INTRODUCTION

Shisha is known by different names depending on the region. It is also called waterpipe, hookah, narghile, or hubbly bubbly. It is a means of smoking tobacco in which the vapor passes through water before inhalation¹. Tobacco is the main ingredient in shisha², and tobacco use is the most important preventable cause of premature death and disease³. The World Health Organization (WHO) reports that every year, more than 7 million people die as a result of tobacco use globally⁴. Of this figure, more than 6 million are from direct tobacco use, and close to 0.9 million from exposure to secondhand smoke⁴. Low-income and middle-income countries like Nigeria bear nearly 80% of the global burden of tobacco-related mortality⁴.

According to WHO, shisha, which was invented in India by a physician known as Hakim AbulFath⁵, has been used to smoke tobacco and other substances by the indigenous people of Africa and Asia for at least four centuries⁵. But there is growing evidence to show that shisha is gaining popularity globally and is fast becoming a serious threat to public health¹. A multi-country study conducted among school children 13–15 years old in several countries in the Arabian Peninsula (Bahrain, Oman, Qatar, United Arab Emirates, Kuwait and Yemen) showed that the prevalence of shisha smoking ranged from 9% to 15%⁶. Shisha smoking prevalence in this study was higher than cigarette smoking⁶.

In two cross-sectional studies conducted among medical students of two universities each in Pakistan and South Africa, the prevalence of shisha smoking was 21.5% and 18.6%, respectively^7,8. Another cross-sectional study involving 427 university students in a private University in Kigali City, Rwanda, found the prevalence of ever smoking shisha to be 26.1%, and 20.8% for those that smoked in the last 30 days⁹. Another cross-sectional study conducted among 389 first-year students in a university in the Western Cape, South Africa, indicated that 40% of the respondents were current shisha users¹⁰. The mean age for first-time shisha smoking in this study was found to be 15.7 years¹⁰.

There is no published study on the prevalence of shisha smoking in Nigeria. However, data from the 2008 Global Youth Tobacco Survey (GYTS) conducted in 5 major cities in Nigeria showed the prevalence of reported current ‘other tobacco products’ use higher than cigarette smoking¹¹. The consistently higher prevalence of other tobacco product use relative to cigarettes, in each of these cities, suggests that other tobacco products are becoming more popular than cigarettes¹¹. One of these alternative tobacco products available in the Nigerian market is shisha. However, only limited information is available on the knowledge of health risks, attitudes and perception of Nigerians towards shisha smoking.

The media has a very significant influence on public awareness, normative believes, perception and understanding of various issues, and information relayed to the public through the media clearly influences health behavior¹². For example, Friend and Levy¹³, in their review of several studies in the US, reported that mass media campaigns are associated with reduced smoking rates among adults and youths. In another study involving 98747 youths in the US, Smith et al.¹⁴ reported that each ten-article increase in newspaper volume over a five-month period was associated with, among others, increased odds of perceiving great harm from smoking, disapproving of smoking, and smoking in the past 30 days.

In Australia, newspaper coverage of tobacco issues has assisted tobacco control¹⁵. This could likely be one of the reasons why Australia is setting the pace globally in the implementation of tobacco control policies such as plain packaging for tobacco products.

Therefore, this study sought to explore the coverage of shisha use in Nigeria by qualitatively analyzing articles published in five of the most read online newspapers.

METHODS

Major newspapers in Nigeria were ranked based on their website traffic¹⁶. The website traffic of newspapers was assessed on the Alexa website¹⁶. The five most popular newspapers based on their ranking, using this web tool, were then selected for the study. A similar study on newspaper coverage of the Ebola virus disease in Nigeria used four newspapers¹⁷. The five newspapers selected for this study according to their rankings include: Punch, Vanguard, Premium Times, The Nation, and The Guardian.

The websites of each of these newspapers were searched between 12 to 28 July 2018 using the search terms: ‘shisha’, ‘Hookah’, and ‘water-pipe’. The inclusion criteria were: articles wholly or partly about shisha, hookah or water-pipe. Articles that did not address shisha smoking as a behavior or were not relevant to tobacco control were excluded in a second round of assessment. There were 30 articles (Figure 1) that met these inclusion and exclusion criteria. The first article was published on 13 July 2014 and the last one was published on 20 July 2018. Key information from each article was extracted and is shown in Table 1. The content of each newspaper article was extracted into a Word document individually and then exported into the software Nvivo 12. This software was used to organize the data into themes following a thematic analysis procedure by Braun and Clark¹⁸. This procedure includes: familiarising yourself with your data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; producing the report¹⁸.

Figure 1

Flowchart showing selection of articles for analysis

RESULTS

We found thirty relevant articles on shisha in the five newspapers searched. Figure 2 shows the number of newspaper reports on shisha from 2014 to 2018 for each of the newspapers used in this study. The following themes were developed from the articles: 1) Perception of prevalence of shisha smoking; 2) General misconception about safety of smoking Shisha; 3) Content of the shisha pot; 4) Addiction to shisha smoking; 5) Reasons for smoking shisha; 6) Financial cost of smoking shisha; 7) Health effects of shisha use; and 8) Laws regulating shisha use and its promotion.

Figure 2

Newspaper coverage of shisha (2014–2018)

DISCUSSION

In this study, newspaper articles that reported on shisha prevalence noted that it was now a growing trend among urban youths especially among university students. This trend is not peculiar to Nigeria; several authors have also reported this trend⁹. In a study of a nationally representative sample in Gambia, West Africa, it was observed that shisha was becoming increasingly popular³⁷. Another cross-sectional study among 503 shisha users in Kuala Lumpur and the Area of Klang Valley in Selangor State, Malaysia also observes this increasing trend³⁸. The reported rising trend of shisha smoking especially among young people globally may be due to several factors, such as the glamorization of shisha use by the media, peer pressure, the quest to appear ‘trendy’, availability of attractive flavours, and the misconception that shisha is a safer tobacco product compared to cigarettes³⁸. Several other studies also show the increasing popularity of shisha use among females^38,39. Reports of an increasing popularity of shisha use among females might not be unconnected with the aforementioned reasons; especially, attractive shisha flavours like strawberry, apple, pineapple that mask the harsh effects associated with the smoking of conventional cigarettes⁴⁰.

A disturbing report in this study is the prevalence of shisha use among minors. Although the Nigerian Tobacco Control (NTC) Act 2015 prohibits the sale of tobacco to and by minors⁴¹, enforcement of this provision has not taken full effect⁴². Access to shisha by minors, as found in this study, shows that there is a lot to be done in the area of awareness raising and strict enforcement of the NTC Act. In a cross-sectional study among 1000 high school students in an Indian city, Anand et al.⁴³ observed that 85.5% of minors reported that they had been to a hookah lounge. These authors therefore called for the legality of shisha lounges to be reconsidered since minors had access to them⁴³.

Reports of the tobacco in shisha being mixed with marijuana and other hard drugs, as well as the water at the bottom of the shisha pot being replaced with gin or rum are likely signs of increasing addiction. It is very likely that the conventional shisha can no longer intoxicate enough some users, therefore the need to explore other options that could make them ‘feel high’. A qualitative study among 31 male and female students in a private university in Nigeria showed that shisha laced with drugs and codeine was favoured by female students over alcohol. The reason for this mixture could be the search for new sources of ‘highs’⁴³. An online based study conducted among 3447 students from 8 colleges in North Carolina, USA, showed that 45% of respondents had marijuana and 18% had hashish in their hookah⁴⁴. These shisha and hard drugs mixtures indicate that shisha could likely be a gateway to the use of other illicit drugs.

For a country where the current minimum wage is N18000 ($50) monthly, and over 50 per cent of its population lives below the poverty line⁴⁵, spending between N1000 ($2.7) to N50000 ($138.9) for smoking shisha shows that the cost of maintaining a shisha addiction in the Nigerian context is financially huge.

Newspaper articles in this study that discussed the health effects of shisha smoking referred to the WHO report which stated that shisha smokers may inhale as much tobacco smoke/nicotine during one session as a cigarette smoker would inhale consuming a hundred or more cigarettes⁵. There is, therefore, the need for studies in Nigeria that link shisha use and its health consequences. There is also the need for increased awareness on the dangers of smoking shisha and other tobacco products.

Nigeria ranks 6th in the Global Tuberculosis burden⁴⁶; is hyperendemic for hepatitis B⁴⁷; and is within the Sub-Saharan Africa meningitis belt, which has the greatest incidence of the disease in the world⁴⁸. The sharing of shisha pipes as it is done in shisha cafes and lounges is a risk factor that can increase the prevalence of these infectious diseases in Nigeria.

The NTC Act empowers the Standard Organisation of Nigeria (SON) to prescribe Industrial standards for tobacco products⁴¹. Although the current SON Industrial Standards for Cigarette bans cigarettes with characterizing flavours including menthol, SON does not at present have an Industrial Standard for shisha. Shisha importation, sale and use is therefore ‘free for all’. This is perhaps one of the reasons for the reported increase in the prevalence of shisha use in the country.

Among the newspaper articles reviewed, eleven had relevant information needed to warn the public about shisha use and the dangers associated with it. However, there were six articles that advertised shisha cafes in hotels and restaurants. The advertisement of shisha cafes is a violation of the National Tobacco Control Act⁴¹, which bans advertisement, promotion and sponsorship of any tobacco product. This violation further calls for the need to implement and enforce the NTC Act urgently.

With proper sensitization, the Nigeria press can do more in passing the right information about tobacco use. This can in turn shape public perception about tobacco and its products and influence policies that have positive impact on tobacco control. Australian newspaper reports of the Marlene Sharp case showed how powerful the media can be in opening up national discourse on tobacco related issues⁴⁹. Marlene Sharp was a non-smoking bar worker in Australia who was awarded damages for laryngeal cancer caused by secondhand smoking. Analysis of the newspaper reports about this case by Wakefield et al.⁴⁹ showed that the most common frame (27% of articles) advanced the view about the need for legislation to protect employees from the adverse health effects of passive smoking. With the growing trend of shisha use in Nigeria, increased media reporting on the health effects of shisha use can play a key role in shaping public perception about the risks associated with its use; it can also influence policies that favour public health.

This study shows that there is a need for either strict regulation of the content of shisha by the Standard Organization of Nigeria or outright ban of shisha by the Federal Government, as done by Uganda, Tanzania, Rwanda, Pakistan, Jordan, Singapore, and Saudi Arabia. Furthermore, there is an indication that there might be a need to tighten the regulation and/ or enforcement of regulations in relation to banning any form of promotion of shisha.

CONCLUSIONS

Although there were not many newspaper articles about shisha in the period under review, this study found an increase in shisha reports within this period from 2 relevant articles in 2014 to 14 articles in 2018. The media plays a vital role in influencing people’s perception, the media also has a wider reach than scientific journals, therefore it is recommended that aggressive sensitization of the public through the media about tobacco control and provisions in the NTC Act be carried out. This will ensure that good and up-to-date information about the dangers of tobacco use (including shisha smoking) and how to quit, are made available to the reading public.

CONFLICTS OF INTEREST

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.