Smoking Behavior in Arab Americans: A Systematic Review

Ghadban R¹, Haddad L^2*, An K¹, Thacker II LR¹ and Salyer J¹

¹School of Nursing, Virginia Commonwealth University, USA

²College of Nursing, University of Florida, USA

*Corresponding Author:

Linda Haddad, RN, PhD, FAAN
College of Nursing, University of Florida, 1225 Center Drive
Gainesville, FL, 32610, USA
Tel: 01-352-273-6520
E-mail: lhaddad@ufl.edu

Received date: August 03, 2016; Accepted date: August 19, 2016; Published date: August 25, 2016

Citation: Ghadban R, Haddad L, An K, Thacker II LR, Salyer J (2016) Smoking Behavior in Arab Americans: A Systematic Review. J Community Med Health Educ 6:462. doi:10.4172/2161-0711.1000462

Copyright: © 2016 Ghadban R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: In the United States (US), Arab Americans who maintain traditional cultural norms after their immigration are more likely to continue smoking as a form of social interaction. Arab Americans and their families are at a high risk for poor health outcomes related to smoking. Objective: This systematic review aimed to explore the smoking behavior, prevalence and use among Arab Americans and examine studies addressing the effect of acculturation on this behavior.
Results: The majority of the studies included focused on smoking prevalence and cessation. Some discussed the impact of acculturation and health beliefs on the smoking behavior of Arab American adolescents. Only two smoking cessation programs have been developed for Arab Americans, despite the high prevalence of both cigarette and water-pipe smoking in this community.
Conclusion: The scarcity of research on smoking among Arab Americans has impeded the development of interventions that improve health outcomes and reduce health disparities.

Keywords

Minorities; Arab-Americans; Acculturation; Health beliefs; Smoking

Introduction

Smoking is one of the most addictive habits and most preventable causes for a broad range of diseases including cancer, cerebrovascular diseases, coronary heart disease, and chronic obstructive pulmonary disease [1-5]. There is sufficient evidence to infer causal relationships between smoking and increased risk for at least ten types of cancers [1,3,4]. The World Health Organization’s (WHO) [6] report on research for universal health coverage notes that smoking is responsible for about six million deaths annually worldwide; more than five million of these deaths occur in primary smokers, and the remainder die as a result of secondhand smoke exposure. Despite the well-established harmful health effects of smoking, and the enormous efforts to reduce the prevalence of smoking, 20.5% of men and 15.3% of women in the US are currently smokers [7].

In the United States (US), minority status is associated with increased smoking rates among adults [7-9]. Individuals belonging to ethnic minorities may choose to accept or reject health behaviors based on their cultural beliefs, and such choices may be prime factors in their health. Consequently, there has been an increased interest in the role of cultural variables and their effect on smoking and cessation rates among various ethnic groups. In fact, according to the CDC [7], American Indians/Alaska Natives have the highest prevalence of smoking (31.4%), followed by African Americans (20.6%), Whites (21.0%), Hispanics (12.5%), and Asians (9.2%). Research shows that racial and ethnic status contributes to health disparities among minorities in the US.9 Arab Americans, who comprise a growing population in the US, have high rates of smoking prevalence (39%-69%) as well as low smoking cessation rates (11.1%-22.2%) when compared with national data [10-12], largely because smoking is a standard cultural behavior that Arab Americans continue after immigrating to the US. However, to date, and due to the classification of Arabs as “White,” there are no national data on Arab American smoking prevalence rates and only a few studies have examined smoking in Arab Americans, a vulnerable minority population at risk for poor health outcomes.

Acculturation is the complex and continuous process of interaction between two cultures that results in cultural and psychological changes [13-16] This interaction and its consequences on families, education, and health have been the primary focus of many sociological, psychological, and anthropological studies [16-18] Culture plays a major role in a person’s ideas about illness, disease, and health [19,20]. Immigration and acculturation are essential parts of US history. The US has drawn people from all over the world for countless reasons; as a result, America is rich in both multinational and multicultural diversity. In the 1880s an influx of European immigrants began, a trend that has continued up to the present and expanded to an even wider variety of immigrants, including Arabs. In fact, according to the Arab American Institute (AAI), [21,22] at least 3.5 million Americans are of Arab descent. The term Arab American is an overarching identity for many Arabs living in the USA. Although the term is simply defined as “the immigrants to North America from Arabic-speaking countries of the Middle East and their descendants” [22] there is a controversy regarding whether speaking Arabic is enough for a person to identify as an Arab. Many of the second, third, or fourth generations do not speak Arabic but still identify as Arab. The majority of Arab Americans have ancestral ties to Lebanon (34%), Syria (11%), Egypt (11%), Palestine (6%), and Iraq (3%) [22]. Arab Americans are found in every state, but more than two thirds of them live in just ten states (California, Michigan, New York, Florida, Texas, New Jersey, Illinois, Ohio, Pennsylvania and Virginia). One-third of the Arab-American population resides in metropolitan Los Angeles, Detroit, and New York [21].

Demographic information on Arab Americans is virtually nonexistent since the US government does not recognize them as a minority group [23] and classifies them as “White.” Because of this classification, Arab Americans continue to be culturally invisible [24]. Arab Americans tend to be young and well educated: more than 30% of the population is under 18 years of age; 22 89% have at least a high school diploma and 45% have a bachelor degree [21] About 60% of Arab American adults are in the labor force; 5% are unemployed and the median income for Arab American households in 2008 was $56,331 with 13.7% of the population living below the poverty line [21]. Recently, however, a few studies have been conducted among Arab-Americans and, more specifically, developed in relation to Arab- American history [22], identity [24,25], the impact of September 11, 2001, [26] feminism and sexuality [27,28], acculturation [25] and health [19].

Individuals from different cultures experience unique trajectories of acculturation. Furthermore, studies have provided evidence that risky health behaviors such as smoking and alcohol consumption are influenced by acculturation in these populations [29-34]. Most of the studies on these minorities found that acculturation may play a role in smoking among these populations and may account for this racial difference in their smoking rates [34-38]. It is well known that health disparities exist in the US, particularly among ethnic minorities [29]. Thus, in recent years, there has been a proliferation of research on human behaviors and practice based on minorities along with an emphasis from the National Institutes of Health (NIH) to have more minorities included in research [39]. In current health research, however, most acculturation studies are generally conducted with Hispanic or African American minorities [36]. The purpose of this systematic review, therefore, was to examine current literature about smoking behavior, prevalence and use among Arab Americans; in order to help outline directions for future research in this understudied area of inquiry.

Methods

Protocol development

We developed the review protocol by stating all aspects of the review methods before starting the review. These included the following: inclusion criteria for studies, search strategy, screening method, abstraction, quality assessment, and data analysis. This aspect of the design was planned to minimize the effect of our possible bias on the review.

Eligibility criteria

Our inclusion criteria included: all kind of study designs (randomized controlled trials, non-randomized trials, observational studies, and qualitative studies) published in English. Studies did not need a minimum sample size to be included. Population: Arab individuals, Arab American groups, or Arab American communities. We Excluded studies reported as abstracts and for which we could not identify a full text after contacting the corresponding author. Additionally articles were excluded if they were conducted outside of the US or if they were literature reviews.

Search strategy

The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) Guidelines [40] was used to conduct this literature search and review on Arab Americans and smoking. This systematic review evaluates research examining smoking behavior in Arab Americans. The review includes all studies that were published in English between January 1, 1990, and June 30, 2016. A systematic literature search was identified through the following databases: PubMed, CINAHL, Embase, ScienceDirect, and Cochrane Library. Ancestry searches were used to identify any relevant studies that were not detected by the primary search. Because water-pipe smoking is a highly-prevalent behavior among Arabs and Arab Americans (practiced by an estimated 17% to 44.2% of this population) [10,41,42], studies that included water-pipe smoking or exclusively looked at water-pipe smoking behaviors among Arab Americans were also included. In addition, studies that included both adolescents and adults were included in this review. Studies were excluded if they were conducted outside of the US or if they were literature reviews.

The search terms included combinations of the following: “minorities,” [All fields] “Arab Americans,” [All fields] “acculturation,” [All fields] “health beliefs,” [Tittle/abstract] “smoking,” [All fields] “water-pipe,” [Tittle/abstract] “hookah,” [Tittle/abstract] “shisha,” [Tittle/abstract]” and “smoking cessation” [Tittle/abstract].

Data abstraction

The data abstraction form was piloted over 5 studies and used to abstract general information about the paper, where the study was conducted, study characteristics, populations studied, design features that affected the quality of the study and the validity of the results, outcome measures, and quality assessment data. Abstraction was performed in duplicate independently. Any disagreement was resolved by discussion.

Data analysis

Two reviewers extracted data from the papers; the reviewers worked independently on each paper and then amalgamated the results. Discrepancies were resolved by referral back to the original papers and discussion. We did not combine the results of the studies because of the heterogeneity of design, outcomes, and populations. In our narrative analysis we consider the results in relation to the design and quality of the studies.

A total of 2105 studies were identified from databases and ancestry searches; 994 were excluded because of duplication, no-applicable titles and abstract review, resulting in 1111 studies on different minorities in the US: Hispanics/Latinos (n=527), African Americans (n=317), Asians (n=213), and Arab Americans (n=54) (Figure 1).

Figure 1: Search results on smoking in minorities in the US.

Results

For this systematic review, the 54 studies identified as relevant to Arab Americans were screened. 31 were excluded because they were conducted outside of the US and another two were excluded because they were literature reviews. Five other articles were identified from the ancestry searches and were included, resulting in a total of 26 studies meeting the inclusion criteria.

Study characteristics

Nineteen articles were cross-sectional studies investigating the different relationships between smoking behavior, smoking cessation, health beliefs, and acculturation, and 7 articles described two smoking cessation interventions (one in adults and one in adolescents) (Table 1). One study used a qualitative descriptive design with focus groups, and 25 studies used different quantitative designs. As for location, one study was conducted in California, one study was conducted in Colorado, two studies were conducted in Texas, 6 studies were conducted in Virginia, and 16 were conducted in the Midwestern region, near Michigan. All studies used convenience sampling and recruited participants from schools and/or faith-based centers (Islamic centers and mosques), Middle Eastern grocery shops, water-pipe bars, and/or health centers depending on the age of the targeted population and Internet. The sample size ranged from 8 participants (pilot intervention) to 3543 participants. In addition, 12 studies were conducted with Arab American adolescents and 14 were conducted with Arab American adults.

Table 1: Summary of studies on smoking behavior in arab americans, N=26.

Data synthesis

Smoking prevalence: Smoking prevalence among Arab Americans is high and ranges from 39% to 69%; rates are also higher in males than in females [10,11,43-45]. Rice et al. [11] conducted one of the earliest studies on Arab Americans and smoking. They surveyed 237 Arab Americans in Detroit, Michigan about their smoking behaviors. The majority of the sample were female (70%), Lebanese (75%), and born in the Middle East (97%), with an average stay in the US of 12.2 years. The authors found that 38.9% of the sample were current smokers, 11.1% were former smokers, and 50% had never been smokers; the majority of the current smokers were between the ages of 25 and 34 years, which was significantly different from the majority of former smokers who were older than 55 (p<0.002). In addition, Arab Americans in this sample had a higher smoking rate (38.9%) and a lower quitting rate (11.1%) compared to national data (28.9% smoking rate; 23% quitting rate) and State of Michigan data (29.2% smoking rate; 25.5% quitting rate).

In a cross-sectional study conducted in Richmond, Virginia [10], 69% of the 221 Arab American participants reported being current smokers. The authors defined current smokers as “having smoked at least one cigarette per day during the past 30 days” (p.787). In addition, men (67.6%) had higher rates of smoking than women (32.2%), and respondents who were born in Iraq or had parents who were born in Iraq had higher smoking rates than those who were born in other countries. Most of the participants (65.7%) grew up in homes with fathers who smoked cigarettes. Similarly, exclusive water-pipe smoking prevalence was high (44.2%) in this sample as well dual-smoking prevalence (e.g., smoking cigarettes and water-pipe) (55.8%) [42]. Similar to the reported prevalence of cigarette smoking, more male participants (66.6%) reported exclusive cigarette smoking than female participants (31.4%) while both groups reported experimenting with water-pipe smoking as young as 12 years of age.

In another study that examined smoking behaviors in 823 pregnant Arab American women who participated in the low-income nutritional supplemental program Women, Infants, and Children during the year 2002 in Michigan, 6% of the sample reported smoking while being pregnant [46]. The sample consisted of a majority of women between the ages of 20-29 (56.7%) with a high school education (50.5%). The reported low birth weight babies in the sample was 5.3%. Both rates of smoking prevalence during pregnancy (6%) and low birth weight babies (5.3%) in Arab American pregnant women were lower than Michigan state (29%; 7.4%) and national statistics (20%; 8.4%), respectively.

Smoking, both cigarettes and water pipe, has also been highly prevalent among Arab American adolescents. Few studies, however, have been conducted in the US to examine the prevalence of dual smoking and associated risk factors in this population. In a study evaluating tobacco use in Yemeni-American adolescents, researchers reported significant positive effects of age (p=0.03), parental smoking (p=0.01), peer smoking influence (p=0.001), and early age experimentation with tobacco (p=0.01) on tobacco use, and a significant negative effect of educational performance (p=0.04) on tobacco use [41,47]. In a sample of 297 Yemeni-American adolescents between the age of 14 and 18, 39% had tried tobacco and 17.2% were currently smoking water pipe. Water-pipe use was nine times as likely to be present among those who were experimenting with tobacco than among those who were not. Surprisingly, water-pipe smoking was not correlated with parental tobacco use [41]. Similarly, Islam et al. [48] performed a cross-sectional survey of 461 Muslim Arab American adolescents (12 to 19 years of age) in Virginia and were able to calculate the prevalence of susceptibility to smoking (50%), experimentation (e.g., having “ever” smoked) (45%), smoking in the last 30 days (18%), and current smoking (12%) in young adults. Males reported smoking experimentation at twice the rate as that reported by females. The authors also reported several significant risk factors associated with both susceptibility to smoking and experimentation with smoking such as peer pressure, perceived peer norms, and culturally based gender-specific norms (p<0.05). Religious influence and perceived negative consequences of smoking were significant protective factors in this sample (p<0.05). When susceptibility to smoking was analyzed by gender, religious influence was a protective factor for female participants (p=0.002) but not for male participants (p>0.05), and gender-specific norms were a risk factor for male participants (p=0.02) but not for female participants (p>0.05).

Weglicki et al. [49,50] conducted a study to compare cigarette and water-pipe smoking between Arab and non-Arab American youth. The sample consisted of 1872 students from Midwestern high schools; 70% of the samples were Arab Americans. Compared to non-Arab American adolescents, Arab Americans had significantly lower rates of cigarette smoking (ever and current) (20.1% and 6.9% versus 39.3% and 21.9%, respectively; p<0.01) but a significantly higher rate of water-pipe smoking (ever and current) (38% and 16.7% versus 21.3% and 11.3%, respectively; p<0.01). In addition, participants who reported family members smoking water pipes at home were 6.3 times more likely to be current water-pipe smokers.

El Hajj et al. [51] conducted the latest study in Colorado to examine tobacco use among Arab immigrants living in Colorado and the effect of some cultural predictors such as socioeconomic status on the smoking prevalence in this population as well as understanding the effect of acculturation on their tobacco use. The sample consisted of 100 adult Arab immigrants living in Colorado. The results showed that 19% of the participants were current cigarette smokers which is higher then the state average (16%) and 21% were current hookah smokers. When compared with the population in Colorado, Arab immigrants were twice as likely to use tobacco products. Participants in the sample who were more integrated into Arab culture were more likely to use tobacco products (p=0.03), to be current hookah smokers (p=0.008), to have family members who smoke cigarettes (p=0.02) and friends who use tobacco products (p=0.007). In addition, analysis showed that Arabic culture was the best predictor of family members who smoke cigarettes (R²=0.047) and of having friends who smoke hookah (R²=0.091).

Smoking cessation: Few researchers have addressed smoking cessation attempts among Arab Americans. Athamneh et al. [52] conducted a study in Houston, Texas to investigate the predictors of intention to quit water-pipe smoking among Arab American adults (n=340) and found that only 27% of the sample reported having the intention to quit. There was no significant relationship between the intention to quit water-pipe smoking and gender, income, marital status, or education. Several factors were associated with lower intentions to quit smoking; these included older age, cultural acceptability of water-pipe smoking, and perceptions of water-pipe smoking as less harmful than cigarette smoking. In another study, several barriers to smoking cessation and water-pipe use were reported among Arab Americans. El-Shahawy and Haddad [53] investigated the correlation between nicotine dependence and barriers to smoking cessation in a sample of 131 Arab Americans smokers living in Richmond, Virginia. The mean age for the sample was 28 and females comprised 28.6% of the sample. The authors found a significant difference in nicotine dependence between the exclusive cigarette smokers (Mean score for nicotine dependence=2.55) and the dualsmokers (cigarettes and water pipe; Mean score for nicotine dependence=3.71), who had a significantly higher nicotine dependence (p=0.006). Similarly, the barriers for smoking cessation such as “fear of failing to quit,” “thinking about never being able to smoke again,” “gaining weight,” or “no encouragement or help from friends,” were significantly higher for dual smokers compared to exclusive cigarettes smokers (Mean scores for barriers to cessation=45.21 vs. 38.47; p=0.005). In another study conducted in 2016, the authors [54] examined the effect of theory of planned behavior (TPB) constructs on the intention to quit water pipe smoking among 340 Arab Americans adults in Houston. The study sample consisted mainly of males (67%) and married (50%) with a mean age of 30 years. Out of the 340 Arab American water pipe smokers, only 27.43% (n=93) reported having an intention to quit. In the study, analysis showed that only half the constructs of the TPB were significantly associated with the intention to quit water pipe smoking; that is, behavioral evaluation and subjective norms.

To date, few interventions have been developed to facilitate smoking cessation in Arab Americans. We were able to identify one smoking cessation program in Arab American adolescents [12,55] and one in Arab American men [56]. The first study, which targeted Arab American adolescents, used an intervention titled the Project Toward No Tobacco Use (Project TNT), which was culturally-tailored in collaboration with ACCESS, the Arab Community Center for Economic and Social Services in Detroit, Michigan, which is home to the largest Arab American community in the US [12,55]. The Project TNT intervention has helped many Arab American adolescents stop smoking, and the results have been published in 7 articles [12,43,44,56-58] The intervention, which was composed of educational materials on smoking cessation, was tailored for youth through interactive power point presentations and video clips; the program was provided in both Arabic and English languages and featured Middle Eastern and non-Middle Eastern figures [53] Students who received the intervention reported a significantly lower rate of ever use of cigarette smoking after one year at 23.3% (Odds Ratio [OR]=1.31, 95% CI: 1.05, 1.64). Students who received the intervention were also 1.43 times (95% CI: 1.03, 2.01) more likely to abstain from smoking in the past 30 days than those who did not receive the intervention. In addition, the authors discussed that post-intervention, Arab American adolescents reported greater experimentation with water-pipe smoking than cigarettes (38% vs . 22%), and more current (16% vs. 6%) and regular (7% vs. 3%) use of water pipes than cigarettes, respectively. The water-pipe experimentation post-intervention probably occurred because the intervention targeted cigarette use only. Thus, future interventions in Arab American adolescents should target water-pipe smoking as well as cigarette smoking cessation.

The second intervention, which targeted Arab American adults, was conducted in Virginia and aimed at the development and pilot testing of a culturally-tailored and linguistically-sensitive Arabic-language smoking cessation program [57]. The intervention utilized the How to Quit Smoking in Arabic (HQSA) program and was comprised of 5 stages over a total of 12 weeks. Out of the 11 male participants who participated in the pilot study and completed all stages of the intervention, 8 reported that they were ready to stop smoking and 3 had stopped smoking by the three-month follow-up. Participants also provided feedback that helped in evaluating and revising the intervention to meet the cultural and linguistic needs of the Arab American population. Some of the feedback mentioned the use of a few colloquial terms that varied among different Arab nationalities, including the use of the word “In Sha’allah” (if God wills), as well as the difficulty in keeping up with a journal for daily activities, which is not part of Arab culture.

The two interventions demonstrated promising results for smoking cessation in Arab American populations. However, the results also highlighted the need for additional research and intervention studies to address the studies’ limitations. For example, the intervention targeting Arab American adults was a pilot study of 11 participants and was limited to males who were all recruited from one faith-based center. Data were collected based on self-report and no biological validation was used. Future studies should include diverse recruitment strategies, inclusion of Arab American women, and biological measures to validate the results of smoking cessation interventions.

Acculturation and smoking: Acculturation, which is the continuous process of interaction between different cultures, can influence healthrelated behaviors such as smoking, especially over time [9,16,30,36]. Although measuring the degree of acculturation is complex, researchers have either used validated instruments that can capture aspects of the acculturation process, or proxy indicators such as length of stay in the country or the language spoken at home. For example, one study used three proxy indicators for acculturation (language spoken at home, number of years in the US, first language learned) and found that the number of years spent in the US and the age when an individual moved to the US were positively correlated with the number of smoked cigarettes per day (F=3.4, p<0.00). Similarly, these factors were negatively correlated with the number of attempts to quit smoking (OR=0.93, CI: 0.87, 0.98; and OR=0.93, CI: 0.88, 0.98 respectively) [10].

In another cross-sectional study [58], 96 Arab American smokers (71%) and ex-smokers (29%) were recruited from the Midwest area; the sample consisted of mostly men (81.3%) who had lived in the US for five years or more (62%) and were approximately 35 years of age. The findings revealed a significant positive correlation between acculturation and tobacco dependence as well as between tobacco exposure and tobacco dependence [59,60]. Acculturation was measured using the Male Arab American Acculturation scale that has four subscales (separation, assimilation, integration, and marginalization). There was a positive significant correlation between separation versus assimilation and nicotine dependence (r=0.18, p<0.05) but no significant relationship between integration and marginalization and nicotine dependence. Indeed, Arab Americans who behaved like and spent the most time with their ethnic peers were more dependent on nicotine.

Health beliefs and smoking: Individuals’ health beliefs that are related to their susceptibility to or severity of a disease, as well as their beliefs of the barriers and benefits of certain health behaviors, strongly influence health behaviors such as smoking [61] In a study by Haddad et al. [10], 59.3% of respondents who were asked about general harmful effects of smoking stated that it had no harmful effects; in addition, fewer than 33% of respondents were concerned about the negative effects of smoking on their health. Prestige and social acceptance in the new culture were the most frequently reported reasons for smoking. Of the 69 participants who were non-smokers, only 7 reported that the harmful effects of smoking were good reasons to avoid the habit. None of the studies found and included in this review applied a model such as the Health Belief Model, which is an effective tool in examining smoking behavior and barriers to cessation in Arab Americans.

Sociocultural factors and smoking: In addition to health beliefs, sociocultural factors play a key role in the smoking behavior of adolescents. In a qualitative study that explored opinions about tobacco use and cessation programs among 28 Arab American adolescents, the authors [58] reported that being cool, hanging out with friends, easy accessibility to cigarettes, and feeling good after smoking were the reasons adolescents chose to smoke. Additionally, one of the main barriers to smoking cessation was having friends who smoke. Despite awareness of the dangers of smoking, the adolescents were mainly concerned with the present effects of smoking on their health, such as the possibility that their growth might be stunted or that they would be unable to play sports. In another study, Kassem et al. [61] examined the initiation, and pros and cons of hookah use in a sample of 458 adult Arab Americans (mean age: 28.4 years). Results showed that 41.2% of the participants first tried hookah smoking at an age younger than 18 years, and the majority were with friends when they first tried hookah smoking. However, early hookah initiators were 1.9 times more likely than late hookah initiators to be with family when first tried hookah (p=0.004). A total of 61.2% of participants were ‘ever dual smokers’ while 31% were ‘current dual smokers’ and men were more likely than women to be current dual smokers (p=0.035). Participants mainly enjoyed the flavors of hookah tobacco, and their major complaints were coughing, dizziness, and headaches.

Discussion

The reviewed studies in this systematic review showed that smoking, both cigarettes and water pipe, is highly prevalent among Arab Americans. Investigating the acculturation process among immigrants has been an increasingly important topic in multicultural research and in understanding the health outcomes of the immigrant populations in the US. Acculturation has been linked to health behaviors and health outcomes among immigrants [9,30,36]. According to the research, Arab Americans have high rates of smoking and low rates of smoking cessation [11,60]. In addition, because they are ethnic minority immigrants, they are vulnerable to a range of health disparities, such as high rates of smoking, obesity, and low rates of yearly regular checkups, which can negatively affect their health outcomes in the long-term. Strong evidence is available to support the existence of health disparities among ethnic minorities in the US and its impact on their health outcomes [61,62]. These disparities are related to several intersecting factors including the language barrier, lack of resources, education, acculturation, poverty, immigrant status, lack of health insurance, discrimination, and cultural and religious factors [63]. In addition, Arab Americans are a very heterogeneous group from diverse socio-economic backgrounds and can be found in all fifty states across the US. The reviewed studies were mostly conducted in the Midwest near Michigan and in Virginia. The findings of these studies do not adequately represent Arabs in the US. Michigan, for example, has one of the highest populations of Arabs in the US; however, this population represents a disproportionate amount of lower-income Arab Americans compared to other Arab Americans living in different states [64].

Despite the increasing numbers of Arab Americans in the US and their high rate of smoking prevalence, findings of this systematic review reveal that limited research has been conducted on smoking behavior in Arab Americans. Of the studies that exist, the majority focused on smoking prevalence, smoking cessation, acculturation, and health beliefs in Arab Americans adolescents. To date, only two smoking cessation programs have been developed for Arab Americans, despite the high prevalence of both cigarette and water-pipe smoking in this community. The review also demonstrated that there have been no studies conducted in the US investigating the relationship between acculturation, smoking behavior, and cancer in Arab Americans.

Gender and religion are other important factors that need to be addressed in Arab American studies. Most studies reviewed showed that males had higher smoking rates than females for both cigarette and water-pipe smoking. A study examining Muslim US students also reported that males were twice as likely to be lifetime water-pipe smokers than females [65]. Male dominance, gender roles and norms, and patriarchy in Arab societies can be interpreted as some of the reasons for gender differences in smoking; however, more studies that specifically investigate these gender differences are needed, while controlling for other socio-demographic variables. In the reviewed studies, religion, religiosity, and their impact on daily life and health behaviors, specifically smoking, have not been addressed. Despite the fact that Arabs in the Arab world are mostly Muslims, Arabs in the US are mostly Christians [66]. In addition, cultural traditions and religion are very entangled among Arabs, thus making it difficult to differentiate whether a specific behavior is supported by the culture or the religion. For example, fatalism and total reliance on God’s will are common beliefs of both Muslim and non-Muslim Arabs [67], making these important factors influencing certain health beliefs and behaviors such as smoking and its association with cancer. Therefore, religion and religiosity are also important to address in future studies investigating smoking and smoking cessation in Arab Americans.

This systematic review signifies the need for future studies focusing on determining the health beliefs and sociocultural factors that influence smoking prevalence in Arab Americans, and the effect of acculturation on smoking rates over time in order to develop culturally appropriate smoking cessation interventions for this population. In addition, future research needs to address the limitations of present studies by including female participants, expanding recruitment strategies, examining a broader range of geographical areas, and conducting additional research on water-pipe smoking. In this way, researchers in health promotion can develop interventions to reduce the high rates of smoking among Arab Americans as well as prevent diseases such as cancer, stroke, heart disease, and diabetes in both primary smokers and their family members, who are exposed to second hand smoke. A limitation for this review, only articles published in English were included. This may have created some bias concerning the conclusions (i.e, a language bias). Non off the reviewed studies used randomized control design, also most of the studies used a convenient sample which limit generalizability.

Conclusion

Evidence clearly exists that establishes a connection between high smoking rates and health disparities. To our knowledge we are the first to review Arab American smoking behavior. This systematic review provides a description of Arab Americans’ smoking behavior, specifically focusing on the relationship between this behavior and the acculturation level and health beliefs in this population. Findings demonstrated the scarcity of research on smoking in Arab Americans. This knowledge gap has impeded the development of interventions that aim to improve health outcomes and reduce health disparities in this vulnerable, ethnic minority population. Given the rapid increase of Arab American residents in the US, more research about the smoking behavior, use, and cessation attempts of this population is warranted.

Acknowledgments

The authors would like to acknowledge Debra McDonald from the University of Florida College of Nursing for editing the final manuscript.

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