The current study aimed to evaluate the long-term effectiveness of a multi-component community-based lifestyle intervention on tobacco behaviors in a large population of Iranian adults. The intervention reduced the risk of cigarette and hookah use as well as the intensity of cigarette smoking in men; although its effect on hookah was short-term and disappeared after the second follow-up. No change was observed in men’s passive smoking between the intervention and control group. The intervention made women less likely to smoke tobacco (cigarette or hookah) and reduced their exposure to secondhand smoke. None of the observed effects of the intervention on women was time-dependent.
The present study showed that the TLGS community-based lifestyle modification reduced the odds of cigarette smoking (by 27%) and decreased its mean intensity (by 1.58 cigarettes/day) in men. Women in the intervention group were less likely to smoke any tobacco (cigarette or hookah). The TLGS intervention maintained its effects in long-term. These results showed that implementing behavior change interventions in the context of the community and in the platform of existing national anti-tobacco policies have positive long-term results in tobacco control. Multi-component, multi-setting interventions have been previously suggested to curve the smoking epidemic 26. Many community-based studies, with the ultimate goal of reducing the burden of cardiovascular disease, simultaneously targeted their behavioral risk factors, including tobacco smoking. North Karelia Project (Finland) and Minnesota Heart Health Program (USA) are among the very firsts with the former being the most successful one 23, 27. Although successful in increasing awareness and changing attitudes toward smoking, many of these programs failed to reduce the smoking prevalence in general population 7. But more recent reviews still emphasis on community strategies as an important part of health promotion activities especially those with multiple risk behavior approach. In their review, Ebrahim et al. 10, showed that such interventions reduced the prevalence of smoking in the community by 24%. In 2021, Bergum et al. 11 also showed that the numerical prevalence of smoking in the intervention group was lower than the control. However, none of these studies were longer than three years and no intervention effect was seen in the meta-analysis. Minian et al. 28 argued that health-improving interventions should invest in modifiable factors that increase participant's commitment to behavior change instead of individual epidemiological strategies.
The intervention reduced the prevalence of mens’ hookah use, but only in short-term. After the 2nd follow-up, no significant difference was observed between the intervention and control in this regard. In women, due to the low prevalence, we reported the odds of hookah use pooled with cigarette smoking and the intervention reduced the likelihood of any tobacco use. Due to common determinants of cigarette and hookah use, programs designed for cigarette control can affect hookah use at the community level, but it seems that maintaining the effects in the long run requires designing hookah-specific contents and interventions 29. Positive social norms, more acceptability, misperceptions about health risks and addictiveness of hookah, visual appeals, and added smell and flavor are among unique features that distinguish hookah from cigarette 29, 30. The WHO FCTC is mostly based on available evidence on cigarette, indicating the lack of strong policy support for hookah control interventions. In recent years, international institutions are making more efforts to develop hookah-specific legislations. Researchers are also paying more attention to hookah control 16, however, quality interventions are still limited 31, 32. Influential studies in this field, which are few in number, have often been conducted with emphasis on education and counseling on hookah cessation in small groups 16. Like cigarette, behavioral interventions have been effective in raising awareness of the dangers of hookah at the community level 33, 34, and have led to behavior change in some cases 35, 36, but there is little evidence of their effectiveness in the long run.
The TLGS intervention reduced the risk of passive smoking in women by 33%, with no effect on mens’ passive smoking. Due to the higher prevalence of smoking among Iranian men, women constitute a large share of the population at risk of SHS with the majority being the home-based SHS. The present study showed that implementing a behavioral community-based intervention in the existing legal framework can reduce passive smoking in women by targeting the home environment which is generally considered outside the realm of government regulations. Many countries have launched community-based interventions using educational media campaigns, advocacy, and public events mostly targeting vulnerable populations (pregnant women and children) 37–41. At individual-level, increasing awareness, and changing attitudes and practice, can reduce SHS exposure especially in women and children. Interventions act through empowering individuals to create a smoke-free environment and avoid exposure, and also reducing the risk of smoking in the community (both prevalence and intensity) 42. At community-level, mass media, knowledge campaigns and widespread messages are used to raise public awareness about the dangers of smoking and SHS which could gradually change social norms. All of these components rely on existing social structures such as smoke-free public environment that is mandated by law and enforced by the government 42.
This is one of the few multi-behavioral community trials in the Middle Eastern region whose long-term effectiveness on cigarette, hookah and passive smoking is being investigated. The current study with its large sample size and long-term follow-up of more than 12 years, contributes substantially to the weak body of literature available from this region. The study, however, has some limitations, one of which is the non-randomized design of the study. Collecting behavioral information including smoking and physical activity using questionnaire-based methods, may increase under reporting and recall bias. Moreover, as a part of TLGS, the current study was conducted in urban areas; therefore, the results may not be generalized to suburban and rural populations.
Our results provide evidence for the sex-specific effectiveness of a long-term multi-level healthy lifestyle intervention on smoking behaviors in a Middle-eastern population. It reduced cigarette smoking risk and its intensity in men, in long-run. We saw a short-term positive effect of intervention on mens’ hookah use. In women, intervention reduced the likelihood of any tobacco smoking (cigarette or hookah) and exposure to SHS. These findings demonstrate the importance of community-based behavioral interventions to control tobacco. However, to be more effective in controlling hookah, such interventions seem to benefit from hookah-specific contents.