|Year : 2016 | Volume
| Issue : 1 | Page : 93
Experiences of cigarette smoking among Iranian educated women: A qualitative study
Azam Baheiraei1, Mojgan Mirghafourvand2, Eesa Mohammadi3, Reza Majdzadeh4
1 Department of Reproductive Health; Community Based Participatory Research Center, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
4 Community Based Participatory Research Center; Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||15-Aug-2015|
|Date of Acceptance||10-May-2016|
|Date of Web Publication||21-Jul-2016|
Department of Midwifery, Tabriz University of Medical Sciences, Tabriz
Source of Support: None, Conflict of Interest: None
Background: Smoking is a well-known public health problem in women as well as men. In many countries including Iran, there is an increase in tobacco use among women. Exploring the experience of smoking by educated women in order to develop effective tobacco prevention programs in these women is necessary. This study aimed to explore the experiences of smoking among Iranian educated women.
Methods: This study used a method of qualitative content analysis with the deep individual, semi-structured interviews on a sample of 14 educated female smokers, selected purposefully. Data were analyzed using qualitative content analysis with conventional approach while being collected.
Results: The data analysis led to 16 subcategories which were divided into four main categories: (1) Personal factors including subcategories of imitation, show-off and independence, inexperience and curiosity, personal interest and desire, improved mood, and social defiance; (2) family factors including smokers in the family, intrafamily conflicts, and family strictures and limitations; (3) social factors including subcategories of effects of work and school environment, gender equality symbols, peer pressure, and acceptance among friends; and (4) negative consequences of smoking including subcategories of a sense of being physically hurt, psychological and emotional stress, and being looked upon in a negative and judgmental manner.
Conclusions: The findings of this study showed that smoking among Iranian educated women is a multifactorial problem. Thus, it is necessary to address smoking among educated women in a holistic approach that focuses on different determinants including personal, family, and social factors particularly the gender roles and stereotypes.
Keywords: Cigarette smoking, education, Iran, qualitative study, women
|How to cite this article:|
Baheiraei A, Mirghafourvand M, Mohammadi E, Majdzadeh R. Experiences of cigarette smoking among Iranian educated women: A qualitative study. Int J Prev Med 2016;7:93
|How to cite this URL:|
Baheiraei A, Mirghafourvand M, Mohammadi E, Majdzadeh R. Experiences of cigarette smoking among Iranian educated women: A qualitative study. Int J Prev Med [serial online] 2016 [cited 2020 Jan 20];7:93. Available from: http://www.ijpvmjournal.net/text.asp?2016/7/1/93/186585
| Introduction|| |
Over the past 30 years, the use of tobacco in most industrial countries has decreased significantly. , This has been due to increased awareness of its dangers and also effective tobacco control policies. , Hundred million deaths occurred due to tobacco in the 20 th century and 1 billion are expected to die in the 21 st century.  By 2030, over 70% of tobacco-related deaths are likely to occur in the developing countries. 
Just like the shifting of tobacco use from industrial countries to developing nations, a pandemic of tobacco in many countries has become widespread among women.  Smoking is a well-known public health problem in women.  Women constitute 20% of 1 billion world's smokers. The spread of smoking among female population is directly related to the tobacco companies marketing strategies increasingly targeting this group, particularly in the low- to middle-income countries. Tobacco companies promote the idea that smoking is fashionable and keeps women and girls in shape and beautiful, and symbolizes vitality, progress, liberty, and independence. 
Smoking leads to cancer, pulmonary diseases such as chronic obstructive pulmonary disease, emphysema and pneumonia, cardiovascular diseases, periodontal disease, ,, depression,  cervical neoplasia,  and obstetrics complications. , In addition, smoking by mothers during breastfeeding leads to episodes of apnea, excessive irritability, vomiting, and colic in the infants. 
The prevalence of smoking in Iranian girls has been reported from 2% in Tehran  to 10.1% in Kerman.  Unfortunately, what is most thought-provoking about smoking is that the higher rate of usage is found among the educated women in Iran, , In the study among women of reproductive age in Tehran, the odds of cigarette smoking were higher in women with university education compared with those with a high school diploma or less.  Similarly, Ukrainian women who lived in large cities and had university education were more likely to smoke.  While, according to the most studies carried out in other countries, the higher prevalence of tobacco use is among the least educated. ,,, Some studies reported a strong association between higher educational level and higher socioeconomic status, which in turn, will lead to decreased smoking rates. , This discrepancy may be due to the fact that higher educational level does not necessarily lead to higher socioeconomic status in Iranian women. Furthermore, getting into social environments, such as universities and finding new friends, may contribute to smoking; a relationship between friends and smoking has been established in previous studies. ,,, Thus, further research is required to explore the experiences of Iranian educated women about smoking.
Considering the facts that university educated people are more likely to know and be aware of the dangers and consequences of smoking,  it is paradoxical why this group of people should have such behavioral patterns that are certain of degradation of their quality of life, leading them to early deaths. Therefore, to reduce smoking among these people (who could be a role model for our youths and future generations), different motivational approaches must be found that would influence these highly educated peoples' decisions to smoke. Qualitative studies are the most appropriate research methods to explore the underlying issues and the nature of people's experiences.  Using these methods, it may be possible to obtain deep seated information about beliefs and experiences of highly educated female smokers.
Understanding the causes of smoking is helpful in developing effective prevention approaches,  and cultural differences play an important role in the inclination of people to smoke,  and given the fact that so far, the quantitative studies, ,,, carried out in Iran, have been inadequate in exploring people's perspectives on smoking, this qualitative study aimed to explore the experiences of cigarette smoking among educated female smokers in which they could elaborate on their smoking habits in a comfortable environment. Such information will provide a comprehensive image which is necessary for planning successful anti-smoking interventions and policies.
| Methods|| |
Participant selection and data collection
The present qualitative study aimed to explore the experiences of educated female smokers; this method is able to clarify individuals' real understanding of their daily life phenomena.  This study was conducted in Tehran (capital of Iran) in 2012. Tehran is the most populated city in Iran, with a population of almost 12 million people including almost 6 million women. 
Sampling was purposive. The inclusion criteria were having education level higher than a diploma, residency in Tehran, able to express the experiences about smoking and desire to participate in the study. The participants' demographic characteristics have been shown in [Table 1]. Sampling was continued until no new information or codes were present in the data (data saturation). A total of 14 women participated in the interviews. Number 1 was belonged to the first participant (p. 1), 2 for the second participant (p. 2) and, respectively, number 14 to the fourteenth participant (p. 14). Each interview took 30 min on average. The corresponding author conducted semi-structured interviews with open-ended questions, which are useful to explore the participants' experiences.  The interview began with some predetermined and general questions including: (1) When did you start smoking? (2) Describe your initial feelings and memories of the first time you smoked? (3) What factors made you smoke? (4) What have you gained by smoking? (5) How do you feel about smoking now? The interviews were conducted at participants' convenience in places such as a park, home, and university.
MAXQDA software version 10 (Sozialforschung GmbH, Berlin, Germany)was used for data management. After each interview, the data were analyzed using content analysis method with a conventional approach. In this approach, data are gathered directly from study participants without imposing preconceived categories and previous theoretical perspectives. The generated knowledge is based on the unique views of the participants and is rooted in text data. ,
In this study, interviews were recorded on tapes, and nonverbal communicative acts like expressions were written down. The data were transcribed verbatim. The transcripts were read several times and meaning units were identified and coded based on the participants' explanations. The codes were evaluated several times and classified into main categories and subcategories on the basis of differences and similarities.
In this study, four trustworthiness criteria of credibility, conformability, transferability, and dependability, as proposed by Lincoln and Guba, were used. 
The credibility of the study was supported by prolonged engagement with the participants, maximum variant sampling and member checking. Participants were selected different age categories with different work experiences and educational degrees. Interview transcripts and the extracted codes from each of the interviews were given to the participants and were confirmed by them (member check). Other factors which increased the credibility of the research included spending sufficient time to conduct the study and developing a close relation with participants in order to feel more comfortable and to express their experiences.
To enhance the dependability and conformability of data, a team-based approach for data analysis was used. The interview transcripts were coded by this team, and the emerged categories were discussed and agreed. Moreover, the transcript of some interviews, codes, and categories was checked and confirmed by two colleagues, who were expert at the qualitative study and did not involve in this study. To increase the transferability of findings, the sample and setting of the study were described completely.
| Results|| |
In total, interviews with 14 educated female smokers led to richness, saturation, and repetition of data. Through data analysis, 425 codes were extracted that were classified in 16 subcategories and 4 main categories included personal factors, family factors, social factors, and negative consequences of smoking [Table 2].
Personal factors influencing smoking is one of the main categories which comprise subcategories of imitation, show-off and independence, inexperience and curiosity, personal interest and desire, improved mood, and social defiance. Some of the participants expressed imitation of popular family members, grownups, community reference groups such as intellectuals, movie stars, poets… for instance, two of the participants said:
"Posters of famous poets Farokhzad and Shamloo with a cigarette in their hands always looked attractive to me and I always thought how fine I would feel if I had a cigarette in my hand" (p. 12).
Another participant stated, "My fathers" persona was always the bold persona in my life. When I was little, I used to say to myself, if I wanted to marry someone I would marry someone like my father, and I remember from childhood, my father, who was a children's book writer, smoked. I followed his footsteps exactly, and do not consider cigarettes bad at all, somehow my father's smoking while writing stayed in my mind, so I do not consider cigarettes are bad at all (p. 13).
Show-off, being different from others, being like grownups, and feeling of independence were some of the reasons for smoking given by some participants. One participant expressed, "The only thing on my mind was to gain that feeling of independence and self-confidence, and so now, smoking is a part of my personal life. Besides other things that I do in my personal life, I smoke, too. My approach to everything else is the same as my smoking" (p. 11).
Some women gave reasons such as immaturity, playfulness, and curiosity in their adolescence for their initiation to smoking. For example, one of the participants said, "My first cigarette was because of my curiosity. I think I was in the second or third grade of middle school when I filched a cigarette from my father and started smoking; I just wanted to experience what it felt like" (p. 14).
Half of the participants expressed that they started smoking because they desired themselves. For example, one said, "I never had a negative feeling about it and still don't. For example, when they say that cigarettes are bad for your health and for your skin or taint your teeth, these negative feelings never affected me, and from the very first time it was attractive to me" (p. 12).
Almost half the participants thought of cigarettes as something that would relieve them of anger, sorrow, stress, fear, depression, and sadness and believed that smoking would improve their mood. For instance, two of them expressed:
"When I was stressed out, I started smoking" (p. 13).
"It is more stress and fear that makes me smoke" (p. 6).
Desire to breaking the rules, rejection of culture and customs, also defiance of societal values and limitations were other factors causing some women to smoke. As two women express:
"It was not customary to smoke, and generally I was a bit of norm breaker. Maybe it was not customary for girls to smoke, but I liked to defy that. Usually at some age, the youngsters like to break the rules" (p. 4).
"If 1 day evaluating and judgments disappear, maybe then I could smoke whenever I liked to. Now I analyze that most of my smoking is due to social pressures. When I walk in the street, I have to tolerate it when I am told that my slacks are too short or my hair is exposed. The result is that I go home and have a couple of cigarettes, or at least that is how I feel. As we have a thousand psychological complexes, and that is too bad. I hope the day comes that it just so happens that judgments and evaluating disappear" (p. 12).
Some women believed that cigarettes gave them a special feeling of pleasure, tranquility, and satisfaction, etc. Two women said:
"I really enjoy it when I smoke" (p. 11).
"It soothed me. When I was stressed and I smoked, I felt relaxed, just like addiction to tea. When you drink it, all your headaches go away. I think it was its nicotine that gave me a good feeling" (p. 13).
Family factors influencing cigarette smoking is another main category comprising subcategories of smokers in the family, intrafamily conflicts, and family strictures and limitations. Most of the participants agreed that smoking of parents and family members had a great influence on their smoking. The presence of a smoker in the family makes smoking the norm for the rest of the family. Just as two participants expressed:
"I was brought up in a family where my father, my mother, and my older brother, all smoked. I took my first cigarette from mothers' pocket. I felt I had to smoke too, just because everyone else smoked. In our house everyone smokes" (p. 7).
"In my house, we had smokers, women smokers. Women smokers were accepted even in my fathers' family. That was why I felt I had my fathers' permission to smoke and he probably wouldn't show a very harsh reaction to my smoking" (p. 13).
Some participants recognized family conflicts such as divorce, inappropriate behavior of parents toward their children, and severe conflicts as the cause of their smoking. In this context, one of the participants stated; "It was a difficult situation for me. There was a very intense conflict in the family. And in the quarrel between my husband, me, and my mother-in-law, one night, I could smoke 7 or 8 cigarettes, perhaps even 10" (p. 1).
Another main category is social factors influencing smoking patterns, indicating that as well as personal and family factors, social factors play an important role in initiation and continuance of smoking in women, with all women participants repeatedly pointing it out. This category comprises subcategories of effects of work and school environment, gender equality symbols, peer pressure, and acceptance among friends.
Some participants considered their work and school environments conducive to their smoking habits, for instance, they believed that using cigarettes in some work environments such as the media or arts is acceptable and normal even for women. As one participant said, "It was very interesting for me to see girls smoking so freely, and in a place like newspapers they are so comfortable. My own perception was that in the workplace it must be really bad for women to smoke, and when I started working in newspapers, generally, it became normal for me, too" (p. 8).
Some of the participants agreed that university environment or restrictions imposed in these places have influenced their smoking habits and made them even more determined about their smoking. One participant expressed, "There were surveillance cameras around the university to identify anyone who smoked. I think the more restrictions there are, the more is the tendency to experience smoking. This means stubbornness. You are not just one individual doing this for yourself, especially in an environment like the faculty of social sciences. You want to represent a group, you want to represent women, and you want to represent social intellectuals, and say that you felt like it and it has nothing to do with others. So it is less individualistic and more collective. This goes back to restrictions" (p. 9).
Some participants, particularly those at postgraduate levels recognized smoking as a symbol of gender equality, and considered it as a feministic move, and believed that by doing this, they could break taboos and paradigms of smoking for women in society. Some participants stated: "This is something of a feministic move, which means that if I do this, I'll be happy with myself and this will continue" (p. 9).
"On the outset, for me the reason is like social taboo, the social taboo that considers it bad for me to smoke as a girl and not so bad if a boy smoked. Whenever I am confronted with a sexually unequal environment, I try to mess things up there. That is, if I am forced to do something because of my gender, then, I do break the atmosphere, and that is no problem" (p. 11).
Majority of women mentioned friend smokers and parties with friends and people of the same age group as one of the most influential factors in their smoking habits and related this issue to impressionability of individuals. For instance, some participants expressed:
"Well, truthfully, parties were not ineffectual, either. In fact, in most parties some people were only social smokers. When one or two people lit up, the rest would start to light up their cigarettes as well, as the atmosphere was so conducive to smoking" (p. 8).
"When gathered together with my friends who thought alike and were mostly smokers, well their lifestyles automatically attracted me and I trusted them and this part of their lives, so it was interesting for me to explore this, with the people whom I had accepted and felt easy and comfortable with, and as I feel that we are in the same boat in life, their smoking became normal for me. I repeat, it is the same bunch of people that give you the audacity to smoke for the first time" (p. 11).
Some participants stated that when they wanted to be accepted among a group of friends and showed that they think and act like them, they had to start smoking. For instance, one of them said, "The truth is when you like a group or a bunch of people and wants to be one of them, well it is difficult at first and making them understand that you are just like them takes time, but with a cigarette this happens much quicker. When you light up your cigarette, suddenly, they open up to you. For example, if a bunch of people are smokers and you want to join them, you are accepted very easily if you have a cigarette in your hand" (p. 8).
Negative consequences of smoking
Negative consequences of smoking is another main category and comprises subcategories of a sense of being physically hurt, psychological and emotional stress, and being looked upon in a negative and judgmental manner.
All participants were aware of negative consequences of smoking and their effects on their health, and some pointed out that smoking has harmful physical effects such as headaches, skin damage, reduced power and energy, disorders of vocal chords, and impaired breathing. For example, two participants expressed:
"It has many damaging effects. For example, I used to swim and had many swimming titles, but I witnessed its negative effects in sport, as well. Even I can see its negative effects in running now. I cannot really do sports anymore and don't have the physical power I used to. Well my breathing doesn't help" (p. 7).
"My skin is really damaged for smoking and it doesn't feel good" (p. 1).
Most participants mentioned the psychological and emotional stress due to smoking such as fear, stress, anxiety, reduced feeling of freshness, addiction, and dependence. Considering that most participants smoked without the knowledge of their families, they expressed their stress and concerns because they were fearful that their families find out about their smoking. Two participants stated:
"The fear is always there because you don't want your family to worry and you are careful that they never do. Not just in the family, but other places like university, you take care that your professor doesn't find out about your smoking" (p. 10).
"My mind is always entangled in it. I have no physical problems, but in my mind, I am disturbed. When I want a cigarette, I must smoke, if I don't, I am very uncomfortable" (p. 7).
Most participants believed that smoking has made the society and others to look upon them in a negative and judgmental way and felt they were stigmatized. For instance, one of the women described her experience as: "Many a time I sit down in a solitary corner to smoke, and I am always conscious of people walking by and how they look at me in disbelief. Well, this is something that anybody might do. But the way they look at a lady smoker is so very different from when they look at a man smoking. They think he must have a lot of problems on his mind and he smokes to forget. But when they see a lady smoking (of the same age group as the man), they look upon her in a different way and think to themselves that she cannot be trusted (to put it politely)" (p. 14).
| Discussion|| |
The present study explored educated women's experiences regarding smoking with a qualitative approach. The findings of this study showed that personal, family, and social factors have influenced initiation and continuation of smoking in women and continuation of cigarette smoking could have negative physical, emotional, and psychological consequences for women, leaving them exposed to negative judgments in the society.
The findings of this study showed that the reasons for smoking root in a complex interaction among personal, family, and social factors, which is consistent with other studies. , Niknami et al. (2008) have reported personal factors, social factors, and beliefs about smoking as risk factors for initiating smoking by adolescents.  Moreover, in another qualitative study conducted by Rezaei et al., family and social factors had a more prominent role in creating the smoking tendency compared to individual factors.  Also, in a qualitative study by Ebrahimi et al., personal inefficacy, family inefficacy, and vulnerable social environment were the risk factors of initiation and continuation of smoking.  These findings suggest that effective smoking prevention programs must be comprehensive and need to take all the influencing factors into consideration, especially more attention should be paid to the social and family risk factors that reported in all studies.
One of the important findings of this study was the impact of gender on smoking in women. Participating women in this study believed that smoking was a symbol of gender equality and to make members of society understand that (with regards to this issue), there is no difference between men and women, and to show their disagreements with opposing gender perspectives, they smoked. It is thought that the increase in smoking over the past century is linked to changes in the economic and social status of women.  The social positions of women have improved in recent years, and restrictions on their behavior have diminished and similarities between the roles of men and women have increased so that the change in norms and gender roles and gender equality has led to women's acceptance of beliefs, habits, and behaviors of men, such as smoking, which has caused the rate of smoking among women to rise in recent decades.  In a qualitative study, different smoking patterns due to gender differences have been reported, indicating that smoking for women has been a positive social experience. This partly reflects the causes of increase in women smoking in recent decades.  In another study from Canada, a relationship was found between gender empowerment and increased smoking among women. In other words, in countries with greater empowerment of women, smoking rate among men and women is almost the same.  Also in Iran, social participation, social status, and cultural levels in the form of cultural activities of women have grown in recent years with a considerable leap forward.  In a study by Bottorff et al., three key principles were identified for inclusion of gender-related factors when developing tobacco reduction and cessation interventions: (a) Tobacco interventions need to consider gender and its interaction with other social determinants of health, (b) tobacco interventions must include components that comprehensively address gender-related influences, and (c) tobacco interventions should promote gender equity and healthy gender norms, roles, and relations.  Thus, it is necessary to consider the relationships between smoking and gender inequity in order to prevent smoking by women.
Another finding of this study was that the majority of participants believed that cigarettes had adverse effects and were aware of its harmful effects, yet they experienced smoking. Therefore, it is essential that the health education interventions about smoking to be further developed. It needs to move from only providing information and giving advice toward changing attitudes and behaviors through purposeful educations based on health education models and theories. In a similar qualitative study in Slovenia, although participants were aware of the harmful effects of smoking on health but they did not seriously consider quitting, and passively have accepted the health consequences of smoking. 
In another study, it was noted that smoking is one of the most widely used group habits and for a youngster to belong to a group, even though he knows smoking is harmful, he sees no other choice but to give into the group's habits. 
As in the 2008 and 2009 World Health Organization report is stated "tobacco industry has targeted women, and through their advertising methods promotes tobacco as socially acceptable for women," therefore, it is pointed that in order to address the needs of girls and women by health professionals, it is necessary that appropriate numbers of women participate in planning and implementation of anti-smoking policies.  The emphasis should be on policies that prevent tobacco industry from targeting women by banning all advertising and imposing policies that would help reduce demand by increasing cigarette prices and applying higher rates of taxations. 
Gaining participants' trusts were the most difficult part of collecting qualitative data. So that, in accordance with the principles of ethics and confidentiality, the researcher tried to gain their trusts by stating the purpose of the study. Given that the present study was conducted on educated female smokers in Tehran. Thus, the findings of this study should be cautiously generalized to other female smokers with lower level of education. It is recommended to conduct qualitative studies with other approaches in order to replicate and further generalize these results. Also, future quantitative research to confirm these qualitative findings would be useful.
| Conclusions|| |
Based on the findings of this study, smoking among educated women is a multifactorial problem, and personal factors, family background, and social factors, particularly the gender roles and stereotypes affect their smoking behavior. Accordingly, taking into accounts all the influencing factors of smoking including, personal, family, and social, authorities must come up with programs and policies that would prevent and control tobacco use. Future interventions for preventing of smoking should focus on changing social norms regarding smoking at the population level by effective educational methods such as mass media campaigns. In addition, such interventions could be effectively provided in both the family and social environments. Also, health providers should promote smoke-free homes and other anti-smoking attitudes and behaviors.
The authors wish to thank all the individuals who participated in the study.
Financial support and sponsorship
This study was funded and supported by Tehran University of Medical Sciences; Grant no. 90-01-62-13249.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]