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Hookah pipe smoking among health sciences students

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N Van der Merwe
N Van der Merwe
N Van der Merwe
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T Banoobhai
T Banoobhai
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A Gqweta
A Gqweta
A Gqweta
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Abstract

Background: Hookah pipe smoking is a social practice and has gained popularity, especially among South African youth. The extent of this practice among health sciences students, and their knowledge regarding the health risks, are unknown. This is important, as these students will become future health professionals possibly influencing the practice of individuals and communities. Objective: To explore the knowledge, attitudes and practices of hookah pipe smoking among students at the Faculty of Health Sciences, University of Cape Town. METHODS. A cross-sectional study was conducted among undergraduate and postgraduate students. A self-administered questionnaire was distributed as a hard copy and online survey. Results: Of 228 participants, 66% had smoked a hookah pipe before, with 18% still smoking. Most began smoking in high school, with 25% initiating at university. Of the current smokers, 65% smoked occasionally socially, commonly at friends' houses for 30 - 60 min/session. A further 11% smoked cigarettes concurrently and 30% added other substances, mainly cannabis, to pipes. Most current hookah smokers had no interest in quitting (84%). Only 30% of participants had prior health information about hookah pipe smoking. Most knew that it was harmful (91%), with many not knowing why. A total of 80% of participants perceived that the practice was socially acceptable and 84% would recommend it to others.CONCLUSION; The poor knowledge about the dangers of hookah pipe smoking and the extent of its practice among health sciences students is alarming. These findings highlight the need for school and university health promotion campaigns, and for better regulation of hookah pipe smoking.
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RESEARCH
847 November 2013, Vol. 103, No. 11 SAMJ
The practice of hookah pipe smoking is centuries old
and has long been used in India, Pakistan, China and
the Eastern Mediterranean.
[1]
Its use has now permeated
many countries and is becoming a popular social
practice globally, especially among young people.
[1-4]
While the water filter and the fruity flavoured tobacco of hookah may
make it seem innocuous, inhaled smoke contains toxic compounds
such as nicotine, carbon monoxide, formaldehyde, polyaromatic
hydrocarbons, arsenic and lead.
[4,5]
A hookah smoking session is
usually longer in duration and involves exposure to much larger
Hookah pipe smoking among health sciences students
N van der Merwe,
1
BSc, BSocSci (Hons), MSc; T Banoobhai;
1
A Gqweta;
1
A Gwala,
1
BSc (Hons), SPED; T Masiea;
1
M Misra,
1,2
MB ChB, MBA;
V Zweigenthal,
1,2
MB ChB, DTM&H, FCPHM (SA)
1
Faculty of Health Sciences, University of Cape Town, South Africa
2
School of Public Health and Family Medicine, University of Cape Town, South Africa
Corresponding author: N van der Merwe (nicolina.vandermerwe@gmail.com)
Background. Hookah pipe smoking is a social practice and has gained popularity, especially among South African youth. The extent of this
practice among health sciences students, and their knowledge regarding the health risks, are unknown. This is important, as these students
will become future health professionals possibly influencing the practice of individuals and communities.
Objective. To explore the knowledge, attitudes and practices of hookah pipe smoking among students at the Faculty of Health Sciences,
University of Cape Town.
Methods. A cross-sectional study was conducted among undergraduate and postgraduate students. A self-administered questionnaire was
distributed as a hard copy and online survey.
Results. Of 228 participants, 66% had smoked a hookah pipe before, with 18% still smoking. Most began smoking in high school, with 25%
initiating at university. Of the current smokers, 65% smoked occasionally socially, commonly at friends’ houses for 30 - 60 min/session.
A further 11% smoked cigarettes concurrently and 30% added other substances, mainly cannabis, to pipes. Most current hookah smokers
had no interest in quitting (84%). Only 30% of participants had prior health information about hookah pipe smoking. Most knew that it
was harmful (91%), with many not knowing why. A total of 80% of participants perceived that the practice was socially acceptable and 84%
would recommend it to others.
Conclusion. The poor knowledge about the dangers of hookah pipe smoking and the extent of its practice among health sciences students
is alarming. These findings highlight the need for school and university health-promotion campaigns, and for better regulation of hookah
pipe smoking.
S Afr Med J 2013;103(11):847-849. DOI:10.7196/SAMJ.7448
RESEARCH
848 November 2013, Vol. 103, No. 11 SAMJ
volumes of smoke.
[6,7]
Studies investigating the acute and long-term
effects of hookah pipe smoking show that it is a risk factor for lung
cancer, periodontal diseases, cardiovascular disease and adverse
pregnancy outcomes.
[8]
It also poses the risks of transmission of
acute and chronic infections, such as tuberculosis and hepatitis, with
sharing of the hookah pipe mouthpiece.
[6,8]
Thus, while hookah pipes
are commonly perceived to be safer than cigarettes,
[3]
they may be
even be more harmful.
Hookah pipe smoking is a highly social practice occurring on
campus, in the family home, at parties, at a friend’s place, or in
restaurants.
[9]
The influence of peers is a major factor in determining
the initiation of using hookah.
[2]
The South African Tobacco Control
policy prohibits tobacco smoking in public spaces, but policies
specifically prohibiting hookah pipe smoking in public spaces
have not yet been implemented.
[9]
Research shows that knowledge
about the hazards of hookah pipe smoking tend to be limited in
adolescents.
[2,9,10]
Easy social and retail access to both the hookah
and its tobacco, combined with a lack of alternative activities,
[11]
contribute to the popularity of hookah.
In South Africa (SA), the use of hookah pipes among students
is highly prevalent.
[9,11,12]
This has been noted with concern by the
Cancer Association of South Africa (CANSA), resulting in them
approaching the School of Public Health and Family Medicine at the
University of Cape Town (UCT) to conduct a study exploring the
knowledge, attitudes and practices regarding hookah pipe smoking.
The extent of this practice among health sciences students who
will become future health professionals is unknown and they could
impact on the practice of individuals and communities.
Objective
To explore the knowledge, attitudes and practices with regards
to hookah pipe smoking among students at the Faculty of Health
Sciences, UCT.
Methods
A cross-sectional study was conducted in March 2013 among the
3582 undergraduate and postgraduate students registered in 2013. The
minimum sample size was calculated to be 256 based on a 40% smoking
prevalence estimate for the Western Cape
[9]
and a precision of 6%.
A self-administered questionnaire was adapted from a previous
hookah pipe study conducted in the Western Cape. Data were
collected via two methods: distribution of hard-copy questionnaires
on campus, and an online survey.
Hard copies were more likely
to be completed by undergraduates who make the most use of
campus areas, while the online questionnaire served to reach senior
undergraduate students and postgraduates. Informed consent was
obtained prior to participation in the study. The study was approved
by the UCT Human Research Ethics Committee.
Results
Sample
A total of 228 students completed the questionnaire; 111 in hard copy
and 117 online. The majority of participants were female (64%). The
mean age of participants was 21.4 years (standard deviation ±4.38).
Over half were undergraduate medical students (54%); 29% health
and rehabilitation sciences and 9% postgraduate health sciences
students. A further 8% were taking subjects in the faculty towards
degrees registered in other faculties.
Hookah pipe practices
Two-thirds of respondents had smoked a hookah pipe before, even if
only once or twice, while 18% are currently smoking. Of the current
smokers (n=41), the majority smoked occasionally socially (65%).
The most common place for smoking hookah was at friends’ houses
(41%), at home (30%), or in clubs and cafés (21%). A small number
smoked on campus (8%). Most participants smoked with friends
(59%), while some smoked with family (20%). Most participants
(61%) smoked between 30 - 60 min/session.
Almost a third of participants (29%) supplemented hookah
products with other substances, most often cannabis (86%), with a
small number adding alcohol. Methamphetamine (‘tik’) and other
drugs were not added. A minority of those who currently smoke
hookah pipe smoked cigarettes too (11%), most daily (60%).
A minority of students (27%) reported adverse health effects (e.g.
cough, shortness of breath, loss of taste and headaches) that they
attributed to hookah pipe smoking. Most current smokers did not
wish to quit (84%).
Most participants began smoking in high school (67%), while a
quarter (26%) began in university. The majority of participants began
smoking hookah pipes because they ‘just decided to’ (67%), while a
smaller number were recommended to do so by someone else (19%).
For most smokers (55%), parents or partners knew that they were
hookah pipe smokers and most (76%) were accepting of the practice.
Knowledge and attitudes
Only 31% of participants had prior infor mation regarding the
dangers of hookah pipe smoking, with 60% obtaining knowledge
from printed and audiovisual media. Knowledge of the health effects
of hookah pipe smoking, drawn from answers to six questions that
referred to these health effects, was categorised as good (29% of
respondents), average (55%) and poor (16%).
Almost all participants (91%) knew that smoking hookah pipes
was harmful. Responses to an open-ended question about why they
thought hookah pipe smoking was harmful or not are shown in Fig. 1.
The majority had a permissive attitude towards hookah pipe
smoking, with 80% believed it to be socially acceptable, and 84%
were willing to recommend it to others. Contrary to this, the majority
of individuals (74%) believed the practice should be subject to legal
regulation.
Discussion
While it was encouraging that most of the sampled students were
not currently hookah pipe smokers, the majority had tried it at least
once, suggesting an ease of accessibility and acceptability of the
practice. Of those smoking, a third smoked on a regular basis, in
contrast to other SA research indicating that the majority of hookah
pipe smokers smoke daily.
[9]
The social element of hookah smoking is
significant, and peer pressure is a major factor in initiating usage,
[2]
and the majority of participants started smoking in high school and
university, with peers. It is concerning that hookah pipe smoking is
permissible in families, as there are high levels of acceptance and
practice among family members.
Hookah bars, cafés and restaurants are social places for hookah
smoking.
[9]
However, selection of smokers’ or friends’ homes were
more common among the sample. In contrast to the findings of
a study done at another local university where a large proportion
of students smoked hookah on campus,
[9]
few students smoked on
campus in our survey. This may be attributable to the strict policies
on any tobacco products on UCT campus.
Although the number of concurrent cigarette users may be higher
than that of exclusive users of hookah,
[9]
we found that only 11%
smoked cigarettes and hookah concurrently.
Nearly a third of hookah smokers in the current sample
supplemented their hookah products with cannabis, which suggests
RESEARCH
849 November 2013, Vol. 103, No. 11 SAMJ
that this practice could provide an
opportunity for the use of narcotics, thus
increasing associated risks.
Only a small number of hookah pipe
smokers noticed any health effects attributable
to their smoking, which suggests that the
effects are not readily apparent. Thus, the
practice is seemingly innocuous, concealing
the serious long-term consequences.
[6-8]
Knowledge and attitudes
Most students had only an average level
of knowledge of the risks associated with
hookah pipe smoking, indicating a need for
education on the topic. Important to consider,
is that a large number of participants had
not received any health information about
hookah pipe smoking previously.
While most could identify that hookah
pipe smoking was harmful, many gave
incorrect reasons, indicating a knowledge
gap. Some perceived hookah pipe smoking
to be less harmful than cigarette smoking,
suggesting that hookah is perceived as a safer
alternative. However, previous studies have
suggested that hookah pipe and cigarette
smoking share similar health risks, with
more carbon monoxide, similar nicotine
and more smoke exposure during a session
of hookah
pipe smoking.
[6,7]
It is concerning
that the health effects of hookah pipe
smoking are unclear.
Most students had permissive attitudes
towards hookah pipe smoking, believing it
to be socially acceptable and that they could
easily access hookah pipe products. However,
not as many would recommend it to others
and the majority believed that the practice
should be subject to stricter regulation.
Currently, while the South African Tobacco
Control policy prohibits tobacco smoking
in public spaces, such prohibition does not
explicitly extend to hookah pipe smoking.
[9]
Study limitations
Limitations of the current study include
possible response and recall bias in
questionnaire responses, as well as selection
bias. Hard copies were distributed to students
in the social areas of the campus, which
may influence the composition of the sample
despite an online questionnaire being
available to all health sciences students to
counteract this effect. The current study
neither explored reasons why those who no
longer smoked hookah pipe had stopped,
nor the temporality of cigarette smoking
on hookah pipe smoking. This would have
been useful in the interpretation of attitudes
towards the practice.
Conclusion
The current study was conducted among a
subset of SA’s future health professionals.
Their poor knowledge about the dangers
of hookah pipe smoking, coupled with the
extent of its practice is alarming. Permissive
attitudes toward the practice, the young age
of first experimentation in high school and
at university, together with low exposure
to information about hookah smoking
highlights the need for school and university
health-promotion campaigns, as well as for
the better regulation of hookah pipe smoking
and awareness campaigns at a national level.
Acknowledgements. e authors thank CANSA
and the Faculty of Health Sciences, UCT, for
support throughout this research, as well as the
students who participated in the research.
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S, Mathee, A. High prevalence of hookah smoking among
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Accepted 5 September 2013.
0
5
15
30
35
Frequency, %
20
Causes illness/
damages lungs
Contains harmful
substances
Addictive
Not addictive
Equally as harmful
as cigarettes
Less harmful than
cigarettes
Heard it was bad via
media
Did not know
25
10
Response
Fig. 1. Responses to open-ended question about why hookah pipe smoking was harmful or not (N=206).
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Article
  • Jun 2022
Aim: The aim of the study was to assess the impact of COVID-19 pandemic on patterns of cigarette, hookah and marijuana consumption among undergraduate students of Bosnia and Herzegovina. Methods: The first part of the double cross-sectional study was conducted among undergraduate students of the University of Sarajevo from 22nd to 26th January 2020, prior to the first COVID-19 case in the country (study period 1), and the second part from March 25th to August 26th 2021, during the third wave of COVID- 19 outbreak (study period 2). Results: The majority of the 1,230 respondents were women (N1 70.9%, N2 70.1%), pursuing medical sciences (N1 60.0%, N2 55.0%), in their 3rd year of study (N1 26.3%, N2 26.7%), and living in urban environment (N1 84.9%, N2 86.4%). Similar proportion of cigarette smokers (N1 38.5%, N2 39.2%), and smaller, similar portions of hookah smokers (N1 19.3%, N2 21.1%) were classified in both study periods, while the smallest portion of marijuana smokers (N2 8.0%) was classified during COVID-19. Similar number of cigarettes per day, types of cigarettes consumed and consumption frequency in the last 30 days, with the similar independent predictors of cigarette consumption (being woman and living in rural environment associated with decreased risk, and age older than 22 associated with increased risk) were identified both before and during COVID-19 pandemic. Compared to before COVID-19 pandemic, increased trends in intentions (73.6% vs. 81.2%) and attempts (51.9% vs. 75.1%) to smoking cessation among cigarette smokers, but decreased determination not to smoke in the coming year among cigarette non-smokers (N1 72.2%, N2 51.6%) and decreased awareness of smoking harmfulness among both cigarette smokers (N1 68.0%, N2 46.5%) and especially cigarette nonsmokers (N1 60.9%, N2 22.9%) were seen during COVID-19 pandemic. Also, risky behavior among hookah smokers was evident during COVID-19 pandemic. Conclusions: COVID-19 pandemic seemed to positively affect intentions and attempts to smoking cessation among cigarette smokers while negatively affecting attitudes towards cigarette smoking among cigarette non-smokers.
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... In our study 70 students or 15.3% consumed shisha, these results are close to the results obtained in a study conducted in South Africa at the University of Health Sciences of Cape Town in 2013 with a prevalence of 18% [16]. Moreover our results are lower than those obtained in a study conducted among medical students at the University of Science and Management of Shah Alam in Malaysia in 2012 with a prevalence of 20% [17], also lower than those obtained in a study at the Faculty of Medicine in Damascus in 2008 with a prevalence of 23.5% [18]. ...
Prevalence of Substance Use Among Students in The Faculty of Medicine and Pharmacy of Casablanca, Morocco
Article
  • Oct 2021
Introduction: Substance use is a major public health problem. Medical students are an interesting population category to study, given the particularity of the stress factors to which they are exposed, predisposing them to the use of psychoactive substances. The objective of this study is to determine the prevalence of psychoactive substance use in this category, as well as the levels of dependence and risky use, and also to define the characteristics of use and the relationship between substance use and sociodemographic characteristics. Methods: Cross-sectional study with a descriptive aim, carried out in the form of a survey using a questionnaire, among 456 medical students in Casablanca, all levels combined. Results: The most widespread psychoactive substances are tobacco: 16.6%, chicha: 15.3%, cannabis: 14.9% and alcohol: 13.1%. The highest rate of risky use was noted with tobacco use: 30%, and cannabis use: 80%. More than half of the users had a family background of use, and one third of the users were repeaters. The age of initiation, for all substances, varied between 10 and 29 years. In our study, 18.6% of the students were poly-substance users. Psychiatric background was found in 42% of users vs 17% of non-users. Conclusion: The extent of psychoactive substance use among students is considerable, and the study has made it possible to identify certain socio-demographic risk factors.
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... This high demand for waterpipe (shisha) use, especially by youth can be attributed to the deceptive and aggressive marketing strategies of the tobacco industry, falsely presented as safer form of cigarette smoking 6,9 . Studies have confirmed that most shisha smokers are unaware of the harmful health effects of shisha smoking 10,11 being deceived that the toxins in the smoke are filtered out by the water in the pipe 12 . Shisha contains the same chemicals and substances as cigarettes including carbon monoxide (CO), tar, nicotine and highly toxic and carcinogenic substances. ...
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The Use of Waterpipe Tobacco Products and Its Associated Risk Factors among University of Limpopo Students, South Africa
Chapter
Full-text available
  • Jun 2022
The use of tobacco products is a modifiable risk factor for non-communicable diseases. The aim of the study was to determine the prevalence of waterpipe tobacco product use and associated risk factors amongst University of Limpopo students aged 17–43 years. This cross-sectional study comprises 916 (415 males and 501 females) University of Limpopo students aged 17–43 years. The questionnaire was validated for the University of Limpopo student population before it was used. Logistic regression was used to determine the associated risk factors for waterpipe tobacco product use among the University of Limpopo students. Staying on campus (OR 2.54 95%CI 1.87 3.44) or off-campus (0.39 95%CI 0.29 0.54) was significantly (p<0.05) associated with using waterpipe tobacco products even after adjusting for age and gender and receiving a bursary (on Campus OR=3.8095%CI 2.59 5.57) off-campus (0.26 95%CI 0.18 0.39). Our results demonstrate that waterpipe smoking was more prevalent among university male students than female students. Liking the taste and difficulties to refuse were significantly (p<0.05) associated with the use of waterpipe amongst University students. Future research should investigate the association of waterpipe use with risk factors for non-communicable diseases over time.
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A descriptive study of the perceptions and behaviors of waterpipe use by university students in the Western Cape, South Africa
Article
Full-text available
  • Feb 2013
Waterpipe smoking started as a cultural phenomenon but has become a social phenomenon. Hookah cafes are an increasingly popular venue for socializing. Studies suggest that waterpipe users perceive smoking the waterpipe as less addictive and harmful than cigarette smoking. The aim of this study was to assess the beliefs, and associated behaviours, regarding the health-risk of smoking the waterpipe. A cross-sectional descriptive study was conducted with a sample of first year students at a historically black university in the Western Cape, South Africa. A self-administered questionnaire was constructed from the College Health Behaviour Survey. The final sample was 389 university students, 64% (250) females and 36% (139) males. The sample had a mean age of 22.2 years (SD = 5.04). Waterpipe users perceived the health risks of smoking the waterpipe to be exaggerated (48%) and less addictive (58%) than non-users (13% and 17%, p<.001). Additionally, the findings confirm that waterpipe smoking is conducted in a social setting (61%). This social setting included smoking on campus (28%), in the family home (11%), at a party (9%), at a friend’s place (6%) and in a restaurant (1%). Of concern was the majority of users smoked the waterpipe on a daily basis (70%) and that the tobacco mix was easily available (90%). The most common self-reported reason for smoking the waterpipe was for relaxation. As with previous studies, the results of this study confirm the false perception that smoking the waterpipe is not a health risk and is socially acceptable. Additionally, the findings of the study raise concerns and an awareness of smoking the waterpipe in the family home and implications for children. The results of this study provide important information for tobacco control and substance abuse policies in South Africa. These findings highlight the need for further research to determine the extent of waterpipe smoking at other universities in South Africa.
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Water Pipe and Smokeless Tobacco Use Among Medical Students in South Africa
Article
Full-text available
  • Oct 2011
  • NICOTINE TOB RES
This study sought to determine the sociodemographic and behavioral factors associated with water pipe and smokeless tobacco (SLT) use among a population of medical students in the Pretoria area, South Africa. Undergraduate medical students (N = 722) in their 2nd and 6th year of study in 2 medical schools in South Africa completed a self-administered questionnaire during 2008. Information on ever and current use of water pipe and SLT was obtained along with information on sociodemographic variables, alcohol use, and cigarette smoking status. Multiple logistic regression analysis were used to determine factors associated with current use of water pipe and SLT. The mean age of study participants was 23 years. Of the participants, 53% were female and 55% were self-identified as Black Africans. Of the study participants, 18.6% were current water pipe users, 3.1% were current SLT users, while 17.3% were current cigarette smokers. Factors independently associated with current water pipe use were having an alcohol drinking-problem (odds ratio [OR] = 2.43; 95% CI = 1.48-3.40), currently smoking cigarettes (3.40; 2.04-5.67), and reporting exposure to smoking in places other than home (2.51; 1.29-4.90). Compared with Black students, White medical students were more likely to have smoked a water pipe in the past month (3.14; 1.74-5.70) but less likely to have ever used SLT (0.37; 0.19-0.73). These findings suggest that the use of alternative tobacco products is common among South African medical students and may form part of a pattern of risk-taking behavior. Furthermore, there appear to be cultural differences in the use of certain tobacco products.
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Harm Perception, Attitudes and Predictors of Waterpipe (Shisha) Smoking among Secondary School Adolescents in Al-Hassa, Saudi Arabia
Article
Full-text available
  • Jan 2010
  • ASIAN PAC J CANCER P
This study aimed to determine the prevalence and social determinants of waterpipe (WP) smoking among secondary school students in Al-Hassa, Saudi Arabia and to assess their health related knowledge and attitudes toward WP. A cross-sectional study was conducted with 1,652 Saudi secondary school students of both genders aged between 15-19 years selected by multistage sampling method. A self-administered anonymous Arabic version of Global Youth Tobacco Survey modified with items dedicated to WP smoking and to assess perception of health related hazards and attitudes towards WP was employed for data collection. Prevalence of current smokers 'all forms' was 30.3% among males (C.I= 27.5- 33.2%) and 8.5% in females (C.I= 6.6-10.9%). WP was used by 53.9% of the current tobacco users, significantly higher among older age students. Of the regular WP smokers, 20.7% smoked WP on daily basis, 23.8% weekly, 64.2% stated using flavored " Muassel " tobacco. Primary motives for WP smoking were outings with friends, company, boredom and wasting time. Of the total, 49.7% of students stated that WP smoking is less harmful than cigarettes, 60.5% believed that harmful substances were purified through water filtration, with non-addictive properties in 67.8%. Knowledge about health hazards of WP smoking was low, irrespective of student's smoking status. WP smoking is more socially acceptable than cigarettes (52.1%), represents a good opportunity for gathering of friends and family (33.8%), and smoking of WP can relieve stress and tensions (37.8%). Hierarchical regression analysis showed that socializing motives, cigarette smoking, smoking among close family and friends, male gender and increasing age were positive predictors for WP smoking. Social acceptability, poor knowledge of WP health related hazards and certain socio demographics are favoring the increasing current trend of WP use among adolescents in Al Hassa, Saudi Arabia.
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Health warning labelling practices on narghile (Shisha, hookah) waterpipe tobacco products and related accessories
Article
Full-text available
  • Jun 2010
  • TOB CONTROL
Waterpipe tobacco smoking prevalence is increasing around the globe despite current evidence that smoke emissions are toxic and contain carcinogenic compounds. To evaluate current health warning labelling practices on waterpipe tobacco products and related accessories. All waterpipe tobacco products, as well as waterpipe accessories, were purchased from Lebanon and a convenience sample was obtained from Dubai (United Arab Emirates), Palestine, Syria, Jordan, Bahrain, Canada, Germany and South Africa. Of the total number of waterpipe tobacco products collected from Lebanon, the majority had textual health warning labels covering on average only 3.5% of total surface area of the package. Misleading descriptors were commonplace on waterpipe tobacco packages and related accessories. There are no WHO FCTC compliant waterpipe-specific health warning labels on waterpipe tobacco products and related accessories. Introducing health warnings on waterpipe tobacco products and accessories will probably have worldwide public health benefits.
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High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg
Article
Full-text available
  • May 2010
Smoking of hookahs (also known as water-pipes) represents an emerging trend in tobacco use. Hookah smokers are at risk for the same diseases caused by cigarette smoking - cancer, respiratory and heart diseases, and pregnancy-related complications. Globally, the highest rates occur in the North African and East Mediterranean regions and among young people in the USA and European countries. There has been little research on hookah smoking in southern Africa.
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The effects of waterpipe tobacco smoking on health outcomes: A systematic review
Article
Full-text available
  • Mar 2010
  • INT J EPIDEMIOL
There is a need for a comprehensive and critical review of the literature to inform scientific debates about the public health effects of waterpipe smoking. The objective of this study was therefore to systematically review the medical literature for the effects of waterpipe tobacco smoking on health outcomes. We conducted a systematic review using the Cochrane Collaboration methodology for conducting systematic reviews. We rated the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Twenty-four studies were eligible for this review. Based on the available evidence, waterpipe tobacco smoking was significantly associated with lung cancer [odds ratio (OR) = 2.12; 95% confidence interval (CI) 1.32-3.42], respiratory illness (OR = 2.3; 95% CI 1.1-5.1), low birth-weight (OR = 2.12; 95% CI 1.08-4.18) and periodontal disease (OR = 3-5). It was not significantly associated with bladder cancer (OR = 0.8; 95% CI 0.2-4.0), nasopharyngeal cancer (OR = 0.49; 95% CI 0.20-1.23), oesophageal cancer (OR = 1.85; 95% CI 0.95-3.58), oral dysplasia (OR = 8.33; 95% CI 0.78-9.47) or infertility (OR = 2.5; 95% CI 1.0-6.3) but the CIs did not exclude important associations. Smoking waterpipe in groups was not significantly associated with hepatitis C infection (OR = 0.98; 95% CI 0.80-1.21). The quality of evidence for the different outcomes varied from very low to low. Waterpipe tobacco smoking is possibly associated with a number of deleterious health outcomes. There is a need for high-quality studies to identify and quantify with confidence all the health effects of this form of smoking.
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Knowledge, attitude and perception of water pipe smoking (Shisha) among adolescents aged 14-19 years
Article
Full-text available
  • Jul 2008
  • J Pakistan Med Assoc
To study the impact of educational intervention on knowledge, attitude and practices with regard to water pipe smoking among adolescents (14-19 years old) in Karachi. A cross-sectional survey of adolescents aged 14-19 years studying at different educational institutions of Karachi, Pakistan was conducted through multistage sampling on a pre-tested self-administered questionnaire. They were divided into high, middle and lower socioeconomic strata on the basis of monthly fee structure. The impact of health messages was assessed two months after education sessions through post-test of only high and middle socioeconomic strata. A total of 646 students were surveyed for the pre test and 250 students for the post test. A significant association was found for water pipe smoking among the socioeconomic class (p < 0.001). Water pipe is more addictive as compared to cigarettes was marked by more students after the sessions (54% vs 68%; p < 0.001). A significant difference was seen for water pipe being more socially acceptable (58% vs 80%; p < 0.001), it is part of our cultural heritage (29% vs 58%; p < 0.001). Shisha smoking was more prevalent among the high socio economic group, which might be because of the cost, accessibility and availability. The knowledge of the students regarding water pipe smoking improved after the health awareness sessions.
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Maziak WThe waterpipe: An emerging global risk for cancer. Cancer Epidemiol 37(1): 1-4
Article
  • Nov 2012
Tobacco smoking continues to be the leading preventable cause of morbidity and mortality worldwide. Each year more than 5 million smokers die prematurely because of their habit wreaking havoc on the welfare of families and communities worldwide. While cigarettes remain the main tobacco killer worldwide, for many youth tobacco use and addiction is maintained by means other than cigarettes. In particular, over the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become increasingly popular among youth in the Middle East, and is rapidly spreading globally. Available evidence suggests that waterpipe smoking is associated with many of the known risks of tobacco smoking, particularly cancer. Despite these worrisome signs, policies and interventions to address this emerging public health problem have been lagging behind. In this short review I discuss briefly the evidence generated mostly in the past decade about the global spread of waterpipe smoking and its cancer risk potential.
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Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative
Article
  • Oct 2012
Tobacco smoking using a waterpipe (narghile, hookah, shisha) has become a global epidemic. Unlike cigarette smoking, little is known about the health effects of waterpipe use. One acute effect of cigarette smoke inhalation is dysfunction in autonomic regulation of the cardiac cycle, as indicated by reduction in heart rate variability (HRV). Reduced HRV is implicated in adverse cardiovascular health outcomes, and is associated with inhalation exposure-induced oxidative stress. Using a 32 participant cross-over study design, we investigated toxicant exposure and effects of waterpipe smoking on heart rate variability when, under controlled conditions, participants smoked a tobacco-based and a tobacco-free waterpipe product promoted as an alternative for "health-conscious" users. Outcome measures included HRV, exhaled breath carbon monoxide (CO), plasma nicotine, and puff topography, which were measured at times prior to, during, and after smoking. We found that waterpipe use acutely decreased HRV (p<0.01 for all measures), independent of product smoked. Plasma nicotine, blood pressure, and heart rate increased only with the tobacco-based product (p<0.01), while CO increased with both products (p<0.01). More smoke was inhaled during tobacco-free product use, potentially reflecting attempted regulation of nicotine intake. The data thus indicate that waterpipe smoking acutely compromises cardiac autonomic function, and does so through exposure to smoke constituents other than nicotine.
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Waterpipe (Hookah) Tobacco Smoking Among Youth
Article
  • Feb 2011
Waterpipe tobacco smoking is a centuries old practice, influenced by cultural tradition in Eastern Mediterranean countries, the Middle East, and parts of Asia. It historically has been an activity enjoyed primarily by men. In the past 2 decades, however, this method of tobacco smoking has increased in popularity in other parts of the world, including the USA. Growing interest in this form of smoking can be traced, in part, to the advent of a flavored tobacco, called maassel. The combination of flavoring agents and the paraphernalia itself used in the smoking process, along with its mystic appeal, novelty, affordability, and the social atmosphere in which smoking often occurs, has made waterpipe smoking attractive to women as well as men, cigarette smokers and nonsmokers alike, and particular groups, including persons of college age and younger adolescents. Although waterpipe smoking is perceived by its new generation of users to be less addictive and hazardous to health than cigarette smoking, researchers draw diametrically opposed conclusions. Research demonstrates that numerous toxic agents, including carcinogens, heavy metals, other particulate matter, and high levels of nicotine, are efficiently delivered through waterpipes. Moreover, sidestream smoke exposes others in the vicinity of waterpipe smokers to the risk of respiratory diseases and other conditions. In addition, persons sharing waterpipe mouthpieces may share infectious agents as well. Waterpipe tobacco smoking has been declared a public health problem by the World Health Organization and other authorities. Recognition of the deleterious effects of waterpipe smoking has led to initial attempts to expand regulatory control. Because waterpipe tobacco is not directly burned in the smoking process, many existing control measures do not apply. Public health authorities should monitor waterpipe tobacco use carefully. Finally, pediatricians and other healthcare providers should discourage experimentation and continued use among their adolescent patients.
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