INTRODUCTION

Waterpipe smoking, also called shisha, narghile, hubble-bubble, and hookah, consists of heated tobacco smoke inhalation after passing through water¹. Waterpipe smoking is now increasingly popular globally², and is one of the most common forms of tobacco smoked, particularly in the Eastern Mediterranean Region (EMR)^3,4. According to GYTS school-based survey results, high prevalence of waterpipe smoking was reported among school students in the Gulf region⁵. Moreover, waterpipe smoking is the second common form of tobacco used among university students in Qatar⁶. However, in the United Arab Emirates, medwakh (traditional Arab pipe) smoking precedes waterpipe smoking⁷.The popularity of waterpipe smoking in the EMR is mostly due to the low price of tobacco in the region, weak tobacco control policies, and being a common habit in social gatherings^3,8.

Most people incorrectly believe that waterpipe smoking is less harmful than cigarette smoking^9,10. However, waterpipe smokers inhale large quantities of toxicants that may lead to tobacco-related disease^11-13, including cancer¹⁴, and when compared to cigarette smokers, they can be exposed to an equal or greater health risk^15,16. Toxic substances in tobacco smoke include carbon monoxide, nitric oxide, nicotine, polycyclic aromatic hydrocarbons, nanoparticles, volatile aldehydes, and others¹. Waterpipe smoking is associated with an identified dependence effect exhibited by nicotine withdrawal symptoms trying to quit, similar to cigarette smoking^17-19.

Despite its deleterious effects, waterpipe smoking is highly popular among university students, females, and in social gatherings^20-24. Greater social acceptability and tolerance toward waterpipe smoking than cigarette smoking are some of the facilitating factors for female students, in some Arab countries, to use the waterpipe²⁵. Nowadays, waterpipes are available for socializing at parties, in households, hotels, cafés, and in restaurants¹⁰. This trend for females is due to increased availability of appealing tobacco flavors, the flourishing café culture, affordability, and the absence of policies related to prevention of waterpipe smoking in contrast to the negative attitude toward cigarette smoking^2,26.

The increase in waterpipe smoking has prompted the World Health Organization (WHO) to declare its use as a growing public health concern in its 2015 advisory note²⁷. Within the WHO Convention on Tobacco Control (FCTC) framework, Qatar has adopted effective measures for tobacco control such as tax increase, smoke-free policies, ban on advertising and provision of tobacco intervention services along with free-of-cost complete cessation treatment^28,29. Additionally, telephone-based smoking cessation counseling support during the COVID-19 pandemic has also been provided³⁰. Though Qatar has signed and ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2004, a high prevalence of cigarette use is reported in the country^31,32 along with a growing number of waterpipe cafés that attract both adults and teenagers³³. Qatar represents a culturally diverse society in the Middle East Region. Expatriates from over 100 nationalities and multiple ethnicities live in Qatar. According to a recent population-based study, the rate of overall tobacco use among adults in Qatar was 25.2%, with waterpipe being the second most common form of tobacco used³⁴.

Due to the increasing practice and the potential harmful health effects of waterpipe smoking, and based on our previous published study about the epidemiology of tobacco use in Qatar³⁴, we aimed to support the Framework of WHO Tobacco Free Initiative by: 1) determining the prevalence of waterpipe smoking and explore its patterns in Qatar; 2) describing the knowledge, attitudes, and practices related to smoking behaviors; 3) recognizing waterpipe smoking locations and symptoms experienced during waterpipe sessions; and 4) evaluating the frequency of waterpipe smoking and the initiation age. Therefore, this study focuses on waterpipe smoking in Qatar, which is not commonly assessed by previous studies. The study findings could be instructive in better planning waterpipe smoking control strategies in the country.

METHODS

RESULTS

Cessation efforts in waterpipe smokers

Figure 1 shows the percentage of waterpipe smokers’ cessation trials by sex and nationality. Almost half of waterpipe smokers (n=475) tried to quit smoking during the past 12 months (45.5%). Compared to Qataris, expatriates tried to quit more (45.4% vs 46.3%) and females tried to quit less than males (43.8% vs 46.1%). Nevertheless, only 2.3% of the study population tried to use prescription medication, 4.5% tried to use nicotine replacement therapy, and 3.5% tried to use counseling with a physician/psychologist to stop smoking during the past 12 months.

Figure 1

Cessation efforts in waterpipe smokers, Qatar 2019

DISCUSSION

Of the total sample, the prevalence of waterpipe smoking among adults ≥18 years in Qatar is 8.3% (95% CI: 7.7–9.0), higher than the overall rate of Global Adult Tobacco Survey (GATS) in 2013, which reported that 3.4% of people aged ≥15 years smoked waterpipe³⁵. In the WHO EMR, waterpipe smoking is second only to cigarette smoking and, in some countries, has surpassed cigarette use like in Lebanon^2,3. Cigarette and waterpipe smoking is a significant health threat among university students in Egypt, Kuwait, Kingdom of Saudi Arabia, Jordan, Libya, Lebanon, Yemen, Palestine and United Arab Emirates⁴. Similarly, our results show that the highest proportion of waterpipe smokers are aged 18–24 years. This supports previous studies reporting that young adults are more likely to engage in waterpipe tobacco use^3,4.

The prevalence of waterpipe smoking among males was twice the prevalence among females, however in a previously published study, there was a big difference of tobacco use among males and females (36.6% and 9.2%). This could be largely explained by the social appeal and the cultural tolerance of females smoking waterpipe and not cigarettes in traditional societies³⁶. Females in the region tend to underreport their smoking behavior³⁷, however this may not be a major problem in our study since the survey was self-administered and the completed surveys were returned in a sealed envelope to ensure optimum privacy and confidentiality. Though results are not shown, female waterpipe smokers were predominantly expatriates (16.1% Qataris vs 83.9% expatriates). The Qatari society tends to be conservative in most of its aspects because of its traditional and cultural influences, where females are highly unlikely to smoke. The implemented policy framework is the same for the whole population of Qatar, where tobacco use is not encouraged and preserving overall health is highly promoted. Not surprisingly, high prevalence of waterpipe smoking was reported among expatriates coming from the Levant countries due to cultural similarities where waterpipe smoking is a socially acceptable behavior^3,20 and poorly regulated²⁶.

Being single involves fewer social responsibilities and less financial stress that prevents smoking³⁸, however this was not true for our sample, where waterpipe smoking was highest among unmarried individuals. These individuals may experience social isolation and not having spousal support which could be a trigger for unhealthy lifestyles or behaviors. Also, within the prevailing culture that highly respects family values, it is possible that married individuals are likely to abstain from smoking in front of the children and family.

Studies show that waterpipe smoking is usually not a daily practice and many regular smokers usually use more than one type of tobacco^2,9. Waterpipe smokers are at risk of initiation of poly-tobacco use and are highly likely to become cigarette smokers in the future1. In fact, waterpipe smoking is a possible risk factor for other forms of tobacco consumption, including electronic cigarettes³⁹. Data from 2013 GATS in Qatar show that current e-cigarette use among those aware of e-cigarettes was 1.8%⁴⁰. In another recent study, exclusive electronic cigarette use was reported as 2.0% in Qatar, however concomitant with other types of tobacco products, it reached up to 11.3%³⁴. Dual usage may promote and reinforce nicotine addiction. For instance, in a study conducted in Jordan, dual users were associated with higher waterpipe nicotine dependence compared to only waterpipe smokers⁴¹, which may postpone tobacco cessation and lower chances of successful cessation⁴². Therefore, dual and poly-tobacco use is an emerging pattern² that is becoming a public health concern since their synergistic health effects remain mostly unknown. Our study findings can be used to inform new policy recommendations and to enact new regulatory laws and restrictions that do not apply to electronic cigarettes and to other tobacco forms. Moreover, they can aid in the design of cessation interventions relevant to the unprecedented increase in dual and multiple tobacco product use, especially among the Qatari nationals where medwakh use precedes e-cigarette use.

Importantly, this study identified that females tried less to quit smoking than males during the past 12 months. This might be attributed to the misconception that a lesser risk is associated compared with cigarette smoking, which possibly gives them a feeling of security regarding waterpipe smoking¹⁰. Future studies can explore factors that are barriers for treatment such as stigma, lack of education, and knowledge. Female-specific tobacco programs and services tailored to meet their preferences may reduce these barriers and motivate them to initiate treatment⁴³. However, for males who tried to quit, their uptake of medication to stop smoking including nicotine replacement therapy and counseling was very low. Qatar is currently well placed to help tobacco smokers to quit, with the expansion of tobacco dependence treatment services across Qatar along with coverage for full cost of tobacco cessation support²⁹. Yet, marketing of such smoking cessation treatments must be improved in the country.

In our study, waterpipe cafés were the most common place of smoking. Although smoke-free laws for clean indoor air exist in Qatar, waterpipe cafés are frequently exempted³³. This is true for most countries where they do not address and do not effectively implement waterpipe tobacco smoking regulations and legislations⁴⁴. However, most females in our study preferred restaurants for waterpipe smoking. This may be due to its popularity, accessibility and convenience and the availability of a variety of choices in types and fragrances of waterpipe, with a relatively affordable price. The recent upsurge in waterpipe smoking among females in Arab countries emphasizes the need to identify and address the gaps in tobacco regulations along with focused interventions targeted to this specific population⁴.

Waterpipe smoking has considerable short- and long-term harmful health effects. Its short-term health issues may include headache, nausea, and dizziness, among others1. Long-term health effects include respiratory and pulmonary diseases as well as cardiovascular complications^45-47. As seen in our findings, cough was the third most prevalent health symptom among males and older age categories specifically 35–44 years and 45–54 years. It is apparent that waterpipe smoking poses a significant public health risk. One of the alternative ways to prevent and reduce smoking prevalence among the community is to empower health professionals by training them to identify waterpipe smokers, educate them about potential harmful effects, and refer them to cessation services. Fortunately, according to a recent study conducted among governmental healthcare workers in Qatar, about 60% of them routinely promoted tobacco cessation interventions, thus being effective in helping users to quit²⁸.

Males more than females were using five or more waterpipes per week (35.6% vs 24.1%). Likewise, about half of Qataris (44.1%) smoked five or more waterpipes per week, these findings raise concerns regarding the dependence of waterpipe use among Qataris, which can lead to addiction and hazardous effects on health^17-19.

The age of initiation for waterpipe smoking is much dependent on the age range of the sample studied and it is unlike cigarettes, where most initiation usually takes place before the age of 18 years². According to the Qatar 2013 GATS survey, among people aged ≥15 years, approximately 11% of waterpipe smokers started waterpipe smoking before the age of 18 years³⁵. However, more than half of Qataris (52.1%) started smoking waterpipe before the age of 18 years. Our sample included individuals ≥18 years making it hard to strictly compare the two findings, but it still provides an insight. Knowing that most long-term smokers start smoking from the age of 18 to 25 years and that young adulthood is the time when individuals are most susceptible to starting tobacco use, it is recommended that the legal age to buy tobacco is raised to 21 years and higher taxation is introduced on waterpipe tobacco to decrease its affordability like cigarette taxation⁴⁸ and waterpipe bottles labelled with health warnings²⁷. In 2018, the Ministry of Finance increased the minimum import duty from 100 to 200 Qatari Riyals per 1000 cigarettes. The minimum import duty on waterpipe tobacco was 6 Qatari Riyals per kilogram in 2014, this was increased to 12 Qatari Riyals per kilogram in 2016⁴⁹ and to 24 Qatari Riyals in 2018, because of tobacco taxation set at 100%³⁴. Although government efforts are underway, further urgent action can lead to improving the situation.

We found that 83.3% of waterpipe smokers reported that waterpipe smoking is harmful, however 39.3% of the sample considered that waterpipe smoking is less harmful than cigarette smoking. In a systematic review, a large number of studies found that most people¹⁰ perceived waterpipe smoking as less harmful than cigarette smoking and more socially acceptable than cigarette smoking in general. This is consistent with the findings of previous studies in Qatar reporting that waterpipe smokers perceive waterpipe to be safer than cigarettes or have insufficient knowledge about its effects^9,50. For instance, in our study only 42.2% of waterpipe smokers agreed that smoking tobacco causes stroke and only 69.2% reported that it causes heart attack. Given the health risks of waterpipe smoking, health campaigns should be delivered to the public to correct misconceptions that contribute toward a reduced perception of harm about tobacco use in general and waterpipe smoking.

In our sample, 75.5% believed that smokers can stop smoking if they want to. However, evidence suggests the opposite, by confirming that waterpipe smokers have difficulty in quitting^19,51. Among a sample of 268 waterpipe smokers, 86.5% believed they could quit waterpipe at any time, however 60% of the participants had been unsuccessful in their previous attempts⁵². In another study, 47.5% of the participants were very confident that they could quit waterpipe smoking at any time, however they did not have the intention to quit⁹. Surprisingly, in our study females more than males were recommending waterpipe to their friends or to other people. This also highlights the association between the positive attitude toward smoking and waterpipe use^4,10. Urgently, mass media and awareness campaigns are needed to address the addictive and deleterious health consequences of waterpipe smoking to improve knowledge and to change attitudes towards waterpipe smoking since it is becoming a socially normative behavior as part of leisure events among friends and families^9,51.

CONCLUSIONS

Waterpipe smoking is considerably high in Qatar (8.3%). Waterpipe use should receive special consideration in Qatar’s overall tobacco control program. The current situation in Qatar warrants further implementation of effective strategies to reduce waterpipe smoking with dual and multiple usage of other tobacco products. These strategies could include the introduction of more stringent regulations and legislations specific to waterpipe advertising and marketing, educating the community about its health risks, and designing tobacco control programs for women and for poly-tobacco product users. Compared to earlier years, to date Qatar has been more comprehensively implementing FCTC measures. However, dissemination and implementation of waterpipe preventive measures and regulations deserve due attention by decision makers in the country.