Elsevier

Public Health

Volume 129, Issue 4, April 2015, Pages 370-376
Public Health

Original Research
Parental smoking and exposure to environmental tobacco smoke are associated with waterpipe smoking among youth: results from a national survey in Lebanon

https://doi.org/10.1016/j.puhe.2015.01.011Get rights and content

Highlights

  • Waterpipe is the most common form of smoking among sixth & seventh graders in Lebanon.

  • Pluralistic ignorance and religiosity are associated with current use.

  • Parental & peer tobacco use, & exposure to advertising are associated with current use.

  • Current habits warrant increased tobacco surveillance in this age group.

  • Waterpipe specific legislation is needed to prevent initiation, and control use.

Abstract

Objectives

Waterpipe tobacco smoking (WTS) is a growing public health concern worldwide yet little is known about the epidemiology of use among young people. The objectives of this study were to examine the prevalence, patterns and correlates of WTS among students across Lebanon.

Study design

The study design was a cross sectional survey.

Methods

126-item tobacco questionnaire was conducted among 1128 sixth and seventh grade students across Lebanon. Current patterns of use were descriptively analysed, and logistic regression models examined correlates of WTS.

Results

Ever WTS prevalence was 44.3%, current WTS prevalence was triple that of cigarettes (22.1% vs 7.4%), and 40.0% of current users were at least weekly or daily smokers. Initiation and patterns of use, as well as addiction and cessation attitudes have been reported. Significant correlates of current WTS included older age, reduced religiosity, peer and parent tobacco use, recent waterpipe advertisement exposure, increased pluralistic ignorance and current cigarette use. Significant correlates of ever WTS were similar to current WTS, but included second hand waterpipe tobacco smoke exposure at home and did not include recent waterpipe advertisement exposure. Neither gender nor socio-economic status were significant correlates of current or ever WTS.

Conclusions

Waterpipe is the most common form of tobacco smoking, and is used regularly, among sixth and seventh grade Lebanese students. It should be considered a public health priority with increased tobacco surveillance and legislation. Widespread educational and policy interventions might help denormalize the social acceptability of WTS. Meanwhile, more research is needed to understand the changing paradigm of WTS epidemiology and the health outcomes among young smokers.

Introduction

The waterpipe (shisha, hookah, narghile) is a traditional device where smoke is passed through a body of water prior to inhalation.1 Although used to smoke various substances of misuse,2 waterpipe is now commonly an apparatus for flavoured tobacco consumption, known as Mo'assel. This is thought to contain 30% tobacco and 70% honey and treacle,1 although the product is unregulated and its chemical content variable between brands.3

The waterpipe industry employs ubiquitously misleading marketing strategies for Mo'assel tobacco.4 A study from Lebanon identified that all 74 packets of waterpipe tobacco, mainly sourced from the Middle East, were non-compliant with recommendations from the World Health Organisation Framework Convention on Tobacco Control (WHO FCTC),5 and include deceptive descriptors such as ‘0% tar’ and ‘0.05% nicotine’.6 This is in stark contrast to studies reporting up to 50 times more tar produced by one waterpipe session compared to one cigarette,7 and sufficient nicotine absorption to induce dependence, cravings and withdrawal symptoms among regular users.8, 9 Furthermore, waterpipe tobacco smoking (WTS) is associated with cigarette-like illnesses such as lung cancer, respiratory disease, low birth weight and periodontal disease,10, 11 and other significant health concerns such as carbon monoxide poisoning12 and transfer of infectious disease resulting from sharing waterpipe with peers.13

Despite this, a recent systematic review concluded users perceived WTS to be less harmful, less addictive and more socially acceptable than cigarette smoking.14 The lack of health warnings on Mo'assel tobacco packets and the paucity of widespread health awareness campaigns are likely contributing factors to this reduced harm perception,15 which is further compounded by the fact that WTS is not routinely legislated on par with cigarettes. For example, in the United States WTS is exempt from indoor smoking bans in many states, taxed at a lower rate than cigarettes, and exempt from bans on flavoured tobacco sales.16

A high prevalence of WTS is therefore unsurprising, especially among young people. Among London high school students, 7.6% are current waterpipe users; double the prevalence of current cigarette use.17 In the United States, 2.6% of adolescents are current waterpipe users.18 The Eastern Mediterranean region, and in particular Lebanon, has among the highest rates of WTS among young people.19 High school students in Lebanon reported a current waterpipe prevalence of 29.6% in 2004, while current cigarette smoking was reported at a lower 11.4%.20 This in contrast to countries in the same region such as Oman and Syria, where current WTS prevalence was documented at 9.6%21 and 17.6%,22 respectively.

Still little is known about the epidemiology of WTS among young people. The handful of prevalence studies on this topic often lack important data on frequency of use,20, 23 restrict correlates to a small number of variables,21, 24, 25, 26, 27, 28 limit analyses by virtue of low (<100 respondents) current waterpipe prevalence,17, 26, 28 or use atypical measures of current waterpipe prevalence (i.e. not past-30 day use) that make cross-country comparisons difficult.17, 29 Correlates including religiosity, exposure to WTS advertising and exposure to second hand waterpipe tobacco smoke at home have not been explored among young people in the WTS literature, but have the potential to guide tobacco control interventions. This is particularly important considering parental smoking is known to directly effect the cigarette prevalence of young people30 and parental smoking cessation can reduce the prevalence of adolescent cigarette use.31 Therefore the aim of this study is to gain further insight into the epidemiological patterns of WTS among young people in Lebanon, and examine a wider breadth of correlates associated with its use.

Section snippets

Design, setting, and sampling

Data for this paper comes from a cross sectional analysis of baseline data collected as part of a randomized controlled trial of a school based interventions to prevent waterpipe use. The study period was over the 2011–2012 academic year. The sample frame was all public and private Lebanese schools registered with the Ministry of Education and Higher Education (MEHE) and enrolling at least 60 students in grade 6, grade 7 or both. Based on the overall number of students, a sample size of 40

Sample characteristics

The sample of 1128 students had a mean age of 12.3 ± 1.2 years, 51.3% were female, almost three quarters (72.9%) perceived their family financial status as average and just under half (47.5%) described their religiosity as committed. Almost half (44.5%) of students had at least a few friends who used at least one form of tobacco, and 75.9% had at least one parent that smoked at least one form of tobacco. Approximately 67.4% had at least one household member that smoked at least one form of

Main findings

This study presents the findings of a large cross-sectional study among young people in Lebanon. The prevalence of current WTS was worryingly high and triple that of current cigarette smoking (22.1% vs 7.4%). A significant proportion of current waterpipe users (40.0%) were regular (at least daily or weekly) users. Results showed the key role of parents in driving initiation and maintenance of current WTS by introducing the product to students and providing finance. A fifth of our respondents

Acknowledgements

This study approved by the MEHE and Institutional Review Board at the American University of Beirut.

The authors would like to thank the Ministry of Education and Higher Education in Lebanon, the principals of the schools, parents, and especially the students who gave a unique insight into their lives particularly with regard to WTS.

The authors would like to thank the field team – Lina Jbara, Rima Sleiman, Hala Alaouie, and Lama Aridi - for their dedication to this project.

Mohammed Jawad was

References (43)

  • A. Combrink et al.

    High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg

    South Afr Med J

    (2010)
  • A.R. Vansickel et al.

    Waterpipe tobacco products: nicotine labelling versus nicotine delivery

    Tob Control

    (2012)
  • J. Khalil et al.

    The tobacco health nexus? Health messages in narghile advertisements

    Tob Control

    (2009)
  • WHO

    World health organisation framework convention on tobacco control

    (2003)
  • R. Nakkash et al.

    Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories

    Tob Control

    (2010)
  • F. Hammal et al.

    A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria

    Tob Control

    (2008)
  • K.D. Ward et al.

    Are waterpipe users interested in quitting?

    Nicotine Tob Res

    (2005)
  • E.A. Akl et al.

    The effects of waterpipe tobacco smoking on health outcomes: a systematic review

    Int J Epidemiol

    (2010)
  • J. von Rappard et al.

    Carbon monoxide poisoning following use of a water pipe/hookah

    Dtsch Ärzteblatt Int

    (2014)
  • R. Martin et al.

    Mixed methods pilot study of sharing behaviors among waterpipe smokers of rural Lao PDR: implications for infectious disease transmission

    Int J Environ Res Public Health

    (2013)
  • E. Akl et al.

    Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review

    Harm Reduct J

    (2013)
  • Cited by (36)

    • Individual determinants of emotional eating: A simultaneous investigation

      2018, Appetite
      Citation Excerpt :

      These models were tested with single interaction terms that were entered hierarchically.2 We did this to keep the models interpretable and resistant to overfitting, and to avoid building a regression model using correlated data (Jawad et al., 2015). Indeed, when testing all the interactions in one model, we found variance inflation factors (VIF) larger than 5, indicating multicollinearity (Kutner, Nachtsheim, & Neter, 2004).

    • Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking

      2017, Addictive Behaviors
      Citation Excerpt :

      Parental figures tend to not discourage use in their children, with familial attitudes in Syria and Pakistan reported to be either neutral or positive when compared to CTS (Akl et al., 2015). Mother or father WTS has also been directly correlated with waterpipe use in youth as young as 11 years of age (Jawad, Bakir, et al., 2015; Jawad, Nakkash, et al., 2015). The apparent influence of parental smoking as well as research that has linked early initiation of WTS to higher dependency (Alzyoud et al., 2016), suggests parents as a potential target for intervention to prevent initiation.

    • The relationship of waterpipe use with cigarette smoking susceptibility and nicotine dependence: A cross-sectional study among Hong Kong adolescents

      2017, Addictive Behaviors
      Citation Excerpt :

      Youth often use waterpipe with friends and family to foster social connection (Akl et al., 2015; Alzyoud, Weglicki, Kheirallah, Haddad, & Alhawamdeh, 2013; Hammal, Mock, Ward, Eissenberg, & Maziak, 2008; Maziak et al., 2015), same as cigarette smoking (Acosta et al., 2008; Hoek, Maubach, Stevenson, Gendall, & Edwards, 2013; Nichter, Nichter, Carkoglu, Lloyd-Richardson, & Tobacco Etiology Research Network (TERN), 2010). This environmental influence (i.e., tobacco use among peers and family) is an important determinant of tobacco use among youth (Amrock, Gordon, Zelikoff, & Weitzman, 2014; de Vries, Engels, Kremers, Wetzels, & Mudde, 2003; Jawad et al., 2015), according to Social Cognitive Theory (Bandura, 1986). Therefore it is possible that a waterpipe user later initiates cigarette smoking under certain contexts to meet the social needs.

    View all citing articles on Scopus

    Name and location of institution where work was done: American University of Beirut, Lebanon.

    View full text