Assalaamu Alaykum”, my name is Darlene Liberti and I will be your speaker for this presentation on Muslim American culture and health promotion. “Assalaamu Alaykum” is a common greeting among Muslims, meaning &quot;Peace be with you.&quot;
The term Arab is frequently associated with the Middle Eastern region extending from the Atlantic coast of Northern Africa to the Arabian Gulf. The classification is based largely on a common language, which is Arabic and a shared sense of geographic, historical and cultural identity (Ahmed, 2004). Arab Americans have emigrated from one of the approximately 22 countries that compose this Arab world. Many immigrated to the US to escape war, political instability or in search of economic opportunities Arab countries are diverse with respect to customs and religious beliefs. Originating from many different countries with tremendous regional and national differences in language, politics, religion and culture. The cultural norm is varied and no practice is universal to all. Religions include Christians, Jews and Muslims. However, 92% of Arabs are Muslim who believe in Islam. There is an estimated 2-3 million Arab Americans living in the US with the largest concentration being in the northeast. The exact number of Arab Americans is not known because they are reluctant to identify themselves as being of Arabic descent out of a fear of possible negative social reactions (De la Cruz & Brittingham, 2003). Arab Americans tend to have more education than other US ethnic groups in part because educational achievement and economic advancement are encouraged within the Arab culture. More than 40% of Arab Americans hold a bachelors degree or higher (De la Cruz & Brittingham, 2003). They have assimilated into mainstream society and have been active in creating Muslim schools and charities and providing Arab language classes.
Most Muslim Americans speak Arabic and understand English Gender considerations: Muslim homes are typically very private. Throughout time, gender has played a huge part in how families function. Although Muslim women are subservient to men, Arab American women have more freedom than other women in the Arabic culture. Orthodox Muslims actually separate women from men and many times women may have little contact outside of the home. In many cases women must have a male escort, which is typically a family member, when leaving the home and when receiving medical care In the healthcare setting, providers should direct questions to the male companion; even questions regarding conditions such as menstruation. In addition, male providers must ask females for permission to examine them. They prefer to be treated by a medical provider of the same sex; this is especially true for female patients. This also applies when an interpreter is required. Nurses are perceived as helpers and not health care professionals and their suggestions and advice are not taken seriously. The doctor may need to explain the nurse’s role to the patient. Many Muslims rely on their families other relatives and close friends for support and help. They prefer medical treatment that involves prescribing pills or giving injections rather than counseling. Health care providers must understand that many Muslims follow a “halal” or Muslim diet which prohibits pork (including medications such as insulin) or other medications that contain alcohol Among devout Muslims, abstaining from alcohol is mandatory Ramadan: fasting during the holy month of Ramadan, with no food or drink consumed between sunrise and sunset is required. The sick are suppose to be exempt from fasting; however among those who are fasting, oral medications and IV solutions are prohibited. IM injections are permitted. Women are exempt from fasting during menstruation and 40 days post partum. Despite their illness, many Muslims may try to fast during Ramadan. Among many devout Muslims they pray as many as 5 times a day beginning before sunrise and ending after sunset Many Muslims consider the left hand unclean since it is used to clean oneself after going to the toilet (Amhad, 2004)
Marriage: M uslims believe marriage is sacred and is viewed as creating a sacred bond between two families. In Islam, men can have up to four wives, however here in the US they have one. Men have total control over the finances while women control the children. Although divorce is rare, if an Arabic marriages end in divorce, men typically have custody of children . Family: Family is also very important to the Muslim culture. Many times elder generations are cared for by younger generations. It is also common for Arabs to hide certain medical diagnosis in fear of shaming and dishonoring the family. Health: Many times conservative elderly Muslims’ do not believe in Western medicine; they believe in divine intervention, “In sha Allah” or God Willing. Therefore, some treatments and preventative measures are not accepted. Younger generation cares for older generation Many Muslims consider the left hand unclean since it is used to clean oneself after going to the toilet; don’t use left hand to serve food, drink tea or shake hands (Amhad, 2004)
Muslim culture is one closely connected to religion. It is important to note that a Muslim is a person who follows the Islamic faith. The three domains I will discuss are spirituality, family roles and organization and high risk behaviors. Culture practices influenced by religion can have a impact on health behaviors. (Yosef 2008).
The basis of the Islamic faith is the belief that there is only one God who is called, Allah. Mohammed is believed to be a prophet of Allah who was born in 571 C.E. Mohammed was to have received messages from Allah. He had followers who documented his messages of the faith in a book called the Koran. Followers of Islam use the Koran to guide their practice of faith. These include practices of prayer, nutrition, hygeine, sexuality and more. Unique to this faith is the annual month long fasting during Ramadan and the pilgrimage to Mecca at least once in a lifetime (Yosef 2008).
Followers of Islam are advised to adhere to the 5 pillars. These include previously mentioned prayers, fasting and the pilgrimage to Mecca. Another item, Zakat, is the action of donating a percentage of one’s income on a yearly basis to those in need. In relation to the topic of smoking, the Ramadan fast includes refraining from smoking. Muslim patients in America may have special considerations with healthcare due to the bond of their faith and their health practices (Yosef, 2001).
Family is believed to be an important part of the Muslim culture. Many families join together with marriages to begin an extended family. If female oppression occurs in some Muslim people, it is important to note that it is not from the Islamic faith. Women are considered equal. There is a great importance on modesty and the dress of Muslim women is due to the modesty beliefs. Women and men are discouraged from socializing with each other outside of the marriage. A Muslim woman may not be alone with a man who is not her husband, including a doctor. Women may seek to work but also have to continue the responsibility of child rearing (Hodge, 2005).
High risk behaviors noted in the Muslim culture include smoking, obesity, and lack of healthcare. Studies show these high risk behaviors are increased in immigrants. Reasons for this behavior can be immigration stress and cultural conflict. Immigration stress can cause decrease in exercise and overeating. There can be lack of social support system. Immigrants can have a difficult time obtaining health care in the new country. Modesty of women may prevent them from seeking healthcare with a male provider. Predestination beliefs are a part of the religion and may impede healthy decisions (Hodge, 2005).
Regina White: Tobacco use was seen to be higher in this population than the average United States smoker; see next slide. The health concern of poorly controlled blood sugar and diabetes was examined in various studies. In 2003 Jaber, Brown, Hammad, Zhu & Herman had 520 Arab Americans participate in a study that looked at a correlation between dysglycemia and acculturation (how one assimilates into their new surroundings or country). The study also included components of perceived stress and physical activity. This study used participants from Dearborn, a city outside of Detroit that has a large Arab population. This particular study looked at men and women who had moved to the United States from various areas in the Middle East. This study looked at how well they assimilated into their new country. The study results showed a higher risk of diabetes was associated with less acculturation particularly if the participant was of older age, unemployed, consuming more Arabic food, and generally not adapting as well into the new country. Also in 2003, the same group as above did a quantitative study examining how prevalent diabetes and glucose intolerance was for Arab Americans, again utilizing the large Dearborn Arab population. There were 542 participants in this study, 214 men and 328 women. They obtained height, weight, weight and hip measurements, as well as fasting blood sugar levels and glucose tolerance tests. 70% of the study participants over 60 years of age had an abnormal glucose tolerance test. In this same age group, diabetes was found in 36% of women and 54% of men! These rates were much higher than other Americans of the same age. Undiagnosed diabetes had a rate of 10%. During Ramadan long periods of fasting can lead to difficulty managing blood sugar. This is an important educational component for patients with diabetes. Another study of 542 people looked at insulin resistance and found a high level in the Arab community. Because of these findings diet and weight loss programs were recommended to help combat heart disease. In regards to the less frequent female health screening, as a gynecologic oncology nurse this is concerning to me. Again in Michigan a Behavioral Risk Factor survey was conducted by the Michigan Department of Public Health in 1995. In the group that was questioned, only 39.6 % of Arab females performed breast self exams as compared to 56.8 % for their white counterparts. Only 59.9 % had pap smear tests compared to 78.5%. There are cultural concerns particularly for Muslim females that may interfere with adequate health care. Modesty is very important in this culture, and women do not want to be exposed or touched by a male that they are not married to, or that is not a close relative. They would also prefer to be seen by a female health care practitioner. This is a very sensitive and important consideration and possible barrier to getting timely and adequate health care.
This is an older study, but one that is frequently referred to when examining the issues of tobacco use in the Arab American population. Study was conducted in a large Arab American community outside of Detroit. Looked at the prevalence of smoking in this population 38.9% of the participants were active smokers at the time of the study. 50% had never started smoking, and 11.1% were former smokers. 68.2 % of the participants in the study smoked from ½ to 2 packs of cigarettes a day. Men and women had the same smoking rates in this particular study, but other data looked at does not show such high rates for Arab American women. There was also data to support the fact that participants that had smoked for greater than 16 years had no formal schooling. Most concerning was that this group started smoking earlier and smoked more than the general smoking population of the United States. IN 2005…The National Interview Health Survey found the percentage of smokers to be: Native Americans (American Indians or Alaskan natives) at 25%, then White Americans at 21%, Black Americans at 21% and Asian Americans at 13%. Arab American were not identified in this survey. During the time period of 2004-2005, 1872 Arab-American and non Arab-American high school students from the Midwest were asked to complete a 24 item tobacco survey. Arab-Americans reported less cigarette smoking than non Arab-Americans; 7% versus 28%, but were more likely to smoke a water pipe; 17% versus 11%. (Weglicki, Templin, Rice, Jamil & Hammad, 2008)
500 year old tradition, originally associated with older men. Growing popularity around the world. There is much data and information on the health risks of cigarette smoking, but not as much research has been done on the health issues related to the use of the water pipe. Many users feel that this is not a harmful habit, and could be one of the reasons for the increased use. (Baker & Rice, 2008).
Tobacco use is one of the leading causes of death worldwide contributing to cardiovascular and pulmonary diseases. The World Health Organization (WHO) is greatly concerned with the increased rate of tobacco usage among adolescents and men in developing countries. WHO estimates that over 50% of men in developing countries use some form of tobacco. Tobacco related deaths are preventable and the WHO along with many developing countries have developed Tobacco Free Initiatives to help stem tobacco usage by educating the public on healthier lifestyles. Center for Disease Control (2008) Smoking Facts and Statistics. Retrieved on April 1, 2010 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm World Health Organization (2009). Facts and Statistics on Tobacco Usage. Retrieved on April 1, 2009 from http://www.emro.who.int/tfi/Facts.htm#fact2
Tobacco consumption among women for lowest consumption is: United Arab Emirates ( <1.0%), and Saudi Arabia( 1.0) and Oman (1.5%). Djibouti (47.4% young males 15 to 19)and Lebanon (33.7% both sexes) have highest percentage of adolescents using tobacco. The Middle Eastern Region and South East Asia have a proportionately higher usage of tobacco than many other regions in the world. Yemenese men have twice the rate of tobacco usage than western countries such as United States and Great Britain. It is interesting to note that many of the secular Muslim countries have a higher rate of tobacco usage compared to many Muslim countries that have a theocratic state. Saudi Arabia and Oman are deeply religious and have banned smoking in many public areas and have deemed tobacco usage as not only unhealthy but morally wrong by stating “a good Muslim will not smoke”. Smoking is often not reinforced in private places such as the home. Lebanon leads the Middle East with the highest percentage of adolescents and women who smoke.( Interesting to note that many Christians live in Lebanon and Jordan) Smoking is high among teenagers in the Middle and Far East countries because of the easy access to tobacco. In many countries there are not laws prohibiting the young from purchasing cigarettes. However, the WHO explains that even countries that have enacted age laws for the purchase of tobacco, most of these laws are not reinforced by local law enforcement or government agencies. Egypt had one of the highest tobacco usage decades ago, but along with WHO and the Egyptian government, they launched a tobacco free initiative nationally aimed at adolescents which had dramatically reduced the percentage of smokers to 35% whereas the region is closer to 50%. World Health Organization (2009). World Atlas Statistics on Tobacco. Retrieved on April 2, 2010 from http://www.who.int/tobacco/en/atlas5.pdf World Health Organization (2010). Tobacco Free Initiative Middle East. Retrieved on April 2, 2010 from http://www.emrowho.int/TFI/CountryProfile-Part6.htm World Health Organization (2006). Tobacco Free Initiative Facts. Retrieved on April 2, 2010 from http://www.emro.who.int/tfi/wntd2006/PDF/FactSheet_English.pdf
There are many cultural factors to why smoking is a common practice in the Muslim society. First, smoking is believed to demonstrate power and strength; therefore that is why it is acceptable among men but not so much for women. Secondly, social interaction among family, friends, and neighbors is very strong and in many larger Muslim cities there are coffee and hookah houses that men meet to relax and socialize. Also, stress plays a large factor and many Muslims interviewed by WHO said they smoked to relieve stress. Traditions play a large part for tobacco usage such as water pipes. Water-pipes go by many names such as hookahs, bhangs, narghiles or shishas and have been part of Muslim tradition for over 500 years. There are hundreds of variety of tobacco smoked and some even use fruit in water pipes so it is believed by society to be less harmful than cigarettes. WHO educates that smoking water pipes are even more harmful because of lack of filter. In many devoutly religious states such as Saudi Arabia, smoking is banned in most public places and decreed immoral by Islam. Weglicki, L.S, Templin, T.C, Rice, V.H., Hikmet, J. & Hammand A. (2008). Comparison of Cigarette and Water-pipe smoking by Arab and Non-Arab Americans. Retreived from PubMed on April 2, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575814/
Highest tobacco use in U.S. among American Indian at 32.4%, whites follow at 22.0% (Middle Eastern Men in U.S. fall into this category). The United States government with help of the General Surgeon and other public and private organizations have created a national health agenda to improve the health of our citizens. There are over 28 different goals set by Healthy People in order to improve health outcomes for people by providing access to healthcare and educational programs across our nation. Tobacco usage is one of the main focus initiatives and the government is trying to enforce stricter laws and smoking cessation programs to prevent smoking especially among teenagers. Smoking is the leading cause of lung cancer and cardiovascular/pulmonary diseases in the United States and globally. Center for Disease Control (2008) Smoking Facts and Statistics. Retrieved on April 1, 2010 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm Healthy People (2010). Goals and Health Indicators. Retrieved on April 1, 2010 from http://www.healthypeople.gov/About/goals.htm
Eric Jackson Smoking and Cancer from the National Cancer Institute Cigarette smoking causes 87 percent of lung cancer deaths and is responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder. Secondhand smoke is responsible for an estimated 3,000 lung cancer deaths among U.S. nonsmokers each year. Tobacco smoke contains thousands of chemical agents, including over 60 substances that are known to cause cancer. The risk of developing smoking-related cancers, as well as noncancerous diseases, increases with total lifetime exposure to cigarette smoke. Smoking cessation has major and immediate health benefits, including decreasing the risk of lung and other cancers, heart attack, stroke, and chronic lung disease. Patients diagnosed with lung cancer may suffer more than patients with other cancer diagnosis. This type of cancer may be associated with greater distress because of its poorer prognosis or because patients feel responsible for having caused their cancer through continued smoking or because of stigma stemming from lung cancer’s association to smoking.
Tobacco advertising and endorsement enhances the possibility of adolescents beginning smoking. Advertising is the utilization of media to produce explicit product images or connections. Endorsement or marketing is the combination of activities aimed at augmenting (increasing) sales. There are no assessments of the influence of tobacco advertising and endorsement on people taking up smoking (Sussman, 2001). According to the Federal Trade Commission cigarette manufacturing companies spend approximately $1.06 billion for the promotion of cigarettes. A large amount of this money is spent at the retail store level targeting youngsters and teenagers. Earliest Quit Smoking ads focused on health issues such as lung cancer, effects of passive smoking etc. However, nowadays, Quit Smoking ads focus on issues such as erectile dysfunction and loss of attractiveness. Recently released Quit Smoking ad shows a 58-year old woman suffering from Buerger’s disease as a result of smoking
Health Promotion: Muslim Culture
Muslim-American Culture and Tobacco Use By Darlene Liberti, RN أّلموألكوم (Assalaamu Alaykum)
Introduction <ul><li>Muslims considered “Arab” or “Middle Eastern” </li></ul><ul><li>Emigrate from many Arabic-speaking countries </li></ul><ul><li>Muslims believe in Islam (Ahmed, 2004) </li></ul><ul><li>Diverse Arab heritage </li></ul><ul><li>Largest number reside in northeast US </li></ul><ul><li>40% have bachelor’s degree or higher </li></ul><ul><li>(De la Cruz & Brittingham, 2003). </li></ul>
Cultural Considerations <ul><li>Speak Arabic at home, understand English </li></ul><ul><li>Men dominate </li></ul><ul><li>Same sex provider </li></ul><ul><li>Nurses are helpers not professionals </li></ul><ul><li>Ramadan: a time for fasting </li></ul><ul><li>Pray 5 times per day </li></ul><ul><li>(Amhad, 2004) </li></ul>
Heritage <ul><li>Marriage is sacred </li></ul><ul><li>Strong family bonds </li></ul><ul><li>Many do not believe in Western medicine </li></ul><ul><li>Divine intervention (“In Sha Allah”) </li></ul><ul><li>Younger generation care for older generation </li></ul><ul><li>Left hand is unclean </li></ul><ul><li>(Amhad, 2004) </li></ul>
Three Domains of Muslim Culture <ul><li>Spirituality </li></ul>High Risk Behaviors Family Roles and Organization (Yosef 2008)
Spirituality <ul><li>Muslims believe in one God, Allah </li></ul><ul><li>Beliefs are written in the Koran </li></ul><ul><li>Daily practices include prayer </li></ul><ul><li>Human body is to be cherished </li></ul><ul><li>Ramadan strengthens relationship with God </li></ul><ul><li>Pilgrimage to Mecca once in lifetime </li></ul><ul><li>(Yosef 2008) </li></ul>
Muslim Spirituality <ul><li>5 “Pillars of Islam” include: </li></ul><ul><ul><li>The profession of faith </li></ul></ul><ul><ul><li>Daily prayers </li></ul></ul><ul><ul><li>Fasting during Ramadan </li></ul></ul><ul><ul><li>Giving alms to the poor, Zakat </li></ul></ul><ul><ul><li>A pilgrimage to Mecca once a lifetime </li></ul></ul><ul><ul><li>(Yosef, 2001) </li></ul></ul>
Family Roles and Organization <ul><li>Patriarchal, man is head of household </li></ul><ul><li>Extension of families with marriage bonds </li></ul><ul><li>Men are responsible for financial support of family </li></ul><ul><li>Women are equal; role is to raise children </li></ul><ul><li>Women are not discouraged from working </li></ul><ul><li>(Hodge, 2005) </li></ul>
High Risk Behaviors <ul><li>High rate of smoking </li></ul><ul><li>Overeating and lack of exercise </li></ul><ul><li>Not obtaining healthcare </li></ul><ul><li>Little data on HIV/AIDS; related to modesty </li></ul><ul><li>(Hodge, 2005) </li></ul>
Three Health Problems Identified in the Muslim Population <ul><li>Tobacco use </li></ul><ul><li>Diabetes </li></ul><ul><li>Less frequent female health screening </li></ul><ul><li>(Jaber, Brown, Hammad, Zhu & Herman, 2003) </li></ul>
Tobacco Use <ul><li>Cardiovascular risk factors of Arab Americans </li></ul><ul><li>Study particularly looked at smoking history </li></ul><ul><li>Results showed higher smoking rate </li></ul><ul><li>Results showed lower rate of quitting smoking </li></ul><ul><li>(Weglicki, Templin, Rice, Jamil & Hammad, 2008) </li></ul>
Water-Pipe Use <ul><li>Also called hookah, narghile, sheesha </li></ul><ul><li>Popular in Middle East and North Africa </li></ul><ul><li>100 million daily users </li></ul><ul><li>Smoking promotes feeling of relaxation </li></ul><ul><li>Promotes conservation </li></ul><ul><li>Social interaction </li></ul><ul><li>(Baker & Rice, 2008) </li></ul>
Epidemiological Data on Global Smoking <ul><li>4 million tobacco related deaths per year and will double by 2020. </li></ul><ul><li>Every 8 seconds, someone dies from tobacco use </li></ul><ul><li>Smoking has increased in most developing nations </li></ul><ul><li>Smoking has decreased in U.S. the last three decades </li></ul><ul><li>Every minute 10 million cigarettes are sold </li></ul><ul><li>(CDC, 2008) </li></ul>
Epidemiological Data on Global Smoking <ul><li>Highest rate of smoking worldwide: Western Pacific Region </li></ul><ul><li>80,000 - 100,000 children start smoking every day </li></ul><ul><li>Among young teens: 1 in 5 smoke worldwide </li></ul><ul><li>50% of adolescents who start smoking go on to smoke as adults </li></ul>
Epidemiological Data for Middle- East and Smoking <ul><li>According to WHO in 2000, Yemen is in the top 10 countries worldwide for tobacco use </li></ul><ul><li>Other Middle Eastern Countries with highest percentage of tobacco consumption among men is as follows: Tunisia (69%), Djibouti (57.5), Iraq and Syria (50%), Jordan (48%) and Lebanon (46%). </li></ul><ul><li>Highest female tobacco consumption: Lebanon (35%) followed by Jordan (10%) </li></ul><ul><li>Lowest percentage: Oman (15.5%), United </li></ul><ul><li>Arab Emirates (18.3%) and Saudi Arabia </li></ul><ul><li>at (22%) for men </li></ul><ul><li>(WHO, 2009) </li></ul>
Cultural Factors about Smoking in Muslim Society <ul><li>Male dominated society and demonstrates power. </li></ul><ul><li>Social interaction </li></ul><ul><li>Stress </li></ul><ul><li>Traditions such as usage of water-pipes. </li></ul><ul><li>Water -pipes believed to be less harmful than cigarettes. </li></ul><ul><li>Saudi Arabia and Oman </li></ul><ul><li>have banned smoking in </li></ul><ul><li>public places. </li></ul>
Healthy People 2010-2020 Initiatives on Smoking <ul><li>National Health Objectives in order to improve health of society. </li></ul><ul><li>Tobacco Use is major focus area for health initiative and focus goal for program. </li></ul><ul><li>Smoking is one of the leading cause of health indicators in United States </li></ul><ul><li>23.1% of males and 18.3% of females smoke in United States </li></ul>
Consequences of Smoking <ul><li>Cigarette smoking causes many cancers </li></ul><ul><li>Second hand smoke </li></ul><ul><li>Risk increases with exposure to cigarette smoke </li></ul><ul><li>Benefits of smoking cessation </li></ul><ul><li>Suffering increased with lung cancer </li></ul>
Negative Media Ads <ul><li>Advertising geared towards adolescents </li></ul><ul><li>Marketing aimed at increasing sales </li></ul><ul><li>$1.06 billion spent on promoting cigarettes </li></ul><ul><li>Quit Smoking Ads </li></ul><ul><li>(Sussman, 2001) </li></ul>
References <ul><li>Ahmad, N.M. (2004, April). Arab-American culture and healthcare. Retrieved March 28, 2010 from http://www.case.edu/med/epidbio/mphp439/Arab-Americans.htm </li></ul><ul><li>De la Cruz, P., & Brittingham, A. (2003). The Arab population: 2000 census. U.S. Department of Commerce, Economics and Statistics Administration. Retrieved March 28, 2010 from https://ask.census.gov/cgi-bin/askcensus.cfg </li></ul><ul><li>Dobbins, M., DeCorby, K., Manske, S. & Goldblatt, E. Effective practices for school-based tobacco use prevention. Preventive Medicine. 46(4) (2008), p.p.289-297. </li></ul><ul><li>Glynn, T. J.,& Manley , M.W. (1989). How to kelp your patients stop smoking: A national cancer institute manual for physicians. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Bethesda </li></ul><ul><li>(MD): NIH Publication No. 89-3064,1989. </li></ul><ul><li>Grossman, M., Coate, D., Lewitt M. & Shakotko A. (1983). Economic and other factors in youth smoking. National Science Foundation. Washington (DC) </li></ul>
References <ul><li>Hodge, D.R. (2005).Social work and the house of Islam: orienting practitioners to the beliefs and values of Muslims in the US. Social Work. 50(2) pp162-173. </li></ul><ul><li>Project Towards No Tobacco Use, retrieved on March 31, 2010 from </li></ul><ul><li>www.minorityhealth.hhs.gov/npa /.../ ProjectTowards NoTobaccoUse.pdf </li></ul><ul><li>Rice, v., Weglicki, L, Templin, T., Jamil, H., Hammand, A. Intervention effects on tobacco use in Arab and non-Arab American adolescents. Addictive Behaviors. 35 (1) (2010), p.p. 46-48. </li></ul><ul><li>Sussman, S. School-based tobacco use prevention and cessation: where are we going? American Journal of Health Behavior. 25 (3) (2001), p.p. 191-199 </li></ul><ul><li>Walker, M.S. (2006). Depressive symptoms after lung cancer surgery: Their relationship to coping style and social support. Psycho-Oncology 15: 684-693 </li></ul><ul><li>Weglicki, L.S., Templin, T.N., Rice, V., Jamil, H., & Hammad, A. Comparison of cigarette and water-pipe smoking by arab and non-arab american youth. 2008. Retrieved on April 2, 2010 from www.ncbi.nlm.nih.gov › Journal List › NIHPA Author Manuscripts </li></ul>
References <ul><li>Yosef, A. Culturally sensitive care of the Muslim patient. Journal of Transcultural Nursing.12(3)(2001),pp.228-233. </li></ul><ul><li>Yosef, A. Health beliefs, practices and priorities for health care of Arab Muslims in the United States. Journal of Transcultural Nursing. 19(3)(2008), pp. 284-291. </li></ul>