Nursing Reports 2015; volume 5:5306

Water pipe : smoke from and water pipe tobacco (WT) smoking at confined places.1 Often, WT Correspondence: Govindaraj Vaithinathan are the Bahraini smokers aware smoking occurs in groups as a social activity Asokan, College of Health Sciences, University of of its health effects? that has a history of at least 400 years in the Bahrain, Salmanya Medical Complex, P.O. Box Middle East, India, and parts of Asia. WT varies 32038, Kingdom of Bahrain. Ebrahim Khalil, Sajida Mansor Ayyad, in size and shape; it is also known as shisha, Tel.: 00973.17285421 - Mobile: 00973.39497564. E-mail: [email protected] Fatima S. Sharaf Al-Alawi, Hasan A. Ali hookah, narghile, goza, and hubble bubble. Khalil, Muyassar Sabri Hassan Awadalla, The specially made tobacco in water pipe Key words: Water pipe; smoking; health effects. Govindaraj Vaithinathan Asokan comes in different flavors and the popular fla- vors are: apple, banana, berry, cherry, choco- Acknowledgments: the authors are grateful to Dr. College of Health Sciences, WHO late, cappuccino, coconut, mint, licorice and Aneesa Al-Sindi, Dean, College of Health Collaborating Centre for Nursing watermelon. Sweeter additives and flavors Sciences, University of Bahrain for the support Education, University of Bahrain, were developed to attract female consumers.2 and encouragement provided in this work. The authors would like to thank Mr. Hasan Al Basri for Salmanya Medical Complex, Kingdom All forms of are harmful to statistical assistance. of Bahrain health. More than 4000 chemicals in tobacco smoke have been identified; at least 250 are Contributions: GVA, idea conceiving; EK, SMA, known to be harmful and more than 60 are HAAK, data collection; MSHA data interpretation. known to cause cancer. Toxic trace metals All authors contributed equally in drafting and Abstract have been found in herbal shisha products and editing the manuscript. their smoke emissions contained carcinogens Conflict of interest: the authors declare no poten- equivalent to, or in excess of, those of tobacco The tobacco epidemic kills half of its users tial conflict of interest. annually and 600,000 deaths occur in people products.3 A meta-analysis of data from four exposed to cigarette and water pipe tobacco (WT) nations indicated that daily use of WT pro- Received for publication: 1 June 2015. smoking. A population-based cross sectional duced nicotine absorption of a magnitude sim- Revision received: 3 September 2015. study was conducted to explore the knowledge ilar to that produced by daily cigarette use.4 Accepted for publication: 3 September 2015. and perceptions on health effects of WT smoking Smoking WT for approximately 20 to 80 min is only amongst Bahraini adults in the popular coffee equivalent to smoking 100 or more of ciga- This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- shops of Bahrain and in women’s congregations. rettes.5 Besides, smoking WT produces more NC 3.0). Randomly, 206 Bahraini adults of both genders second hand smoke than ; thereby, were selected and distributed with a developed passive smokers are at similar risk for theuse dis- ©Copyright E. Khalil et al., 2015 questionnaire to collect data; results were ana- eases caused by cigarette smoking. Existing Licensee PAGEPress, Italy lyzed using SPSS (SPSS Inc., Chicago, IL, USA). evidence of diseases as a result of WT smoking Nursing Reports 2015; 5:5306 Among the WT smokers, the highest proportion includes lung cancer, oral cancer, stomach can- doi:10.4081/nursrep.2015.5306 (45%) was observed between 21 and 30 age group cer, cardiovascular and respiratory diseases, and in the higher educational category. Majority reduced lung function, coronary heart disease smoked daily. The leading motives of WT smoking and adverse effects during pregnancy. Babies were meeting friends, passing of time and pleas- born to mothers who smoked WT weighed less similar to cigarettes.11 Over the past several ure. Many smokers believed WT as less harmful at birth6 and were also found to be at increased years, a global upsurge of WT smoking has than cigarettes, but affect the respiratory system, risk of respiratory diseases. The risks of con- been recorded in the Middle East, USA, and causes: cancers, cardiovascular disease and tracting infectious diseases and the opportuni- Canada, France, Russia, UK and Australia pregnancy-related disorders. The knowledge ty to spread arise from the shared mouthpiece owing to the increasing popularity amongst scores were significantly higher in the younger of commercial water pipe and moist smoke. WT smoking young people. In the West: more than half of age group, higher educational qualifications, and has been associated with outbreaks in the the young population in Denmark reported higher income. A considerable proportion of Middle East; for instance, two outbreaks in tried smoking WT,12 and a Canadian study on smokers perceived WT smoking as a sign of 2010, which revealed a possible association nicotine dependence in teens, reported 23% maturity, acceptable by the society. The percep- between tuberculosis and sharing a WT pipe.7 WT use.13 In the Arab World: a premarital tion scores were significantly higher inNon women Factors attributed to WT smoking comprise screening program in Abu Dhabi recorded and in the age group of >40. This study has social acceptability, lack of knowledge of health 4.8% smoking WT;14 amongst Egyptian female revealed a lack of knowledge amongst the effects, and concentrated preventive programs university students, 37.8% smoked WT only, Bahraini adults who assume that health risks of to cigarette more than WT smoking.8,9 and 35.2% smoked both WTS and cigarettes,15 WT are lower than cigarettes demanding further Lingering popular myths of WT smoking are: i) and the prevalence of WT smoking amongst research to evaluate WT smoking risks, health WT is less harmful and addictive than ciga- male medical students in Saudi Arabia16 was effects, environmental effects of smoke, and reg- rettes; ii) nicotine content in WT is lower than 12.6% and was lower compared with the preva- ulatory services in Bahrain for a responsive that of cigarettes and water used in WT filters lence in dental students. According to the approach to curb the WT tobacco epidemic. all the hazardous chemicals such as carbon National non-communicable diseases monoxide, tar and nicotine.10 On the other (NNCDs) risk factor survey of 2007, Bahrain, 17 hand, water in the pipe partially cools the the prevalence rate of tobacco use was 23.1% smoke, makes it less irritating by its taste, and smoking WTS was 8.4%. WT smoking was Introduction smell and smoothness of sweetened tobacco. higher amongst males, particularly in young Yet, by all yardsticks, WT is not less toxic; adults between the age group of 20 and 29 The global tobacco epidemic kills half of its greater exposure to toxins with higher nico- (17.8%). Amongst females, the prevalence rate users annually accounting up to 6 million tine intake results from more frequent puffs was higher in older women between the age deaths. An additional, 600,000 deaths occur in and longer sustained sessions. Further, fre- group of 50 and 64 (11.5-13.2%). non-smokers being exposed to second-hand quent use of WT is a determinant for addiction Governmental and non-governmental

[page 24] [Nursing Reports 2015; 5:5306] Article healthcare organizations have a shared com- smoking on a five point Likert scale (Table 3). mitment to in which nurses The questionnaire was built in English lan- Results are a vital force in the interdisciplinary health guage and translated to Arabic language. Back care team. More specifically, public health or translation of the Arabic version of the ques- A total of two hundred and six participants community nurses have a greater role in tionnaire to English language ensured reten- participated in the study and the gender distri- tobacco cessation practices as public health tion of the originality of the questions. For bution was skewed (male: 174, female: 32). nursing involves working with communities affirming face and content validity, the ques- Among the four categorized age groups, the and populations as partners, focusing on pri- tionnaire was scrutinized by a panel of experts highest proportion (45%) of WT smokers was mary prevention and health promotion. Public from College of Health Sciences, University of observed in the age group between 21 and 30. health nurses practice in diverse settings. Bahrain. Pre-testing and piloting our question- Participants with college degree/equiva- High-risk and vulnerable populations are often naire in thirty WT smokers (coffee shops lent/other higher degrees had the highest pro- the focus of care that includes WT smokers.18 n=15, matams n=15) rendered suitable modi- portion (45%) of smoking WT, whereas, no With deep-seated myths amongst smokers fications to the questionnaire before embark- explicit variation among the four categories of of WT, we hypothesized a significant relation- ing the main study. The developed question- income was noticeable (Table 1). The mean ship between adults smoking WT and their low naire used in the study was specific, realistic age of the smokers was 30, declared age at ini- level of knowledge on its health effects in and measurable that had an acceptable inter- tiation of smoking WT was 19 and an average Bahrain. Although, objectively, the NNCD sur- nal consistency (Cronbach’s a=0.61). time spent in a smoking session was 75 min. vey has estimated the prevalence of WT smok- Generally, by late evenings the coffee shops Through a solitary attempt, 47% of the partici- ing amongst adults in Bahrain along with are vibrant with customers and data collection pants had admitted to have made efforts to quit other non-communicable diseases, the survey was accomplished during such ideal time. smoking WT. did not examine their knowledge or percep- Bahraini adults aged 18 years and above, in The three leading motives of WT smoking tions regarding non communicable diseases, both genders, who are WT smokers in the cof- were meeting friends and family (45%) fol- or health effects resulting from the use of fee shops and matams were alone included in lowed by boredom/passing of time (25%) and tobacco in any form. The aim of this study was the study. After briefing the study purpose, pleasure/happiness (16%). Among the fre- to explore the knowledge and perceptions on each one was provided with a self-adminis- quency of WT smoking, majority (55%) smoked health effects of WT smoking amongst adults tered questionnaire to complete it with their dailyonly and 25% smoked during weekends. The in Bahrain. responses. Informed consent was obtained bulk of the smokers (46%) recalled spending from the participants without persuasion. US$ 2.5 to 5 per smoking session and the most Confidentiality, anonymity and data of the par- preferred flavors of WT were apple (27%), ticipants gathered were protected throughoutuse grape (22%) and grape with mint (19%). Materials and Methods the study and after. The data from the ques- Table 2 describes the binary responses of tionnaire was cleaned, categorized, coded and the participants’ knowledge about the health A population based cross sectional study was entered in Excel (Microsoft, Redmond, WA, effects of WT smoking. Many smokers believed conducted during 2014, in the most populated USA), exported to SPSS version 21 for win- WT: less harmful compared to cigarettes and diverse (traditional and non-traditional) dows (SPSS Inc., Chicago, IL, USA), for (60%), affects the respiratory system (89%), coffee shops of Bahrain that catered WT, as descriptive and inferential statistical analysis. leads to lung cancer, oral cavity cancer, and well as in women matams (places of religious The College of Health Sciences research com- tongue cancer (73%), causes cardiovascular and social congregation) where women smoke mittee has approved the study. diseases/hypertension (67%) and responsible WT, within the three governorates of Bahrain for the most pregnancy related disorders i.e., Northern, Capital and Muharaq. A random (83%). The for and against views on transmis- sampling process was followed in selecting the sion of infections through smoking WT were governorates, coffee shops/matams and partic- commercial even. Contrary to the fair knowledge on above ipants. A sample size of 140 WT smokers was required for the NNCD16 survey reported preva- lence of 8.4% of WT smoking in Bahraini pop- ulation to give a 95% chance of being within Table 1. Demographic data. 5% of the true result allowing for Nonup to 10% of invalid or missing responses. Demographic characteristics n=206 Percentage Based on an in-depth literature review of Age <=20 36 17.5 smoking, socio-cultural aspects and health effects of WT, the data collection instrument 21-30 93 45.1 was designed. The instrument was structured 31-40 40 19.4 and sequentially ordered with the following >40 37 18.0 four sections: i) demography of the partici- Gender Male 174 84.5 pants that included age, gender, highest Female 32 15.5 attained educational level and monthly income (Table 1); ii) general information regarding Educational level 500 43 20.9

[Nursing Reports 2015; 5:5306] [page 25] Article stated health effects, two thirds of the smokers knowledge, promote action, and sustainable Bahrain and the Gulf region. Alarmingly, the presumed that smoking WT does not affect implementation of health policies must be average time spent in a smoking session of 75 sexual ability or cause infertility or affect con- based on reliable estimates and understand- min found in our study is reckoned to smoking centration and attention. In aggregate, the ings of any misconceptions, prevailing knowl- 100 or more of cigarettes according to the knowledge scores (mean: 5.47) were signifi- edge and perceptions. Yet, no reports docu- tobacco product regulation advisory note.5 cantly higher in the groups of: 21-30 age mented in Bahrain on the knowledge or per- Smokers with higher income, higher educa- (P<0.02), higher educational qualifications ceptions regarding health effects result from tional qualifications and aged between 21 and (P<0.002), and in higher income (P<0.02). the use of WT amongst adults. Therefore, this 30 had significantly higher knowledge scores The perceptions of WT smokers described in study was purported to examine the use of WT than others but their illusion of WT as less Table 3 are: one third of them agreed that com- in Bahrain and to recommend necessary meas- harmful than cigarettes and accepted by the pared to cigarettes, WT is accepted by the soci- ures to promote health by cessation of WT society is baffling. The prevailing myths of the ety, however, half of them strongly agreed that smoking. Our study has revealed that most WT smokers in our study were similar to a the parents would object their son/daughter water pipe tobacco smokers were around 30 reported perception of medical students in smoking WT and most felt smoking WT is a years, have higher educational qualifications, Malaysia24 but contrary to a report from sign of maturity. One fourth disagreed with the smoked daily, frequently with friends or fami- Pakistan, where majority considered WT more notion that WT smokers have more friends lies. Complementary to our findings, the dangerous than cigarettes.25 Notably, with the than non-smokers. A strong resentment (45%) NNCD survey in Bahrain,16 and a report from highest perception scores amongst partici- was observed for women smoking WT. One the Arab world23 considered WT as a major pants over 40 years of age and women, most of third of the smokers strongly disagreed that tobacco use method amongst the youths of them perceived their parents would object teenagers smoke WT to imitate celebrities. In aggregate, the perception scores were signifi- cantly higher in: the age group of >40 (P<0.02) and women (P<0.001). Table 2. Knowledge about the health effects of water pipe smoking. Knowledge on health effects (n=206) True False n only % n % Discussion I consider water pipe smoking is less harmful 83 59.7 83 40.3 Global disease patterns have changed from compared to cigarettes smoking infectious diseases to predominantly chronic Cigarettes contain less content of harmful use 140 32.0 140 68.0 diseases and injuries. Tobacco use is consid- substances than water pipe ered as the leading preventable cause of most Water pipe smoking causes damage 23 88.8 23 11.2 morbidity and mortality of chronic diseases to the respiratory system such as cardiac diseases and cancer. By and Water pipe smoking leads to lung cancer, 56 72.8 56 27.2 large, scientific research and cessation meth- oral cavity cancer, and tongue cancer ods of tobacco have focused on cigarette smok- Water pipe smoking may transmit infections 107 48.1 107 51.9 ing. Often, WT has not been regarded in paral- Water pipe smoking causes stomach ulcer 136 34.0 136 66.0 lel to that of cigarettes in Water pipe smoking causes cardiovascular 68 67.0 68 33.0 methods. Although, smoking WT is a global health concern, a bibliometric analysis has diseases and hypertension reported marginal research addressing tobacco Water pipe smoking causes 35 83.0 35 17.0 smoking using WT,19 despite WT smoking gain- pregnancycommercial related problems ing popularity over the past two decades.20,21 Water pipe smoking causes affects sexual 143 30.6 143 69.4 Evidence accumulated so far suggests that ability and may cause infertility in men some WT smokers become addicted, face diffi- Water pipe smoking affects the ability of 143 30.6 143 69.4 culty quitting, and experience healthNon risks concentration and attention 22 similar to cigarette smokers. To advance Values in italics represent higher proportion.

Table 3. Perceptions of water pipe smoking. Perception (n=206) Strongly disagree Disagree Undecided Agree Strongly agree n % n % n % n % n % Water pipe smoking is more acceptable 28 13.6 25 12.1 38 18.4 71 34.5 44 21.4 by the society compared to cigarettes Parents would object their son/daughter 15 7.3 12 5.8 29 14.1 54 26.2 96 46.6 smoking water pipe Water pipe smoking is a sign of maturity 37 18.0 30 14.6 40 19.4 50 24.3 49 23.8 Water pipe smokers believe that they 36 17.5 50 24.3 48 23.3 40 19.4 32 15.5 have more friends than non-smokers Woman smoking water pipe is socially accepted 92 44.7 36 17.5 36 17.5 21 10.2 21 10.2 Teenagers smoke water pipe to imitate celebrities 69 33.5 44 21.4 42 20.4 25 12.1 26 12.6 Values in italics represent higher proportion.

[page 26] [Nursing Reports 2015; 5:5306] Article smoking WT. Whereas, a cause for concern is is evident from our study that parents disap- health outcomes: a systematic review. Int J that a considerable proportion considered the prove their son/daughter smoking WT and the Epidemiol 2010;39:834-57. practice of WT smoking as a sign of maturity. attitude scores were higher for smokers >40 8. Amin TT, Amr MA, Zaza BO, Kaliyadan F. In addition, women smoking WT was disagree- years of age, which indicates that parents can Predictors of water pipe smoking among able to most of our study participants probably be further motivated to restrain their secondary school adolescents in Al owing to more men in our study sample who son/daughter against smoking WT. Hassa,Saudi Arabia. Int J Behav Med still consider smoking in any form is a male To bridge the gap between research on WT 2012;19:324-35. domain. smoking and health promotion, evaluation of: 9. St Helen G, Benowitz NL, Dains KM, et al. Tobacco use in Bahrain is strictly under con- WT smoking risks, health effects, environmen- Nicotine and carcinogen exposure after trol that includes higher taxes, ban of tobacco tal effects that include main stream and side water pipe smoking in hookah bars. smoking in public places and advertising in stream smoke, and regulatory services in Cancer Epidemiol Biomarkers Prev the media, and prohibition of sale of tobacco Bahrain are required by undertaking further 2014;23:1055-66. products to children. Despite the existence of studies. Owing to the unique features of WT 10. Sameer-ur-Rehman, Sadiq MA, Parekh MA, these regulations, tobacco use in any form and the misconceptions about health risks, et al. Cross-sectional study identifying seems to be high in Bahrain. The new national specific evidence based public health policy forms of tobacco used by Shisha smokers in guidelines on smoking cessation in Bahrain interventions are required to equip the public Pakistan. J Pak Med Assoc 2012;62:192-5. attempt to integrate primary health care into to clear the misconceptions and make 11. Maziak W, Ward KD, Eissenberg T. Factors smoking cessation services.26 Such an integra- informed decisions about WT smoking. Such related to frequency of narghile (water tion requires providing leadership roles to pub- interventions should be synonymous to ciga- pipe) use: the first insights on tobacco lic health or community nurses for an effective rette cessation methods. Above all, we must dependence in narghile users. Drug policy to practice translation. The public health develop a more proactive rather than respon- Alcohol Depend 2004;76:101-6. nurses’ leadership role would make an assess- sive approach for tobacco control to curb the 12. Døssing M. Water-pipe smoking - a survey ment of assets and needs of communities and WT tobacco epidemic. of a Cochrane review. Ugeskr Laeger populations and propose solutions in partner- 2009;171:2721-3 [In Danish]. ship. 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