Knowledge and perceptions of smoking according to income level in Morocco

Tobacco Control

Knowledge and Perceptions of Smoking According to Income Level in Morocco

Samira El Fakir, MD; Zineb Serhier, MD; Mohammed Berraho, MD; Karima Elrhazi, MD;

Nabil Tachfouti, MD; Karen Slama, PhD; Chakib Nejjari, MD, PhD

Abstract

Purpose. To determine the association between income level and variations in knowledge and perceptions about tobacco smoking in Morocco.

Design. Cross-sectional study.

Setting. Random sample of 9195 subjects representative of the Moroccan population.

Subjects. Subjects aged .15 years from households.

Measures. Data were collected from selected households using a standardized questionnaire about smoking, educational level, household monthly income, and knowledge of health effects of smoking.

Analysis. Stepwise logistic regression was used for multivariate analysis. Adjusted odds ratios with 95% confidence intervals for each variable were calculated as an estimate of the likelihood of having knowledge that smoking causes selected diseases.

Results. Among 9195 subjects, 27.8% reported low income (,2000 Moroccan dirhams [MAD]), and 9.9% reported the highest income level ( § 6000 MAD). Higher income was significantly associated with higher knowledge of health effects of smoking (p , .0001); 55% of low-income respondents compared to 71.5% of respondents with higher income knew about the relationship between cigarette smoking and cancer.

Conclusions. Lower income level was associated with lower awareness of the harms of smoking. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population. (Am J Health Promot 2011;25[6]:387–391.)

Key Words: Income Level, Knowledge, Morocco, Smokers, Prevention Research.

Manuscript format: research; Research purpose: modeling/relationship testing;

Study design: nonexperimental; Outcome measure: behavioral; Setting: state/

national; Health focus: smoking control; Strategy: culture change; Target

population age: adults; Target population circumstances: education/income level

INTRODUCTION

The evolution of tobacco use is described as an epidemic.

Although tobacco deaths rarely make headlines, tobacco kills one person every 6 sec- onds.

Tobacco kills a third to half of all people who use it,

on average 15 years prematurely.

Today, tobac- co use causes 1 in 10 deaths among adults worldwide—more than 5 million people a year.

By 2030, unless urgent action is taken, tobacco’s annual death toll will rise to more than 8 million.

Cigarette smoking is considered to be the single most important avoidable cause of premature morbidity and mortality in the world.

In recent years, the prevalence of smoking has been declining in many industrialized countries; in developing countries, however, there has been a large increase in the number of young adults starting to smoke and in per capita cigarette consumption.

Socioeconomic status (SES) is strongly associated with smoking be- havior.

Social class differences in smoking contribute substantially to social inequalities in mortality.

In- come level is a major component of SES.

Many theories of behavior change rely on a person’s risk awareness and access to information.

Knowledge of the health effects of smoking is one of the possible prerequisites for quit- ting and is targeted by prevention programs.

In developed countries, the majority of people are aware of the association of smoking with heart disease and lung cancer.

Given that having knowledge of the health effects of smoking is essential for behavior change, an examination of income Samira El Fakir, MD; Zineb Serhier, MD; Mohammed Berraho, MD; Karima Elrhazi, MD;

Nabil Tachfouti, MD; and Chakib Nejjari, MD, PhD, are with the Department of Epidemiology, Clinical Research and Community Health, Fez University, Fez, Morocco. Karen Slama, PhD, is with the International Union Against Tuberculosis and Lung Diseases, Paris, France.

Send reprint requests to Samira El Fakir, Laboratory of Epidemiology and Public Health Faculty of Medicine of Fez, BP 1893, Km 2.200, Route Sidi Harazem, Fez, Morocco; elfakirsamira@yahoo.fr.

This manuscript was submitted January 23, 2009; revisions were requested December 29, 2009; the manuscript was accepted for publication March 4, 2010.

Copyright

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0890-1171/11/$5.00+0

DOI: 10.4278/ajhp.090123-QUAN-30

levels to measure differences in knowledge can help explain part of the pronounced SES differentials in smoking prevalence and cessation rates.

The MARTA survey,

a nationwide population survey, was undertaken to better understand the smoking phe- nomenon in Morocco. It is the first national survey in Morocco to examine factors related to tobacco use. The aim of this analysis of data from the survey was to determine the association be- tween income level and variations in knowledge and perceptions towards tobacco smoking.

METHODS Population

A cross-sectional survey based on a representative sample of the Moroccan population was conducted in 2006 (the MARTA survey). The survey adopted a multistage, stratified probability-sam- pling design. In the first stage, seven administrative regions containing 43.75% of the total population and representative of the ethnic and socio- demographic characteristics of all of Morocco were drawn. Each region was stratified into urban and rural areas. In each urban area, three socioeconomic levels of residential districts were de- fined as low, middle, and high income.

In the second stage, residential districts of each socioeconomic cate- gory were selected according to the size of the population. In the third stage, all households from residential dis- tricts chosen in urban and rural areas were visited. After giving informed consent, individuals aged § 15 years in the selected household were invited alternately between men, women, and children (aged 15–18 years) to partic- ipate in the survey. Subjects aged between 15 and 18 years were inter- viewed in the absence of their parents.

It was estimated that to obtain sufficient numbers of smokers, ex- smokers, and nonsmokers so as to study factors related to each of these groups with an alpha error of 5%, the survey would need to recruit at least 9000 individuals.

Data Collection and Variables

The questionnaire was adapted from an existing tobacco use questionnaire

developed by the International Union Against Tuberculosis and Lung Dis- ease. The questionnaire was translated from French to Arabic dialect; the translation was done by a team who spoke both languages. The question- naire was pilot tested on a random sample of 500 individuals in the Diagnosis Center of the CHU Hassan II in Fez, and the wording of some of the questions was modified for the survey.

The questionnaire was administered face-to-face to one person per house- hold according to inclusion criteria.

Respondents were asked to report personal smoking status and were classified as current smokers (daily and occasional smokers) if they had smoked more than 100 cigarettes in their lifetime and (1) were smoking at the time of the survey or (2) had stopped smoking for less than 3 months. Respondents were defined as ex-smokers if they had smoked more than 100 cigarettes in their lifetime but had stopped smoking for more than 3 months at the time of the survey, and they were defined as never smokers if they had never smoked or had smoked less than 100 cigarettes in their life- time.

The survey comprised 63 questions.

This analysis looked at information on knowledge of consequences of smok- ing on health and sociodemographic characteristics (age, sex, marital status, level of education, income). Family income was reported in Moroccan dirhams (MAD; 1000 MAD 5 U.S.

$134) in these categories: under 1000, 1000–2000, 2000–4000, 4000–6000, and 6000 and over.

Analysis

Data entry was done using Excel.

Chi-square test and t-test analyses were used for comparisons. We used three separate multivariate logistic regres- sion models to assess independent associations with the following dichot- omized outcomes: (1) heart disease, (2) lung disease, or (3) cancer as the dependent variable. The explanatory factors were age, income, educational level, gender, and smoking status.

Adjusted odds ratios with 95% confi- dence intervals (CIs) for each variable were calculated as an estimate of the likelihood of having knowledge that smoking causes selected diseases, and

probability values were determined. A p value of , .05 was considered significant. All the above analyses were performed using the Epi-info software (version 3.3.2) elaborated by the Unit- ed States Centers for Disease Control.

RESULTS

A total of 9195 subjects were includ- ed in the study. The overall survey response rate was 92.1%. The male/

female ratio in Morocco is 1.08; in our study, 52.0% of respondents were men.

The age of the study population ranged from 15 to 90 years, with a mean (standard deviation) age of 31.08 6 13.7 years. The overall preva- lence of current smoking was 18.0%

(95% CI 5 17.2%–18.8%); 11.4%

(95% CI 5 10.7%–12.0%) were ex- smokers, and 70.7% (95% CI 5 69.7%–71.6%) were never smokers. At all ages the prevalence of smoking was significantly higher among men than women: 1506 of 4781 men smoked (31.5%; 95% CI 5 30.2–32.9) com- pared with 145 of 4414 women (3.3%;

95% CI 5 2.8%–3.8%; p , .0001).

Concerning household income, 27.8%

reported low income (,2000 MAD/

month). 62.6% of all participants lived in urban areas; 34.1% of them lived in low-socioeconomic-level residential ar- eas.

Attitudes of Smokers

More than 94.4% of smokers were aware of the fact that cigarette smoking affected their health, and a similar percentage realized that cigarette smoking affected the health of people around them. About 83% of respon- dents reported that smoking in the presence of their children affected their health. When asked about smok- ing in the future, about half (55.6%) of smokers were confident that they would not be smoking in the next 5 years.

The most common reasons for smoking among both men and women were having problems, to feel relaxed, and the influence of other smokers around the respondent. About 66.5%

of all smokers stated that they wanted

to stop smoking. This desire was

reported by more men than women

(68% vs. 48%).

Knowledge of Health Risks of Tobacco Smoking

The most common reasons for not smoking for both men and women were to protect their health (89.5%), to be a good example to children (78.5%) and to respect their principles (for example, religious beliefs; 75.7%;

Table 1).

The majority of people were aware of the health consequences of smoking;

95% responded that smoking was bad for health. Most could also name illnesses that could be attributable to smoking: 63% named cancer and 63%

lung problems. Few (22%) named cardiovascular conditions.

Table 2 presents bivariate relation- ships between each knowledge item and income. For nearly all knowledge items, higher income levels were asso- ciated with higher awareness.

As shown in Table 3, the multivari- ate logistical regression models in-

cluded gender, age, income, smoking status, and educational level. The analysis revealed that males were least likely to have knowledge of the harms of smoking and that higher income was significantly associated with higher awareness for all items except cancer.

Compared to subjects who had low income, the odds ratios for partici- pants with medium and high income on knowledge of heart disease were 1.26 (95% CI 5 1.13–1.39) and 1.48 (95% CI 5 1.27–1.74) and for knowl- edge of lung disease, 1.20 (95% CI 5 1.14–1.40) and 1.22 (95% CI 5 1.03–

1.44). Higher education was associated with higher awareness, and this rela- tionship was significant for all items.

Ex-smokers and never smokers report- ed more accurate risk beliefs than current smokers for all items. No significant association was observed between knowledge of health hazards of smoking and age, but the younger

population tended to have a higher awareness for knowledge of heart disease and cancer.

DISCUSSION

From a survey of a nationally repre- sentative sample, the present study examined the association between in- come level and variations in knowledge and perceptions towards tobacco smoking in the Moroccan population.

This study found that lower SES is associated with less knowledge of the health effects of smoking.

A limitation of the study relates to the veracity of reported monthly in- come. In the Moroccan context, peo- ple are reticent about discussing in- come. Nevertheless, we feel that the answers given can be used overall to understand the relationship between household income and smoking.

This study’s major strength comes from the number of subjects (n 5 9195) representing the national popu- lation. It is the first survey undertaken to provide information about the epidemiology of smoking in Morocco.

In the present study, the overall prevalence of smoking in the Moroc- can population was 18.0%. The preva- lence for men was 31.5%; this rate is lower than rates reported for men in most other North African populations and among men in Turkey, Lebanon, and Iran.

Women’s low rates are similar to women’s rates from a num- ber of low-income countries.

Knowledge of the health risks of smoking was generally good, in line with results from other studies that show that the majority of people are aware of the health consequences of smoking.

In traditional societies, the family value system exerts an important in- fluence on an individual’s behavior and attitudes. In our study, the most common reason for not smoking for both men and women was to be a good example to children (78%). This find- ing indicates the presence of a major aspect of successful tobacco control:

not wanting one’s children to become smokers. The makes us believe that health promotion campaigns looking at the effects of passive smoking on children would reinforce this impor- Table 1

Smoking-Related Attitudes and Knowledge

Attitudes and Knowledge N %

Do you want to quit smoking? (smokers only)

Yes 1100 66.5

No 555 33.5

Does smoking affect your health?

Yes 8663 94.9

No 149 1.7

Does smoking affect the health of people around the smoker?

Yes 7601 92.6

No 603 7.4

How important are the following reasons not to smoke?

Certain symptoms showing up 6504 71.4

Not to harm people around me 5807 63.9

To be a good example for my children 7138 78.5

To abide by social pressure 4328 47.8

To protect my health 8139 89.5

Out of respect for my principles 6851 75.7

Table 2

Distribution of Knowledge of Health Effects of Smoking by Income*

Cancer Lung Disease Heart Disease

Low 56.5 61.5 27.7

Medium 69.9 67.5 35.9

High 67.0 69.8 43.5

* All numbers are percentages.

tant issue concerning reasons for quit- ting.

The results of this study revealed that lower income is associated with less knowledge of health effects of smoking.

The association between SES and knowledge of some of the health effects of smoking has been reported in the past. Nourjah et al.

found that, in the United States, white-collar employees were more likely to be knowledgeable of the effect of smoking on heart disease.

Siahpush et al.

reported that lower SES is associated with less knowledge of health effects of smoking. The specific effects of the relationship with income level confirms this.

In our study, never smokers and ex- smokers were more knowledgeable compared to current smokers about tobacco-related health hazards. These findings are congruent with the body of research demonstrating a tendency among smokers to underestimate their risk of smoking-related disease.

Educational level is usually chosen as a proxy measure to determine socioeco- nomic levels. Our own and other stud- ies

show that higher education is associated with higher awareness that smoking causes heart disease, cancer, and lung disease. Similar findings about the association of education and occu- pation with the knowledge of heart disease are reported in Canada

and Sweden.

The few studies that have examined the association of SES with knowledge of lung cancer

suggest a positive relationship. Knowledge acquisi- tion and increases in knowledge are among the first steps in the process of behavior change.

This research con- firms that the least educated and least well-off smokers are least aware of smoking harms. It also suggests that the lowest-income groups are not protected from smoking by their poverty. There is a clear need to improve knowledge of the dangers of smoking among the disad- vantaged segments of the population.

Lower awareness of the harms of smoking is only one of many reasons for the higher prevalence of smoking among lower-SES groups. A successful tobacco control strategy for disadvan- taged groups would need to address their life circumstances and social environment, in addition to educating them about the health consequences of smoking.

Finally, for effective surveillance of the tobacco epidemic and tobacco control in Morocco, studies should be conducted regularly to monitor changes in prevalence, knowledge, attitudes, and behavioral and socio- economic determinants of starting, continuing, and quitting smoking.

These studies would provide baseline data for antismoking interventions, keep attention on low-income groups, and permit evaluation of programs.

Table 3

Adjusted Odds Ratios (95% Confidence Intervals) From Logistic Regression of Having Knowledge That Smoking Causes Selected Diseases on

Sociodemographic Covariates

Knowledge That Tobacco Causes

Heart Disease Lung Disease Cancer Age, y

,20 1.07 (0.83–1.38) 0.83 (0.66–1.04) 0.88 (0.70–1.10)

20–29 1.16 (0.91–1.49) 0.90 (0.72–1.12) 1.06 (0.85–1.32) 30–39 1.16 (0.90–1.48) 0.97 (0.78–1.21) 1.06 (0.85–1.32) 40–49 1.11 (0.86–1.44) 0.99 (0.79–1.24) 1.13 (0.90–1.41) 50–59 1.09 (0.82–1.44) 1.11 (0.87–1.43) 1.21 (0.94–1.55)

§60 1 1 1

Income

Low 1 1 1

Medium 1.26 (1.13–1.39) 1.20 (1.14–1.40) 1.39 (1.25–1.54)

High 1.48 (1.27–1.74) 1.22 (1.03–1.44) 1.01 (0.84–1.16)

Educational level

Illiterate 1 1 1

Koranic 1.38 (1.09–1.75) 1.32 (1.07–1.64) 0.92 (0.74–1.13) Primary 1.50 (1.28–1.75) 1.50 (1.30–1.72) 1.32 (1.15–1.52) Secondary 1.54 (1.32–1.79) 1.83 (1.60–2.11) 2.21 (1.92–2.55)

High 2.42 (2.05–2.86) 2.38 (2.03–2.80) 2.61 (2.22–3.07)

Gender

Male 0.96 (0.88–1.06) 0.83 (0.75–0.95) 0.97 (0.89–1.06)

Female 1 1 1

Smoking status

Current smoker 0.96 (0.84–1.10) 1.07 (0.95–1.22) 0.81 (0.71–0.92) Ex-smoker 1.20 (1.03–1.40) 1.51 (1.29–1.76) 0.84 (0.72–0.98)

Never smoker 1 1 1

SO WHAT? Implications for Health Promotion Practitioners and

Researchers

What is already known on this topic?

The association between socio- economic status and knowledge of some of the health effects of smok- ing has been reported in the past.

What does this article add?

This study is the first national survey in Morocco to examine fac- tors related to tobacco use. The majority of people are aware of the association of smoking with cancer and lung problems. Awareness that smoking causes heart disease is rarely reported. Lower socioeco- nomic status is associated with less knowledge of the health effects of smoking and higher education was associated with higher awareness.

What are the implications for health promotion practice or research?

For practitioners, the findings suggest that information about the dangers of smoking should be in- cluded in health promotion mes- sages particularly for low income Moroccans.

For researchers, this study pro-

vides baseline data for anti-smoking

interventions. Follow up studies

would permit evaluation of these

programs.

Acknowledgments

We thank the Moroccan Health Ministry and Interior Ministry for having authorized the survey and the International Union against Tuberculosis and Lung Diseases (The Union) for its support and help.

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