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Evidence for an increase in cannabis use in Iran – A systematic review and trend analysis

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PDF version. Shahesmaeili: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. Background : Cigarette smoking is a shared risk factor for a variety of health conditions. Aims : To estimate the prevalence of cigarette smoking among Iranian adolescents and young adults. Cross-sectional studies that reported the prevalence of cigarette smoking among high school students, university students or general population aged 14—30 years were eligible. Data on prevalence of smoking, age and gender of subjects, sample size, date, and location of studies were extracted by 2 independent reviewers. Results : We included 99 studies in the analysis. The prevalence of current smoking among the general population aged 15—24 years was 3. The prevalence of regular smoking among this population was 1. Conclusion : Cigarette smoking is notable among Iranian young adults especially boys and university students. Our findings call for reinforcement of tobacco prevention and control policies across Iranian schools and universities. Prevalence of cigarette smoking in Iranian adolescents and young adults: a systematic review and meta-analysis. East Mediterr Health J. Open Access. Some rights reserved. Cigarette smoking is one of the most important causes of death and disability worldwide. Smoking imposes a heavy economic burden globally, especially in developing countries. Cigarette smoking usually begins at an early age of adolescence. The early onset of smoking is associated with early incidence of noncommunicable diseases 4 as well as infectious diseases 5. Furthermore, tobacco dependence is more severe in people who start smoking at younger ages, and quitting smoking is more difficult in this group 6—8. The prevalence of adolescent and young adult smoking varies in different regions of the world. In the Islamic Republic of Iran, the prevalence of monthly smoking among high school students varies from 2. Policy-making requires that we take into account the public health importance of cigarette smoking, and provide timely and comprehensive information on current status of cigarette smoking among adolescents and young adults. In this systematic review, we provided a nationwide estimate of current, regular and life-time cigarette smoking among Iranian adolescents and young adults aged 18—30 years. Furthermore, we reported the gender-specific prevalence of smoking in various subgroups including high school and university students as well as the general population. Studies were eligible for inclusion if they were cross-sectional; conducted among adolescents aged 14—18 years or young adults aged 18—30 years; and published in either English or Farsi languages. Studies were excluded if they used nonrandom sampling; the sample size was not clearly declared; the prevalence was not reported or could not be calculated from the data; and the prevalence was reported based on the level of nicotine. The search was restricted to January to December Two independent reviewers MA and ZKh carefully scanned the titles, abstracts and keywords of each article for their relevancy and eligibility. Any disagreements between the reviewers were resolved by further investigation and discussion among the authors. If the information in the title or abstract was insufficient, the full text was reviewed. The following information was extracted from each eligible article by 2 independent reviewers, and if there was any discrepancy between the reviewers, the decision was based on negotiation with the third reviewer. Life-time smoking was defined as whether a person had ever smoked cigarettes in their life-time. Cigarette smoking during the previous month was considered as current smoking. We categorized the prevalence of smoking by level of education, gender, and type of smoking. Furthermore, to increase the generalization of the results, we estimated the prevalence based on the time of the study and type of city. As the prevalence of smoking may vary by time, we estimated the pooled prevalence in — and — The pooled prevalence was calculated using the metaprop command in Stata version The standard error of prevalence, , for each study was calculated based on the binomial distribution formula. The heterogeneity of studies was evaluated using I2 statistics. A forest plot was used to display the results of the meta-analysis. A funnel plot of log odds versus study size was constructed Our search identified articles, and of them were excluded because they were duplicates. Further screening of full-text articles led to the inclusion of 99 eligible articles in the meta-analysis. Forty-six studies were conducted in high school students and included 51 girls and 74 boys. The number of studies on male, female and both genders was 17, 1 and 28, respectively. Twenty-four studies reported current smoking and 33 the lifetime prevalence of cigarette smoking. Daily or regular smoking was reported in 22 studies 12—14,18— Thirty-seven studies were conducted among university students; 4 among men and 33 among both genders. There were 37 female and 25 male students. Twenty-eight studies reported the current prevalence and 13 the life-time prevalence of smoking. Daily or regular smoking was reported in 10 studies 16,61— Finally, 16 studies were conducted in the general population; 1 among women and 15 among both genders. These studies recruited 29 women and 36 men. The current and life-time prevalence of smoking was reported in 7 and 1 studies, respectively. Regular smoking was reported in 13 studies 97— The characteristics of the studies included in the systematic review and meta-analysis of cigarette smoking prevalence in Iranian high school students are presented in Table 1. For regular smoking, there was a decrease in smoking prevalence within the more recent period among girls 0. Furthermore, the pooled prevalence of all types of smoking in both genders was higher in large cities than in small cities Figure 4, see Appendix online. The characteristics of the studies included in the systematic review and meta-analysis of cigarette smoking prevalence in Iranian university students are presented in Table 2. However, the pooled prevalence of life-time smoking was lower within the more recent period than in the previous years. We did not perform the subgroups analysis for regular smoking because of the insufficient number of studies. The pooled prevalence of all types of smoking in both genders was higher in large cities than in small cities Figure 7, see Appendix online. The only exception was a higher prevalence of current smoking among men in small cities than in large cities Figure 7E, see Appendix online. The studies on smoking prevalence in the general population were heterogeneous Table 3 , see Appendix online ; therefore, we could not estimate the pooled prevalence. The prevalence of current smoking among the age group 15—24 years was reported to be 3. The prevalence of regular smoking among this age group varied from 1. The asymmetry in the funnel plots was indicative of some degree of publication bias Figures 8 and 9, see Appendix online. The current systematic review and meta-analysis indicated that the prevalence of cigarette smoking was high among Iranian adolescents and young adults. The pattern of smoking differed among different age groups. The prevalence of smoking among male university students was markedly higher than among male high school students, whereas in female students, the difference between the 2 groups was negligible. In both age groups, male students had a higher prevalence of smoking than female students had. Furthermore, the prevalence of smoking was higher in large cities compared to small cities. Comparison of our findings with those of the STEPS survey indicate that the prevalence of current smoking among university students is higher than in the general population. Furthermore, a meta-analysis in the Islamic Republic of Iran in indicated that However, the main drawback of that meta-analysis is the lack of a clear definition for smoking, which limits any comparison. The prevalence of current smoking in young adults varies in different regions of the world. The global estimates in health profession students showed that the prevalence of smoking varies by region. Compared with these national reports, in our study, the prevalence of smoking among Iranian students, especially women, seems to be lower than in European countries, but similar to most Eastern Mediterranean countries. One explanation for the lower prevalence of cigarette smoking in the Eastern Mediterranean Region, including the Islamic Republic of Iran, may be the increasing tendency of young adults to try other types of tobacco, mainly water pipe smoking. Lack of awareness of the negative effects of water-pipe smoking and lower stigma toward its use are factors that explain this pattern A meta-analysis of 12—year-old adolescents of 68 low- and middle-income countries indicated that The highest prevalence for boys was for the Western Pacific Region The corresponding prevalence in the Eastern Mediterranean Region for girls was estimated at 3. We showed that in both age groups, male students smoked cigarettes more than female students smoked. The sex ratio varied from 2 for life-time smoking in high school to 11 for regular smoking among university students. Global estimates indicate that men smoke 5 times as much as women smoke A variety of national studies have confirmed the higher prevalence of smoking in Iranian men , The lower prevalence of cigarette smoking among women may be due to greater stigma that exists toward smoking among women. We found that the prevalence of smoking was higher in large cities compared to small cities. Despite a slight increase in prevalence of smoking within more recent years, the prevalence of life-time smoking decreased. This decrease may have been due to several factors including increasing awareness of young people about tobacco hazards, tendency to use other drugs, including hookah, and success of tobacco control programmes. In the Islamic Republic of Iran, it is culturally inappropriate for girls to smoke Extrapolating our results to these populations reflects the alarming rate of cigarette smoking among Iranian adolescents. A growing body of evidence indicates that smoking initiation at lower ages is strongly related to subsequent smoking behaviour, including regular and heavy smoking in adulthood, which highlights the importance of early interventions for smoking prevention According to the World Health Organization report on the national tobacco control programme, the Islamic Republic of Iran has performed well compared to other countries in the Eastern Mediterranean Region in many aspects of smoking control including monitoring and smoke-free policies, smoking cessation programmes, health warnings on cigarette packages, and mass media and advertising bans for tobacco use. However, more action is needed in the field of taxation and affordability of tobacco, especially in large cities , The nature of the tobacco epidemic requires a comprehensive prevention and intervention plan focusing on the community as well as schools. A variety of strategies should be reinforced to reduce the prevalence and health effects of cigarette smoking in adolescents. Existing laws to restrict access to tobacco products by banning sales to minors should be reinforced. Effective and comprehensive educational programmes on the health risks of tobacco consumption and exposure to tobacco smoke should be established in schools and universities. Additionally, tobacco cessation facilities should be extended to all areas. Involvement of nongovernmental organizations and parents in tobacco control programmes as well as licensing the distribution of tobacco products in order to decrease availability are other strategies that should be strengthened by policy-makers. Our findings should be interpreted by taking into consideration the limitations of the study. There were high variability and heterogeneity among studies regarding the sampling method, study instruments and reporting of variables. For example, despite the use of random sampling in all recruited studies, the variations in the sampling approach among studies were indicative of possible selection bias. Similarly, the different instruments used in the studies were suggestive of some degree of information bias. While definitions regarding life-time smoking were consistent among the included studies, there was some degree of heterogeneity regarding the definition of current and regular smoking. For example, in most studies, an exact definition of current smoking was not used, but in a small number of studies, it was measured objectively. Therefore, our results should be interpreted with caution. Furthermore, due to the lack of comprehensive databases, we did not have access to grey literature. Nevertheless, this review is important as it provides a comprehensive picture regarding the prevalence of smoking among Iranian young people that could serve as the foundation for policy-makers to develop and implement effective smoking prevention and intervention programmes. Cigarette smoking is notable among Iranian young adults in a way that boys and university students are affected more. Prevention programmes in high schools and universities should focus on information, education and communication, and current policies on tobacco control should be reinforced. WHO report on the global tobacco epidemic Global economic cost of smoking-attributable diseases. Tob Control. Global status report on noncommunicable diseases. Systematic review of cigar smoking and all cause and smoking related mortality. Park S-H. Smoking and adolescent health. Korean J Pediatr. Nicot Tob Res. Public Health Nurs. Tobacco use by university students, Lebanon, Addiction Jul;98 7 —9. Am J Public Health. Tobacco product use among middle and high school students — United States, and Tobacco use and second-hand smoke exposure in young adolescents aged 12—15 years: data from 68 low-income and middle-income countries. Lancet Global Health. The role of social and familial factors as predicting factors related to hookah and cigarette smoking among adolescents in Jahrom, South of Iran. Int J Pediatr. J Epidemiol Glob Health Sep;5 3 — Ahmadi J, Hasani M. Prevalence of substance use among Iranian high school students. Addict Behav. Smoking and asthma symptoms among university students. Tanaffos ;6 1 —8. Cigarette smoking among Iranian university students: reasons and attitudes. Iranian J Psychiatry Behav Sci. In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias. J Clin Epidemiol. Cigarette smoking among male high school students in Rasht. J Guilan Univ Med Sci. Attitude of high school students of Tehran towards tobacco use. Tanaffos 11 — Cigarette smoking experience and its related socio-demographic and environmental risk factors in high school boy students, Shiraz — Iran. Cigarette smoking, knowledge, attitude and prediction of smoking between male students, teachers and clergymen in tehran, iran, In J Prev Med. The determinants of high school students smoking habits with special focus on teachers smoking in Iran: a population based study. Pneumologia Jan—Mar;61 1 — Determinants of smoking behavior among male high school students in Babolsar, Iran. J Mazandaran Univ Med Sci. Payavard Salamat ;4 2 —96 in Farsi. Epidemiology of substance abuse among Iranian adolescents Yazd: Iran J Psychiatry Behav Sci. The causes of smoking tendency and the effect of two methods of counseling, guidance, psychotherapy, and nicotine gum on smoking. Factors affecting cigarette smoking based on health-belief model structures in pre-university students in Isfahan. J Educ Health Promot. Addiction Health. Factors associated with tobacco use among Iranian adolescents: an application of protection motivation theory. Subst Use Misuse Jul 29;53 9 —8. Frequency of tobacco use among students in Tehran city. Tehran Univ Med J. Intention to start cigarette smoking among Iranian male adolescents: usefulness of an extended version of the theory of planned behaviour. Heart Asia Sep 26;4 1 —4. Predicting smoking among adolescents: examining the role of smoking self-identity in the theory of planned behavior. Health Syst Res. Predictors of smoking among the secondary high school boy students based on the health belief model. Int J Prev Med. Predictors of tobacco smoking in male adolescents in Hamadan based on the theory of planned behavior. J Educ Community Health Autumn;1 3 — Modeling the underlying tobacco smoking predictors among 1 st year university students in Iran. Prevalence of cigarette smoking and associated risk factors among adolescents in Hamadan City, west of Iran in J Res Health Sci. Prevalence of cigarette smoking and evaluation of attitude and knowledge in its high school boys in Birjand J Birjand Univ Med Sci. Mohamadkhani S. Prevalence of cigarette smoking, alcohol drinking and illegal drugs use among Iranian adolescents. J Kerman Univ Med Sci. Mohammadkhani S. Prevalence of Ecstasy use and predisposing factors among Iranian female high school students. J Pak Med Assoc. Prevalence of smoking among high-school students of Tehran in Mojahed A, Bakhshani N. Zahedan J Res Med Sci. Prevalence of smoking and associated factors in female high school in Kermanshah. J Kermanshah Univ Med Sci. Smoking habits of adolescent students in Tehran. Tanaffos ;9 2 — Relationship between happiness and tobacco smoking among high school students. Epidemiol Health. The role of sociodemographic factors associated with water pipe smoking among male adolescents in western Iran: a cross-sectional study Tob Induc Dis. Smoking among high school students of an area with medium socioeconomic status. Smoking and its related factors among Iranian high school students. J Shahrekord Univ Med Sci. Smoking stages in an Iranian adolescent population. Acta Med Iran. Smoking stages, prevalence of drug abuse and role of associated psychological and social factors: A study on male high school students in Ilam city. Smoking status in Iranian male adolescents: a cross-sectional study and a meta-analysis. Lifestyles in suburban populations: a systematic review. Electron Physician. Smoking, tooth brushing and oral cleanliness among year-olds in Tehran, Iran. Oral Health Prev Dent. Socioeconomic determinants of inequality in smoking stages: a distributive analysis on a sample of male high school students. Am J Mens Health Jul;11 4 —8. A study on prevalence of cigarette smoking and the age of first smoking in senior high school students in Tehran, — Hakim Res J. Subgrouping high school students for substance abuse—related behaviors: a latent class analysis. Am J Mens Health. Momtazi S, Rawson RA. Substance abuse among Iranian high school students. Curr Opin Psychiatry. Substance abuse in Iranian high school students. The prevalence of psychiatric distress and associated risk factors among college students using GHQ questionnaire. Iranian J Public Health. Cigarette smoking behavior and the related factors among the students of mashhad university of medical sciences in iran. Iran Red Crescent Med J. Jentashapir J Cell Mol Biol. Prevalence and cause of smoking among the dormitories students in Gorgan University of Medical Sciences. Researcher Bull Med Sci. Adv Exp Med Biol. Modeling the underlying tobacco smoking predictors among 1st year university students in Iran. Nojomi M, Najamabadi S. Obesity among university students, Tehran, Iran. Asia Pac J Clin Nutr ;15 4 — Pattern of substance use among students of medical sciences in Tehran, Iran: a latent class analysis. J Subst Use. The prevalance of cigarette smoking and some demographic and psychological characteristics in students of Islamic Azad University of Khorasgan. Iran J Res Behav Sci. Prevalence and causes of tendency to cigarette smoking among students of Ardabil University of Medical Sciences. J Ardabil Univ Med Sci. Prevalence and characterizations of current smoking habit of iranian medical university students: a cross-sectional study in mental health. Int Med J. Prevalence and factors associated with Ecstasy use among college undergraduates in north of Iran — Asian J Psychiatry. 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Am J Mens Health Nov;7 6 — Self-reported and network scale-up estimates of substance use prevalence among university students in Kerman, Iran. Smoking among male medical sciences students in Semnan, Islamic Republic of Iran. Smoking intensity and its relation to general health of the students of kerman university of medical sciences, iran. Addict Health. Social and psychological predictors of initial cigarette smoking experience: a survey in male college students. Am J Mens Health Jan;10 1 — Socio-demographic characteristics associated with cigarettes smoking, drug abuse and alcohol drinking among male medical university students in Iran. Health Scope. Substance abuse: prevalence in a sample of nursing students. J Clin Nurs. Acta Medica Iranica ;47 6 —8. Tobacco use and substance abuse in students of Karaj Universities. Trend of smoking among students of Tehran University of Medical Sciences: results from four consecutive surveys from to Med J Islam Repub Iran. Analysis of smoking behaviour among Iranian population: a cohort and period analysis. Are the predictors of hookah smoking differ from those of cigarette smoking? Report of a population-based study in Shiraz, Iran, Assessment of non-communicable disease risk factors in hormozgan province Life Sci J. Biomonitoring of tobacco smoke exposure and self-reported smoking status among general population of Tehran, Iran. Environ Sci Pollut Res Int. Med J Malaysia. Demographic factors, social capital, and cigarette smoking: a large cross-sectional study in Tehran, Iran. Determinants number of cigarette smoked with Iranian adolescents: A multilevel zero inflated poisson regression model. Iran J Public Health. Personal and family factors affecting life-timecigarette smoking among adolescents in Tehran Iran : a community based study. Oman Med J. A population-based survey on prevalence of cigarette smoking and its socio-demographic risk factors among women of reproductive age in Tehran — Iran. Epidemiol Biostat Public Health. Prevalence of cigarette smoking and associated factors among male citizens in Tehran, Iran. The prevalence of cigarette smoking in residents of Tehran. Ali EN, Jafar A. Prevalence of cigarette smoking in the Rafsanjan urban population. Environl Sci Pollut Res Int. Haghdoost AA, Moosazadeh M. J Res Med Sci. Waterpipe and cigarette smoking among university students in the Western Cape, South Africa. Am J Health Behav. A literature review on prevalence of gender differences and intersections with other vulnerabilities to tobacco use in the United States, — Prev Med. Waterpipe and cigarette tobacco smoking among Palestinian university students: a cross-sectional study BMC Public Health. Smoking behaviour and patterns among university students during the Syrian crisis. Prevalence of tobacco use and perceptions of student health professionals about cessation training: results from Global Health Professions Students Survey. BMJ Open May 26;8 5 :e Waterpipe tobacco use among Iranian university students: correlates and perceived reasons for use Tint J Tuberc Lung Dis. Waterpipe smoking among health sciences university students in Iran: perceptions, practices and patterns of use. Tobacco smoking: findings from 20 years of the Tehran Lipid and Glucose Study. Int J Endocrinol Metab. Gender empowerment and female-to-male smoking prevalence ratios. Bull WHO. Gut microbiota varies by opioid use, circulating leptin and oxytocin in African American men with diabetes and high burden of chronic disease. PLoS One. Curr Addict Rep. WHO report on the global tobacco epidemic, Subscribe via RSS. Volume 30, number 8 August WHO Bulletin. Pan American Journal of Public Health. Main Search Contact. YouTube Rss feeds Twitter Facebook. Eastern Mediterranean Health Journal All issues Volume 27 Volume 27 issue 6 Prevalence of cigarette smoking in Iranian adolescents and young adults: a systematic review and meta-analysis. Abstract Background : Cigarette smoking is a shared risk factor for a variety of health conditions. Study selection Studies were eligible for inclusion if they were cross-sectional; conducted among adolescents aged 14—18 years or young adults aged 18—30 years; and published in either English or Farsi languages. Data extraction The following information was extracted from each eligible article by 2 independent reviewers, and if there was any discrepancy between the reviewers, the decision was based on negotiation with the third reviewer. Definitions Life-time smoking was defined as whether a person had ever smoked cigarettes in their life-time. Statistical analysis The pooled prevalence was calculated using the metaprop command in Stata version Results Literature search Our search identified articles, and of them were excluded because they were duplicates. Meta-analysis of smoking prevalence High school students The characteristics of the studies included in the systematic review and meta-analysis of cigarette smoking prevalence in Iranian high school students are presented in Table 1. University students The characteristics of the studies included in the systematic review and meta-analysis of cigarette smoking prevalence in Iranian university students are presented in Table 2. General population The studies on smoking prevalence in the general population were heterogeneous Table 3 , see Appendix online ; therefore, we could not estimate the pooled prevalence. Discussion The current systematic review and meta-analysis indicated that the prevalence of cigarette smoking was high among Iranian adolescents and young adults. Conclusion Cigarette smoking is notable among Iranian young adults in a way that boys and university students are affected more. Funding : None. Competing interests : None declared. References 1. PMID Current issue Volume 30, number 8 August

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