International Journal of Public Health

, Volume 64, Issue 9, pp 1345–1354 | Cite as

Sex-specific initiation rates of tobacco smoking and its determinants among adults from a Middle Eastern population: a cohort study

  • Donna Parizadeh
  • Seyyed Saeed Moazzeni
  • Mitra Hasheminia
  • Pegah Khaloo
  • Mohammad Ali Mansournia
  • Fereidoun Azizi
  • Amir Abbas Momenan
  • Farzad HadaeghEmail author
Original article



To assess the initiation rate and determinants of tobacco smoking among adults.


In the Tehran Lipid and Glucose Study, a population-based cohort from Iran, 6101 participants ≥ 18 years old who had never smoked tobacco at baseline (phase II: 2002–2006) were followed until phase VI (2015–2018). Sex-specific initiation rates per 1000 person-years for self-reported tobacco smoking and hazard ratios (HR) for its potential determinants (using Cox proportional hazards models) were calculated.


The age- and sex-adjusted smoking initiation rate was 13.77 [95% confidence interval (CI) 12.59–14.94] per 1000 person-years, of which 78% was attributed to water pipe use. Initiation rate was remarkably higher among men [19.1 (16.9–21.2)] than women [8.3 (7.4–9.2)] and declined in older age-groups. Among both genders, being married was protective [men: HR 0.67 (CI 95% 0.48–0.92); women: 0.58 (0.45–0.74)], while intermediate-level education (compared with high level) [men: 1.61 (1.14–2.26); women: 1.33 (0.95–1.84, p value = 0.092)] and passive smoking [men: 1.76 (1.36–2.28); women: 1.82 (1.42–2.33)] increased the risk. Educational intervention decreased the risk among women [0.74 (0.58–0.94)].


The majority of adult smoking initiators started smoking with water pipe. The initiation rate was remarkably higher in men and younger age-groups. Passive smoking, being single and lower education were risk factors. Educational intervention was protective among women.


Tobacco Water pipe Cigarette Smoking Initiation rate Intervention The Tehran Lipid and Glucose Study 



The authors wish to acknowledge Ms. Niloofar Shiva for critical editing of English grammar and syntax of the manuscript. The authors would also like to express their appreciation to the TLGS participants and staff for their kind cooperation.



Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict interest.


  1. Akl EA, Jawad M, Lam WY, Obeid R, Irani J (2013) Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J 10:12CrossRefGoogle Scholar
  2. Azizi F, Ghanbarian A, Momenan AA, Hadaegh F et al (2009) Prevention of non-communicable disease in a population in nutrition transition: Tehran Lipid and Glucose Study phase II. Trials 10:5. CrossRefPubMedPubMedCentralGoogle Scholar
  3. Bernat DH, Klein EG, Forster JL (2012) Smoking initiation during young adulthood: a longitudinal study of a population-based cohort. J Adolesc Health 51:497–502CrossRefGoogle Scholar
  4. Edwards R, Carter K, Peace J, Blakely T (2013) An examination of smoking initiation rates by age: results from a large longitudinal study in New Zealand. Aust N Z J Public Health 37:516–519CrossRefGoogle Scholar
  5. Forouzanfar MH, Afshin A, Alexander LT et al (2016) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388:1659–1724CrossRefGoogle Scholar
  6. Fotouhi A, Khabazkhoob M, Hashemi H, Mohammad K (2009) The prevalence of cigarette smoking in residents of Tehran. Arch Iran Med 12:358–364PubMedGoogle Scholar
  7. Freedman KS, Nelson NM, Feldman LL (2012) Smoking initiation among young adults in the United States and Canada, 1998–2010: a systematic review. Prev Chronic Dis 9:E05PubMedGoogle Scholar
  8. Gakidou E, Afshin A, Abajobir AA et al (2017) Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390:1345–1422CrossRefGoogle Scholar
  9. Goodchild M, Nargis N, d’Espaignet ET (2018) Global economic cost of smoking-attributable diseases. Tob Control 27:58–64CrossRefGoogle Scholar
  10. Henningfield JE, Clayton R, Pollin W (1990) Involvement of tobacco in alcoholism and illicit drug use. Br J Addict 85:279–292CrossRefGoogle Scholar
  11. IPAQ Research Committee (2005) Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ)-short and long forms. Accessed 17 Sept 2008
  12. Jahangiri-Noudeh Y, Akbarpour S, Lotfaliany M et al (2014) Trends in cardiovascular disease risk factors in people with and without diabetes mellitus: a Middle Eastern cohort study. PLoS ONE 9:e112639CrossRefGoogle Scholar
  13. Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA (2018) The prevalence and trends of waterpipe tobacco smoking: a systematic review. PLoS ONE 13:e0192191CrossRefGoogle Scholar
  14. Kaczynski AT, Manske SR, Mannell RC, Grewal K (2008) Smoking and physical activity: a systematic review. Am J Health Behav 32:93–110. CrossRefPubMedGoogle Scholar
  15. Kollath-Cattano C, Osman A, Thrasher JF (2017) Evaluating the perceived effectiveness of pregnancy-related cigarette package health warning labels among different gender/age groups. Addict Behav 66:33–40CrossRefGoogle Scholar
  16. Kviz FJ, Clark MA, Crittenden KS, Warnecke RB, Freels S (1995) Age and smoking cessation behaviors. Prev Med 24:297–307. CrossRefPubMedGoogle Scholar
  17. Leonardi-Bee J, Jere ML, Britton J (2011) Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax 66:847–855CrossRefGoogle Scholar
  18. Lindstrom M (2010) Social capital, economic conditions, marital status and daily smoking: a population-based study. Public Health 124:71–77. CrossRefPubMedGoogle Scholar
  19. Mansournia MA, Etminan M, Danaei G, Kaufman JS, Collins G (2017) Handling time varying confounding in observational research. BMJ 359:j4587. CrossRefPubMedGoogle Scholar
  20. Marcon A, Pesce G, Calciano L et al (2018) Trends in smoking initiation in Europe over 40 years: a retrospective cohort study. PLoS ONE 13:e0201881CrossRefGoogle Scholar
  21. Meysamie A, Ghaletaki R, Haghazali M et al (2010) Pattern of tobacco use among the Iranian adult population: results of the national survey of risk factors of non-communicable diseases (SuRFNCD-2007). Tob Control 19:125–128CrossRefGoogle Scholar
  22. Meysamie A, Ghaletaki R, Zhand N, Abbasi M (2012) Cigarette smoking in Iran. Iran J Public Health 41:1PubMedPubMedCentralGoogle Scholar
  23. Mirbolouk M, Derakhshan A, Charkhchi P, Guity K, Azizi F, Hadaegh F (2016) Incidence and predictors of early adulthood pre-diabetes/type 2 diabetes, among Iranian adolescents: the Tehran Lipid and Glucose Study. Pediatr Diabetes 17:608–616. CrossRefPubMedGoogle Scholar
  24. Moosazadeh M, Ziaaddini H, Mirzazadeh A, Ashrafi-Asgarabad A, Haghdoost AA (2013) Meta-analysis of smoking prevalence in Iran. Addict Health 5:140PubMedPubMedCentralGoogle Scholar
  25. National Center for Chronic Disease P, Health Promotion Office on S, Health (2012) Reports of the surgeon general. In: Preventing tobacco use among youth and young adults: a report of the surgeon General. Centers for Disease Control and Prevention (US), Atlanta (GA)Google Scholar
  26. Nemati S, Rafei A, Freedman ND, Fotouhi A, Asgary F, Zendehdel K (2017) Cigarette and water-pipe use in Iran: geographical distribution and time trends among the adult population; A pooled analysis of national STEPS surveys, 2006–2009. Arch Iran Med 20:295-301PubMedGoogle Scholar
  27. Newell SA, Girgis A, Sanson-Fisher RW, Savolainen NJ (1999) The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review. Am J Prev Med 17:211–229CrossRefGoogle Scholar
  28. O’Loughlin JL, Dugas EN, O’Loughlin EK, Karp I, Sylvestre M-P (2014) Incidence and determinants of cigarette smoking initiation in young adults. J Adolesc Health 54(26–32):e24Google Scholar
  29. Parizadeh D, Momenan AA, Amouzegar A, Azizi F, Hadaegh F (2018) Tobacco smoking: findings from 20 years of the Tehran Lipid and Glucose Study. Int J Endocrinol Metab 16(4 Suppl):e84738PubMedPubMedCentralGoogle Scholar
  30. Reitsma MB, Fullman N, Ng M et al (2017) Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 389:1885–1906CrossRefGoogle Scholar
  31. Ruiz-Alejos A, Carrillo-Larco RM, Miranda JJ, Anderson CAM, Gilman RH, Smeeth L, Bernabé-Ortiz A (2018) Addressing the impact of urban exposure on the incidence of type 2 diabetes mellitus: The PERU MIGRANT Study. Sci Rep 8:5512. CrossRefPubMedPubMedCentralGoogle Scholar
  32. Sarraf-Zadegan N, Boshtam M, Shahrokhi S, Naderi GA, Asgary S, Shahparian M, Tafazoli F (2004) Tobacco use among Iranian men, women and adolescents. Eur J Public Health 14:76–78CrossRefGoogle Scholar
  33. Sozmen K, Unal B, Saidi O et al (2015) Cardiovascular risk factor trends in the Eastern Mediterranean region: evidence from four countries is alarming. Int J Public Health 60(Suppl 1):S3–S11. CrossRefPubMedGoogle Scholar
  34. Thomas RE, Baker PR, Thomas BC (2016) Family-based interventions in preventing children and adolescents from using tobacco: a systematic review and meta-analysis. Acad Pediatr 16:419–429CrossRefGoogle Scholar
  35. Villanti AC, Cantrell J, Pearson JL, Vallone DM, Rath JM (2013) Perceptions and perceived impact of graphic cigarette health warning labels on smoking behavior among US young adults. Nicotine Tob Res 16:469–477CrossRefGoogle Scholar
  36. Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA (2016) The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol 46:32–43Google Scholar
  37. Wellman RJ, Dugas EN, Dutczak H, O’Loughlin EK, Datta GD, Lauzon B, O’Loughlin J (2016) Predictors of the onset of cigarette smoking: a systematic review of longitudinal population-based studies in youth. Am J Prev Med 51:767–778CrossRefGoogle Scholar
  38. World Health Organization (2017) WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. Accessed 01 Aug 2019
  39. World Health Organization (2018) WHO global report on trends in prevalence of tobacco smoking 2000–2025. Accessed 01 Aug 2019
  40. Yi Z, Mayorga ME, Lich KH, Pearson JL (2017) Changes in cigarette smoking initiation, cessation, and relapse among US adults: a comparison of two longitudinal samples. Tob Induc Dis 15:17CrossRefGoogle Scholar

Copyright information

© Swiss School of Public Health (SSPH+) 2019

Authors and Affiliations

  • Donna Parizadeh
    • 1
  • Seyyed Saeed Moazzeni
    • 1
  • Mitra Hasheminia
    • 1
  • Pegah Khaloo
    • 1
    • 2
  • Mohammad Ali Mansournia
    • 3
  • Fereidoun Azizi
    • 4
  • Amir Abbas Momenan
    • 1
  • Farzad Hadaegh
    • 1
    Email author
  1. 1.Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine SciencesShahid Beheshti University of Medical SciencesTehranIran
  2. 2.Endocrinology and Metabolism Research Center (EMRC), School of Medicine, Vali-Asr HospitalTehran University of Medical SciencesTehranIran
  3. 3.Department of Epidemiology and Biostatistics, School of Public HealthTehran University of Medical SciencesTehranIran
  4. 4.Endocrine Research Center, Research Institute for Endocrine SciencesShahid Beheshti University of Medical SciencesTehranIran

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