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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
OPEN ACCESS
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
References
1. Dar-Odeh NS, Bakri FG, Al-Omiri MK, Al-Mashni HM,
Eimar HA, Khraisat AS, et al. Narghile (water pipe) smoking
among university students in Jordan: prevalence, pattern and
beliefs. Harm Reduct J 2010; 7: 10.
2. Jamil H, Templin T, Fakhouri M, Rice VH, Khouri R, Fakhouri
H. Comparison of personal characteristics, tobacco use, and
health states in Chaldean, Arab American, and non-Middle
Eastern White adults. J Immigr Minor Health 2009; 11:
310-317.
3. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an
emerging health risk behavior. Pediatrics 2005; 116: e113-e119.
4. Poyrazoğlu S, Sarli S, Gencer Z, Günay O. Waterpipe (narghile)
smoking among medical and non-medical university students
in Turkey. Ups J Med Sci 2010; 115: 210-216.
5. Slama K, David-Tchouda S, Plassart JM. [Tobacco consumption
among young adults in the two French departments of Savoie in
2008]. Rev Epidemiol Sante Publique 2009; 57: 299-304.
6. Tamim H, Akkary G, El-Zein A, El-Roueiheb Z, El-Chemaly S.
Exposure of pre-school children to passive cigarette and narghile
smoke in Beirut. Eur J Public Health 2006; 16: 509-512.
7. Dar-Odeh NA, Beyari MM, Al-Abdalla M, Al-Shayab MH,
Abdulrazzaq WS, Jarar S, et al. e use of unconventional
substances and tools in narghile (waterpipe) smoking; a pilot
study in Jordan. British Journal of Medicine and Medical
Research 2013; 3: 2042-2052.
8. Al Moamary MS, Al Ghobain MO, Al Shehri SN, Gasmelseed
AY, Al-Hajjaj MS. Predicting tobacco use among high school
students by using the global youth tobacco survey in Riyadh,
Saudi Arabia. Ann orac Med 2012; 7: 122-129.
9. Mandil A, BinSaeed A, Ahmad S, Al-Dabbagh R, Alsaadi M,
Khan M. Smoking among university students: a gender analysis.
J Infect Public Health 2010; 3: 179-187.
10. Dar-Odeh NS, Abu-Hammad OA. Narghile smoking and its
adverse health consequences: a literature review. Br Dent J
2009; 206: 571-573.
11. Gatrad R, Gatrad A, Sheikh A. Hookah smoking. BMJ 2007;
335: 20.
12. Hu X, Primack BA, Barnett TE, Cook RL. College students and
use of K2: an emerging drug of abuse in young persons. Subst
Abuse Treat Prev Policy 2011; 6: 16.
13. Elias W, Assy N, Elias I, Toledo T, Yassin M, Bowirrat A.
e detrimental danger of Water-Pipe (Hookah) transcends
the hazardous consequences of general health to the driving
behavior. J Transl Med 2012; 10: 126.
14. Dar-Odeh NS, Abu-Hammad OA. e changing trends in
tobacco smoking for young Arab women; narghile, an old habit
with a liberal attitude. Harm Reduct J 2011; 8: 24.
15. Chaaya M, Jabbour S, El-Roueiheb Z, Chemaitelly H.
Knowledge, attitudes, and practices of argileh (water pipe or
hubble-bubble) and cigarette smoking among pregnant women
in Lebanon. Addict Behav 2004; 29: 1821-1831.
16. Jukema JB, Bagnasco DE, Jukema RA. Waterpipe smoking:
not necessarily less hazardous than cigarette smoking : Possible
consequences for (cardiovascular) disease. Neth Heart J Mar
2014; 22: 91-99.
Unconventional substances and materials in water pipe ... Baboor et al
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