“I took the initiative and stopped. Khallas, enough is enough.” Perspectives on quitting tobacco from Arab people who smoke and healthcare providers who treat them: A qualitative inquiry in the United Arab Emirates

“I took the initiative and stopped. Khallas, enough is enough.” Perspectives on quitting tobacco from Arab people who smoke and healthcare providers who treat them: A qualitative inquiry in the United Arab Emirates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “I took the initiative and stopped. Khallas, enough is enough.” Perspectives on quitting tobacco from Arab people who smoke and healthcare providers who treat them: A qualitative inquiry in the United Arab Emirates Andrea Leinberger-Jabari, Basema Saddik, Scott E. Sherman, Nicola Lindson, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9113868/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Smoking rates are comparatively high in Arab populations. This study sought to gather the perspectives of health care providers (HCPs) and people of Arab origin who smoke to better understand the social, cultural, and environmental factors that influence smoking behavior in these populations. Methods: We interviewed 17 people; 6 HCPs who work with Arab patients and 11 individuals of Arab origin who smoke. Interviews were semi-structured and guided by the Theoretical Domains Framework. They covered topics related to social influences on smoking behaviors, motivators and barriers to quitting, perceived roles, environmental constraints, and how culture may influence decisions to quit. We coded and analyzed transcripts using thematic analysis. Results: Health concerns and family influence were seen as motivators for quit attempts by HCPs and people who smoked. Both groups reported that culture and social norms can support smoking cessation efforts. Structural barriers such as differential insurance coverage and lack of time were most commonly cited among HCPs. Knowledge of effective ways to quit smoking was low among people who smoked. Both HCPs and people who smoked perceived vaping to be as harmful as smoking. Conclusion: Interviews with HCPs and Arab people who smoked highlighted key challenges and opportunities to improve the effectiveness of existing smoking cessation efforts. Theoretical domains that featured prominently included motivations, social influences, and environmental contexts. Correcting misperceptions about appropriate tools to aid cessation is needed. The cultural context of smoking behavior should be considered in any efforts to improve smoking cessation support in this population. Introduction Combustible tobacco use in Arab populations is a concerning public health problem due to the high prevalence of smoking, particularly among men, and the increasing popularity of products such as shisha (also known as waterpipe, narghile, or hookah) among both men and women.( 1 – 4 ) People who are willing to quit are more likely to succeed when supported by behavioral interventions, medication and/or nicotine e-cigarettes (also known as vapes).( 5 – 7 ) For many, this journey begins in the primary care setting where even brief provider counselling can help people who are trying to quit.( 5 , 8 ) However, the delivery and intensity of such cessation support may vary across physicians. There are few studies of evidence-based smoking cessation interventions, most of which have been almost exclusively developed and tested in Western countries, within Arab cultural contexts.( 9 ) A study among Arab men in Israel found that 40% reported ever receiving physician advice to quit smoking, however receiving advice was not associated with attempts to quit smoking or smoking status.( 10 ) Additional studies in this population suggest that although individuals understand the health consequences of smoking, factors such as stress, environmental influences, and social norms create little motivation or opportunity for them to quit.( 11 – 13 ) These findings highlight the need to explore smoking cessation approaches that take into account cultural norms and contextual factors specific to Arab populations, particularly given recent evidence that suggests culturally tailored interventions improve quit success.( 14 ) Alternative forms of tobacco smoking, such as shisha and midwakh (pipe tobacco common to the Arabian Gulf countries), are popular in the region and have different patterns of use that may make direct implementation of Western-developed interventions challenging.( 15 ) An RCT in Syria that examined the effect of nicotine replacement therapy (NRT) combined with behavioral counselling, a standard approach in primary care, found no difference in quit rates between participants receiving NRT and those who did not (prolonged abstinence: 14.1% vs. 13.4% at 6 months, and 11.9% vs. 12.7% at 12 months in control vs. NRT group, respectively).( 16 ) Another RCT of a shisha smoking cessation intervention in Pakistan showed that behavioral support plus varenicline did not result in higher abstinence rates at 6 months compared with behavioral support plus placebo.( 17 ) Differences in social, environmental, and cultural contexts may influence the efficacy of smoking cessation approaches, and we therefore need to examine, within the Arab context, what factors may impact smoking cessation intervention effectiveness. The aim of this study was to understand the environmental, social, and cultural influences on smoking behaviors among Arab people living in the United Arab Emirates (UAE), to identify factors that could encourage tobacco cessation and to explore the perspectives of the HCPs who work with them. Methods The study protocol was registered on the Open Science Framework prior to data collection (DOI: https:// 10.17605/OSF.IO/Q2X3S ). We received ethical approval from the relevant international and local regulatory bodies. All participants provided written consent to participate and have their interviews recorded. Adults (18 + years) who currently smoked or had recently (< 5 years) stopped, spoke Arabic or English, and self-identified as Arab were eligible to participate in the interviews. Participants who smoked were not required to have made prior quit attempts to be eligible. We also included health care providers (HCPs) who provided smoking cessation support to Arab individuals, without restrictions on area of practice, country of training, or years of experience. We used a purposive sampling strategy and sampled on age, gender, types of tobacco smoked (including poly tobacco use) and area of practice, to ensure a diversity of experiences and perspectives.( 18 ) We relied on a convenience sample, expanded through snowball recruitment. All participants were given the choice of being interviewed in English or Arabic, but all chose to speak in English. We structured interview guides ( Supplement Table S1 ) according to the theoretical domains framework (TDF) and followed a general thematic approach.( 19 , 20 ) The TDF was developed to identify key theoretical domains that may be useful to consider in evidence-based practice and intervention development. All interviews, conducted online or in-person, were recorded and auto-transcribed through a meeting recording program. The lead author (ALJ) reviewed recordings and transcripts for accuracy, and redacted personal information from the transcripts before analysis. People who smoked provided information on the types of tobacco they used, and their perceived level of nicotine dependence. They completed the Hooked on Nicotine Checklist (HONC) and if they reported shisha use, the Lebanese Waterpipe Dependence Scale (LWDS).( 21 – 23 ) We systematically coded all transcripts and summarized units of meaning. The initial set of codes was based on the primary study aims, and additional codes were generated from the interview data. Themes were drawn from the domains identified to explain behavior change in the TDF, and subthemes were generated to more specifically capture meaning in the interviews.( 20 , 24 ) The first three transcripts were independently coded by two researchers (ALJ, BS), with ongoing discussion to establish a shared understanding of codes and interpretations. We then grouped these codes into larger themes. We used NVivo software (version 14) for analysis. Results We interviewed a total of 17 people (9 men and 2 women who smoked, and 6 health care providers; 4 men and 2 women). HCPs came from a variety of clinical disciplines including pulmonology, primary care, nursing, and cardiology and all had more than 10 years of clinical experience in their fields. While two HCPs were physically located outside of the UAE at the time of the interviews, we asked all HCPs to speak about smoking cessation within the context of their Arab patients who live in the UAE. The 11 people who smoked originated from various Arabic-speaking countries, and ranged in age from 19–44 years. At the time of interview, five had quit smoking combustible tobacco; three had quit all forms of nicotine (smoking or vaping) and two had transitioned exclusively to vaping. The remaining six participants were still smoking. They used multiple tobacco products, including cigarettes, shisha, midwakh, and e-cigarettes. They scored an average of 7 on the HONC (range 2–10; higher scores=greater dependence), indicating moderate nicotine dependence. The two participants who completed the LWDS scored 7 (range 1–11; higher scores=greater dependence), indicating a high level of dependence. What are the quitting experiences of Arab people who smoke in the UAE? Motivation: Emotional motivators to quit All participants described multiple quit attempts. One of the main motivators was a health scare; either experienced personally (e.g., a temporary infection that forced them to stop smoking for a period of time) or by a close friend or family member. “Health. I mean, my dad passed away from cancer, same for my both grandparents, like my grand... both grandfathers. They had cancers. Uh, my dad as well. So that's for...Yeah. For health...and I have kids...So that's mainly why I wanna quit. Stay more with them, yeah.” (male, 30s, currently smoking/vaping) Health scares experienced by friends or family appeared to be more severe, with some resulting in death. However, the effects of these experiences on smoking did not seem to be lasting, as participants reported resuming their smoking behaviors, despite the experiences causing emotional reactions for some. HCPs also reported that patients often sought smoking cessation support following a health scare; either their own, in which case, the patient was referred by another HCP, or that of a close relative or friend. “Usually, they have first close relative or very close friend who died of tobacco or have major diagnosis like cancer or something. So, they feel the shock, you know.” (male provider) Patients also came to HCPs because their family members had asked them to quit. “Why? Why are you here in the first place? Who's nagging you? Is it your, your spouse, your mother, your, your bariatric surgeon?” (female provider) For younger people who smoked, one particular motivator was disapproval of their smoking from their mothers. Both HCPs and people who smoked described women as playing a strong role in social and family dynamics. “Most young men hide their smoking from their mothers, some from their fathers. But men, [it] is OK for them to smoke. They hide it more from their mothers. Women can play a role.” (female provider) Though young people hid their smoking behaviors from their older family members, they said those family members were influential in modeling behaviors that encouraged them to start smoking. “It's very rare to find a man who's like 40 years or older who doesn't smoke. My father smokes, my relatives smoke, even my grandfather smokes. So, when I... from the beginning, I always saw cigarettes in the in the household. So it was, I think, a matter of time.” (male, 20s, recently quit) Motivation: Roles & Identity Linked to motivation was the individual’s perceived social role. Some of the people who smoked expressed a desire to quit based on their role in their family. Some of the men saw their role as a father as an important reason for wanting to quit smoking. They perceived their role as a provider and role model for their children. “Very much not only for my health it's because I don't want them [my children] to be smokers when they see me smoking. Same thing will happen to them. What I'm saying now that maybe I'll influence them to become smokers and in the future. I don't want them to see me smoking, so they don't think this is something normal they can do.” (male, 30s, currently smoking/vaping) “Knowing it causes cancer and then I have children and then it's like, OK, I'm not like an 18-year-old or 20-year-old doing something because it's for me. Then I'm now responsible for my kids.” (male, 40s, currently smoking) HCPs talked about their role as a motivator/supporter, in-line with principles of shared decision making, rather than being prescriptive. “We tell them it's a journey and we work on it together and we do actually share with them the mechanism of tobacco addiction and make them feel this is not their fault, this is not to not to feel guilty, and this is something like any other illness, and we this is we will work with them as a team.” (male provider) However, they were also open about how their opinion of how “easy” a patient is to work with determines the amount of effort they put into the interaction. Some patients are seen as impossible to help because they were satisfied with their smoking, did not perceive it as a problem and were not motivated to stop. “There are some very funny patients who say ‘I enjoy my smoking doc. I don't want to stop.’ It's very clear. ‘I'm happy. I'm 65. I had a very happy life. I want to continue smoking and die smoking.’ So, there you can do nothing about it, right? You can do nothing.” (male provider) Environmental constraints or barriers to quitting HCPs primarily identified structural barriers to cessation, particularly insurance hurdles. “…and dealing with those, the insurance unfortunately only…local patients are covered by tobacco cessation insurance, so the others are not. So occasionally I do counsel them under shortness of breath or other things, you know.” (male provider) Additional structural barriers identified by HCPs included communication barriers, due to inadequate language interpretation services and limited consultation time. “… our clinics are so busy that, you know, we don't have time to really sit down and discuss smoking cessation.” (male provider) “I would say I'm not even getting like half of that stuff that I just told you that I'm doing. I'm not doing that. I'm not able to do that with Arabic speaking patient, you know everyone gets fatigued after, you know, you, the inpatient, the interpreter.” (female provider) In contrast, people who smoked talked about environmental constraints that centered around social contexts in the UAE where smoking is widely permitted and socially embedded. Restaurants and bars often permit smoking and vaping in outdoor patios or other ventilated spaces, making tobacco use highly visible and difficult to avoid. The pervasiveness of smoking in these contexts was frequently described as undermining quit attempts. “First, for the first month it was a bit difficult because everywhere I go, people smoked with their cigarettes, vapes, shisha and I was trying to avoid all of them.” (male, 20s, recently quit) How does the social and cultural environment help or hinder quitting success? Social and cultural influences Participants consistently described how cultural influences encourage and normalize smoking behaviors, making cessation difficult. People who smoked described smoking as deeply embedded in everyday social practices and closely tied to gendered expectations, particularly around male identity. Smoking among men was viewed as commonplace and culturally accepted. At the same time, HCPs noted that tobacco use, particularly shisha and midwakh were also culturally embedded in socializing among females. “Uh, there is a cultural influence because here in the Middle East ... everyone smokes. Yeah, almost like for the men, at least for the males, like 60% of the older individuals. And they are always smoking and they come with a pack of cigarettes. It's like part of the culture, I think.” (male, 20s, vaping) “The shisha and the midwakh and all this cultural, the habit of sitting with people in the friends and families, and for shisha for one hour is such a strong thing here. So, they think it's nothing. What do you call unusual? It's very normal. Even the ladies especially.” (male provider) “Middle Easterners, we like our tobacco. The midwakh is cultural. And they like…they like the slap 1 that they get.” (female provider) ( 25 ) How do people go about quitting smoking? Knowledge In this domain, we explored knowledge specific to quitting smoking, including “how to” quit, and also information that would change the mindset or perspective of an individual around quitting. Knowledge on quitting smoking or quitting aids centered around three main themes: methods people use to limit their smoking; the impact of physician advice on their mindset; and knowledge about using nicotine e-cigarettes (also known as vapes) for harm reduction. Very few of the people who smoked stated that they had used pharmacological aids, such as NRT for smoking cessation. “I didn't find them necessary because if I want to quit vaping or smoking cigarettes, I want to quit using nicotine as well. So why would I use nicotine gums? I want to quit from everything the smoking habit, the nicotine, so I just stopped using. I didn't use any of them; the patches, the gum. I didn't find it necessary.” (male, 20s, recently quit) People who smoked also stated that talking with HCPs had little or no effect on their mindset towards smoking. “Even when you have some disease or some symptoms directly linked to smoking, and I think the majority of the patients will not follow the physician advice. So, for me personally it has zero impact for smoking. It's better to say ‘OK, I will do.’ That is it.” (male, 40s, currently smoking) Vapes have only recently been legally available in the UAE. We asked about knowledge of vaping in the context of smoking cessation. HCPs and people who smoked equated smoking tobacco with vaping. “I would rather catch my daughter smoking a cigarette than vaping cause at least I know or there has been some research on smoking opposed to vaping.” (female, 20s, currently smoking/vaping) Yeah, it's supposed[ly] stops you from smoking cigarettes, but they don't stop the vape, so I don't know. (chuckles)I think it's very controversial, but my personal point of view is it is still smoking and all, and the American Heart and most of the other medical societies have decided that vaping is a form of smoking and it has the same… even though we don't have all the data, it probably has same if not worse, side effects than smoking. (male provider) People also expressed skepticism of e-cigarettes because they contain “unknown chemicals” and they are less familiar with their effects. “It's not just the normal regular tobacco and tar and this stuff. There are chemicals that have not been studied yet and they put lots of unknown stuff for the flavors and everything mixed together makes it very bad I think.” (male, 20s, recently quit) Decision processes When deciding how to approach discussions about smoking, whether it was to counsel people to quit or introduce the idea, HCPs tailored their interactions based on the perceived receptivity of their patients. HCPs perceived those patients who had experienced a related health event, and where this was the reason for the appointment, as being most motivated to quit. “Either they come on their own, asking my help. That's the best group. The second group is sent by other doctors, a cardiologist or a neurologist who saw him few days back. Patient was admitted in the hospital with a stroke. He just recovers from a stroke and straight away the doctor sends the patient to me. They are the ones who are receptive for listening to me. They’re the best patients because they are really literally scared.” (male provider) In contrast, the people who smoked said that during their previous quit attempts they had come to the decision to quit independently. They distinguished their final decision and the physical act of quitting from any earlier HCP interactions or health events. This was despite some citing health concerns as a motivator to quit earlier in the interview. “We're very independent in our decisions and when it comes to stuff like this, like, if I decide to do it, yeah, my mom would be the first to be happy about it. But it's not like there is a forced decision that you have to quit smoking. No, it's just like I'm, I'm on my own. I have to do it on my own.” (female, 30s, currently vaping) Skills and self-efficacy All the HCPs had some level of training in providing smoking cessation counselling; however, their length of experience varied. When describing how they started the conversation about quitting smoking with patients, they described the importance of establishing a positive rapport. “So, you got to [establish] like a good rapport, and 80% or 90% of the times I make a [good] rapport and sometimes 10% they put a wall in front of you, so you can't just go further. So, you just leave them alone, and probably I try again next time in the next visit.” (male provider) Many of the people who smoked talked about addiction, but were hesitant to say they were addicted to nicotine. This was despite an average score of 7 on the HONC, which would indicate a moderate level of dependence. “Um, I believe like I thought that I can quit at any time and I'm not dependent. This is the definition of addiction to me that I'm not dependent. I can leave it anytime.” (female, 30s, currently vaping) Discussion We sought to understand, from the perspectives of Arab adults who smoke and HCPs who support them to quit, the key motivators and barriers to smoking cessation within this population (Table 1 ). Both groups clearly identified how cultural influences present within social interactions and environmental structures may both hinder and help people’s efforts to quit smoking. Domains related to socio-cultural influences, environmental contexts, specifically constraints, and motivations were common themes that emerged in these conversations. Both groups agreed that the social-cultural environment poses a barrier to people wanting to quit, noting that avoiding certain places or social groups is necessary to prevent relapse. Where culture appeared to support cessation was through social supports, specifically family. Family plays an important role in Arab society, and women in particular were perceived as having a strong influence in encouraging and sustaining quit attempts.( 26 , 27 ) Family support was viewed as especially important for maintaining abstinence over time. Table 1 Key UAE and Arab-context specific interview themes mapped to the TDF TDF Domain Key Themes Individuals HCPs Roles and identity Motivator: Role modeling healthier behavior Motivator: Supporter of quitting smoking/vaping Environmental context Barrier: Smoking/vaping permitted in many social gathering places Barrier: Insurance coverage Social influence Motivator: Family influence/support Motivator: Family influence/support Culture and identity Barrier: Cultural identity that supports smoking Barrier: Cultural identity that supports smoking Knowledge Barrier: Lack of knowledge of community-based resources Barrier: E-cigarettes are as harmful as tobacco cigarettes There appeared to be a disconnect between people who smoke and HCPs. People admitted that they did not always follow physician advice, and physicians admitted that they struggled with some patients when trying to discuss smoking behaviors during clinical encounters. This disconnect could lead to patients lacking information on tools available to help them quit smoking, stemming from a lack of communication. Other environmental constraints such as insurance coverage, language barriers and limited consultation time were also identified as challenges to successful quitting. Participants did not distinguish between smoking combustible tobacco and “smoking” nicotine e-cigarettes, despite the latter not containing tobacco or involving combustion. Both groups viewed nicotine vaping as equally or possibly more, harmful than smoking combustible tobacco and did not consider transitioning to exclusive vaping a successful smoking cessation strategy. Limited knowledge about e-cigarette components was identified as a major reason for skepticism toward these products. Results from this study are consistent with previous research conducted in the region. In a previous focus group study, young people who smoked most often described early influences such as male family members or friends who led them to start smoking.( 28 ) In addition, few study participants saw nicotine e-cigarettes as a smoking cessation tool or used pharmacotherapies, such as NRT; instead opting for a “cold turkey” approach.( 28 ) A survey of Arab people who smoked in New South Wales Australia, found a preference for self-help materials over evidence-based cessation methods, such as medication or counseling.( 29 ) Research from across the region further supports the finding that knowledge gaps and misconceptions about vaping are widespread.( 30 – 34 ) Both HCPs and people who smoked agreed that existing knowledge and resources do not adequately address cessation needs. Further exploration of barriers to using evidence-based approaches could inform more effective cessation programming, and targeted initiatives are needed to correct misperceptions about e-cigarettes among both HCPs and the general public. Despite training and experience, HCPs with experience in smoking cessation services in the region remain limited in availability across the region.( 35 – 37 ) In the UAE, formal smoking cessation services are typically accessed via specialty care rather than community-based settings as is the case in other countries.( 38 ) Consequently, the perspectives of the HCPs interviewed reflect a specific clinical context which may differ in other settings. A survey of physicians in the UAE found that less than half (47%) felt confident in their ability to counsel patients on smoking cessation, and only 24% were aware of community-based cessation resources.( 36 ) These barriers are not limited to HCPs in the region; lack of time and inadequate training are commonly reported barriers.( 39 – 41 ) A review of studies examining family doctor attitudes found the most common barriers related to lack of time or perceived ability to provide proper counseling.( 39 ) Another structural barrier HCPs said they faced is insurance coverage for their patients. Research from other parts of the UAE suggests that cessation services can be provided through other channels, such as pharmacy, but any formal evaluation of this is limited.( 37 ) Additional supportive approaches, tailored for the community, which can provide continued support outside of clinical encounters with HCPs, could potentially help. Limitations We experienced challenges in recruiting women who smoke. This may highlight the social and cultural barriers that may influence decisions to seek care for smoking cessation. Smoking rates among Arab women are generally low, and many women who do smoke, do so discreetly.( 42 ) The experiences shared by women in our study highlight the need for cessation messaging tailored specifically for Arab women delivered in a discrete, non-judgmental manner. Another limitation is that all interviews were conducted in English. The study was advertised in both English and Arabic to potential participants. All who expressed an interest were given the choice to participate in either English or Arabic, and all chose to speak in English. It is possible that some participants may have felt limited in their ability to express their thoughts fully. Some participants briefly slipped into Arabic colloquialisms in the conversation, and the interviewer allowed the conversation to continue in an effort to ensure their perspectives were included. Future efforts to adapt smoking cessation interventions for Arab populations should closely examine ways to address social interactions associated with smoking and actively incorporate family-based support. Frameworks such as the Behavior Change Wheel, adapted from the COM-B model, in addition to the Cultural Sensitivity Framework may be useful for guiding the cultural adaptation of intervention strategies, messaging and delivery.( 43 – 46 ) Conclusion In this qualitative inquiry we found that social, cultural, and environmental constraints can act as barriers to Arab adults who want to quit smoking. Within an Arab cultural context, there is the potential to leverage supports from family and peer groups to assist people in quitting. Bridging communication gaps between HCPs and people who may be reluctant to seek advice or cessation support is essential. Smoking cessation interventions that are culturally tailored and that integrate salient social and motivational domains may be more effective in encouraging quit attempts and sustaining abstinence. Declarations Ethics statement: All study procedures involving human participants complied with the ethical standards of the institutional and national research committees reviewing this study, and followed the guidelines of the 1964 Helsinki Declaration and its later amendments. Ethical approval was granted by the University of Oxford Department of Continuing Education Research Ethics Committee (OUDEC C1A 22 047), the New York University Abu Dhabi Research Ethics Committee (HRPP-2023-7 deemed exempt), the University of Sharjah Research Ethics Committee (REC-23-09-05-01-F), the Abu Dhabi Health Research and Technology Ethics Committee (DOH/CVDC/2023/1103), and New York University Langone Institutional Review Board (i24-00687). All people interviewed provided written informed consent to participate in the research and be recorded. Consent for publication: n/a Data availability: The data underlying this article will be shared on reasonable request to the corresponding author. Declaration of competing interests: The authors have no competing interests to declare. Primary funding: This research is supported by Tamkeen under the NYU Abu Dhabi Research Institute (NYUAD-G1206) Author contributions: ALJ conceptualized the study, collected and analyzed the data, and lead the manuscript writing. BS assisted with data analysis and participant recruitment. NL, RB, SES, and JHB provided supervision, and revised drafts of the manuscript. All authors read and approved the final manuscript. Acknowledgements : The authors would like to thank all of the individuals for their time and effort sharing their perspectives in the interviews. We would also like to thank Dr. Anne-Marie Boylan in the Nuffield Department of Primary Health Care Sciences for her guidance and input during the early development of this project. References Al-Houqani M, Leinberger-Jabari A, Al Naeemi A, Al Junaibi A, Al Zaabi E, Oumeziane N, et al. Patterns of tobacco use in the United Arab Emirates Healthy Future (UAEHFS) pilot study. PLoS ONE. 2018;13(5):e0198119. 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Nakkash RT, El Boukhari N, Afifi RA, 'When. I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon. Tob Control. 2021;30(3):351–5. Luna LJ. Transcultural Nursing Care of Arab Muslims. J Transcult Nurs. 1989;1(1):22–6. Khazen M, Guttman N. Nesef Doctora’—When mothers are considered to be ‘half-doctors’: Self-medication with antibiotics and gender roles in the Arab society in Israel. Sociol Health Illn. 2021;43(2):408–23. Elobaid YE, Jabari AL, Al Hamiz A, Al Kaddour AR, Bakir S, Barazi H, et al. Stages of change, smoking behavior and acceptability of a textmessaging intervention for tobacco cessation among cigarette, dokha and shishasmokers: A qualitative research study. BMJ Open. 2019;9(9):e029144. Perusco A, Rikard-Bell G, Mohsin M, Millen E, Sabry M, Poder N, et al. Tobacco control priorities for Arabic speakers: key findings from a baseline telephone survey of Arabic speakers residing in Sydney's south-west. Health Promotion J Australia. 2007;18(2):121–6. Aqeeli AA, Makeen AM, Al Bahhawi T, Ryani MA, Bahri AA, Alqassim AY et al. Awareness, knowledge and perception of electronic cigarettes among undergraduate students in Jazan Region, Saudi Arabia. Health & social care in the community. 2022;30(2):706 – 13. Abdel-Qader DH, Al Meslamani AZ. Knowledge and Beliefs of Jordanian Community Toward E-cigarettes: A National Survey. J Community Health. 2021;46(3):577–86. Abo-Elkheir OI, Sobh E. Knowledge about electronic cigarettes and its perception: a community survey. Egypt Respiratory Res. 2016;17(1):58. Ahmed LA, Verlinden M, Alobeidli MA, Alahbabi RH, AlKatheeri R, Saddik B, et al. Patterns of tobacco smoking and nicotine vaping among university students in the United Arab Emirates: a cross-sectional study. 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General practitioners’ and family physicians’ negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction. 2005;100(10):1423–31. Pipe AL, Evans W, Papadakis S. Smoking cessation: health system challenges and opportunities. Tob Control. 2022;31(2):340–7. Raupach T, Shahab L, Baetzing S, Hoffmann B, Hasenfuss G, West R, et al. Medical students lack basic knowledge about smoking: Findings from two European medical schools. Nicotine Tob Res. 2009;11(1):92–8. Dar-Odeh N, Abu-Hammad O. Tobacco Use by Arab Women. In: Laher I, editor. Handbook of Healthcare in the Arab World. Cham: Springer International Publishing; 2021. pp. 107–32. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. Ahluwalia J, Baranowski T, Braithwaite R, Resnicow K. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9:10–21. Resnicow K, Soler R, Braithwaite RL, Ahluwalia JS, Butler J. Cultural sensitivity in substance use prevention. J Community Psychol. 2000;28(3):271–90. Griffith DM, Efird CR, Baskin ML, Webb Hooper M, Davis RE, Resnicow K. Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research. Annual Review of Public Health. 2024;45(Volume 45, 2024):195–212. Footnotes The “slap” is a common reference to the physiological experience the individual experiences from the initial rush of nicotine from the tobacco that is smoked in the midwakh. Other references to this feeling can be found in another qualitative study of midwakh smokers in Lebanon.25.Nakkash RT, El Boukhari N, Afifi RA. 'When I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon. Tob Control. 2021;30( 3 ):351-5. Additional Declarations No competing interests reported. Supplementary Files ALeinbergerJabarietalQuittingexperiencesqualSupplFinal.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 May, 2026 Reviews received at journal 29 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 24 Mar, 2026 Submission checks completed at journal 23 Mar, 2026 First submitted to journal 23 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Sherman","email":"","orcid":"","institution":"New York University","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"E.","lastName":"Sherman","suffix":""},{"id":626357514,"identity":"1b0c44d8-e8a2-4ef8-98f6-a8bdfe7eddc9","order_by":3,"name":"Nicola Lindson","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Nicola","middleName":"","lastName":"Lindson","suffix":""},{"id":626357515,"identity":"861071ff-896e-44ed-a0c4-e505585a8625","order_by":4,"name":"Jamie Hartmann-Boyce","email":"","orcid":"","institution":"University of Massachusetts Amherst","correspondingAuthor":false,"prefix":"","firstName":"Jamie","middleName":"","lastName":"Hartmann-Boyce","suffix":""},{"id":626357516,"identity":"bdfda644-01dd-4d23-898b-a3d3bcb4adbf","order_by":5,"name":"Rachna Begh","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Rachna","middleName":"","lastName":"Begh","suffix":""}],"badges":[],"createdAt":"2026-03-13 10:53:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9113868/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9113868/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107549658,"identity":"45c34655-19d7-4a5a-bb8c-fc3da447383b","added_by":"auto","created_at":"2026-04-22 13:57:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":296214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9113868/v1/5456a6b3-273a-4936-b4c0-1f180d2a47da.pdf"},{"id":107549459,"identity":"5d6678e3-b40d-43e0-bc08-ad4e6f9093d4","added_by":"auto","created_at":"2026-04-22 13:56:34","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17724,"visible":true,"origin":"","legend":"","description":"","filename":"ALeinbergerJabarietalQuittingexperiencesqualSupplFinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-9113868/v1/9783cb6fb0a29a86bfb6fca5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"“I took the initiative and stopped. Khallas, enough is enough.” Perspectives on quitting tobacco from Arab people who smoke and healthcare providers who treat them: A qualitative inquiry in the United Arab Emirates","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCombustible tobacco use in Arab populations is a concerning public health problem due to the high prevalence of smoking, particularly among men, and the increasing popularity of products such as shisha (also known as waterpipe, narghile, or hookah) among both men and women.(\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) People who are willing to quit are more likely to succeed when supported by behavioral interventions, medication and/or nicotine e-cigarettes (also known as vapes).(\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) For many, this journey begins in the primary care setting where even brief provider counselling can help people who are trying to quit.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) However, the delivery and intensity of such cessation support may vary across physicians.\u003c/p\u003e \u003cp\u003eThere are few studies of evidence-based smoking cessation interventions, most of which have been almost exclusively developed and tested in Western countries, within Arab cultural contexts.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) A study among Arab men in Israel found that 40% reported ever receiving physician advice to quit smoking, however receiving advice was not associated with attempts to quit smoking or smoking status.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Additional studies in this population suggest that although individuals understand the health consequences of smoking, factors such as stress, environmental influences, and social norms create little motivation or opportunity for them to quit.(\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) These findings highlight the need to explore smoking cessation approaches that take into account cultural norms and contextual factors specific to Arab populations, particularly given recent evidence that suggests culturally tailored interventions improve quit success.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Alternative forms of tobacco smoking, such as shisha and midwakh (pipe tobacco common to the Arabian Gulf countries), are popular in the region and have different patterns of use that may make direct implementation of Western-developed interventions challenging.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) An RCT in Syria that examined the effect of nicotine replacement therapy (NRT) combined with behavioral counselling, a standard approach in primary care, found no difference in quit rates between participants receiving NRT and those who did not (prolonged abstinence: 14.1% vs. 13.4% at 6 months, and 11.9% vs. 12.7% at 12 months in control vs. NRT group, respectively).(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Another RCT of a shisha smoking cessation intervention in Pakistan showed that behavioral support plus varenicline did not result in higher abstinence rates at 6 months compared with behavioral support plus placebo.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Differences in social, environmental, and cultural contexts may influence the efficacy of smoking cessation approaches, and we therefore need to examine, within the Arab context, what factors may impact smoking cessation intervention effectiveness.\u003c/p\u003e \u003cp\u003eThe aim of this study was to understand the environmental, social, and cultural influences on smoking behaviors among Arab people living in the United Arab Emirates (UAE), to identify factors that could encourage tobacco cessation and to explore the perspectives of the HCPs who work with them.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003eThe study protocol was registered on the Open Science Framework prior to data collection (DOI: https://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17605/OSF.IO/Q2X3S\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/Q2X3S\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). We received ethical approval from the relevant international and local regulatory bodies. All participants provided written consent to participate and have their interviews recorded.\u003c/p\u003e \u003cp\u003eAdults (18\u0026thinsp;+\u0026thinsp;years) who currently smoked or had recently (\u0026lt;\u0026thinsp;5 years) stopped, spoke Arabic or English, and self-identified as Arab were eligible to participate in the interviews. Participants who smoked were not required to have made prior quit attempts to be eligible. We also included health care providers (HCPs) who provided smoking cessation support to Arab individuals, without restrictions on area of practice, country of training, or years of experience. We used a purposive sampling strategy and sampled on age, gender, types of tobacco smoked (including poly tobacco use) and area of practice, to ensure a diversity of experiences and perspectives.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) We relied on a convenience sample, expanded through snowball recruitment.\u003c/p\u003e \u003cp\u003eAll participants were given the choice of being interviewed in English or Arabic, but all chose to speak in English. We structured interview guides (\u003cb\u003eSupplement Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e) according to the theoretical domains framework (TDF) and followed a general thematic approach.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) The TDF was developed to identify key theoretical domains that may be useful to consider in evidence-based practice and intervention development. All interviews, conducted online or in-person, were recorded and auto-transcribed through a meeting recording program. The lead author (ALJ) reviewed recordings and transcripts for accuracy, and redacted personal information from the transcripts before analysis. People who smoked provided information on the types of tobacco they used, and their perceived level of nicotine dependence. They completed the Hooked on Nicotine Checklist (HONC) and if they reported shisha use, the Lebanese Waterpipe Dependence Scale (LWDS).(\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe systematically coded all transcripts and summarized units of meaning. The initial set of codes was based on the primary study aims, and additional codes were generated from the interview data. Themes were drawn from the domains identified to explain behavior change in the TDF, and subthemes were generated to more specifically capture meaning in the interviews.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) The first three transcripts were independently coded by two researchers (ALJ, BS), with ongoing discussion to establish a shared understanding of codes and interpretations. We then grouped these codes into larger themes. We used NVivo software (version 14) for analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe interviewed a total of 17 people (9 men and 2 women who smoked, and 6 health care providers; 4 men and 2 women). HCPs came from a variety of clinical disciplines including pulmonology, primary care, nursing, and cardiology and all had more than 10 years of clinical experience in their fields. While two HCPs were physically located outside of the UAE at the time of the interviews, we asked all HCPs to speak about smoking cessation within the context of their Arab patients who live in the UAE.\u003c/p\u003e \u003cp\u003eThe 11 people who smoked originated from various Arabic-speaking countries, and ranged in age from 19\u0026ndash;44 years. At the time of interview, five had quit smoking combustible tobacco; three had quit all forms of nicotine (smoking or vaping) and two had transitioned exclusively to vaping. The remaining six participants were still smoking. They used multiple tobacco products, including cigarettes, shisha, midwakh, and e-cigarettes. They scored an average of 7 on the HONC (range 2\u0026ndash;10; higher scores=greater dependence), indicating moderate nicotine dependence. The two participants who completed the LWDS scored 7 (range 1\u0026ndash;11; higher scores=greater dependence), indicating a high level of dependence.\u003c/p\u003e \u003cp\u003eWhat are the quitting experiences of Arab people who smoke in the UAE?\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMotivation: Emotional motivators to quit\u003c/h2\u003e \u003cp\u003eAll participants described multiple quit attempts. One of the main motivators was a health scare; either experienced personally (e.g., a temporary infection that forced them to stop smoking for a period of time) or by a close friend or family member.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Health. I mean, my dad passed away from cancer, same for my both grandparents, like my grand... both grandfathers. They had cancers. Uh, my dad as well. So that's for...Yeah. For health...and I have kids...So that's mainly why I wanna quit. Stay more with them, yeah.\u0026rdquo; (male, 30s, currently smoking/vaping)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHealth scares experienced by friends or family appeared to be more severe, with some resulting in death. However, the effects of these experiences on smoking did not seem to be lasting, as participants reported resuming their smoking behaviors, despite the experiences causing emotional reactions for some.\u003c/p\u003e \u003cp\u003eHCPs also reported that patients often sought smoking cessation support following a health scare; either their own, in which case, the patient was referred by another HCP, or that of a close relative or friend.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Usually, they have first close relative or very close friend who died of tobacco or have major diagnosis like cancer or something. So, they feel the shock, you know.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients also came to HCPs because their family members had asked them to quit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Why? Why are you here in the first place? Who's nagging you? Is it your, your spouse, your mother, your, your bariatric surgeon?\u0026rdquo; (female provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor younger people who smoked, one particular motivator was disapproval of their smoking from their mothers. Both HCPs and people who smoked described women as playing a strong role in social and family dynamics.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Most young men hide their smoking from their mothers, some from their fathers. But men, [it] is OK for them to smoke. They hide it more from their mothers. Women can play a role.\u0026rdquo; (female provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThough young people hid their smoking behaviors from their older family members, they said those family members were influential in modeling behaviors that encouraged them to start smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's very rare to find a man who's like 40 years or older who doesn't smoke. My father smokes, my relatives smoke, even my grandfather smokes. So, when I... from the beginning, I always saw cigarettes in the in the household. So it was, I think, a matter of time.\u0026rdquo; (male, 20s, recently quit)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMotivation: Roles \u0026 Identity\u003c/h3\u003e\n\u003cp\u003eLinked to motivation was the individual\u0026rsquo;s perceived social role. Some of the people who smoked expressed a desire to quit based on their role in their family. Some of the men saw their role as a father as an important reason for wanting to quit smoking. They perceived their role as a provider and role model for their children.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Very much not only for my health it's because I don't want them [my children] to be smokers when they see me smoking. Same thing will happen to them. What I'm saying now that maybe I'll influence them to become smokers and in the future. I don't want them to see me smoking, so they don't think this is something normal they can do.\u0026rdquo; (male, 30s, currently smoking/vaping)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Knowing it causes cancer and then I have children and then it's like, OK, I'm not like an 18-year-old or 20-year-old doing something because it's for me. Then I'm now responsible for my kids.\u0026rdquo; (male, 40s, currently smoking)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHCPs talked about their role as a motivator/supporter, in-line with principles of shared decision making, rather than being prescriptive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We tell them it's a journey and we work on it together and we do actually share with them the mechanism of tobacco addiction and make them feel this is not their fault, this is not to not to feel guilty, and this is something like any other illness, and we this is we will work with them as a team.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, they were also open about how their opinion of how \u003cem\u003e\u0026ldquo;easy\u0026rdquo;\u003c/em\u003e a patient is to work with determines the amount of effort they put into the interaction. Some patients are seen as impossible to help because they were satisfied with their smoking, did not perceive it as a problem and were not motivated to stop.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are some very funny patients who say \u0026lsquo;I enjoy my smoking doc. I don't want to stop.\u0026rsquo; It's very clear. \u0026lsquo;I'm happy. I'm 65. I had a very happy life. I want to continue smoking and die smoking.\u0026rsquo; So, there you can do nothing about it, right? You can do nothing.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eEnvironmental constraints or barriers to quitting\u003c/h3\u003e\n\u003cp\u003eHCPs primarily identified structural barriers to cessation, particularly insurance hurdles.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;and dealing with those, the insurance unfortunately only\u0026hellip;local patients are covered by tobacco cessation insurance, so the others are not. So occasionally I do counsel them under shortness of breath or other things, you know.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditional structural barriers identified by HCPs included communication barriers, due to inadequate language interpretation services and limited consultation time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; our clinics are so busy that, you know, we don't have time to really sit down and discuss smoking cessation.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would say I'm not even getting like half of that stuff that I just told you that I'm doing. I'm not doing that. I'm not able to do that with Arabic speaking patient, you know everyone gets fatigued after, you know, you, the inpatient, the interpreter.\u0026rdquo; (female provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast, people who smoked talked about environmental constraints that centered around social contexts in the UAE where smoking is widely permitted and socially embedded. Restaurants and bars often permit smoking and vaping in outdoor patios or other ventilated spaces, making tobacco use highly visible and difficult to avoid. The pervasiveness of smoking in these contexts was frequently described as undermining quit attempts.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;First, for the first month it was a bit difficult because everywhere I go, people smoked with their cigarettes, vapes, shisha and I was trying to avoid all of them.\u0026rdquo; (male, 20s, recently quit)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHow does the social and cultural environment help or hinder quitting success?\u003c/p\u003e\n\u003ch3\u003eSocial and cultural influences\u003c/h3\u003e\n\u003cp\u003eParticipants consistently described how cultural influences encourage and normalize smoking behaviors, making cessation difficult. People who smoked described smoking as deeply embedded in everyday social practices and closely tied to gendered expectations, particularly around male identity. Smoking among men was viewed as commonplace and culturally accepted. At the same time, HCPs noted that tobacco use, particularly shisha and midwakh were also culturally embedded in socializing among females.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Uh, there is a cultural influence because here in the Middle East ... everyone smokes. Yeah, almost like for the men, at least for the males, like 60% of the older individuals. And they are always smoking and they come with a pack of cigarettes. It's like part of the culture, I think.\u0026rdquo; (male, 20s, vaping)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The shisha and the midwakh and all this cultural, the habit of sitting with people in the friends and families, and for shisha for one hour is such a strong thing here. So, they think it's nothing. What do you call unusual? It's very normal. Even the ladies especially.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Middle Easterners, we like our tobacco. The midwakh is cultural. And they like\u0026hellip;they like the slap\u003c/em\u003e \u003csup\u003e1\u003c/sup\u003e \u003cem\u003ethat they get.\u0026rdquo; (female provider)\u003c/em\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHow do people go about quitting smoking?\u003c/p\u003e\n\u003ch3\u003eKnowledge\u003c/h3\u003e\n\u003cp\u003eIn this domain, we explored knowledge specific to quitting smoking, including \u0026ldquo;how to\u0026rdquo; quit, and also information that would change the mindset or perspective of an individual around quitting. Knowledge on quitting smoking or quitting aids centered around three main themes: methods people use to limit their smoking; the impact of physician advice on their mindset; and knowledge about using nicotine e-cigarettes (also known as vapes) for harm reduction.\u003c/p\u003e \u003cp\u003eVery few of the people who smoked stated that they had used pharmacological aids, such as NRT for smoking cessation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I didn't find them necessary because if I want to quit vaping or smoking cigarettes, I want to quit using nicotine as well. So why would I use nicotine gums? I want to quit from everything the smoking habit, the nicotine, so I just stopped using. I didn't use any of them; the patches, the gum. I didn't find it necessary.\u0026rdquo; (male, 20s, recently quit)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePeople who smoked also stated that talking with HCPs had little or no effect on their mindset towards smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Even when you have some disease or some symptoms directly linked to smoking, and I think the majority of the patients will not follow the physician advice. So, for me personally it has zero impact for smoking. It's better to say \u0026lsquo;OK, I will do.\u0026rsquo; That is it.\u0026rdquo; (male, 40s, currently smoking)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVapes have only recently been legally available in the UAE. We asked about knowledge of vaping in the context of smoking cessation. HCPs and people who smoked equated smoking tobacco with vaping.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would rather catch my daughter smoking a cigarette than vaping cause at least I know or there has been some research on smoking opposed to vaping.\u0026rdquo; (female, 20s, currently smoking/vaping)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eYeah, it's supposed[ly] stops you from smoking cigarettes, but they don't stop the vape, so I don't know. (chuckles)I think it's very controversial, but my personal point of view is it is still smoking and all, and the American Heart and most of the other medical societies have decided that vaping is a form of smoking and it has the same\u0026hellip; even though we don't have all the data, it probably has same if not worse, side effects than smoking. (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePeople also expressed skepticism of e-cigarettes because they contain \u0026ldquo;unknown chemicals\u0026rdquo; and they are less familiar with their effects.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's not just the normal regular tobacco and tar and this stuff. There are chemicals that have not been studied yet and they put lots of unknown stuff for the flavors and everything mixed together makes it very bad I think.\u0026rdquo; (male, 20s, recently quit)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDecision processes\u003c/h2\u003e \u003cp\u003eWhen deciding how to approach discussions about smoking, whether it was to counsel people to quit or introduce the idea, HCPs tailored their interactions based on the perceived receptivity of their patients. HCPs perceived those patients who had experienced a related health event, and where this was the reason for the appointment, as being most motivated to quit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Either they come on their own, asking my help. That's the best group. The second group is sent by other doctors, a cardiologist or a neurologist who saw him few days back. Patient was admitted in the hospital with a stroke. He just recovers from a stroke and straight away the doctor sends the patient to me. They are the ones who are receptive for listening to me. They\u0026rsquo;re the best patients because they are really literally scared.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast, the people who smoked said that during their previous quit attempts they had come to the decision to quit independently. They distinguished their final decision and the physical act of quitting from any earlier HCP interactions or health events. This was despite some citing health concerns as a motivator to quit earlier in the interview.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We're very independent in our decisions and when it comes to stuff like this, like, if I decide to do it, yeah, my mom would be the first to be happy about it. But it's not like there is a forced decision that you have to quit smoking. No, it's just like I'm, I'm on my own. I have to do it on my own.\u0026rdquo; (female, 30s, currently vaping)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSkills and self-efficacy\u003c/h3\u003e\n\u003cp\u003eAll the HCPs had some level of training in providing smoking cessation counselling; however, their length of experience varied. When describing how they started the conversation about quitting smoking with patients, they described the importance of establishing a positive rapport.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, you got to [establish] like a good rapport, and 80% or 90% of the times I make a [good] rapport and sometimes 10% they put a wall in front of you, so you can't just go further. So, you just leave them alone, and probably I try again next time in the next visit.\u0026rdquo; (male provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany of the people who smoked talked about addiction, but were hesitant to say they were addicted to nicotine. This was despite an average score of 7 on the HONC, which would indicate a moderate level of dependence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Um, I believe like I thought that I can quit at any time and I'm not dependent. This is the definition of addiction to me that I'm not dependent. I can leave it anytime.\u0026rdquo; (female, 30s, currently vaping)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe sought to understand, from the perspectives of Arab adults who smoke and HCPs who support them to quit, the key motivators and barriers to smoking cessation within this population (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Both groups clearly identified how cultural influences present within social interactions and environmental structures may both hinder and help people\u0026rsquo;s efforts to quit smoking. Domains related to socio-cultural influences, environmental contexts, specifically constraints, and motivations were common themes that emerged in these conversations. Both groups agreed that the social-cultural environment poses a barrier to people wanting to quit, noting that avoiding certain places or social groups is necessary to prevent relapse. Where culture appeared to support cessation was through social supports, specifically family. Family plays an important role in Arab society, and women in particular were perceived as having a strong influence in encouraging and sustaining quit attempts.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Family support was viewed as especially important for maintaining abstinence over time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey UAE and Arab-context specific interview themes mapped to the TDF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTDF Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eKey Themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividuals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHCPs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoles and identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotivator: Role modeling healthier behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMotivator: Supporter of quitting smoking/vaping\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnvironmental context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarrier: Smoking/vaping permitted in many social gathering places\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier: Insurance coverage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial influence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMotivator: Family influence/support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMotivator: Family influence/support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCulture and identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarrier: Cultural identity that supports smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier: Cultural identity that supports smoking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarrier: Lack of knowledge of community-based resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarrier: E-cigarettes are as harmful as tobacco cigarettes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere appeared to be a disconnect between people who smoke and HCPs. People admitted that they did not always follow physician advice, and physicians admitted that they struggled with some patients when trying to discuss smoking behaviors during clinical encounters. This disconnect could lead to patients lacking information on tools available to help them quit smoking, stemming from a lack of communication. Other environmental constraints such as insurance coverage, language barriers and limited consultation time were also identified as challenges to successful quitting.\u003c/p\u003e \u003cp\u003eParticipants did not distinguish between smoking combustible tobacco and \u003cem\u003e\u0026ldquo;smoking\u0026rdquo;\u003c/em\u003e nicotine e-cigarettes, despite the latter not containing tobacco or involving combustion. Both groups viewed nicotine vaping as equally or possibly more, harmful than smoking combustible tobacco and did not consider transitioning to exclusive vaping a successful smoking cessation strategy. Limited knowledge about e-cigarette components was identified as a major reason for skepticism toward these products.\u003c/p\u003e \u003cp\u003eResults from this study are consistent with previous research conducted in the region. In a previous focus group study, young people who smoked most often described early influences such as male family members or friends who led them to start smoking.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) In addition, few study participants saw nicotine e-cigarettes as a smoking cessation tool or used pharmacotherapies, such as NRT; instead opting for a \u0026ldquo;cold turkey\u0026rdquo; approach.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) A survey of Arab people who smoked in New South Wales Australia, found a preference for self-help materials over evidence-based cessation methods, such as medication or counseling.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Research from across the region further supports the finding that knowledge gaps and misconceptions about vaping are widespread.(\u003cspan additionalcitationids=\"CR31 CR32 CR33\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Both HCPs and people who smoked agreed that existing knowledge and resources do not adequately address cessation needs. Further exploration of barriers to using evidence-based approaches could inform more effective cessation programming, and targeted initiatives are needed to correct misperceptions about e-cigarettes among both HCPs and the general public.\u003c/p\u003e \u003cp\u003eDespite training and experience, HCPs with experience in smoking cessation services in the region remain limited in availability across the region.(\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) In the UAE, formal smoking cessation services are typically accessed via specialty care rather than community-based settings as is the case in other countries.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Consequently, the perspectives of the HCPs interviewed reflect a specific clinical context which may differ in other settings. A survey of physicians in the UAE found that less than half (47%) felt confident in their ability to counsel patients on smoking cessation, and only 24% were aware of community-based cessation resources.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) These barriers are not limited to HCPs in the region; lack of time and inadequate training are commonly reported barriers.(\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) A review of studies examining family doctor attitudes found the most common barriers related to lack of time or perceived ability to provide proper counseling.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) Another structural barrier HCPs said they faced is insurance coverage for their patients. Research from other parts of the UAE suggests that cessation services can be provided through other channels, such as pharmacy, but any formal evaluation of this is limited.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Additional supportive approaches, tailored for the community, which can provide continued support outside of clinical encounters with HCPs, could potentially help.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eWe experienced challenges in recruiting women who smoke. This may highlight the social and cultural barriers that may influence decisions to seek care for smoking cessation. Smoking rates among Arab women are generally low, and many women who do smoke, do so discreetly.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) The experiences shared by women in our study highlight the need for cessation messaging tailored specifically for Arab women delivered in a discrete, non-judgmental manner.\u003c/p\u003e \u003cp\u003eAnother limitation is that all interviews were conducted in English. The study was advertised in both English and Arabic to potential participants. All who expressed an interest were given the choice to participate in either English or Arabic, and all chose to speak in English. It is possible that some participants may have felt limited in their ability to express their thoughts fully. Some participants briefly slipped into Arabic colloquialisms in the conversation, and the interviewer allowed the conversation to continue in an effort to ensure their perspectives were included.\u003c/p\u003e \u003cp\u003eFuture efforts to adapt smoking cessation interventions for Arab populations should closely examine ways to address social interactions associated with smoking and actively incorporate family-based support. Frameworks such as the Behavior Change Wheel, adapted from the COM-B model, in addition to the Cultural Sensitivity Framework may be useful for guiding the cultural adaptation of intervention strategies, messaging and delivery.(\u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this qualitative inquiry we found that social, cultural, and environmental constraints can act as barriers to Arab adults who want to quit smoking. Within an Arab cultural context, there is the potential to leverage supports from family and peer groups to assist people in quitting. Bridging communication gaps between HCPs and people who may be reluctant to seek advice or cessation support is essential. Smoking cessation interventions that are culturally tailored and that integrate salient social and motivational domains may be more effective in encouraging quit attempts and sustaining abstinence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statement:\u003c/strong\u003e \u003cem\u003eAll study procedures involving human participants complied with the ethical standards of the institutional and national research committees reviewing this study, and followed the guidelines of the 1964 Helsinki Declaration and its later amendments.\u003c/em\u003eEthical approval was granted by the University of Oxford Department of Continuing Education Research Ethics Committee (OUDEC C1A 22 047), the New York University Abu Dhabi Research Ethics Committee (HRPP-2023-7 deemed exempt), the University of Sharjah Research Ethics Committee (REC-23-09-05-01-F), the Abu Dhabi Health Research and Technology Ethics Committee (DOH/CVDC/2023/1103), and New York University Langone Institutional Review Board (i24-00687). \u0026nbsp;All people interviewed provided written informed consent to participate in the research and be recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e n/a\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interests:\u003c/strong\u003e The authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary funding:\u003c/strong\u003e This research is supported by Tamkeen under the NYU Abu Dhabi Research Institute (NYUAD-G1206)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e ALJ conceptualized the study, collected and analyzed the data, and lead the manuscript writing. BS assisted with data analysis and participant recruitment. NL, RB, SES, and JHB provided supervision, and revised drafts of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank all of the individuals for their time and effort sharing their perspectives in the interviews. We would also like to thank Dr. Anne-Marie Boylan in the Nuffield Department of Primary Health Care Sciences for her guidance and input during the early development of this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Houqani M, Leinberger-Jabari A, Al Naeemi A, Al Junaibi A, Al Zaabi E, Oumeziane N, et al. Patterns of tobacco use in the United Arab Emirates Healthy Future (UAEHFS) pilot study. PLoS ONE. 2018;13(5):e0198119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJawad M, Al-Houqani M, Ali R, El Sayed Y, ElShahawy O, Weitzman M, et al. Prevalence, attitudes, behaviours and policy evaluation of midwakh smoking among young people in the United Arab Emirates: Cross-sectional analysis of the Global Youth Tobacco Survey. PLoS ONE [Electronic Resource]. 2019;14(4):e0215899.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfifi R, Ghandour L, El Salibi N, Nakkash R, Rady A, Sherman S. Prevalence of Midwakh tobacco smoking in trend-setting Lebanon: an indicator of potential spread across the Arab world? Tob Induc Dis. 2018;16(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaziak W, Nakkash R, Bahelah R, Husseini A, Fanous N, Eissenberg T. Tobacco in the Arab world: old and new epidemics amidst policy paralysis. 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General practitioners\u0026rsquo; and family physicians\u0026rsquo; negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction. 2005;100(10):1423\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePipe AL, Evans W, Papadakis S. Smoking cessation: health system challenges and opportunities. Tob Control. 2022;31(2):340\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaupach T, Shahab L, Baetzing S, Hoffmann B, Hasenfuss G, West R, et al. Medical students lack basic knowledge about smoking: Findings from two European medical schools. Nicotine Tob Res. 2009;11(1):92\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDar-Odeh N, Abu-Hammad O. Tobacco Use by Arab Women. In: Laher I, editor. Handbook of Healthcare in the Arab World. Cham: Springer International Publishing; 2021. pp. 107\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhluwalia J, Baranowski T, Braithwaite R, Resnicow K. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9:10\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eResnicow K, Soler R, Braithwaite RL, Ahluwalia JS, Butler J. Cultural sensitivity in substance use prevention. J Community Psychol. 2000;28(3):271\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffith DM, Efird CR, Baskin ML, Webb Hooper M, Davis RE, Resnicow K. Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research. Annual Review of Public Health. 2024;45(Volume 45, 2024):195\u0026ndash;212.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003e The \u0026ldquo;slap\u0026rdquo; is a common reference to the physiological experience the individual experiences from the initial rush of nicotine from the tobacco that is smoked in the midwakh. Other references to this feeling can be found in another qualitative study of midwakh smokers in Lebanon.25.Nakkash RT, El Boukhari N, Afifi RA. 'When I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon. Tob Control. 2021;30(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e):351-5.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9113868/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9113868/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Smoking rates are comparatively high in Arab populations. This study sought to gather the perspectives of health care providers (HCPs) and people of Arab origin who smoke to better understand the social, cultural, and environmental factors that influence smoking behavior in these populations.\u003c/p\u003e \u003cp\u003eMethods: We interviewed 17 people; 6 HCPs who work with Arab patients and 11 individuals of Arab origin who smoke. Interviews were semi-structured and guided by the Theoretical Domains Framework. They covered topics related to social influences on smoking behaviors, motivators and barriers to quitting, perceived roles, environmental constraints, and how culture may influence decisions to quit. We coded and analyzed transcripts using thematic analysis.\u003c/p\u003e \u003cp\u003eResults: Health concerns and family influence were seen as motivators for quit attempts by HCPs and people who smoked. Both groups reported that culture and social norms can support smoking cessation efforts. Structural barriers such as differential insurance coverage and lack of time were most commonly cited among HCPs. Knowledge of effective ways to quit smoking was low among people who smoked. Both HCPs and people who smoked perceived vaping to be as harmful as smoking.\u003c/p\u003e \u003cp\u003eConclusion: Interviews with HCPs and Arab people who smoked highlighted key challenges and opportunities to improve the effectiveness of existing smoking cessation efforts. Theoretical domains that featured prominently included motivations, social influences, and environmental contexts. Correcting misperceptions about appropriate tools to aid cessation is needed. The cultural context of smoking behavior should be considered in any efforts to improve smoking cessation support in this population.\u003c/p\u003e","manuscriptTitle":"“I took the initiative and stopped. Khallas, enough is enough.” Perspectives on quitting tobacco from Arab people who smoke and healthcare providers who treat them: A qualitative inquiry in the United Arab Emirates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 13:54:33","doi":"10.21203/rs.3.rs-9113868/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-01T17:05:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T12:22:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8491578236038348732570677149017629970","date":"2026-04-22T16:16:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179891478044489291919388824160750570810","date":"2026-04-15T12:25:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T04:15:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T14:35:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T04:22:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T15:03:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-23T12:13:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c413906c-21ef-4c55-903e-c309b31ca454","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-01T17:05:24+00:00","index":89,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T13:54:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 13:54:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9113868","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9113868","identity":"rs-9113868","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}