[Downloaded free from http://www.avicennajmed.com on Sunday, October 20, 2019, IP: 106.198.161.

218]

ORIGINAL ARTICLE

The prevalence and associated factors of cigarette

smoking and its association with opium use among
outpatients in Afghanistan: a cross-sectional study in
Andkhoy city
Mohammad Shoaib Hamrah, Mohammad Hassan Hamrah1,2, Mohammad Hussain Hamrah1,3, Ahmad Edris Hamrah1,
Toba Dahi4, Bagher Pahlavanzade5, Abdurrahman Charkazi6, Mohammad Hashem Hamrah1
Center for Rural Health, School of Health Sciences, University of Tasmania, Tasmania, Australia, 1Dr. Mohammad Hashem Hamah’s Curative
Clinic, Andkhoy, Faryab, Afghanistan, 2Faculty of Stomatology, Kunduz University, Kunduz, Afghanistan, 3Faculty of Medicine, Arya University,
Mazar-i-Sharif, Afghanistan, 4Faculty of Dentistry, AbantIzzet Baysal University, Bolu, Turkey, 5Department of Biostatistics, Faculty of Paramedical
Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran, 6Environmental Health Research Center, School of Health, Golestan
University of Medical Sciences, Gorgan, Iran

Access this article online

ABSTRACT
Website: www.avicennajmed.com
DOI: 10.4103/ajm.AJM_40_19 Purpose: The objectives of this study were to estimate the prevalence and associated
Quick Response Code: factors of cigarette smoking and the association between cigarette smoking and opium
use among patients visiting an outpatient clinic in Afghanistan. Methods: A cross-sectional
study was conducted on consecutive patients aged 18 years and older from January 2018
to April 2018. Data on patients’ sociodemographic characteristics and clinical variables were
collected using an interview-based survey. Results: Six hundred and twenty-two patients
(391males vs. 231 females) were interviewed for this study. The overall prevalence of current
smoking was 50.2% (95% confidence interval [CI]: 46.2–54.2). Males were (odds ratio
[OR] = 9.5; 95% CI: 5.3–17.1) more likely to smoke cigarettes than females. The odds of
current cigarette smoking increased with having a family member smoker or a friend smoker
(OR =3.3; 95% CI: 2.0–5.3). Cigarette smoking was significantly associated with the level of
education (illiterate OR = 8.9; 95% CI: 4.0–19.8), primary/private education (OR = 7.8; 95%
CI: 3.9–15.6), and secondary education (OR = 4.4; 95% CI: 2.3–8.4), with high school or
higher education as the reference group. Rural residents were 3.7 times (95% CI: 2.3–6.2)
more likely to smoke cigarette than urban residents. Opium users were 23.0 times (95%
CI: 12.5–42.3) more likely to smoke cigarettes than non-opium users. Conclusions: The
prevalence of cigarette smoking among patients visiting an outpatient clinic in Afghanistan
was high, and there was an association between cigarette smoking and male gender, a
family history of smoking or a friend history of smoking, level of education, rural residency,
and opium consumption.

Key words: Andkhoy, associated factors, opium use, smoking

INTRODUCTION This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License,
Tobacco use is one of the main preventable risk factors which allows others to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations are licensed under
for noncommunicable diseases including cancers, the identical terms.
cardiovascular disease, diabetes mellitus, and chronic
For reprints contact: reprints@medknow.com

Address for correspondence: Dr. Mohammad Shoaib Hamrah, Cite this article as: Hamrah MS, Hamrah MH, Hamrah MH, Hamrah AE, Dahi
Centre for Rural Health, School of Health Sciences, University of T, Pahlavanzade B, et al. The prevalence and associated factors of cigarette
Tasmania, Locked Bag 1322, Launceston TAS 7250 Australia. smoking and its association with opium use among outpatients in Afghanistan:
A cross-sectional study in Andkhoy city. Avicenna J Med 2019;9;129-33.
E-mail: mshoaibhamrah@gmail.com

© 2019 Avicenna Journal of Medicine | Published by Wolters Kluwer - Medknow 129

[Downloaded free from http://www.avicennajmed.com on Sunday, October 20, 2019, IP: 106.198.161.218]

Hamrah, et al.: Smoking and opium use in Afghanistan

lung disease.[1] Tobacco use causes approximately 6 million ▪ Sociodemographic characteristics: Age, sex, education
deaths annually. If these trends continue, this number is level, marital status, occupation, and place of residence
projected to increase to 8 million per year by 2030.[2] Of ▪ Behavioral: Cigarette smoking and opium use
the 1.3 billion smokers worldwide, 80% of them live in ▪ Clinical characteristics: body mass index (BMI) and
low- and middle-income countries (LMICs). Most LMICs measured blood pressure
have less access for the adequate care of patients with a
Fasting blood sugar, total cholesterol, and triglyceride were
tobacco-related illness.[3]
also measured. The variables are defined in elsewhere.[8]
The high smoking rates reported among illicit drug users
Smoking: Patients were categorized into three groups:
were from population-based studies and among patients
attending substance abuse treatment clinics and facilities.[4] current smokers, past smokers, and nonsmokers. Current
The prevalence of concurrent smoking and substance use smokers were defined as patients who have smoked at least
was between 35% and 44% in the general population, 100 cigarettes in their lifetime and had smoked in the last
whereas this figure for patients attending the substance 30  days. Past smokers were defined as patients who had
abuse treatment clinics and facilities was 80%.[5] smoked at least 100 cigarettes in their lifetime but had not
smoked in the last 30 days. Nonsmokers were defined as
Afghanistan has been the world’s biggest producer of patients who had never smoked cigarettes in their lifetime.
opium.[6] There is a paucity of studies regarding prevalence Both past smokers and those who had never smoked were
of cigarette smoking and its associated factors, and the constituted in the nonsmokers category.[9]
association between cigarette smoking and opium use among
a population of outpatients in Afghanistan. Therefore, the Opium consumption: Opium users reported using any types
primary aim of this study was to estimate the prevalence of opium at least once per week for last 6-month period.[10]
and identify independently associated factors with cigarette All the patients were interviewed as the diagnostic criteria
smoking among adult patients visiting an outpatient clinic. specified in the Diagnostic and Statistical Manual of Mental
Secondary objective was to determine the association Disorders IV criteria for opium dependency.[11]
between cigarette smoking and opium use among patients
visiting an outpatient clinic in Andkhoy, Afghanistan. BMI was calculated as weight in kilograms divided by
height in meters squared. Overweight was a BMI ≥25 kg/
SUBJECTS AND METHODS m2, and obesity was a BMI ≥30 kg/m2.[12] Hypertension:
Hypertension was defined as systolic blood pressure/
From January 2018 to April 2018, we performed a cross- diastolic blood pressure of 140 mm Hg or diastolic blood
sectional study among 622 consecutive patients aged pressure of ≥90 mm Hg or higher, at separate occasions,
18 years and older visiting an outpatient clinic in Andkhoy, and those already on antihypertensive medications at the
Afghanistan. The exclusion criteria were the patients with time of admission.[13] Questions were illustrated if there was
physical and neurocognitive disorders and ≥80 years of age. need for more explanation about the concept of a question.
Informed consent was obtained from the participants. The
Well-trained doctors collected the required information study was approved by the Faryab Public Health Directorate.
using the Persian version of World Health Organization
stepwise approach to noncommunicable diseases risk factors Statistical analysis
surveillance, and the questionnaire has been validated.[7] All of the data were analyzed using IBM SPSS version
The questionnaire was modified into the Dari language. 24.0 (SPSS; IBM Corp, Armonk, NY). The independent
Persian and Dari are mutually intelligible varieties of the samples t-test was used to compare the means of quantitative
same language. Language experts confirmed the equivalence variables across smokers and non-smokers. Results for
of the concept in the questionnaire. Moreover, the cultural quantitative data are represented as mean and standard
validation has been made to check appropriateness of division. The chi-square test was used to compare qualitative
wording and to exclude the potential misinterpretation data in the two groups. Results for categorical data are
due to different ways of thinking. Data were collected on represented in frequency and percentage. Multiple logistic
patients’ sociodemographic characteristics, behavior risks, regression analysis was used to identify factors associated
and physical and laboratory measurements. Questions with cigarette smoking and the association between cigarette
were asked through face-to-face interviews. The following smoking and opium use. The odds ratios (ORs) and 95%
variables were investigated: confidence intervals (CIs) were calculated to determine

130 Avicenna Journal of Medicine / Volume 9 / Issue 4 / October-December 2019

[Downloaded free from http://www.avicennajmed.com on Sunday, October 20, 2019, IP: 106.198.161.218]

Hamrah, et al.: Smoking and opium use in Afghanistan

association in the logistic regression analysis. The level of Table 1: Association between sociodemographic and
statistical significance was determined by P < 0.05. health variables, and smoking among adult patients
visiting an outpatient clinic in Andkhoy, Afghanistan
RESULTS Smokers Nonsmokers P value
(N = 312) (N = 310)
Table 1 indicates the sociodemographic and clinical Age, n (%) 0.424
 <39 14 (4.5) 22 (7.1)
characteristics of all patients. The mean age of the smokers  40–60 57 (18.3) 54 (17.4)
and nonsmokers was 67.8 ± 12.3 years and 66.7 ±13.8 years,  >60 118 (37.8) 122 (39.3)
respectively. The man-to-woman ratio among participants Gender, n (%) <0.001
 Male 244 (78.2) 115 (37.1)
was 1.7. The overall prevalence of current smoking was  Female 68 (21.8) 195 (62.9)
50.2% (95% CI: 46.2–54.2). The prevalence of current Level of education, n (%) <0.001
cigarette smoking among males was 76.0% (95% CI:  Illiterate 215 (68.9) 104 (33.5)
 Primary/private 49 (15.7) 73 (23.5)
71.0–80.6), and this was significantly higher than among education
females 21.2% (95% CI: 16.8-26.1, P<0.001). The majority  Secondary 28 (8.9) 83 (26.8)
of smokers were illiterate 68.9% (95% CI: 63.5–74.0).   High school or more 20 (6.4) 50 (16.1)
Marital status, n (%) 0.031
There was a high prevalence of smoking among married  Single 37 (11.8) 30 (9.7)
patients 84.3% (95% CI: 79.8–88.1). Smoking prevalence  Married 263 (84.3) 254 (81.9)
was significantly higher among opium users 57.1% (95%  Others 12 (3.8) 26 (8.4)
Opium use, n (%) <0.001
CI: 51.5–62.6) compared with nonuser groups 42.9% (95%  Yes 178 (57.0) 54 (17.4)
CI: 37.4–48.6) smoking was not equal among 4 occupation  No 134 (42.9) 256 (82.6%)
groups. The high smoking rates were observed among Occupation, n (%) <0.001
 Employed 16 (5.1) 48 (15.5)
unemployed participants 67.3% (95% CI: 61.8–72.5),  Unemployed 210 (67.3) 113 (36.4)
among rural residents 49.4% (95% CI: 43.7–55.0), among   House wife 66 (21.1) 108 (34.8)
those who had a family member smoker or friend smoker  Farmer 17 (5.4) 27 (8.7)
 Others 3 (0.96) 14 (4.5)
56.1% (95% CI: 50.4–61.7), and smokers mostly didn’t have Residence, n (%) <0.001
hypertension (44.6% versus 57.1%).  Rural 154 (49.3) 110 (35.5)
 Urban 158 (50.6) 200 (64.5)
History of family smoking, 175 (56.1) 111 (35.8) <0.001
Table 2 represents the results of logistic regression analysis n (%)
of smoking cigarettes among patients for sociodemographic Hypertension, n (%) 0.002
characteristics, clinical variables, and opium use. Male  Yes 139 (44.5) 177 (57.1)
 No 173 (55.4) 133 (42.9)
participants were (OR = 9.5; 95% CI: 5.3–17.1) more likely Body mass index, kg/m2, 23.6 ± 2.9 25.2 ± 3.6 <0.001
to smoke than female patients. Those patients who currently mean ± SD
had a smoker family member or a smoker friend had 3.3 Fasting blood sugar (mg/dL) 106.3 ± 34.4 104.2 ± 23.7 0.516
mm Hg, mean ± SD
times (95% CI: 2.0-5.3) greater odds to be a smoker. Those Total cholesterol (mg/dL) 179.4 ± 31.8 177.6 ± 34.3 0.349
that had secondary education were about 4.4 times (95% mm Hg, mean ± SD
CI: 2.3–8.4) more likely, those that had primary/private Triglyceride (mg/dL) mm 158.4 ± 39.4 160.1 ± 37.2 0.722
Hg, mean ± SD
education were 7.8 times (95% CI: 3.9–15.6) more likely, SD = standard deviation.
and those that had no education were 8.9 times (95% CI:
4.0–19.8) more likely to smoke cigarettes than those with an outpatient clinic in Afghanistan was high, and the study
high school or higher education. Rural residents were 3.7 also revealed that factors associated with smoking were
times (95% CI: 2.3–6.2) more likely to smoke cigarettes male gender, education level, rural residency, and opium
than urban residents. Opium users were 23.0 times (95% consumption among adult patients who visited an outpatient
CI: 12.5–42.3) more likely to smoke cigarettes than non- clinic in Andkhoy, Afghanistan.
opium users.
The prevalence of current cigarette smoking in this study
DISCUSSION was high (50.3%). This rate is comparable with the cigarette
smoking prevalence rate obtained from a study among
This article examined the prevalence and associated factors patients of a tobacco cessation clinic of a tertiary care
of cigarette smoking and opium use among patients visiting teaching hospital in Bangalore, India (49%).[14] However,
an outpatient clinic in Afghanistan. Our findings show that the prevalence of smoking reported in this study was lower
the prevalence of cigarette smoking among patients visiting than those reported among those attending an anti-smoking

Avicenna Journal of Medicine / Volume 9 / Issue 4 / October-December 2019 131

[Downloaded free from http://www.avicennajmed.com on Sunday, October 20, 2019, IP: 106.198.161.218]

Hamrah, et al.: Smoking and opium use in Afghanistan

Table 2: Factors associated with smoking among adult patients visiting an outpatient clinic in Andkhoy, Afghanistan
Variables Number (%) OR (95% CI) P value
Gender <0.001
 Female 36 (11.5) 1
 Male 276 (88.5) 9.5 (5.3–17.1)
Family member smoking <0.001
 No 137 (43.9) 1.0
 Yes 175 (56.1) 3.3 (2.0–5.3)
Education
  High school or higher 20 (6.4) 1.0
 Secondary 40 (12.8) 4.4 (2.3–8.4) <0.001
  Primary/private education 18 (5.8) 7.8 (3.9–15.6) <0.001
 Illiterate 234 (75.0) 8.9 (4.0–19.8) <0.001
Occupation
 Employed 16 (5.1) 1.0
  House wife 66 (21.1) 0.5 (0.23–1.2) 0.113
 Farmer 17 (5.4) 1.4 (0.6–3.5) 0.466
 Unemployed 210 (67.3) 1.0 (0.33–3.1) 0.977
 Others 3 (0.96) 5.0 (0.71–35.1) 0.104
Residence 0.001
 Urban 154 (49.3) 1.0
 Rural 158 (50.6) 3.7 (2.3–6.2)
Opium user <0.001
 No 134 (43.0) 1.0
 Yes 178 (57.0) 23.0 (12.5–42.3)
CI = confidence interval, OR = odds ratio.

clinic in the Aseer region, Saudi Arabia (61.6%).[15] A possible for smoking through a social learning model of smoking
reason for the high rates of cigarette smoking in our study initiation.[21]
could be due to the fact that respiratory infections are the
most common reasons among patients who attended the In this study, the prevalence of cigarette smoking was higher
clinic during the winter. Smoking has been found to increase among rural residents compared to urban residents, which
risk of respiratory infection by several bacterial pathogens.[16] is in accordance with results of other studies.[19,22] The reason
for this could be due to lack of awareness among rural
In our study, the prevalence of cigarette smoking was higher residents. Our study showed that literacy rates in rural areas
among males (88.5%) compared to females (11.5%). This are lower than in urban areas.
is consistent with a finding that has been reported by a
previous study among adult patients attending an outpatient Opium use showed an association with smoking cigarette
clinic in India.[14,17] Low prevalence of smoking among in this study, which is consistent with the results on the
females in this study can be linked to social and cultural association between illicit drug use and cigarette smoking.[23]
reasons in the region. It is hypothesized that tobacco is a gateway drug to illicit
drugs.[24] The increase number of cigarette smoking could
We found an inverse association between smoking status be a marker for serious patterns of illicit drug use.[25]
and the level of education. This finding is in line with a
survey conducted in India.[18] It is likely that there is an This study has some limitations. First, our participants
association between the level of education and the level of were from a single outpatient clinic that was located in
health literacy. Therefore, an increase in health literacy can Andkhoy, Afghanistan. Second, the patients were selected
result in an increase in knowledge and awareness among on a convenience basis. This could result in the potential for
people regarding hazards of smoking.[19] selection bias. Third, this study was conducted on a non-
probability technique, and therefore cannot be generalized
The cigarette smoking prevalence was higher among families beyond the study population. Finally, a cross-sectional study
where parents or other family members or friends were smokers. design was used to analyze the association between smoking
This finding was supported with findings reported by a previous and its associated factors.
study in Saudi Arabia among clinic attendees.[20] A possible
explanation for this is a social learning theory that people begin This study, however, provided useful data concerning
to smoke if there are family members or friends who do so. It is smoking and its associated factors among adult patients
believed that they acquire a positive attitude, belief, and behavior attending an outpatient clinic in Afghanistan.

132 Avicenna Journal of Medicine / Volume 9 / Issue 4 / October-December 2019

[Downloaded free from http://www.avicennajmed.com on Sunday, October 20, 2019, IP: 106.198.161.218]

Hamrah, et al.: Smoking and opium use in Afghanistan

CONCLUSION 9. Lim HK, Ghazali SM, Kee CC, Lim KK, Chan YY, Teh HC, et al .

Epidemiology of smoking among Malaysian adult males: prevalence
and associated factors. BMC Public Health 2013;13:8. Available at:
The prevalence of smoking among adult patients attending http://www.biomedcentral.com/1471-2458/13/8.
an outpatient clinic in Afghanistan was high. The identified 10. Nasrollahzadeh D, Kamangar F, Aghcheli K, Sotoudeh M, Islami F,
associated factors with smoking were male gender, a family Abnet CC, et al. Opium, tobacco, and alcohol use in relation to
oesophageal squamous cell carcinoma in a high-risk area of Iran. Br J
history of smoking or friend history of smoking, level
Cancer 2008;98:1857-63.
of education, rural residency, and opium consumption. 11. American Psychiatric Association. Diagnostic and Statistical Manual
Our findings highlight the need for the effective smoking of Mental Disorders. 4th rev. ed. Washington, DC: American
cessation interventions among the Andkhoy population. Psychiatric Association; 2000. Available at: https://books.google.
ro/books/about/Diagnostic_and_Statistical_Manual_of_Men.
html?id=qRj7lwEACAAJ&redir_esc=y.
Acknowledgement
12. Musaiger AO. Overweight and obesity in Eastern Mediterranean Region:
Our study project was subsidized by the Terumo Foundation prevalence and possible causes. J Obes 2011; article ID 407237.
for Life Sciences and Arts. The authors are grateful to 13. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C,
Ms. Terri Stevens for proof reading of the manuscript. Handler J, et al. 2014 evidence-based guideline for the management
of high blood pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA
Financial support and sponsorship 2014;311:507-20.
Nil. 14. Mony P, D′Souza G, Sreedaran P, Rekha D, Srinivasan K. Clinico-
epidemiological profile of tobacco users attending a tobacco
Conflicts of interest cessation clinic in a teaching hospital in Bangalore city. Lung India
2012;29:137-42.
There are no conflicts of interest.
15. Alsamghan AS, Bharti RK, Alhussain MA, Chaudhary S, Dealan KA,
Karkman MJ, et al. Smoking pattern and determinants among adults
REFERENCES attending anti-smoking clinic in Aseer Region, Saudi Arabia. Int J Med
1. World Health Organization. Global Health Risks: mortality and burden Res Health Sci 2017;6:101-6.
of disease attributable to selected major risks. Bull World Health Organ 16. Bagaitkar J, Demuth DR, Scott DA. Tobacco use increases susceptibility
2009;87:646. to bacterial infection. Tob Induc Dis 2008;4:12.
2. World Health Organization. WHO Report on the Global Tobacco 17. K Rao P, Bant DD, Community IJ, Public M, Jan H. A study on the pattern
Epidemic, 2013: Enforcing Bans on Tobacco Advertising, Promotion of tobacco use and its implications on the health of patients, attending
and Sponsorship. Geneva, Switzerland: World Health Organization; Karnataka Institute of Medical Sciences, Hubballi. Int J Community Med
2013. p. 106. Available at: https://apps.who.int/iris/bitstream/ Public Health 2018;5:331-335.
handle/10665/85380/9789241505871_eng.pdf?sequence=1. 18. Sorensen G, Gupta PC, Pednekar MS. Social disparities in tobacco use
3. Saleheen D, Zhao W, Rasheed A. Epidemiology and public health policy in Mumbai, India: the roles of occupation, education, and gender. Am
of tobacco use and cardiovascular disorders in low- and middle-income J Public Health 2005;95:1003-8.
countries. Arterioscler Thromb Vasc Biol 2014;34:1811-9. 19. Shuja M, Sarrafzadegan N, Roohafza HR, Sadeghi M, Ghafari M,
4. John U, Hill A, Rumpf HJ, Hapke U, Meyer C. Alcohol high risk drinking, Mohammadian M, et al. Factors associated with cigarette smoking in
abuse and dependence among tobacco smoking medical care patients central parts of Iran. Asian Pac J Cancer Prev 2017;18:647-53.
and the general population. Drug Alcohol Depend 2003;69:189-95. 20. Siddiqui S, Ogbeide DO, Al Khalifa I. Smoking in a Saudi community:
5. Kouimtsidis C, Reynolds M, Hunt M, Lind J, Beckett J, Drummond C, prevalence, influencing factors, and risk perception. Fam Med
et al. Substance use in the general hospital. Addict Behav 2003;28:483- 2001;33:367-70.
99. 21. Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, et al.
6. Cottler LB, Ajinkya S, Goldberger BA, Ghani MA, Martin DM, Hu H, Parental smoking and adolescent smoking initiation: an intergenerational
et al. Prevalence of drug and alcohol use in urban Afghanistan: perspective on tobacco control. Pediatrics 2009;123:e274-81.
epidemiological data from the Afghanistan national urban drug use 22. Cheah YK, Naidu BM. Exploring factors influencing smoking behaviour
study (ANUDUS). Lancet Glob Health 2014;2:e592-600. in Malaysia. Asian Pac J Cancer Prev 2012;13:1125-30.
7. Delavari AR, Alikhani S, Alaedini F. A National Profile of Non- 23. Khan MM, Aklimunnessa K, Kabir MA, Kabir M, Mori M. Tobacco
Communicable Disease Risk Factors in the I.R. of Iran. Tehran, Iran: consumption and its association with ilicit drug use among men in
Center for Disease Control, Ministry of Health & Medical Education; Bangladesh. Addiction 2006;101:1178-86.
2005. 24. Odukoya OO, Dada MR, Olubodun T, Igwilo UA, Ayo-Yusuf OA. Risk
8. Hamrah MS, Hamrah MH, Ishii H, Suzuki S, Hamrah MH, Hamrah AE, perception and correlates of tobacco use among young people outside
et al . Association between Helicobacter pylori Infection and of formal school settings in Lagos State, Nigeria. Asian Pacific J Cancer
cardiovascular risk factors among patients in the northern part of Prev 2016;17:2833-9.
Afghanistan : a cross-sectional study in Andkhoy City. Asian Pac J Cancer 25. Balley S.L. Adolescents’ multisubstance use patterns: the role of heavy
Prev 2018;19:1035-9. Alcohol and cigarette use. Am J Public Health 1992;82:1120-4.

Avicenna Journal of Medicine / Volume 9 / Issue 4 / October-December 2019 133