EurAsian Journal of BioSciences Eurasia J Biosci 14, 2061-2068 (2020)

Prevalence of smoking hookah (shisha) among students of Salahaddin University

F.A. Shalaw 1, Jangy Esmail Abdulla 2, Ahmed Farhan Shallal 3*, Titi Rahmawati Hamedon 4 1 Surgical Specialist Hospital-Cardiac Center, Ministry of Health-Kurdistan Region, Erbil, IRAQ 2 College of Nursing, University of Raparin, Ranya, KGR, IRAQ 3 Medical Laboratory Science department, College of Science, University of Raparin, Ranya, KGR, IRAQ 4 Department of Community Health, Faculty of Medicine and Health Sciences, UPM, 43400 UPM Serdang Selangor, MALAYSIA *Corresponding author: [email protected]

Abstract The objective of this study was to determine the prevalence of smoking shisha and evaluate the socio-demographic associates of smoking among Salahaddin University (SU) students in Erbil city. Respondents were selected randomly and 378 students who met the inclusion criteria participated in this study. A self-administered questionnaire was used to collect information on socio-demographic and individual characteristics. The prevalence of smoking shisha among SU students (21.2%, n=80) was higher than that of cigarette smoking (12.4%, n = 47) and the highest prevalence of shisha smokers were much higher in males than females 70 (60.5%). Chi square test shows that 4 factors were significantly associated with smoking shisha; gender (χ2=7.723, df=1, p<0.005), age (χ2=37.674, df=2, p<0.001), BMI (χ2=18.901, df=3, p<0.001), cigarette smoking status (χ2=159.097, df=2, p<0.001). Multiple logistic regression test has showed that the most significant risk factors for smoking shisha were age (OR=5.585, 95%CI: 2.016-15.461), and cigarette smoking status (OR=74.060, 95%CI: 23.623-232.179). Among SU students, the overall prevalence of smoking shisha was high and significantly associated with age, gender, body mass index and cigarette smoking status. Effective prevention strategies are required in order to reduce the risk of smoking shisha among SU students.

Keywords: shisha, smoking, students, Salahaddin University, Erbil

Shalaw FA, Abdulla JE, Shallal AF, Hamedon TR (2020) Prevalence of smoking hookah (shisha) among students of Salahaddin University. Eurasia J Biosci 14: 2061-2068.

© 2020 Shalaw et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License.

INTRODUCTION restaurants is increased in Erbil city center. Though the Kurdistan parliament banned smoking in public places, There are massive numbers of public and private Shisha consumption has risen since 2007 (EKurd Daily, institutes, colleges and universities around the world 2019). It is expected that increasing the number of which are still getting increased. That is, they are shisha cafes, bars and restaurants will lead to the rise in standing for the higher education sector where both the the consumption of Shisha. staff and the students are exposed to various risks and As far as the terminology is concerned, more than a hazards in this seemingly safe setting (Shalaw and term is used when it comes to the process of smoking Rahmawati, 2016). Kurdistan region has witnessed a Shisha. The people here mainly mention shisha smoking growth in the higher education sector like other sectors while shisha, water pipe and hookah smoking are used in public and private especially since 2003 (Dream City in other places. Smoking shisha was popular in the Erbil: real stat to investment LTD, 2020). In the capital of Middle East and Asia in the past and it is where it comes Kurdistan, there are several public and private from (Chaouachi, 2007). It has recently developed most universities such as Cihan Private, Lebanese French widely in the UK and other European Union countries Private Universities and Hawler Medical, Salahaddin basically among young people (Kadhum et al., 2015). It Public Universities (Universities in Kurdistan: Ministry of is usually believed that smoking shisha and shisha are Higher Education and Scientific Research, 2020). not as much risky as the cigarettes, but the truth is that Salahaddin University –Erbil is one of the public and the oldest university which is located in the capital of the Iraqi Kurdistan Region, Erbil city. SU has 23 thousand Received: December 2019 students for 2019 academic year (Salahaddin Accepted: March 2020 University, 2019). The number of cafes, bars and Printed: June 2020

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EurAsian Journal of BioSciences 14: 2061-2068 (2020) Shalaw et al. one hour shisha is nearly equal to 100 cigarettes MATERIALS AND METHODS (Hendrick, 2020; Sun, and Yang, 2014), or 50 to 60 Study Design and Study Population cigarettes, and a two to three-hour period of smoking A cross-sectional study design was used to shisha is equal to smoking 25 cigarettes (Hamad determine the prevalence of Smoking shisha and its Medical Corporation, 2020). Interestingly, shisha associated factors. This study was conducted on 378 commonly contains tobacco that is sometimes blended randomly selected students in the Salahaddin with natural products or molasses sugar and specials University. Notably, Salahaddin University – Hawler is types of fruits like apricot, apple, strawberry, mint and one of the biggest and oldest university and is located in cola (Young, 2020). Further, smoking shishahas the capital of Iraqi Kurdistan Region - Erbil. become progressively available mostly because of a Materials growing number of shisha-serving and cheaper prices in Data was collected using pre-tested self- the venues. Despite this, there are many kinds of shisha administered questionnaire, which was directly that differ in content and shape, which indicates that distributed to the respondents. Both English and Kurdish shisha smokers are at risk, and experience the same languages were used in the questionnaire. Reliability of health complications as cigarette smokers such as heart the pre-tested questionnaire showed the internal disease, respiratory problem, infection and cancer consistency of assessment using the Cronbach’s alpha, (Islami et al., 2013; Habib et al., 2001; Tamim et al., which was found to be 0.841 for the reliability of the 2008; Awan et al., 2017). Shisha like other kinds of questionnaire. The questionnaire is divided into various tobacco contains nicotine which has the ability of getting sections. Section A collect information on socio- the smokers addicted. That is, smoking shisha is demographic background, such as gender, age, race, significantly related to several long-term health effects; body mass index and marital states. Individual infection, cardiovascular damage, respiratory problem characteristics are collected in Section B, which collects and cancer (Islami et al., 2013; Habib et al., 2001; Awan information on the type of shisha smoked, companion at et al., 2017). Much of the mortality and morbidity the beginning, frequency of shisha smoking, smoking significantly associated with smoking shisha can be shisha location, smoking time and cigarette smoking attributed to the hurt of the cardiovascular system, status. The last section, Section D, contained details of respiratory system, infection and cancer (Aslam et al., the knowledge of various aspects of shisha smoking, 2014). Many studies in different countries showed that and it includes shisha smoking have health hazard, the prevalence of smoking hookah among university increased risk of heart conditions, infection, cancer and students has increased such as United States, respiratory diseases. European countries, Saudi Arabia and Pakistan (Maziak Data Collection et al., 2015; Shafagoj and Mohammed, 2002; Warren et Questionnaire was distributed to respondents in al., 2009; Aurangzeb et al., 2012). Though smoking October 2019. The respondents were informed about shisha is one of the serious issue, it is rising among the purpose of the study and those participating in this university students in the world (Sutfin et al., 2011). study were on a voluntary basis. Besides, the Smoking shisha basically occurs among friends in public respondents were made sure that their answers would settings such as private place, or in café and restaurants be kept confidential and would only be used for research that offer ready-to-smoke shisha to customers (Joveini purpose. After the respondents have finished answering et al., 2016). Further, different studies also evaluated the questions, the questionnaires were collected demographic variables associated with shisha smoking immediately. for instance age, and male gender (Primack et al., 2010; Data Analysis Eissenberg et al., 2008). In general, it is believed that Data was analyzed by using the IBM Statistical smoking shisha among university students is less Package of Social Sciences (SPSS) version 21. Initially addictive or harmful than cigarettes. That is, in Malaysia, the data was analyzed descriptively using frequency, a study among medical students revealed that percentage, means and standard deviations, as well as significant respondents assumed which shisha smoke median, and interquartile range. All numerical data were does not harmfully affect health (Redhwan Ahmed and tested for normality. Inferential analysis (Chi-square Saghir, 2011; Bazzi, 2015). The aims of this study are to test) was used to determine the association between determine the prevalence of shisha smoking and its smoking shisha and the independent variables (socio- associated factors among the respondents and to demographic, and individual factors). Finally, a determine the association between smoking shisha and multivariate analysis using multiple logistic regressions factors such as socio-demographic and individual. was performed to determine factors associated with the occurrence of smoking shisha. The results were considered statistically significant if p<0.05.

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Table 1. Socio-demographic characteristics of the Table 4. Association between sociodemographic respondents (n=378) characteristics with Smoking shisha

Variables Frequency(N) Percentage (%) Independent SSH Gender Variables Yes No X2 P-value Male 286 75.7 N (%) N (%) Female 92 24.3 Gender Age (Year) Male 70(24.5) 216(75.5) 7.723 0.005 18-20 194 51.3 Female 10(10.9) 82(89.1) 21-23 123 33.6 Age (year) 24-26 57 15.1 18-20 17(8.8) 177(91.2) Marital status 21-23 41(32.3) 86(67.7) 37.674 0.001 Single 361 95.5 24-26 22(38.6) 35(61.4) Married 17 4.5 Marital status Body Mass Index (BMI) Single 75(20.8) 286(79.2) 0.726 0.394 Under weight 35 9.3 Married 5(29.4) 12(70.6) Normal 270 71.4 Body Mass Index (BMI) Over weight 44 11.6 Under weight 18(51.4) 17(48.6) Obese 29 7.7 Undeweight 18.901 0.001 Normal 53(19.6) 217(79.6) Over weight 7 (15.9) 37(84.1) Table 2. Individual characterizes among respondents Obese 3 (10.3) 26(89.7) (n=80) Variables Frequency (N) Percentage (%) Type of shisha smoked Data on the individual characteristics show that out Sweetened and flavored 58 72.5 of 80 respondents who smoked shisha, majority (72.5%) Non sweetened and flavored 22 27.5 of them smoked sweetened and flavored, 76.2% were Companion at the beginning Alone 9 11.3 companions with friends, 47.5% weekly smoked shisha, Friends 61 76.2 62.5% smoked at Cafeterias/cafes, 55% smoked it Family 10 12.5 Frequency of shisha smoking between more than 30 minutes to less than an hour and Daily 27 33.7 majority of them (53.7%) did not smoke Cigarette (Table Weekly 38 47.5 2). Monthly/Occasionally 15 18.8 Smoking shisha location Data on the general information show that out of 87% Cafeterias/cafes 50 62.5 respondents who were reported as shisha smokers have Friend’s residence 16 20.0 health hazard, majority of them 82% think it increased Own residence 14 17.5 Smoking time the risk of heart diseases, 86% increased the risk of Less than 30 minutes 24 30.0 infectious diseases, 80.7% increased the risk of 30 to 60 minutes 44 55.0 More than 60 minutes 12 15.0 respiratory disease and 86.8% increased the risk of Cigarette smoking status cancer (Table 3). Yes 37 46.3 Pearson’s chi-square test was used to determine the No 43 53.7 association among socio-demographic characteristics and individual factors with SSH. Table 4 illustrates the Table 3. Knowledge of various aspects of smoking shisha result of the analysis. Overall, 80 (21.2%) of the among respondents (n=378) Variables Frequency (N) Percentage (%) respondents were reported as shisha smokers. There is Do you think Smoking shisha have health hazard? statistically significant association among gender, age, Yes 329 87.0 BMI and with smoking shisha, (X2=7.723, p=0.005) No 49 13.0 2 2 Increased risk of heart conditions (X =37.674, p=0.001) (X =18.901, p=0.001), Yes 310 82.0 respectively. No 68 18.0 Increased risk of infection diseases Pearson‟s chi-square test was used to determine the Yes 325 86.0 association among knowledge characteristics with No 53 14.0 smoking shisha. Table 5 demonstrates the result of the Increased risk of respiratory disease Yes 305 80.7 analysis. There is statistically significant association No 73 19.3 among thinking shisha is harmful to health, shisha leads Increased risk of cancer to cardiac disease, respiratory disease, infection, cancer Yes 328 86.8 No 50 13.2 and Cigarette smoking status with smoking shisha

(X2=38.864, p=<0.001, X2=26.138, p=<0.001, X2=19.903,p=<0.001, X2=37.047, p=<0.001, X2=41.910, 2 RESULTS p=<0.001, X =159.097, p=0.001, respectively). Table 1 shows that most of the students in the area were as follows: male 286 (75.7%), and their ages were between 18-20 years, 194 (51.3%), and single 361 (95.5%). Most of the participants have a normal BMI 270 (71.4%).

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Table 5. Association between knowledge characteristics arrives at the same results of other studies that have with Smoking shisha among respondents been previously reported among university students in Independent SSH Variables Yes No X2 P-value Estonia (21%), Czech Republic (22.1%), and in Latvia N (%) N (%) (22.7%) (Jawad et al., 2016). In this research, the Shisha is harmful to health prevalence of smoking shisha is indicated, which is Yes 53(66.2) 27(33.8) 38.864 <0.001 No 276(92.6) 22 (7.4) found to be lower than those published among students Smoking shisha leads to cardiac disease in Lebanon, Uganda and Saudi Arabia, where the Yes 50 (62.5) 30 (37.5) 26.138 <0.001 prevalence of smoking shisha was respectively reported No 260 (87.2) 38(12.8) Smoking shisha leads to respiratory disease to be (36.9%, 36.4%, and 32.8%) (Jawad et al., 2015; Yes 51(63.8) 29(36.2) 19.903 <0.001 Aanyu et al., 2019; Muzammil et al., 2019). As a No 254(85.2) 44(14.8) Smoking shisha leads to infection comparison, the prevalence of smoking shisha among Yes 52(65.0) 28(30.0) the respondents in the present study is higher compared 37.047 <0.001 No 273(91.6) 25(8.4) to those in other countries; 10.7%, 8.6%, and 5.6% Smoking shisha leads to cancer Yes 52(65.0) 28(30.0) prevalence of smoking shisha that occurred among 41.910 <0.001 No 276(92.6) 22 (7.4) university students in Southern California, Saudi Arabia, Cigarette smoking status and the UAE individually (Gilreath et al., 2016; Taha et Yes 43(53.8) 37 (46.2) 159.097 <0.001 No 4 (1.3) 294(98.7) al., 2010; Mandil et al., 2007). The findings of those studies that have been reported in the previous studies Table 6. Logistic Regression predicting likelihood of having among students in other areas show that the prevalence SSH of using shisha is less than our study prevalence. Form Variables B Wald Sig. Adjusted 95% C.I. for OR public health perspective would recommend that a OR Lower Upper Gender chance exists for the general public health workers’ Male 0.867 3.393 0.065 2.380 0.946 5.991 demand with the order of reducing the burden of Female smoking shisha among the students to place Age 18-20 1.720 10.950 0.001 5.585 2.016 15.461 intervention plans that might lower the prevalence of 21-23 0.136 0.085 0.770 1.145 0.461 2.848 smoking shisha amongst the students (Global Health 24-26 Body Mass Index Workforce alliance, 2020). Additionally, it provides an Under weight -2.257 5.083 0.024 0.105 0.015 0.745 area for health experts to increase the professional Normal -0.772 0.907 0.395 0.462 0.078 2.734 improvement of health students, and it properly provides Over weight -0.823 1.068 0.594 0.441 .054 3.560 Obese a platform for seasoned public health experts to share Cigarette smoking status their expertise. Various seminars and workshops on Yes 4.305 54.526 0.000 74.060 23.623 232.179 professional development of health students are No Constant -7.420 24.487 0.000 0.001 prepared (Islami et al., 2013). According to WHO, over

1.1 billion people who smoked tobacco showed that

Logistic regression analysis was used to show an much more males than females used tobacco for association between smoking shisha with gender, age smoking in 2015. The frequency of smoking tobacco groups, cigarette smoking status and body mass index. seems to get increased in the Eastern Mediterranean These associations were lost for only gender variable. Region and the African Region (WHO, 2020). From The other factors which remained significant at 2008 to 2010, according to Global Adult Tobacco in multivariable analysis were age group (adjusted different countries showed that the prevalence of OR=5.585, p=0.001); cigarette smoking status (adjusted smoking shisha among males is much more in OR=74.060, p=0.001) and body mass index (adjusted Philippines, Uruguay, Mexico, Thailand, Brazil, China, OR=7.26, p=0.023) (Table 6). India, Bangladesh, Ukraine, Turkey, Russia, Egypt, and Vietnam DISCUSSION (0.01%,0.02%,0.02%,0.03%,0.2%,0.7%,1.1%,1.3%,3.2 %,4.0%,4.4%,6.2%,13.0% respectively) (Morton et al., Smoking shisha could be one of the reasons beyond 2014). The findings of this study indicate that the highest spreading it easily. There are some studies provided that prevalence of shisha smokers was much higher in males the practice of sharing shisha smoking raises a serious than females 70 (60.5%). This finding is similar to the risk of transference of communicable diseases like study among university students in Pakistan which viruses and bacteria (Zhong et al., 2020; Lewis, 2020; showed that the rate of males who smoke shisha is Sardari et al., 2018), and this shows a great risk of much higher since the rate is 440 males (59.22%) viruses’ transmission when the mouthpiece is shared compared to 54 females (22%) (Masood and Sohail, (Hakim et al., 2011; Steentoft et al., 2006). 2013). The recent study showed that the mean age of In this study, the prevalence of smoking shisha smoking shisha is 19 years. However, this result was among SU students (21.2%, n=80) was higher than that nearly corresponding to that result in the national survey of cigarette smoking (12.4%, n = 47). It seems that this of Saudi Arabia that the mean starting age of smoking

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EurAsian Journal of BioSciences 14: 2061-2068 (2020) Shalaw et al. shisha was 19.1 years (Muzammil et al., 2019). These shisha is usually common in groups in social places such results enforced the educators and the parents to bear as cafes and restaurants (Haroon et al., 2014; Ahmed et responsibility and take steps in the direction of al., 2011). This study is in compatibility with previous prevention and eradication of smoking shisha conducts studies (Roskin and Aveyard, 2009; Al-Naggar and among younger students. There are few studies that Bobryshev, 2012), which found that university students have examined the prevalence of smoking and the look at smoking shisha with friends as something relationship between smoking with BMI in the Eastern reasonable. This is because such practices of university countries in general or in Iraq in particular. Furthermore, students are done through attending social settings there were several kinds of research in Western where social networking is found and the reputation of countries that showed significant association between peers in encouraging risky performances. Shisha is smoking and BMI (Pednekar et al., 2006; Sneve and usually smoked in social settings and after the first trial Jorde, 2008; Jitnarin et al., 2014). Besides, previous of shisha, the sweetened flavor in cafes and restaurants smokers showed reaching weight after giving up would be the first effective factor for attracting them and smoking. Our findings show there is a relation between convincing them to keep up smoking. Though similar BMI and smoking shisha. It also requires further findings reported that typical smoking period is between investigations. In a concrete, several studies found that 30 and 50 minutes, the smoking period might possibly there are adverse effects of smoking shisha on the continue for several hours (Knishkowy and Amitai, 2005; health and there are some of the potential health effects Maziak et al., 2015). of smoking shisha including infections when sharing a Finally, there is a noticeable increase in the shisha, respiratory diseases, infection, heart problems popularity of smoking shisha among students and this and several kinds of cancer (Jawad et al., 2016; Gilreath becomes an increasing phenomenon globally (Aanyu et et al., 2016; Hakim et al., 2011). According to the general al., 2019). This is definitely due to several factors such sample in our study, 87% knew that Shisha might cause as the lack of awareness about the harmful effects of serious health hazards like 86% of cancer (especially smoking shisha, flavored shisha, social acceptability of lung, throat, and mouth cancer), 80.7% respiratory the restaurants and cafes, and having no sufficient diseases and increase the risks of infectious diseases regulation (WHO, 2009). and result in the increase of 82% risk of heart condition. This is supported via studies conducted in Pakistan and CONCLUSION Rwanda among university students indicating that (54%, Since the smoking prohibition in early June 2008 in 60% respectively) knew that Shisha might be the cause Kurdistan region (EKurd Daily, 2019), especially in the of serious health effects (Masood and Sohail, 2013; Erbil city, smoking shisha has been an increase in the Omotehinwa et al., 2018). Moreover, in a similar study cafes and restaurants. The overall prevalence of among university students conducted in Egypt, the smoking shisha was high and significantly associated majority of the shisha smokers informed that they knew with several factors among SU students. Effective that smoking shisha was related to the transmission of prevention strategies are required in order to reduce the infection, respiratory diseases, heart disease, and some risk of smoking shisha among SU students. types of cancer (Labib et al., 2007). In addition, smoking

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