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Objectives: To investigate the use of unconventional substances and materials in water pipe among cafe water pipe smokers. Methods: This was a questionnaire-based survey among subjects attending coffee shops in the region of Al Madinah, Saudi Arabia between February and March 2013. Results: We invited 110 subjects, only 90 consented to participate in the study. A percentage of 1.1% used fluids other than water in the water pipe tank, 18.9% added other soft drinks to the tank, and 7.8% added flowers, spices or drugs to the tobacco mix placed in the head of the water pipe. A proportion of participants used fruits to replace the water pipe head (12.2%), or to replace water pipe tank (4.4%). Higher number of children the smokers had and cafe smoking were all significantly associated with unconventional practices. Conclusions: A substantial percentage of sample of water pipe smokers in Al Madinah, Saudi Arabia use unusual materials and/or substances in the water pipe and this is probably encouraged by cafe smoking.
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890 Saudi Med J 2014; Vol. 35 (8) www.smj.org.sa
Unconventional materials and substances
used in water pipe (narghile) by smokers
in central western region, Saudi Arabia
Ashraf S. Baboor, BDS,
Ahmad A. Alnazzawi, MSc, PhD,
Osama A. Abu-Hammad, MSc, PhD,
Najla S. Dar-Odeh, BDS, FDS RCS.
ABSTRACT
Objectives: To investigate the use of unconventional
substances and materials in water pipe among café
water pipe smokers.
Methods: is was a questionnaire-based survey
among subjects attending coffee shops in the region
of Al Madinah, Saudi Arabia between February and
March 2013.
Results: We invited 110 subjects, only 90 consented
to participate in the study. A percentage of 1.1%
used fluids other than water in the water pipe tank,
18.9% added other soft drinks to the tank, and 7.8%
added flowers, spices or drugs to the tobacco mix
placed in the head of the water pipe. A proportion
of participants used fruits to replace the water pipe
head (12.2%), or to replace water pipe tank (4.4%).
Higher number of children the smokers had and
café smoking were all significantly associated with
unconventional practices.
Conclusion: A substantial percentage of sample of
water pipe smokers in Al Madinah, Saudi Arabia use
unusual materials and/or substances in the water pipe
and this is probably encouraged by café smoking.
Water pipe smoking is now considered an epidemic
that is affecting all continents.1-7 Recent reports
have indicated a high prevalence of water pipe smoking
among Saudi adolescents,8 and university students.9
Besides the documented health hazards of conventional
water pipe smoking,10 reports have emerged to indicate
that there are other unconventional methods of water
pipe smoking. ese methods may employ certain
materials other than Muassel, the conventional mix,
such as cannabis,11 psychoactive drug,12 marijuana or
hashish.3 A recent study conducted in neighboring
Jordan found that approximately 6% of a sample of
water pipe smokers mix alcohol with the tank water,
and approximately 2% mix other substances with
Muassel such as cannabis, antihistamine drugs, and
paracetamol.7 Former studies have found an association
between water pipe smoking and an increased risk of
being involved in road accidents, and this was attributed
to the use of cannabis in water pipe.13 Other aspects
of water pipe smoking that have received little or no
attention is the unconventional use of fruits to replace
certain components of the water pipe instrument itself
like the head or water tank. is practice increases
the appeal of the habit particularly among females,14
but may pose certain health hazards that are yet to be
investigated. e aim of this study was to investigate
the prevalence and pattern of unconventional materials
and substances incorporated in water pipe in a sample
of water pipe smokers in AlMadinah AlMonawara,
Saudi Arabia.
Methods. e study was based on a cross sectional
survey whereby a questionnaire was designed to explore
the pattern of unconventional practices in the water
pipe set. e questionnaire included personal questions,
questions on smoking history including unconventional
practices, and finally questions on health perceptions
and awareness. Before distributing the questionnaire, it
was validated for clarity and it was further tested for
reliability. Subjects included in this study were regular
male patrons at coffee shops that serve water pipe in
Almadinah Almonawara, Saudi Arabia. To make sure
that only participants who fit these inclusion criteria
are included in this study, we conveniently recruited
participants during their smoking sessions at the coffee
shops. Recruitment and data collection took place
during February and March 2013. We explained to
the participants the nature of the study and after their
acceptance (informed consent form) to participate in
the study, they completed the questionnaires privately.
e study was approved by the ethical committee of
the College of Dentistry, Taibah University.
Statistical analysis. Statistical analysis was performed
using the Statistical Package for Social Sciences for
Windows version 17.0 (SPSS Inc., Chicago, IL, USA).
Frequency distribution were obtained and chi-square
test was used to assess the statistical differences between
frequencies. Statistical significance was set at a p-value
of 0.05, with a confidence interval of 95%.
Results. One hundred and ten subjects were invited
to participate in this study. Only 90 subjects agreed to
participate giving a response rate of 81%. e subjects
were all males and had an age range of 19-52 years
(mean=31.4, median=31, SD=8.54). Personal and
social characteristics of the study sample are shown in
Table 1. Although all subjects were water pipe smokers,
98% of them responded that they are smokers when
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891
www.smj.org.sa Saudi Med J 2014; Vol. 35 (8)
asked if they believe that they were smokers. Table 2
shows characteristics of water pipe smoking in our
sample.
In total, 23.3% of the study group used unusual
methods and/or materials in water pipe; 12.2% used
fruits as the water pipe head (pineapple, apples, pears,
orange), while 4.4% used fruits to replace water pipe
tank (watermelon, cantaloupe). Only 1.1% used fluids
other than water in the water pipe tank (blueberry
juice), 38.9% of the subjects added ice to water pipe
tank, 18.9% added soft drinks to the tank (rose water,
mint, lemon, orange juice, apple juice and fizzy drinks),
and 7.8% added flowers, spices or drugs to Jarak, the
type of tobacco mix placed in the head of the water
pipe in the region of Saudi Arabia, (roses, banana
peels, euphoric substances, cardamoms, carnations,
paracetamol). When the number of participants who
practice unconventional water pipe smoking was cross-
tabulated with social characteristics, only the higher
number of children that married people have, and the
occupation of employee were significantly associated
with unconventional practices with P values of p=0.005
and p=0.013. Also, when number of participants who
practice unconventional water pipe smoking was cross-
tabulated with characteristics of water pipe smoking,
the only significant association was with coffee shops
as the place of smoking (p=0.017). Health awareness
perceptions were as follows: 42% used disposable tips
when smoking the water pipe outside their homes,
100% believed water pipe was harmful, 95% wished
to quit water pipe smoking, and 23.3% tried to quit.
Also, 1.1% of the subjects visit the physician routinely
while 4.4% visit the dentist routinely. Cross-tabulation
in association with unconventional practices did not
show a significant association with the desire to quit
water pipe (p=0.231), routine visits to the dentist
(p=0.569), and oral hygiene practice (p=0.363). Table 3
shows perceived health hazards of water pipe and reason
for difficulty to quit the habit.
Discussion. is study was a survey similar to
a previous study.7 Although both Jordan and Saudi
Arabia are predominated by the Arab Muslim culture,
Unconventional substances and materials in water pipe ... Baboor et al
Table 3 - Perceived health hazards of water pipe smoking and reasons for
difficulty in quitting the habit.
Perceived health hazards of water
pipe smoking
n (%)
Chest problems 75 (83.3)
Cancer 32 (35.5)
General health problems 5 (5.6)
Reasons for not being able to quit
It became a habit 32 (35.6)
To lift the mood 32 (35.6)
To break the routine 18 (20.0)
To spend time with friends 4 (4.4)
Addiction 4 (4.4)
Table 1 - Social characteristics of participants, and the number of
participants from each category that do unconventional
practices. P value resulting from cross tabulation between social
characteristics and unconventional practices is displayed.
Characteristics n (%) Participants
with
unconventional
practices
n
Cross
tabulation with
unconventional
smoking
methods
(P-value)
Marital status
Single
Married
50
40
(55.6)
(44.4)
10
11
0.215
Number of children
for married subjects
(n=40)
No children
1 child
2 children
3 children
4 children
5 children
5
11
13
6
4
1
(12.5)
(27.5)
(32.5)
(15.0)
(10.0)
(2.5)
11 have children
0
1
3
4
2
1
0.005
Occupation
Employed
Student
Retired
48
38
4
(55.5)
(41.1)
(4.4)
13
5
3
0.013
Table 2 - Characteristics of water pipe smoking in our sample. P value in
association with unconventional practices is shown. Introducer
is the person(s) introducing the smoker to water pipe smoking.
Companion is the person(s) with whom water pipe smoking
session is spent.
Characteristics n (%) Participants with
Unconventional
practices
n
Cross
tabulation with
unconventional
practices
(P-value)
Frequency per week
1-3 times
4-7 times
14-21 times
24 (26.7)
55 (61.1)
11 (12.2)
6
10
5
0.132
Age of onset (years)
16-18
19-26
8 (8.8)
82 (91.2)
3
18
0.143
Introducer
Alone
Friends
11 (12.2)
79 (87.8)
3
18
0.742
Companion
Alone
Friends
17 (18.9)
73 (81.1)
7
14
0.064
Favorable place for
smoking
Coffee shop
Home
79 (87.8)
11 (12.2)
16
5
0.017
892 Saudi Med J 2014; Vol. 35 (8) www.smj.org.sa
it is known that the community of Al Madinah Al
Monawara is more conservative than that of Amman.
e city is considered one of the 3 most sacred places
for Muslims around the globe. e holy Muslim city is
geographically divided into 2 main areas; the Haram
itself and the area outside the Haram, where it is allowed
to smoke and to provide the service of water pipe in
coffee shops. Another characteristic of this community
is the unavailability of water pipe to females in coffee
shops. is explains why our sample was purely made
of males. is limitation should be avoided in future
studies to include females regardless the place where
they smoke a water pipe. e sample was a convenient
sample of 90 participants which was another limitation
of the study.
e use of unconventional smoking methods was
practiced by a substantial proportion of water pipe
smokers (23.3%), mostly represented by adding soft
drinks to the tank (18.1%), while the least popular
practice was mixing Jarak (tobacco mix) with other
substances in the form of flowers, spices, and drugs
(7.8%). Materials added to tank, or used to replace
head and tank seem to be innocuous. However, they
may be associated with unknown health risks. Unlike
other studies,7 alcohol was not used by this sample
which reflects a number of trends such as the religious
nature of people in Al Madina and also the fact that
alcohol consumption is prohibited in Saudi Arabia.
However, this did not deter subjects who mixed
euphoric substances with Jarak (n=2), or the man who
added paracetamol to it. Unconventional practices were
not significantly associated with marital status. On the
other hand, they were associated with a higher number
of children that married men had. Moreover, employees
followed by retired people were significantly associated
with this practice. Whether these 2 observations are
age-related or not, this needs further exploration.
Statistical analysis for the association of nationality with
unconventional practices was not performed because
of the relatively small number of non-Saudi’s (n=4)
participating in the study.
Smoking water pipe once or more daily is considered
heavy smoking.15 Most of the sample were heavy
smokers (73.3%), smoking water pipe 4-7 times a
week (61.1%), while a substantial proportion (12.2%)
smoked 14-21 times a week. e frequency of water pipe
smoking was not significantly associated with the use of
unconventional practices, indicating that other factors
make water pipe appealing to the heavy smokers, apart
from unconventional practices. It may also indicate
that the use of unconventional practices does not lead
to heavy smoking. ese factors were explained by the
answers to the question:” why do you think that quitting
is difficult?” with comparable proportions describing it
as a habit, and as a “mood modifier”. Four of the sample
(4.4%) even admitted to being addicted to the habit.
Neither companions nor introducers, were significantly
associated with unconventional practices, although it
was mostly friends who introduced to the habit or later
became the companions. It was the favorable place for
smoking, cafés, which was significantly associated with
unconventional practices. is is reasonably explained
by the length of time and amount of expertise needed
to prepare the water pipe setting incorporating fruits, or
fluids other than water in the tank (Figure 1). Recently,
in neighboring Jordan there are active campaigns to
ban café water pipe. But one cannot be optimistic
yet regarding cutting the popularity of water pipe.
Other existing methods for expert preparation of
unconventional water pipe are still operative, like home
delivery, or the “take- away” water pipe. ese methods
should be addressed efficiently if the practice of water
pipe is to be counteracted.
Only 2% of water pipe smokers perceived that they
were non-smokers, and 95% wished to quit the habit.
Furthermore, the whole sample believed that the habit
is harmful to health. However, they had poor knowledge
on health hazards of the waterpipe, and actual practices
of this sample show that they need more education in
this regards. ey did not even recognize the dangers
of sharing the water pipe like infections similar to
cold, herpes, and tuberculosis.16 is observation
was evident in that less than half of the sample used
disposable tips when smoking away from home.
Moreover, negligible proportions visit the dentist and
physician routinely. is has significant consequences
taking into consideration that the population of water
Figure 1 - Fruits such as melons, cantaloupe, and apples are sometimes
used to replace the water tank or the head of the water pipe.
Unconventional substances and materials in water pipe ... Baboor et al
893
www.smj.org.sa Saudi Med J 2014; Vol. 35 (8)
pipe smokers are prone to various health problems.
Perceived health hazards of water pipe were very general
and excluded other important documented hazards. It
is worth mentioning that similar studies in neighboring
countries reported less awareness regarding the health
perceptions and desire to quit water pipe.1,14
In conclusion, unconventional risky practices seem
to be associated with café water pipe smoking.
Received 13th February 2014 . Accepted 27th May 2014.
From the College of Dentistry, Taibah University, Al Madinah Al Monawara,
Kingdom of Saudi Arabia. Address correspondence and reprints request to:
Dr. Najla S. Dar-Odeh, College of Dentistry, Taibah University, Al Madinah
Al Monawara, PO Box 344, Al Monawara 30001, Kingdom of Saudi Arabia.
E-mail: najla_dar_odeh@yahoo.com
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S U M M A R Y In recent years, the prevalence of hookah smoking has increased worldwide, particularly in young people, which may have potentially serious consequences for their health. The aim of this study was to examine the factors associated with the consumption of hookah by high school students. The present study was conducted in the city of Novi Pazar, and students aged 17-19 years attending the following high schools were included: Medical School, Grammar School, Economic-Commerce School and Catering School. The study was designed as a case-control study. The cases were students who consumed nargile, while the control group consisted of students who had never smoked nargile. A special questionnaire was constructed for the purpose of this research, which was used to evaluate the opinions of adolescents on the consumption of nargile. Our research included a total of 270 seniors in high schools in Novi Pazar. The average age of the students was 18 years. The most important factors that may contribute to start using nargile were: previous consumption of nargile by older family members, divorced parents, and active smoking of cigarettes by other family members. Most students emphasized that hookah smoking is socially unacceptable form of behavior. Also, hookah smoker were neither more attractive nor popular. Nargile consumption is more common by adolescents whose parents are divorced, as well as by adolescents whose family members are smoking nargile or tobacco. The most common reason for nargile consumption among adolescents is a desire for relaxation.
... One phenomenon raised by participants in this study, which has been noticed in the past few years in Jordan and other countries, is adding medications to the water-pipe or the so-called Narghile (Baboor et al., 2014). In a crosssectional survey of 61 cafes in Jordan, almost 10% of respondents reported adding antihistamines, paracetamol of cannabis to the tobacco or tank water of the Narghile (Dar-Odeh et al., 2013). ...
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... Our estimates are similar to a study among 90 waterpipe users in Saudi Arabia, where 18.9% mixed the apparatus water with soft drinks, and 7.8% added flowers, spices, or drugs to the tobacco. [41] A qualitative analysis with local governments in London highlighted that several waterpipe-serving premises openly advertise 'alcoholic waterpipes', usually at premium prices. [30] Public health implications While waterpipe tobacco smoking appears to be a prevalent but infrequent activity, longitudinal studies indicate that it may serve as a gateway for future cigarette use among adolescents in the US [42] and Jordan. ...
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Cigarette smoking has declined over the last years in modern countries. On the contrary, waterpipe smoking has increased, especially among young people visiting waterpipe bars. Unfortunately, most waterpipe smokers seem to know little about the possible cardiovascular and other health consequences of waterpipe smoking. To describe by narrative literature review the known adverse consequences for the human body caused by smoking the waterpipe compared with the consequences of smoking normal cigarettes. Also, to get a picture of public awareness of these consequences as deducted from the literature and a small new survey in the Netherlands. Tobacco smoking is associated with serious adverse (cardiovascular) health effects, and there is no evidence that these effects are less serious if a waterpipe is used. The increasing use together with the limited amount of awareness and attention for the possible health consequences of smoking the waterpipe is worrisome. Especially considering the increasing acceptance and use of the waterpipe among the youth. Therefore we recommend more systematic research into the possible health hazards of waterpipe smoking. In the meantime education campaigns and materials are needed to raise public awareness on the possible health risks of waterpipe use.
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To identify the predictors that lead to cigarette smoking among high school students by utilizing the global youth tobacco survey in Riyadh, Kingdom of Saudi Arabia (KSA). A cross-sectional study was conducted among high school students (grades 10-12) in Riyadh, KSA, between April 24, 2010, and June 16, 2010. The response rate of the students was 92.17%. The percentage of high school students who had previously smoked cigarettes, even just 1-2 puffs, was 43.3% overall. This behavior was more common among male students (56.4%) than females (31.3%). The prevalence of students who reported that they are currently smoking at least one cigarette in the past 30 days was 19.5% (31.3% and 8.9% for males and females, respectively). "Ever smoked" status was associated with male gender (OR = 2.88, confidence interval [CI]: 2.28-3.63), parent smoking (OR = 1.70, CI: 1.25-2.30) or other member of the household smoking (OR = 2.11, CI: 1.59-2.81) who smoked, closest friends who smoked (OR = 8.17, CI: 5.56-12.00), and lack of refusal to sell cigarettes (OR = 5.68, CI: 2.09-15.48). Several predictors of cigarette smoking among high school students were identified.
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Narghile smoking by young females is becoming more acceptable than cigarettes in the conservative societies of Arab countries. Lack of social constraints on narghile smoking has resulted in an increased prevalence of narghile smoking among young Arab females and an earlier age of onset of this habit when compared to cigarette smoking. Documented health hazards of narghile smoking including pulmonary, cardiovascular and neoplastic ailments are consequently expected to affect this vulnerable sector of the population together with their offspring. In this commentary, we shed some light on the changing trend of tobacco use among young Arabic women as shown by an increasing number of studies investigating habits of tobacco use in young people.
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K2 or "spice" has emerged as a popular legal alternative to marijuana among adolescents and young adults. However, no data has been published assessing prevalence of and associations with ever K2 use in any population. This study's aims were to examine prevalence of ever K2 use among a sample of college students, to determine characteristics of persons who use K2, and to access the association between K2 and other drug use. Ever use of K2 was reported by 69 (8%) of the sample of 852 college students. Response rate was 36%. Bivariate and multivariate analyses assessed whether sociodemographic characteristics and other drug use were associated with ever use of K2. Ever use of K2 was reported by 69 (8%) of the sample. Among these 69 individuals, 61 (88%) had used a cigarette and 25 (36%) had used a hookah to smoke K2. In multivariate analyses, K2 use was more common in males (vs. females, adjusted Odds Ratio (aOR)=2.0, 95% Confidence Interval (CI)=1.2-3.5, p=0.01) and 1st or 2nd year college students (vs. 3rd year or above, aOR=2.4, 95% CI=1.2-5.0, p=0.02). Ever use of K2 in this sample was higher than ever use of many other drugs of abuse that are commonly monitored in adolescents and young adults. Although DEA had banned five synthetic cannabinoids recently, clinicians and public health officials concerned with substance abuse in youth should be aware of and monitor the use of this drug in college students over time.
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The main objectives of this paper were to estimate the consumption patterns of tobacco use among King Saud University (KSU) undergraduate students; and investigate different risk factors which may contribute to tobacco use among female students. A representative sample (n=7550) of the total KSU undergraduate student population of 69,498 (males and females) was selected, stratified according to college and gender. A modified version of the WHO/CDC Global Youth Tobacco Survey (GYTS) questionnaire was used for data collection. Overall smoking prevalence among KSU students was estimated at 14.5%, prevalence among male students (32.7%), and females (5.9%). Independent risk factors for smoking among males were found to be: age, father's smoking habits, and "friends' smoking habits"; while among females were: sister's smoking habits and "friends' smoking habits." The findings of this study re-emphasize the significance of peer pressure on smoking among university students of both sexes; influence of family members, usually of same sex. We need to foster gender-sensitive tobacco prevention intervention programs, to prevent youngsters of both sexes from taking up such habit. We also need to raise awareness of girls and young women, of the consequences of smoking in general, water-pipe in specific, on their own health, that of their spouses, families, and off-springs, many of whom could develop chronic respiratory disorders, as passive smokers in the beginning/potential smokers themselves, later on. All such efforts should be backed and supported by strong governmental commitment, to ensure success of their implementation accordingly.
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This investigation was performed in order to determine the prevalence rate of waterpipe smoking in students of Erciyes University and the effects of some socio-demographic factors. A total of 645 students who study the first three grades of the medical faculty and the engineering faculty of Erciyes University were enrolled in the study. A questionnaire including 48 questions was applied. Chi-square test and logistic regression method were performed for the statistical analyses. The total prevalence rate of waterpipe smoking was found to be 32.7%. The prevalence rate of waterpipe smoking was 28.6% in the medical and 37.5% in the non-medical students. It was determined that 41.6% of the males and 20.2% of the females currently smoke waterpipe. Gender, cigarette smoking, and the presence of waterpipe smokers among family members and friends have significant effects on the prevalence of waterpipe smoking. Residence and economical status of the family and with whom the students live have no significant effect on the prevalence rate. Approximately one-third of the students currently smoke waterpipe. Smoking of both cigarette and waterpipe was frequently found. The measures against all tobacco products should be combined.
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Narghile is becoming the favorite form of tobacco use by youth globally. This problem has received more attention in recent years. The aim of this study was to investigate the prevalence and pattern of narghile use among students in three public Jordanian universities; to assess their beliefs about narghile's adverse health consequences; and to evaluate their awareness of oral health and oral hygiene. The study was a cross-sectional survey of university students. A self-administered, anonymous questionnaire was distributed randomly to university students in three public Jordanian universities during December, 2008. The questionnaire was designed to ask specific questions that are related to smoking in general, and to narghile smoking in specific. There were also questions about oral health awareness and oral hygiene practices. 36.8% of the surveyed sample indicated they were smokers comprising 61.9% of the male students and 10.7% of the female students in the study sample. Cigarettes and narghile were the preferred smoking methods among male students (42%). On the other hand, female students preferred narghile only (53%). Parental smoking status but not their educational level was associated with the students smoking status. Smokers had also significantly poor dental attendance and poor oral hygiene habits. This study confirmed the spreading narghile epidemic among young people in Jordan like the neighboring countries of the Eastern Mediterranean region. Alarming signs were the poor oral health awareness among students particularly smokers.
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Background: As a result of tobacco control measures in France, smoking among adolescents is decreasing. However, this decrease is associated with changes in the way youth are consuming tobacco and turning towards new tobacco products: cheaper forms of tobacco such as rolling or chewing tobacco, or fashionable forms such as narghile. The aim of this study is to describe in young adults: (1) prevalence of tobacco use and main risk factors of daily smoking, (2) the entry mode for tobacco use and (3) prevalence and main risk factors related to "chewing tobacco" used as snuff. Methods: A descriptive transversal study was undertaken in five private and public high schools in the French Alps region in 2008. Anonymous questionnaires were given out to the students of 12th grade (last year of general secondary education) and BTS (professional training). Smoking prevalence and other forms of tobacco consumption were described, as well as the entry mode in tobacco use. Finally, we used logistic models to identify the main determinants of smoking cigarettes and using chewing tobacco. Results: This study included 920 students: 22.3% (95% IC: 19.6-25.0) were daily smokers and 65.9% (95% IC: 62.8-69.0) had tried tobacco. Approximately 40% had experimented with rolling tobacco, cannabis or narghile. We found the usual determinants of daily smoking: an environment conducive to smoking, and not belonging to a sports club. Around 11% (95% IC: 9.2-13.2) had tried chewing tobacco. Risk factors associated with chewing tobacco were: having a smoking friend (adjusted OR: 3.07; 95% IC: 1.95-4.83), studying in a private school (adjusted OR: 2.57; 95% IC: 1.52-4.31), or being male (adjusted OR: 1.79; 95% IC: 1.15-2.79). Conclusion: As found in national studies, cigarette smoking is declining among young adults, but the use of other tobacco products (narghile, chewing tobacco) is emerging. The relatively high consumption rate and the risk factors of chewing tobacco need to be examined in depth in order to organize prevention programs for young adults.