Prevalence of Hookah smoking and associated factors among male high school students in Iraq.

Abstract

Background The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region and reaching to Western countries. Hookah smoke users are exposed to a lot of chemical compounds and several chronic diseases. The purpose of this study was to determine the prevalence of hookah use among male high school students and to study different associated factors linked with hookah smoking.

Methods A descriptive cross-sectional study was conducted among students in three high schools in Al-Karkh District, Baghdad. The study period was from Oct. 2017 till Jan. 2019 and included 847 male students. A structured Knowledge Attitude and Practice questionnaire was used to identify their knowledge and use of hookah smoking. Descriptive, chi-square, bivariate and multivariate logistic regression analysis of data was carried out using the available software statistical package of SPSS-25.

Results The overall prevalence of hookah smoking among high school male students was high (46%). More than two-thirds (70.6%) of them think that waterpipe smoking is acceptable socially more than cigarette smoking. More than half of the participants (55%) first heard about hookah smoking from friends and friends constitute close to two-thirds (65.2%) of those who smoke hookah around students. Almost half of the respondents think hookah smoking is not encouraged in the faith of Islam (47.3%) and less than a quarter (20.9%) think it's completely forbidden in Islam.

Conclusions Hookah smoking is increasing among high school students and becoming a socially acceptable behavior that needs preventive strategies targeting this age group.

Background

Globally, tobacco use is considered the second leading cause of death, and it is responsible for the deaths of 1 in 10 adults [1]. Many carcinogenic compounds are found in the smoke from tobacco which is the leading cause of different types of cancer in the body especially; lung cancer [2] is considered the leading cause of cancer mortality in the world [3]. In addition to cancer, it can cause several respiratory infections where nicotine contained in cigarette smoke decreases the immune response defending the body from malignant growth [4]. Smoking along with hypertension and diabetes, among others are major risk factors for cardiovascular diseases. The effects of each of these risk factors potentiate the risk of cardiovascular events [5,6,7].

Hookah “Shisha, Hubble-Bubble, Nargileh & Water-Pipe (WP)” smoking is another form of tobacco use. Although hookah smoking practices dating back at least 400 years, nowadays the use of this device to smoke is increasing at large scale from the Eastern Mediterranean region reaching Western countries [8,9]. Hookah design features a water bowel size, hose, and mouthpiece. Several studies have been shown that hookah contains harmful chemicals [10–13], and a single 45-minute hookah session can expose the smoker to 48.6 times the amount of smoke as to smoking a cigarette [14]. In the US and from 2011 to 2016, current use of hookahs increased among middle and high school students, and in the year 2016 2% of middle school students reported that they had used a hookah in the past 30 days “an increase from 1.0% in 2011” [15,16]. Also in the US, a study shows the prevalence of Males use hookah more than females (17).

In Iraq, few research studies are related to hookah smoking and were done mostly among college students [18]. This study aimed to find out the prevalence of hookah use among male high school students and the associated factors with it.

Methods

A cross-sectional survey of adolescent students in high schools in Baghdad was done. The cluster was a convenient non-probability sampling within one of the two districts in Baghdad (Al-Kharkh and Risafa). Al-Karkh side “twin half of Risafa side” of Baghdad City was selected to be the place of study which consists of 3 educational directorates. One school was selected at simple random sampling from each directorate to be the sample representative of the students. All students were recruited as the population under study.

Ethical approval was granted by the ethical committee at Anbar University and Directorate of education at Al-Karkh district. Also, permission from school principals and staff was obtained to enter classes and made interviews with the students. Students were verbally consented by the research staff and according to accepted research standards in Iraq, no parental consent was required. The collection of data was from Oct. 2017 till Jan. 2019.

Sample size calculation is based on the equation: (n = Z2 1-a p (1-p)/ d2) where n is the required sample size [19] and sample size of 847 students aged 15 to 18 years old were included in the study, with level of significance at 5%, and a random selection of high schools was made to include all eligible students. The questionnaire was based on the California Tobacco Surveys for tobacco use [20] and modified to the social context of Iraq. A structured Knowledge, Attitude and Practice (KAP) questionnaire form was prepared to students which include questions to identify their knowledge and use of hookah smoking, their sources to obtain tobacco hookah smoking, the effect of cultural and social relations in starting hookah smoking, and their ability to quit hookah smoking.

Analysis of data was carried out using the available software statistical package of SPSS-25 (Statistical Packages for Social Sciences- version 25). Data were presented in simple measures of frequency, percentage, mean, standard deviation, and range (minimum-maximum values). The significance of the difference between different percentages (qualitative data) was tested using the Pearson Chi-square test (χ²-test) with the application of Yate's correction or Fisher Exact test whenever applicable. Bivariate application and multivariate logistic regression analysis of data was carried out for comparison between independent variables among those who smoke hookah. Statistical significance was considered whenever the P-value was equal or less than 0.05.

Results

Table 1 shows that a highest percentage of students first heard and knew about hookah from friends (55%) and most of them (86.1%) knew that there is a café shop for hookah smoking near their residence. It was found that the friends who smoke hookah are the highest group among the people who surround the hookah user (65.2%) followed by close relatives (31.6%), brothers/sisters (31.6%) and father/mother (4.5%).

Participant’s opinion about different types of smoking and its effect on health from the worst to the better rate order was hookah, cigarette, e-cigarette and tobacco gum.

The student’s knowledge about Islam’s opinion regarding shisha smoking as mostly being discouraged (47.3%) or forbidden (20.9%).

More than two-thirds (70.6%) of the students think that waterpipe smoking is more acceptable socially than cigarette smoking and only 37.1% of them thought that waterpipe smoking was less harmful and less addictive than cigarette smoking. There was an agreement for the need for regulations to prevent or forbid hookah café places (81.5%).

Table 1: First heard about hookah, Café near a residence, smoke hookah from the surrounding, Opinion of participants regarding the harmfulness of tobacco, Islam’s opinion, social acceptance, hookah harmfulness and addictiveness, and regulations against hookah café.

Regarding the average number of hookah smoked in the last 30 days, table 2 shows that 28.1% tried it once, 16.6% tried it twice, and 11.3% tried it three times. Among hookah smokers, 85.5% smoked it in the last six months. Age at first hookah use was the highest at the age of 16 and 15 (27.4 % and 26.3 % respectively), followed by the age of 14 (15.1%).  The average number of hookah smoking sessions among current regular users per day was one in 13.3%, two, three, four, five times and more in 34.3, 31, 20.7 & 0.8% respectively. The prevalence of sharing the mouthpiece with others during hookah smoking was never in 30.7%, sometimes in 34.6%, most of the time in 15.1%, and always in 19.7% of the students.

Table 2: Number of hookahs smoked (last month), hookah smoking in the last 6 months, age first smoked hookah, hookah sessions per day, duration of sessions, mouthpiece sharing, confident to quit hookah smoking.

Regarding the place of hookah smoking, high rate of students smoke at Café shop (61.1%) and more than three-quarters of participants in this study get their hookah tobacco from a hookah shop (78%).

Low prevalence rate (only 12.9%) think that Electronic cigarette (e-cigarette) can be a substitute to hookah smoking but high percentage of them (61.3%) do not know if it is less harmful and less addictive than hookah smoking. 

Table 3 demonstrates the association between hookah smoking among students and various factors. The association was significant with friends (first heard about hookah), media, café around residence, brother & sister (who smoke around student) and friends, Cigarette more harmful than other types of smoking, Islam discourage smoking, socially acceptable and within regulation to forbid café shop.

Table 3: Bivariate analysis for association of different factors affecting hookah smoking.

In Table 4, logistic regression reveals that all sub variables among who smoke from surrounding students, hookah acceptable socially, hookah less harmful than cigarette, Islam forbid smoking, and regulation to forbid café shop are significantly associated with hookah smoking among high school students.

Table 4: multivariate logistic regression of risk factors affecting hookah smoking

Discussion

In this first study of male high school students in Baghdad, we found that although most students who smoked hookah had correct opinions about the harm of hookah smoking as well as support for regulations against café shops, the overall prevalence of hookah smoking among those students was high (46%). This high prevalence is similar to a study in Saudi Arabia (secondary school adolescence male, aged >18 years) were the overall prevalence of hookah smoking was 44% [21]. However, this was much higher than the prevalence in Iran and Jordan. Abbas et al. and Alzyoud et al. studies of Iranian and Jordanian high school male students reported different lower rates (6% and 24% respectively) [22,23]. The high reported in our study might reflects the acceptance and spread of such harmful behavior in such a young age group of students due to recent problems of conflict imposed on Iraq making smoking control and education of priority.  

More than half of participants first heard about hookah smoking from friends and more than two-third have friends who smoke hookah which highlighted the role of friends in initiating hookah smoking and play as an important factor of their tendency towards using it more and more. The same findings were reported by Azodi et al and Bejjani et al [24, 25]. This points out a new generation of hookah users, unlike previous generations where it was not smoked as commonly which is seen globally.  

Among different types of tobacco smoking, hookah smoking was the highest among students who believe it causes more harm to the health of humans. Aslam et al. in his review explained the significant association between hookah smoking and increased risk of heart disease, cancer, and hypercholesterolemia. [26]. Although adolescence in this study believe that hookah has worse health effects on them than other types of smoking but perhaps the effect of the nice aroma of smoke, flavor, and taste of hookah smoking overcomes their perception about harm and choice of smoking. Besides, the hookah device can bring new and more groups of friends smoking together in restricted or specific places. These could explain the reason hookah smoking is more acceptable socially than cigarette smoking. This is in agreement with Fitzpatrick et al. in the USA, Momenabadi et al in Iran and Tamim et al in Lebanon all showed that attempts of hookah smoking among young adult users were associated with their belief that it is socially and culturally acceptable than cigarette smoking [27-29]. All this led to an increase in the prevalence of this behavior. Therefore, it is a challenge that norm of acceptance can be changed in the society so that hookah users consider it similar to cigarette smoking.

High prevalence of students thinks hookah smoking is discouraged and forbidden in Islam (68.2%) reflecting that religion could play an important role in preventing smoking in addition to a lot of risky behaviors such as drug abuse, gambling, alcohol drinking. A study was done in Jordan where they studied smoking habits among university students in different faculties and academic level, it showed that those in the faculty of religious studies were less likely to smoke compared to those in other faculties [30].

More than one-third of hookah smokers in this study share the same mouthpiece of hookah devices most of the time and always. Sharing the same mouthpiece with a different group of people and friends can lead to different types of infection from mouth, sputum, and lung.  Munckhof et al. concluded in his study that transmission of tuberculosis was found in people sharing a marijuana hookah with a case of pulmonary TB [31].

Sajid et al. reported that carboxyhemoglobin concentration in cigarette smokers is lower (6.1 ppm) as compared to shisha smokers (8.8 ppm) [32]. In the current study more than three-quarters of adolescence smoke hookah for equal or more than 30 minutes at each session. Duration of hookah smoking sessions, depth of inhalation, and frequency of puffing all participate in the level of exposure to nicotine and other carcinogenic chemical materials present in charcoal and tobacco in shisha smoke.  In this report, more than three-quarters were confident that they can quit hookah smoking. It’s doubtful they could quit hookah smoking. As mentioned above hookah has more concentration of carboxyl group, nicotine, and other chemical materials than cigarette smoking that has addictive patterns once the body is saturated with its difficult to withdraw or quit from smoking.

Multivariate logistic regression in this study shows a significant difference among subgroups of those who smoke around the students that can reflect the influence of family and peers on adolescent health and behavior [33]. The hookah was the only sub variable significant among others in comparison with the reference category e-cigarette. Also, hookah smoking is acceptable socially and less harmful than cigarette smoking, and agree on regulations to forbid café places all were significant in comparison with their references. 

Limitations and strength of the study

The study was not a random representation of all Iraqi high school students but we believe that these results would be relevant to the rest of the students in the country given the similar social norms across the country. Also, the questions might be sensitive to some leading to underreporting. However, the students filled the questionnaire in absence of their teachers, and therefore no one would be able to track the answers to specific students. There were no missing forms. 

Conclusions

Hookah tobacco smoking rates are very high among high school students and becoming an acceptable socio-cultural phenomenon in Iraq, urging the need for effective preventive measures to be started to overcome the spread of hookah smoking among adolescents who will carry this addiction into adulthood.

Declarations

Ethics approval and consent to participate

The Research Ethics Committee at the College of Medicine, University of Anbar approved the study. All students were informed of the study purpose and the voluntary and anonymous nature of participation, before providing written informed consent.

Consent for publication

‘Not Applicable’

Availability of data and material

The datasets generated and/or analyzed during the current study are not publicly available.

Competing interests

The authors declare that they have neither competing interests nor financial disclosure.

Funding   

This study was self-funded.   

Authors' contributions

Both authors read and approved the final manuscript.

Acknowledgments

The authors thank the study participants for their contribution to the research, as well as school staff.

Author information

Affiliations

Family & Community Medicine Department, Medical College, the University of Al- Anbar

Ahmed K. Al-Dealimy

Family & Community Medicine Department, Medical College, University of Al-Mustansiriyah

Waleed AT Al-Ani

Corresponding author

Correspondence to Ahmed K. Al-Delaimy

Abbreviations

KAP: Knowledge, Attitude, Practice

WP: Water Pipe

e-cigarette: electronic cigarettes

References

1. Al-Numair K, Barber-Heidal K, Al-Assaf A, El-Desoky G. Water-pipe (shisha) smoking influences total antioxidant capacity and oxidative stress of healthy Saudi males. Journal of Food Agriculture and Environment. 2007 Jul 1; 5(3/4): 17.
2. Hecht SS. Tobacco carcinogens, their biomarkers, and tobacco-induced cancer. Nature Reviews Cancer. 2003 Oct; 3(10): 733.
3. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA: a cancer journal for clinicians. 2005 Mar; 55(2): 74-108.
4. Sopori M. Effects of cigarette smoke on the immune system. Nature Reviews Immunology. 2002 May; 2(5): 372.
5. Beaney T, Burrell LM, Castillo RR, Charchar FJ, Cro S, Damasceno A, Kruger R, Nilsson PM, Prabhakaran D, Ramirez AJ, Schlaich MP. May Measurement Month 2018: a pragmatic global screening campaign to raise awareness of blood pressure by the International Society of Hypertension. European heart journal. 2019 May 1; 40(25): 2006-17.
6. Rashid AA, Devaraj NK. Oh no! now I have diabetes. RMJ. 2018; 43(4): 776-78.
7. Chia YC, Ching SM, Chew BN, Devaraj NK, Siti Suhaila MY, Tay CL, Kang PS, Verna Lee KM, Kong SZ, Teoh SW, Nurjasmine AJ. May Measurement Month 2017 blood pressure screening: findings from Malaysia—South-East Asia and Australasia. European Heart Journal Supplements. 2019 Apr 1;21(Supplement_D): D77-9.
8. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine & tobacco research. 2007 Oct 1; 9(10): 987-94.
9. Maziak W. The global epidemic of waterpipe smoking. Addictive behaviors. 2011 Jan 1; 36(1-2): 1-5.
10. Al Rashidi M, Shihadeh A, Saliba NA. Volatile aldehydes in the mainstream smoke of the narghile waterpipe. Food and Chemical Toxicology. 2008 Nov 1; 46(11): 3546-49.

11. Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. American journal of health behavior. 2010 May 1; 34(3): 275-85.
12. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects. Nicotine & Tobacco Research. 2010 Dec 2; 13(2): 78-87.
13. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide,“tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology. 2005 May 1; 43(5): 655-61.
14. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. American journal of preventive medicine. 2009 Dec 1; 37(6): 518-23.
15. Singh T. Tobacco use among middle and high school students—United States, 2011–2015. MMWR. Morbidity and mortality weekly report. 2016; 65.
16. Arrazola RA, Dube SR, King BA. Tobacco product use among middle and high school students—United States, 2011 and 2012. MMWR. Morbidity and mortality weekly report. 2013 Nov 15; 62(45): 893.
17. Majeed BA, Sterling KL, Weaver SR, Pechacek TF, Eriksen MP. Prevalence and harm perceptions of hookah smoking among US adults, 2014–2015. Addictive behaviors. 2017 Jun 1; 69: 78-86.
18. Thabit MF, Mohsin MA, Niazy SM. Water pipe (Shisha) smoking among a sample of Iraqi male college students: knowledge and attitudes. Age (years). 2015; 20: 20-24.

19. Kadam P, Bhalerao S. Sample size calculation. International Journal of Ayurveda research. 2010 Jan;1(1):55.
20. Al-Delaimy, WK; Edland, S; Zablocki, RW (2016): California Smokers Cohort (CSC) 2011. In California Smokers Cohort (CSC). UC San Diego Library Digital Collections. https://doi.org/10.6075/J00V89RP
21. Amin TT, Amr MA, Zaza BO, Suleman W. Harm perception, attitudes and predictors of waterpipe (shisha) smoking among secondary school adolescents in Al-Hassa, Saudi Arabia. Asian Pac J Cancer Prev. 2010 Jan 1; 11(2): 293-301.
22. Fakhari A, Mohammadpoorasl A, Nedjat S, Sharif Hosseini M, Fotouhi A. Hookah smoking in high school students and its determinants in Iran: a longitudinal study. American journal of men's health. 2015 May; 9(3): 186-92.
23. Alzyoud S, Weglicki L, Kheirallah K, Haddad L, Alhawamdeh K. Waterpipe smoking among middle and high school Jordanian students: patterns and predictors. International journal of environmental research and public health. 2013 Dec; 10(12): 7068-82.
24. Azodi F, Sharif F, Azodi P, Shirazi ZH, Khalili A, Jahanpour F. The reasons of tendency toward hookah smoking among teens and youth in Iran-A qualitative study. Journal of Pharmaceutical Sciences and Research. 2017; 9(9): 1642-46.
25. Bejjani N, El Bcheraoui C, Adib SM. The social context of tobacco products use among adolescents in Lebanon (MedSPAD-Lebanon). Journal of epidemiology and global health. 2012 Mar 1; 2(1): 15-22.
26. Aslam HM, Saleem S, German S, Qureshi WA. Harmful effects of shisha: literature review. International archives of medicine. 2014 Dec; 7(1): 16.
27. Fitzpatrick M, Johnson AC, Tercyak KP, Hawkins KB, Villanti AC, Mays D. Peer Reviewed: Adolescent Beliefs About Hookah and Hookah Tobacco Use and Implications for Preventing Use. Preventing chronic disease. 2019; 16.

28. Tamim H, Al-Sahab B, Akkary G, Ghanem M, Tamim N, Roueiheb ZE, Kanj M, Afifi R. Cigarette and nargileh smoking practices among school students in Beirut, Lebanon. American journal of health behavior. 2007 Jan 1; 31(1): 56-63.
29. Momenabadi V, Hashemi SY, Borhaninejad VR. Factors affecting hookah smoking trend in the society: A review article. Addiction & health. 2016 Apr; 8(2): 123.
30. Khader YS, Alsadi AA. Smoking habits among university students in Jordan: prevalence and associated factors. East Mediterranean Health J, 2008; 14(4): 897-904.
31. Munckhof WJ, Konstantinos A, Wamsley M, Mortlock M, Gilpin C. A cluster of tuberculosis associated with use of a marijuana water pipe. The International Journal of Tuberculosis and Lung Disease. 2003 Sep 1; 7(9): 860-65.
32. Sajid KM, Akhter M, Malik GQ. Carbon monoxide fractions in cigarette and hookah (hubblebubble) smoke. JPMA. 1993; 993: 43.
33. Tomé G, de Matos MG, Simões C, Camacho I, Alves Diniz J. How can peer group influence the behavior of adolescents: explanatory model. Global journal of health science. 2012 Mar; 4(2): 26.