This post is not about a specific smoking culture that is unique to Egypt, but rather how smoking as a set of attitudes, beliefs and behaviours is widely accepted here. I will try to summarise my experiences with smokers, their attitudes, their relationship with public space and non-smokers.

This post is also an appeal to smokers. If you are a smoker reading this, I am appealing to the kinder side of you. I want to show you how smoking is harmful to others. I want you to respect non-smokers and limit your smoking to outdoor areas, even if smoking is allowed. Even if others are doing it. Even if there is no one else in the room.

Smoke that calms and relaxes you has the opposite effect on me. Not only does the smell of smoke irritate my lungs, it also triggers a whole range of other symptoms that I've come to associate with prolonged exposure to cigarette smoke, such as nausea, headaches, or just the worry that I'm going to get a headache that's going to ruin my day.

I am not trying to persuade you to quit. I want smokers to imagine for a moment that they are non-smokers and to put themselves in the shoes of those who might be bothered or harmed by second- and third-hand smoke. I want them to understand how smoking indoors harms people with weak lungs or asthma.

Especially after COVID has left so many of us with weaker lungs.

How smoking is harmful to you is not the point of this post. I fully believe in your right to harm yourself by smoking as long as it doesn't harm others.

I also want other non-smokers to understand that they don't have to remain silent about the harm and accept toxic indoor air as a fact of life.

Disclaimer: I'm not an economist, a cancer specialist, a pulmonologist or a qualified environmental scientist. So much of what is here is a mixture of my observations, my professional knowledge as a psychiatrist and my lay opinion.

Smoking Culture Dominates Public Space

In my early twenties, I learnt to dance salsa. Salsa dancing is exercise and when you exercise you breathe more air. The studio I went to was smoke-free, but when I finished the introductory class and went to dance venues to practice, I was alarmed at how my lungs and eyes burned when I went home. I never went back.

At the time, I didn't know much about passive or second-hand smoke. Passive smoking is inhaling smoke from other people's cigarettes. I never experienced any harm from it. I tried smoking when I was a teenager, but I couldn't inhale and quickly decided it wasn't for me. I was also lucky that I didn't have anyone in my family to copy. Now I know the evidence points to passive smoking as a cause of lung cancer and coronary heart disease.

I learnt about third-hand smoke in 2009 from this NYT article, the term refers to the particles that smoking leaves on carpets, surfaces, clothes, hair and walls. These particles contain cancer-causing chemicals that build up gradually over time and don't go away by opening windows and letting in fresh air. Animal studies have shown that these chemicals can cause cancer, but there is still no clear evidence of how they affect adult humans. However, there is clear evidence that third-hand smoking harms children. The only way to prevent exposure to third-hand smoking is to prevent smoking indoors.

Smokers dominate all public spaces, making non-smokers feel like a minority. Statistically, only 22% of Egyptians smoke but if you enter any public building, you would think that a much larger percentage smoke.

Most restaurants, cafes and bars allow smoking. If there is a non-smoking section, it's usually in the least desirable area and not physically isolated. A few large café chains have been more successful in isolating smokers, but most small independents don't. In restaurants, smoke ruins the taste and smell of the food and makes the experience of eating out terrible.

There are no non-smoking bars in Egypt. Very few have outdoor areas. If they do have an area for music or dancing, it is never smoke-free. Smoking patrons rarely think about the effects of passive smoking on the health of workers who have to work 8-hour shifts every day and are exposed to toxic air.

Offices often don't ban smoking indoors; a more understanding workplace will designate a room for smoking. This is often the office kitchen or lunch area. Smoke is rarely completely contained in the kitchen and will naturally spread to the rest of the office. It is also disgusting and ruins the lunch break for everyone else.

In hospitals, doctors' lounges or rest areas aren't smoke-free. Doctors who smoke rarely care about their non-smoking colleagues who often have to spend the night in these rooms. They sleep on sheets covered with carcinogenic dust.

Smoking is allowed in psychiatric hospitals, even though it is harmful to mental health. Smoking worsens depression and anxiety, and smoking reduces the effectiveness of certain psychiatric drugs. There is evidence from large UK mental hospitals that banning smoking leads to a counter-intuitive reduction in violence.

Cigarettes and tobacco products are given very special treatment when they are sold; in supermarkets, cigarettes are sold in special dazzling infinity displays. These are often placed in the most prominent part of the shop. Petrol station shops sell everything above the list price except cigarettes.

Smokers' cars are sold on the second-hand market at the same price as non-smokers' cars. Asking for a reduced price because the car smells bad is met with blank stares.

Some smokers do not care whether they smoke in an air-conditioned room or not. The air conditioning filters become saturated with smoke and it is impossible to make the room smell clean again. The maintenance required to keep an indoor smoking area clean is unreasonable. Air conditioning filters need to be cleaned frequently, walls painted every year and sofas reupholstered every so often to keep the place looking and feeling clean.

In trying to defend my right not to be poisoned by second and third-hand smoke. I have witnessed the most bizarre behaviours and justifications.

• Smokers gang up and bully colleagues who try to change the rules around smoking in the workplace.

• Smokers underestimate (willingly or not) the damage they do to others, often sneer at people who complain, and fail to understand the physics of gases (that they spread in all directions and pollute the air for everyone).

• Smokers often stand by a door and point their cigarette arm out of the room, as if this would prevent the smoke from spreading inwards.

• Many smokers don't care if children or pregnant women will use the room they are using. As long as they are not blowing smoke in their face it is fine.

• If unobserved, smokers will smoke in non-smoking areas. They will throw cigarette butts everywhere.

• When I complain to smokers, they roll their eyes, look blank as if I am saying something unintelligible, or make derogatory comments to their fellow smokers.

• Outside hospitals and religious buildings, smokers don't intervene when their fellow smokers break the rules. They turn a blind eye or laugh it off.

If smoking makes you feel better, please do it outside, otherwise your temporary relief will be stolen from others who will feel worse if you spoil the shared space.

This is the norm. This is the normalised attitude that the smoking culture has enabled. The few people who behave in a civilised way are the exception. But they rarely turn their understanding into lasting action, telling other smokers off or helping to change the rules in their workplace.

Smoking Culture Dominates Imagination

The way smoking has captured our collective imagination makes it hard for people to change their behaviour, which reduces the space available for non-smokers to work or enjoy basic activities unharmed.

You can't have lived in Egypt if you haven't noticed how daytime smokers during Ramadan, especially men, are often seen as justified in their anger at not being allowed to smoke. People tiptoe around them. But the opposite is unthinkable.

Smoking is portrayed gratuitously in films, literature and works of art. If you are an artist and include smoking characters in your work, think about how the behaviour of your creation is a model for young people.

When portrayed in the media, smoking sends a powerful message to young people. Film directors and actors use smoking to project character traits typically seen in tobacco advertising: toughness, rebelliousness and sexiness.

So if you smoke, you are essentially a British American Tobacco brand ambassador, or your character is free marketing for tobacco companies. And there have to be more imaginative and less clichéd ways of portraying what you are trying to project.

Smoking Culture Dominates Policy

The Egyptian government has a monopoly on the manufacturing of cigarettes in the country. Through holding 50.5% of the shares of the Eastern Company. At the same time, it is the one in charge of tobacco policy. There are laws banning smoking in government buildings but they are never enforced.

Given the rates of increase in the number of smokers (4 times that of the population growth) and the major youth bulge in the population pyramid (35% of the population are in the age range of initiation of smoking), the Eastern Company should expect unimaginable profits in the next few years. I don't think any serious enforcement of laws regarding public smoking or any strict policy change would be introduced any time soon.

Cigarettes are treated as a basic product. Like sugar, wheat and cooking oil. The prices of cigarettes are relatively cheap compared to the rest of the world. Taxes are certainly not enough to offset the public and private spending on healthcare costs of tobacco-related illnesses.

Smoking cessation clinics are rare and under-equipped and smoking cessation treatments are either unavailable (Nicotine Replacement Therapy) or very expensive (Varenicline).

Smoking and the Environment

There is a common misconception about the relationship between smoking and the environment. There are charity and government-sponsored events promoting smoking cessation or smoke-free Ramadan tents to save the environment. The emphasis is on how the smoke-filled rooms damage the 'environment' of the participants.

Tobacco farmers in Brazil, Kenya, Zimbabwe and India are trapped in cycles of debt (and slavery) to tobacco companies that end in suicide. Children working in tobacco fields are poisoned by the nicotine in wet tobacco leaves and exposed to toxic pesticides that cause kidney damage, convulsions and cancer. Land that could be used to grow food is being taken for the cash crop. Whole forests are cut down to make way for tobacco. Forest wood is burned to cure the tobacco leaves. Disposable plastic lighters end up in landfills and cigarette butts pollute the oceans.

A few months ago I went to a cafe for a quick coffee and a bite to eat before starting my clinic. The cafe had just been renovated. On the upper floor, they had divided the place up unevenly, with one-third enclosed in glass with separate ventilation and the other more spacious. As a well-trained non-smoker, I took my tray and sat down in the enclosed space, thinking how thoughtful they were to create a protected area for us. Having sat down, I suddenly realised I couldn't breathe. It turned out that the cafe had, by design, created a larger, more welcoming area for non-smokers and a smaller, separate area for smokers with its own ventilation. I think cultures change. I also think that public spaces should be made accessible to everyone.

I took my tray and sat outside and watched smokers as they swam in their smoke-filled glass bowl. I contemplated the common counter-argument to banning indoor smoking - that indoor smoking can be allowed if there is adequate ventilation, but I can't see how this is feasible without completely isolating smokers from non-smokers. Not to mention the cost of modifying buildings for such a segregated system. Perhaps, it would be much easier if each smoker stepped outside, finished their cigarette and got back in.

As my health and tolerance to second-hand smoke deteriorate, I can see myself being prevented from enjoying live music, dancing, hanging out with friends and colleagues, celebrating their birthdays or eating outside.

This toxic culture of smoking harms those around you, traps people from a young age, lines the pockets of tobacco companies, drives deforestation, pushes farmers to suicide and makes it harder for you to quit.