effects of smoking are now widely known and thus fewer people are willing to deal with the consequences of such a risky lifestyle. Whatever the reason, smoking is collectively perceived as an unattractive practice. Being a cross sectional survey, the present study can only describe the present attitude of youth towards smokers. It cannot provide information on the evolution of this attitude nor describe the factors that are responsible for the evolution.
In conclusion, most participants, both males and females, are not willing to marry smokers and prefer to have non-smokers as spouses. Also, smokers are seen as less attractive by both genders in contrast to what appears as popular beliefs among youngsters and what is depicted in tobacco advertisements. The results of this study can be used to plan a comprehensive health education program for tobacco control.