Attitudes of Roma toward Smoking: Qualitative Study in Slovenia

Abstract

Aim

To understand the reasons for widespread smoking behavior among Roma in Slovenia for the purpose of developing successful smoking cessation interventions.

Method

A qualitative focus group approach using a combination of pre-structured and open-ended questions was applied to collect the data from the representative members of the Roma community in southern Slovenia. The discussions were audiotaped and transcribed, and the collected data analyzed according to qualitative content analysis theory.

Results

The content analysis revealed that smoking was a strong part of the cultural, ethnic, and individual identity of the Roma. Even children smoked. Doctor’s advice to quit smoking was usually not followed and the attempts to quit were usually unsuccessful. Difficult financial situation was never mentioned as a possible motive to quit. Roma held a tenacious belief that the harmful effects of smoking were in the hands of destiny and did not associate the smoking-related illness with the habit.

Conclusions

Traditional strategies for smoking cessation are largely ineffective among the Roma because of their different attitudes toward smoking. Therefore, innovative and culturally acceptable methods need to be developed.

According to the 2002 Census, 0.2% of inhabitants in Slovenia are Roma. However, on the basis of reports of social centers and schools, their real number could be up to four times higher than this (1). The socio-economic status, education level, and employment rate among Roma are considerably worse than among other Slovenian population, which places many of them into the category of poor people and thereby, at increased health risk.

From the cultural point of view, the Roma are a highly specific ethnic minority. These once nomadic people now mostly live in poor accommodation and have difficult housing situation. The health culture of the Roma and their use of health care are low despite the fact that most of them can obtain full state-provided medical insurance irrespective of their employment status (2). Due to low hygienic and microclimatic conditions, low health education, and excessive smoking, diseases of the respiratory system seem to be among their most important health problems (3-5). Although epidemiologic data hardly exist, the Roma are known to be heavy smokers. The Roma trust in traditional folk medicine and do not believe smoking is a health-threatening habit (2). The percentage of smokers among the Roma in Slovenia is unknown. Studies from other countries show that, similar to other cardiovascular risk factors, smoking is by far more frequent in Roma than in other populations (5,6).

Countries with a Roma population, whose health status is usually poor and socioeconomic position the lowest in the country (7-10), realized that research into the health status of the Roma people is needed for the planning of health intervention strategies, such as antismoking campaign (11,12). From everyday practice we know that the Roma never stop smoking and that they smoke heavily. We performed a qualitative study to understand the reasons for widespread and heavy smoking among the Roma in Slovenia for the purpose of developing more successful public health actions against smoking in their community.

Methods

Three Roma women and 9 men, aged between 17 and 74 years, were invited to join two focus groups to discuss smoking-related issues. The participants were representative of the Roma community in southern Slovenia with respect to socioeconomic and educational parameters. Two men had jobs; 3 men were retired, and 4 were unemployed. Seven participants were married, 4 were single, and one was a widower. Seven men and one woman had not finished primary school. Seven men and all 3 women had full health insurance. The participants were invited through the Roma tribal leaders and investigators’ contacts in their community during fieldwork. Since the population is stable and closely linked together, based on a specific hierarchy, the sampling was very specific, purposeful, and stratified.

The discussion was led by a trained interviewer (DL), using a combination of pre-structured and open-ended questions. Each focus group met once at the local radio station. The questions were prepared in advance and based on a topic guide derived from the existing literature on the cultural context of the Roma. The focus group discussions had duration of 70 minutes on average. The issues addressed included the smoking behavior and habits, the attitudes toward quitting, the opinions about relations of smoking, and health damage.

The discussions were audiotaped and transcribed, and the collected data analyzed according to qualitative content analysis theory (13,14). Two investigators (DP and DL) independently marked and coded important quotations (statements with some important meaning) in the textual material. The differences in the coding process were solved by reaching a consensus. The process was repeated until no new codes emerged. The application and revalidation of the codes and quotations into the themes and categories, which represented the final textual data set, was performed by three investigators (IŠ, DP, and DRP).

Results and Interpretation

The statements of our study participants confirmed that Roma around the world see smoking as part of their ethnic and individual identity. Smoking is acceptable for men and women, adults and children alike (Table 1). Smoking is part of family life, a habit introduced by older family members to younger ones. Mothers do not actively prohibit smoking to their children. Father who smokes represents especially strong risk factor for smoking in children (15). Smoking motivates children to start working and earn money for the cigarettes. Parents quickly accept that their children smoke because it is part of growing up.

Table 1.

Key statements on smoking in two focus groups representative of Slovenian Roma community

Smoking	Comments (transcripts)
Part of ethnic identity and family life	All Gypsies smoke, everywhere, in Germany, France, the Netherlands. Until they die I’ll tell this literally, Gypsies won’t be forbidden to smoke, I’m positive about that, it's inside me...
Smoking among children	Roma children start smoking at five, or seven, put simply, when they come out of diapers, they already smoke. …My cigarettes were missing… She would go out, daddy isn’t watching, she would smoke 5,6 in a row… Then I said something like this: “You can smoke I allow you, but you will smoke according to the rules. When mama lights up, mama gives you two smokes.”
Source of pleasure	I smoke cigarettes as a hobby, when others smoke.
Awareness of health risks associated with smoking	The cigarette isn’t harmful to me, it’s my pleasure and I light it up when I feel like it… As I said it’s not harmful to me, only now have I started to feel pressure in my chest. When I inhale that smoke … I sometimes suffocate, sometimes I use an inhaler… I was told I have chronic bronchitis. I have breathing difficulties, I don’t know whether it comes from cigarettes or not. I think they (cigarettes) harm my health… I have a short breath… then I light a cigarette and breathe even more difficult… then I smoke two, three packages… I hope I will never quit. You die anyhow. When the destiny comes, you die. I don’t feel any harmful effects. Maybe, if I were older, like my father.
Passive smoking within the family	Cigarettes are very harmful to my little one, when I smoke beside her. She is screaming at me to put the cigarettes away, she has bronchitis…
Attempts to quit	When I open my eyes, a cigarette is first. If I don’t have it, my nerves break down. My body needs nicotine. I abstained from (smoking) only one day. I would like to give up (smoking)… no way… cigarettes will go to the grave with me. My doctor suggested I stop smoking, but I said I can’t, it’s not possible. I think, I’m still young, I don’t know. Maybe I’ll quit one time, maybe not.

Smoking is a hobby, part of social life, and a source of pleasure (calming effect).

The Roma have basic knowledge about the harmful effects of cigarettes on health, but they do not seriously consider quitting and passively accept the health consequences of smoking. Such attitudes are even stronger in younger Roma, who feel that bad effects of smoking are something that goes with older age. The Roma do not pay any attention to passive smoking of other family members, even children.

The Roma in our focus groups who stated they had health problems had tried to quit smoking. Very heavy smokers were often aware that smoking was sort of a drug addiction and could not cope with the problems of physical addiction (Table 1). The mentioned attempts at quitting were unsuccessful. Difficult financial situation was hardly ever mentioned as a motive for quitting.

Physicians are perceived by the Roma only as a source of information on smoking-related diseases and providers of medications for better breathing. In response to physician’s advice to stop smoking, the Roma felt that switching to lighter cigarettes was as much as they could do. Young Roma did not even try to stop smoking as they did not see a need for that.

A nationwide preventive program implemented in Slovenia in the last decade has led to a slight decrease in the smoking population (16), but it has obviously failed to reach Roma people. Low educational level, low income, and low level of acculturation could be the reasons for generally unsuccessful effects of such public health actions.

The Roma do not see smoking as harmful to everybody. Destiny is the only thing they believe in. Even symptoms of lung illnesses do not alarm the Roma to change their smoking behavior (Table 1). Young people are unaware of the detrimental health effects of longterm smoking that they could suffer in older age. Sick people in their surroundings do not increase their feeling of vulnerability or their desire to quit.

It is difficult to find an effective method to change smoking behavior among the Roma. Education is quite insufficient. It seems that only the people close to them, such peer educators or their permanent primary care physician, have a chance of influencing their attitudes. The idea of peer education on the hazards of smoking has led to positive results in previous studies (17). The preventive approach that primary care physicians, albeit respected by the Roma, currently use is not being taken seriously. Also, physicians’ efforts do not seem to go far beyond short advice to already ill individuals. We could not conclude if the motivation of those who had stated a desire to quit was real or the personal ability to carry out the process of quitting was low. However, the rational knowledge about the harmful effects of cigarettes seemed less important to the Roma than their emotional standpoint.

Some participants stated they were personally incapable of change but felt it would be important for them to quit. These individuals could be the initial target of antismoking campaigns. Since Roma live in close and well-connected small territorial groups with established social hierarchy, the wider Roma population could be reached through the members willing to try quitting. Probably other methods tailored to their culture could also be developed. Those medical and social workers who are familiar with Roma culture should be involved in the development of such programs.

In conclusion, to provide quality medical care to such a specific ethnic group, the physican needs information on their health care problems and needs. Continuous medical education and adjusted programs for changing unhealthy habits among Roma are necessary, as well as different forms of interventions. Caregivers familiar with the Roma culture should be involved in the development of such interventions.