INTRODUCTION

Smoking is the leading yet most preventable cause of premature death worldwide¹. The annual premature deaths due to smoking are estimated to be 0.48 million in the US². Additionally, more than 41000 deaths annually are attributed to secondhand smoking in the US². The economic burden on the US population is estimated to be $300 billion annually, of which, $190 billion are related to direct medical costs². An evolving tobacco trend, waterpipe smoking has gained increasing popularity worldwide, especially among adolescents and young adults^3-5. The waterpipe is variously known as hookah, shisha, argeela, gouza, hubble-bubble, and nargeela³.

The term waterpipe refers to any type of instrument that involves passing tobacco smoke through water before inhalation⁶. The waterpipe includes: 1) a tobacco bowl, 2) a body made of metal, 3) a glass bowl filled with water, and 4) a rubber hose connected to a mouthpiece. The tobacco bowl is filled with tobacco and sealed with aluminum foil, and a piece of burning charcoal is placed over the foil. When the smoker inhales air through the mouthpiece, the air passes through coal, becomes hot, and burns the tobacco. Then, the smoke passes through the metal body and reaches the water glass. Finally, it travels through the hose to the mouthpiece⁷. Sweetened flavors are available as additives, giving the smoke a distinctive odor and making it fashionable among the youth³.

Studies have found that waterpipe smokers are exposed to more carbon monoxide than nicotine when compared to cigarette smokers^3,8,9. In addition, waterpipe smoke contains several toxic agents such as hydrocarbons, heavy metals, and tar, which can cause cancer^3,9,10.

Invented in India in the 16th century¹¹, the waterpipe first migrated to Persia, where it evolved from its basic design to its current shape^12,13. Later, it traveled to the Mediterranean countries¹³. Waterpipe smoking-related health risks are similar to those of cigarette smoking^14,15. These include cardiovascular disease, cancer, pulmonary disease, higher risk of nicotine dependence, poor fetal outcome, periodontal disease, and chronic obstructive pulmonary disease^9,14-18. Furthermore, sharing of the mouthpiece during group waterpipe smoking can cause transmission of infectious diseases^3,16. Additionally, waterpipe smoking has negative effects on pregnancy outcomes. In particular, mothers who smoke cigarettes more than once daily are approximately two and half times more likely to deliver low birth weight babies compared to non-smoking mothers¹⁷.

According to the American Lung Association, waterpipe smoking is ‘an emerging deadly trend’¹⁹. The main source of waterpipes is the Middle East4, with Saudi Arabia alone importing more than $3.4 billion worth of tobacco products from 2010 to 2014²⁰. In Saudi Arabia, waterpipe smoking is most prevalent among adolescents. However, studies on waterpipe use among university students show considerable variations in its prevalence. The cigarette smoking rate among high school students is 46.1%. While 37.4% of the students smoke only waterpipe, 16.5% smoke both waterpipe and cigarettes²¹.

A recent survey conducted in Saudi Arabia indicated that the prevalence of tobacco smoking is 12.2% among those aged ≥15 years. Daily waterpipe smokers account for 4.3% of the total population compared to 1.4% of daily cigarette, cigar, and waterpipe smokers²². In the past two decades, waterpipe smoking has increased among adolescents and young adults²³, with its popularity reaching alarming levels among university students in some Arab countries. In a recent meta-analysis, three studies found the greatest prevalence of waterpipe smoking in Saudi Arabia²⁴. In Saudi Arabia, two studies reported a prevalence of 21.2–40%^21,25-29. In Lebanon, it was found to be 29%³⁰. Furthermore, a study conducted in four Jordanian universities indicated that the incidence of current waterpipe smokers among university students is 30%³¹. Prevalence in other Arab countries has been reported as 5.6–19.8%^32-36. Among non-Arab countries, in Iran the prevalence of waterpipe smoking was found to be approximately 25%³⁷. In Turkey, using the Global Youth Tobacco Survey, it was reported that the prevalence of children (aged 13–15 years) who had used waterpipe was 24.6% and current waterpipe smokers were 11.2%³⁸. Furthermore, the prevalence among school students in Israel was 40%³⁹.

While already very popular in the Middle East, waterpipe is becoming increasingly popular in other countries as well⁴⁰. A study conducted in the US in 2012 showed that the majority of waterpipe smokers were men aged >22 years and only 5.1% of them showed an intention to quit waterpipe smoking in the following year compared to 83.2% who had no intention of quitting. Furthermore, participants who believed that waterpipe smoking was harmful were more likely to have an intention to quit⁴¹.

Predicting factors associated with waterpipe smoking is important to help legislators and researchers to develop strategies to help smokers quit waterpipe smoking. A study conducted in 2012 among Saudi college students found that one-third of all male students (30.9%) were current smokers. The average age of cigarette smokers’ smoking debut was 16 years (range: 8–30). In addition, significantly heavy cigarette smokers (29.8%) had an income of approximately US$3200/year compared to non-smokers (19.3%). In general, smokers report the presence of at least one cigarette smoker in the family (48.2%) compared to non-cigarette smokers (28.4%). Cigarette smokers have one or more brothers who smoke (43.7%), and at least one cigarette smoker friend (92.9%) in contrast to non-cigarette smokers (72.3%). Additionally, students with low academic performance (grades C to D) demonstrate a two-fold risk of becoming cigarette smokers. Therefore, students with friends or family members who smoke cigarettes are more likely to begin smoking cigarettes themselves⁴². However, so far, no study has evaluated the factors associated with waterpipe smoking among Saudi college students. Thus, this study aimed to identify the predictors of waterpipe smoking among university students in Saudi Arabia.

METHODS

RESULTS

Of the 1158 questionnaires that were distributed to students, 928 were completed and returned, resulting in a response rate of approximately 80.1%. The majority (54.9%) of the participants were aged 21–23 years and unmarried (95.6%) (Table 1). The study included 820 (88.7%) men and 105 (11.3%) women. Almost all participants (96.9%) earned ≥990 SR/month ($264/month). Approximately 94.7% of the respondents had good academic performances throughout their academic lives. Roughly 57.6% of the participants reported that they had a friend who smoked a waterpipe and 26.3% had a brother who smoked a waterpipe. Furthermore, approximately 11.6% and 5.6% of the participants had fathers and mothers who smoked, respectively, and 19.7% of the participants had smoked a cigarette at least once within the past 30 days.

The results of the bivariate analysis of smoking status are summarized in Table 1. There were more smokers in the 21–23 years age group (56.2%, p<0.001). Substantially more of the waterpipe smokers were male (95.7%) than female (4.3%, p=0.001). There were more unmarried participants among the non-smoking group (97.3%) than married participants (2.7%, p=0.001). Substantially less non-waterpipe smokers (8.1%) reported receiving financial aid of >990 SR ($264) compared to non-waterpipe smokers who received financial aid of ≥990 SR (91.9%, p<0.001).

Fewer waterpipe smokers reported having a mother who smoked a waterpipe (10.3%, p=0.002), father who smoked a waterpipe (17.8%, p=0.003), and/or brother/s who smoked a waterpipe (44.3%, p<0.001). More non-waterpipe smokers than smokers reported having friends who did not smoke a waterpipe (54.4% vs 45.6%, p<0.001). Moreover, more waterpipe smokers (56.0%) had smoked cigarettes within the past 30 days compared to those who did not smoke within the past 30 days (44%, p<0.001). Additionally, of the waterpipe smokers, more had engaged in other types of smoking within the past 30 days (53.0%) than had not (47%, p<0.001). Approximately 27.7% of waterpipe smokers considered waterpipe smoking less harmful than cigarette smoking (p<0.001), whereas significantly more non-waterpipe smokers (72%) found waterpipe smoking equally or more harmful (p<0.001). Lastly, more non-waterpipe smokers (77.1%) reported less social acceptance of waterpipe smoking than waterpipe smokers (22.9%, p=0.001).

Table 2 presents the results of the multiple logistic regression analysis of the predictors of waterpipe smoking among university students in Saudi Arabia, including variables with a significance level of <0.2 in the bivariate analysis. The risk of waterpipe smoking was higher in students aged >21 years: 21–23 years (OR=3.11; 95% CI: 1.67–5.79), 24–26 years (OR=2.94; 95% CI: 1.38–6.24), and >26 years (OR=3.39; 95% CI: 1.30–8.80). Additionally, the risk of waterpipe smoking was approximately three times higher among men than in women (OR=2.73; 95% CI: 1.13–6.61), and among married individuals than in unmarried individuals (OR=3.21; 95% CI: 1.36–7.59). Furthermore, the risk of waterpipe smoking increased by 78% for individuals who had a sibling who smoked a waterpipe (OR=1.78; 95% CI: 1.13–2.79). The risk increased in waterpipe smokers who had smoked cigarettes within the past 30 days (OR=3.18; 95% CI: 1.89–5.34) and in those who had smoked other tobacco products within the past 30 days (OR=6.39; 95% CI: 3.69–11.07). Waterpipe smokers who believed that waterpipe smoking was less harmful than cigarette smoking had an increased likelihood of waterpipe smoking (OR=2.61; 95% CI: 1.54–4.41), while the risk of waterpipe smoking decreased with receiving financial aid above 990 SR ($264)/month (OR=0.34; 95% CI: 0.13–0.89).

DISCUSSION

Waterpipe smoking is a significant public health concern. Recently, waterpipe and cigarette smoking have shown an unprecedented increase worldwide⁴³.

In this study, we examined the predictors of waterpipe smoking among university students in Saudi Arabia. Among 928 students, 80% were non-waterpipe smokers and 20% were waterpipe smokers. Among the smokers, 88.7% were men and 11.3% were women. The percentage of current cigarette smokers in the past 30 days was 19.7%. A previous study conducted in the Qassim region with 371 university students identified that the inclusive predominance of waterpipe smoking (46.63%) is higher than that of cigarette smoking (26.68%). Among students, waterpipe smokers were more aware of the adverse effects, such as lower cognitive function, compared to cigarette smokers⁴⁴.

Another study involving college students at Qassim University revealed a 40% prevalence of waterpipe smoking²⁹. In 2006, a study conducted in Al-Hassa comprising 1652 secondary male students identified 30.3% of the participants as current waterpipe smokers, which is consistent with our study findings⁴⁵. The increased prevalence of waterpipe smoking may be attributed to society’s acceptance of waterpipe smoking and the rapidly increasing number of waterpipe cafes⁴⁶. Additionally, the most common influencing factor that increased the risk of waterpipe smoking is the misconception that waterpipe smoking is less harmful, less dangerous, and less toxic than cigarette smoking⁴⁷. A systematic review and meta-analysis showed that the overall estimation of tobacco smoking among university students in Saudi Arabia is 17%, which is 5% higher than the mean prevalence of Saudi Arabian daily current smokers aged 15–25 years. This suggests that the national representative sample of university students in Saudi Arabia smoke at a higher rate than a marginally comparable age group⁴⁸.

A majority of waterpipe smokers were aged 21– 23 years, and there was a remarkable increase in waterpipe smoking with increased age. This result is consistent with a similar study among Chinese adults wherein the majority of cigarettes smokers were aged 26–40 years (42.1%)²⁵. The better employment status of the higher age group may affect its association with the increased risk of cigarette smoking. Moreover, in young people, cigarette smoking may be prevented by their parents who make them either stop or delay cigarette smoking⁴⁹.

While previous studies in geographical regions similar to our study included only male students, this study included both male and female students to determine the variation in waterpipe smoking prevalence. Our study included 820 (88.7%) men and 105 (11.3%) women, which could be attributed to the gender distribution at the survey location. Male students were more likely to smoke waterpipe (95.7%) than female students who were less likely to smoke (4.3%). A previous study conducted among university students in Saudi Arabia found that a majority of waterpipe smokers were men²⁸. Moreover, a previous study on 7317 adults across the 13 regions of Saudi Arabia reported that the prevalence of cigarette smoking was 32.5% among men and only 3.9% among women⁵⁰. This may explain the low social acceptance of cigarette-smoking women in Saudi Arabian society. Furthermore, the adverse effects of smoking on women’s health are more serious, such as its effects on fertility, pregnancy, osteoporosis, and other health conditions⁵¹. In Saudi society, there is a community that considers female smoking of all types shameful⁵². The association between male sex and smoking waterpipe has also been observed in studies conducted outside Saudi Arabia, such as in a study of 345 Lebanese college students³⁰.

Furthermore, our study revealed that receiving low financial aid was associated with an increased risk of waterpipe smoking. Students receiving financial aid below $264 were more likely to smoke waterpipe. This supports the results of a similar study conducted with 406 participants in Riyadh, in which low income was significantly associated with an increased risk of waterpipe and cigarette smoking¹⁹.

Education level has also been reported to play an important role in predicting waterpipe smoking; students with low education and awareness levels, such as those from underprivileged populations, have lower economic status and a higher risk of smoking waterpipe⁵³. A study conducted among 600 Jordanian adults, who were cigarette smokers, reported that students with lower academic grades during their school years were more likely to smoke cigarettes⁵⁴. However, academic performance was not significant in our study.

Being married significantly increased the likelihood of waterpipe smoking, which is consistent with a study involving Chinese cigarette smokers that showed that being married increased the risk of cigarette smoking⁴⁹, explaining that being unmarried involves fewer social and financial responsibilities and less stress, leading to less smoking⁴⁹.

In our study, the influence of family members (father, mother, brother) who were smokers was a significant predictor of waterpipe smoking among the students. Furthermore, the risk of waterpipe smoking with a first-degree relative who was a waterpipe smoker was found to be significant only in the bivariate analysis, except for siblings, for whom the risk was identified in both bivariate and multiple logistic regressions. Findings of a longitudinal study conducted between 1991 and 1994 on 3rd to 8th grade students in the US support the present results. The results revealed that having a family member who smoked cigarettes at home was a significant predictor of smoking at a young age⁵⁵. Moreover, a study on 600 Jordanian adults identified the waterpipe smoking behavior of siblings as an important factor in predicting waterpipe smoking. This may occur because waterpipe smoking may become a part of the family’s social events, which may encourage the waterpipe smoking habit and affect any preventive efforts⁵⁶.

An interesting finding in our study was that friends were not significant predictors of waterpipe smoking when compared to family members. This may be attributed to the fact that family members are strong role models who have a potential influence on young people’s waterpipe smoking behavior^42,57,58. Future studies should focus on family members to distinguish the predictors of smoking waterpipe among university students.

This study identified that smoking cigarettes and other tobacco products within the past 30 days was a significant predictor of waterpipe smoking, whereas students who had not smoked such products in the past 30 days had a decreased risk of waterpipe smoking. A similar study conducted among university students in Saudi Arabia found that most waterpipe smokers also smoked cigarettes⁵⁹. Another study on 744 university students in the US reported that having smoked cigarettes within the past 30 days was a strong predictor of waterpipe smoking⁶⁰. Additionally, in a study conducted with Lebanese university students, smoking cigarettes was found to be a predictor of waterpipe smoking³⁰. Another study on Jordanian adults found that participants who had smoked cigarettes within the past 30 days were 2.69 times more likely to use waterpipe⁵⁶. This suggests that general health-risk behaviors are correlated with waterpipe smoking⁶¹.

The present study revealed that the majority of waterpipe smokers believed that waterpipe smoking was less harmful than cigarette smoking, which is a remarkable predictor of waterpipe smoking; this is consistent with the findings of previous studies in the US⁶² and Saudi Arabia⁵⁹. However, in contrast to our findings, participants in a study conducted in Jordan believed that waterpipe smoking is equally or more harmful than cigarette smoking⁵⁶. The misconception among university students that fewer risks are involved with waterpipe smoking compared to cigarettes gives them a feeling of security regarding waterpipe smoking⁶³.

CONCLUSIONS

This study examined the predictors of waterpipe smoking among university students in Saudi Arabia. We identified that the main predictors included being male, belonging to a higher age group, being married, receiving low financial aid, and having one or more brothers who smoked. Furthermore, individuals who had smoked cigarettes or used other tobacco products within the past 30 days or believed that waterpipe smoking was less harmful than cigarette smoking were significantly more likely to engage in waterpipe smoking. Awareness regarding the adverse effects and early prevention of waterpipe smoking, particularly in young adults, is crucial. Waterpipe smoking cessation at a younger age is better than treating complications of smoking later in life.