Arab Americans, Smoking behavior, Pregnant women



  1. Kulwicki, Anahid DNS, FAAN
  2. Smiley, Karen MSN, APRN, BC
  3. Devine, Susan MSN, APRN, BC


Objectives: To determine the smoking behavior in pregnant Arab American women who attended a Women, Infant and Children (WIC) program at a local county public health clinic and compare the incidence of smoking behaviors of pregnant Arab American women with pregnant women who were not Arab Americans.


Design and Methods: Data were extracted from a computer database that contained information from health history charts of pregnant Arab and non-Arab American women. The study sample was 830 women, 823 of whom were Arab American participants enrolled in the WIC program in Michigan.


Results: Approximately 6% of pregnant Arab Americans smoked during pregnancy. The prevalence of smoking behavior among pregnant Arab American women was similar to that of smoking behaviors of Hispanics and Asian Americans in the United States.


Conclusion: Although smoking behavior is a serious problem among Arab American immigrants in general and in the Arab world in particular, cultural factors that support healthy behavior during pregnancy in the Arab culture seem to limit the use of tobacco in pregnant women. Nurses who care for Arab American pregnant women can use this information to better inform their care of these patients.


Article Content

Cigarette smoking is the leading cause of preventable death in the United States and continues to be a public health problem (Centers for Disease Control and Prevention [CDC], 2002). Smoking has been associated with increasing one's risk of cancer, stroke, heart attack, premature aging, depression, and giving birth to a low birth weight baby (CDC, 2002). Throughout the past several decades, researchers have examined smoking characteristics in both the general population and in various ethnic groups. Despite smoking being one of the most studied human behaviors, its effects on women have just recently been investigated. U.S. national statistics are available pertaining to the smoking characteristics of ethnic minorities, such as Hispanics, Asians, Blacks, and American Indians. However, very little has been documented about the smoking behaviors of Arab Americans. The purpose of this study was to determine the prevalence of smoking behavior in a select sample of Arab American women in order to eventually develop culturally appropriate prenatal health promotion and smoking cessation program for Arab American pregnant women.

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Maternal/Fetal Risks of Cigarette Smoking

Cigarette smoking during pregnancy is associated with adverse outcomes such as low birth weight, attention hyperactivity disorder in children, obesity in children, and increased risk of infant mortality (Law et al., 2003; Thapar et al., 2003; Ventura, Hamilton, Mathews, & Chandra, 2003; Von Kries, Toschke, Koletzko, & Slikker, 2002). The 2004 Report from the Surgeon General (U.S. Department of Health and Human Services, 2004) provided evidence that smoking during pregnancy causes several other suboptimal birth outcomes, such as placenta previa, spontaneous abortions or miscarriages, congenital birth defects, ectopic pregnancies, and long-term health problems for the children of pregnant smokers. In addition to these adverse outcomes, there was a twofold increase in deaths secondary to sudden infant death syndrome in babies whose mothers smoked during pregnancy (Blackburn, 2003). Additional risks to infants include vulnerability for developing respiratory difficulties, including asthma, and nicotine dependence (Buka, Shenassa, & Niaura, 2003; CDC, 2002; Thapar et al., 2003). The risk of increasing infant mortality from smoking during pregnancy also has been documented (Mathews & MacDorman, 2006).


According to the CDC (2001), most individuals begin smoking during their teen years. Factors that may influence smoking initiation include differences in race/ethnicity, health beliefs, living environment, influence of tobacco advertising, gender, peer smoking, and the strength of relationships with friends and relatives. In 2004, the CDC reported that the prevalence of smoking among White, non-Hispanic women was 20 +/- 0.9; among Black, non-Hispanic women, 17.2 +/- 2.1; among Hispanics, 10.9 +/- 1.3; among American Indian/Alaskan Natives, 28.5 +/- 11.4; and among Asians, 4.8 +/- 2.1. Several factors have been associated with smoking status, including limited education, low socioeconomic status, and psychosocial deprivation. The Report of the Surgeon General (U.S. Department of Health and Human Services, 2004) suggested that although smoking for adults overall has decreased nationally, in certain segments of the population smoking continues to be pervasive. The report indicated that prevalence of smoking among adults with a GED diploma was approximately 40%, and among adults with a 9th-11th grade education, it was just over 30%. In women, the prevalence of smoking among adults with 9 to 11 years of education (32.9%) was approximately three times higher than among individuals with more than 16 years of education (11.2%) (CDC, 2001). Orr, Newton, Tarwater, and Weismiller (2005) also reported that low level of education was a risk factor for smoking.


Smoking During Pregnancy

The National Center for Health Statistics reported that 10.2% of women giving birth in the United States in 2004 admitted smoking during their pregnancy; this rate was 12.6% for White pregnant women in the United States (Martin et al., 2006). Individuals with >12 years of education were less likely to smoke during pregnancy (2.1%), compared to individuals with <12 years of education (10.4%). Among racial groups, approximately 2.6% of Hispanic women reported smoking while pregnant compared to 8.4% of Blacks and 2.2% of Asian/Pacific Islanders. The highest rate of smoking during pregnancy belonged to American Indian/Alaskan Natives (18.2%), followed by non-Hispanic White women (13.8 %).


Smoking Among Arab Adults

It is very difficult to obtain data related to the smoking characteristics of Arab Americans. Kulwicki and Rice (2003) reported that cigarette smoking in the Arab world and smoking among Arab Americans is common. In a study of Arab American adolescent smoking perceptions and behaviors, Kulwicki and Rice (2003) reported that smoking started during early adolescence and that boys smoked their first cigarette in order to be "cool" like their peers. They also considered smoking an activity that could be shared among friends while hanging out. Several other reasons for smoking included that smoking a cigarette relaxed the smoker, smoking tasted good, and it made them feel part of a group. The role of family and friends is important in Arabic culture, and participation in group activities is encouraged. Smoking the argileh (water pipe or hubble-bubble) in the home is a common, accepted family activity in the Middle East (Kulwicki & Rice, 2003; Rice & Kulwicki, 1992). The argileh is connected to a long, flexible tube and a water container. Smoke from the burning tobacco allows the water to bubble, and the user inhales the smoke. Many Arab Americans, including women, continue this practice in the United States.


Several studies have examined smoking among various Arab groups. Chaaya, Awwad, Campbell, Sibai, and Kaddour (2003) reported on two national Lebanese studies that found a 54% prevalence rate of smoking in adults aged 18 years or older and a 26% prevalence rate of smoking among individuals aged 15 and older. Determinants of smoking were low education, low socioeconomic background, and psychosocial deprivation. Baron-Epel, Havis-Messika, Tamir, Nitzan-Kaluski, and Green (2004) identified ethnic differences in smoking behavior among Jewish and Arab adults in Israel. According to their report, prevalence of smoking among Arab men and immigrant men from the Soviet Union was higher than that of Jewish men. Among women, the opposite association was reported.


Smoking Among Pregnant Arab Women

In Lebanon, Chaaya et al. (2003) found that 18% of women and 6% of pregnant women reported smoking. A study in Beirut found that one third of women in Beirut and its suburbs reported smoking before pregnancy and 20% of women reported smoking during their pregnancy (Chaaya et al., 2003). Fisher et al. (2005) reported that 1.8% of Arab women in Israel smoked cigarettes during their pregnancy, and this rate was considerably lower than the smoking rate of 8% found among Jewish women. In addition to smoking cigarettes, Arab Americans also may engage in argileh (hubble-bubble) smoking. Although argileh smoking may not be considered harmful to some individuals, Nuwayhid, Yamout, Azar, and Kambris (1998) found that women who smoked the hubble-bubble during pregnancy had increased adverse pregnancy outcomes. Chaaya, Jabbour, El-Roueiheb, and Chemaitelly (2004) reported that 4% of pregnant women in Lebanon smoked argileh and 1.5% smoked both cigarettes and argileh.


Study Design and Methods

This descriptive study was part of a larger study that explored characteristics of Arab pregnant women attending a local health department. Demographic data were abstracted from the Dearborn, Michigan clinic of the Wayne County Health Department. Data were collected from the charts of women who participated in the low-income nutritional supplemental program Women, Infants, and Children (WIC) during the year 2002. This program is designed to serve pregnant women whose annual income does not exceed $18,000 (Wayne County Health Department, 2004).


SAS v9 software was used to extract data from state WIC data sources. Incomplete data were excluded from the analysis. Some of the main reasons for incomplete data were participant's lack of knowledge or uncertainty about the answer and interviewer error in accurately entering the data on the interview form. In addition to data from the Dearborn clinic, state and national WIC data were also collected from the same computer database. The information was gathered from the WIC pregnancy health history form, which included the following demographic and pregnancy information: (a) race/ethnicity, (b) mother's education, (c) mother's age, (d) marital status, (e) smoking during pregnancy, (f) pregnancy weight gain, (g) birth outcome, and (h) breastfeeding practice. Approval for the study was obtained from Oakland University Institutional Review Board.


Setting of the Study

Michigan has one of the largest Arab American settlements in United States. Dearborn, a suburb of the city of Detroit, has the most densely populated Arab American community in Michigan. Individuals who reside in Dearborn are from many Arab countries, including Lebanon, Jordan, Yemen, Syria, Iraq, and Palestine. Many of the Arab Americans residing in Dearborn are recent immigrants and practice many of the cultural norms of their countries of origin. Many grocery stores are Arab owned, and most carry food products that are commonly consumed in the Arab world. It is not uncommon to see Arab women wearing traditional dresses and speaking only in Arabic, and many city signs, storefronts, and newspapers are written in Arabic. Dearborn is a unique American city that has both Western style amenities and services but is also home to many traditional Middle Eastern values, culture, and community.



The sample size from the clinic was 830 female subjects. The ethnic backgrounds of the participants included 823 Arab Americans, 3 Black non-Hispanics, 3 Hispanics, and 1 Asian-Pacific Islander. All subjects were enrolled in the Dearborn WIC program. Demographic data revealed that most of the women-56.7% (n = 471)-were between 20 and 29 years of age; 12% (n = 100) were in their teen years; most of the women-85.7% (n = 711)-were married. Table 1 shows the educational background of the 823 subjects, with most having completed high school. Of the 649 Arab American women responding to questions related to smoking, 41 (6.3%) smoked (Table 2). The percentage of low birth weight babies (5.3%) in the Arab American population was less than both the state (7.4%) and national (8.4%) percentages.

Table 1 - Click to enlarge in new windowTABLE 1. Level of Education of Sample
Table 2 - Click to enlarge in new windowTABLE 2. Smoking and Low Birthweight Among Participants

Clinical Implications

This study can inform all nurses who work with an Arab American population of pregnant women. In this group of low-income women, most of whom had less than 11 years of education, only 6.3% of the women smoked during pregnancy. When compared to Michigan's White non-Hispanic and Black non-Hispanic population, smoking behavior among Arab American pregnant women was considerably lower than the White non-Hispanic (19.6%) and Black non-Hispanic population (12.7%) (Pregnancy Risk Assessment Monitoring System Report 2002, 2005). In the Arab culture, children are highly valued, and pregnancy is considered an important milestone for women who are fulfilling their role as procreators and child rearers. Because Arab Americans view pregnancy as a protective period, smoking during pregnancy is considered harmful behavior for the unborn child. Hence, abstaining from smoking or any other undesirable behavior that may cause harm to the fetus is encouraged (Kulwicki, 2004). The finding that the percentage of low birth weight babies (5.3%) in the Arab American population was less than both the state (7.4%) and national (8.4%) percentages could be related to the low smoking rate among Arab American women, although the purpose of this study did not include examining this finding. Nurses working with these populations of pregnant women should encourage the cultural norms that support healthy lifestyles, such as avoidance of smoking during pregnancy.


The findings of this study are important for several reasons. First, a limited number of studies have focused on Arab American health and behavior. Second, because Arab Americans are not a large minority in the United States, many Arab Americans are categorized as Caucasian under the ethnic category in databases. It is difficult to obtain health data that are specific to this population. Third, this study was unique in that the data were obtained from a predominantly Arabic community in which the Arabic ethnic lifestyle was still preserved by the availability of Arabic grocery stores, restaurants, businesses, schools, mosques, and the predominance of Arabic language usage on the radio and television. Although some acculturation may have occurred, the impact of the acculturation did not seem significant enough to alter the strong sense of Arabic tradition and culture in the community.


More health-related research should be conducted in Arab American and other ethnic communities, because the demographics of the United States are rapidly changing. It becomes increasingly important for healthcare providers and institutions to provide culturally competent care to this population.




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