INTRODUCTION:

Tobacco epidemic is considered as one of the biggest public health threats ever faced by the world. The World Health Organization (WHO) reported that there are approximately 1.3 billion current tobacco users worldwide. Tobacco use kills more than 8 million people annually around the world and the number is increasing globally in spite of anti-smoking international campaigns. Surprisingly, over 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries¹. Smoking and chewing tobacco has become very common, favorite and fashionable custom, especially among young boys².

It is a known fact that all forms of tobacco are harmful, and there is no safe level of exposure to tobacco. The damage to the health system from waterpipe (shisha) tobacco use is similar to cigarette tobacco use. However, the health dangers of waterpipe tobacco use are often little understood by users^3,4. A common misconception regarding waterpipe is that the water filters out toxins, thus making it healthier than cigarettes. Contrary to popular belief, the smoke that emerges from a waterpipe contains numerous toxicants known to cause lung cancer, heart disease and other diseases^5,6. It is reported that waterpipe smoke contains measurable levels of carcinogens including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons (PAH), volatile aldehydes like formaldehyde, benzene, and toxicants such as nitric oxide and heavy metals. Additionally, the burning charcoal in waterpipe generates high levels of carbon monoxide (CO) and carcinogenic PAH^7,8. These toxic substances have been linked to addiction, heart disease, stroke, lung diseases, diabetes, chronic bronchitis and cancer in cigarette smokers and therefore can result in similar outcomes in waterpipe users if these toxicants are absorbed in the body in appreciable amounts. Smoking also increases risk for tuberculosis, eye diseases, oral diseases, fertility problems, anemia and problems of the immune system, including rheumatoid arthritis^9-13,. A typical 1-hour long water pipe smoking session involves inhaling 100-200 times the volume of smoke inhaled with a single cigarette^7,9 smoking shisha can be addictive and harmful; however, many dabblers do not realize the dangers according to the published report¹⁴.

Oman-Global Youth Tobacco Survey (GYTS) report of 2003 showed the prevalence of current users of water pipe to be 9.9% (males= 16.6%, females=2.6%) among age groups between 13-15 years¹⁵. The 2007 version of Oman-GYTS again showed a high prevalence of smoked waterpipe of 7.9 % (male= 10.8%, females= 5.2%)¹⁶, and the 2016 version¹⁷ is not being much different from 2007 and 2010. A cross-sectional study examined the prevalence and determinants of waterpipe tobacco use among adolescents in Oman¹⁸. This study highlighted interesting characteristics of waterpipe users among adolescents in Oman; 26.5% were ever users of waterpipe, males were 7 times more likely to be waterpipe users than females, 50% of current waterpipe smokers were also current cigarette smokers and having a parent who was a cigarette smoker and a waterpipe user. The result of this study clearly suggest that tobacco smoking is a risk behavior among young adults in Oman. Another epidemiologic study revealed the prevalence of smoking to be 11.5% among males in the age group of 20-29 years and 17.5% in the age group 30-39 years¹⁹. The WHO Report on Global Tobacco Epidemic, 2013 reports that among Omani Nationals aged 18+ years, the prevalence of current tobacco smoking among males is 14.7%²⁰. The studies conducted in neighboring countries also showed similar results. A cross-sectional study among medical college male students in Saudi Arabia reported an overall prevalence of shisha smoking as 12.6%²¹. A study conducted in Kuwait reported the prevalence of current smoking to be 46% among college male students; of them 10% were shisha smokers²². A study conducted among Taibah University students in Jeddah region, Saudi Arabia, reported the prevalence of current and ever waterpipe use as 24.2% and 36.04%, respectively while current and ever cigarette smoking was reported as 31.9% and 42.7%, respectively²³. A study conducted among university students in Gaza, Palestine reported that 36% students were smoking Shisha only²⁴. Another study from Palestine reported the overall prevalence of tobacco smoking among university students and 30% more men were current Shisha and cigarette smokers as compared to women²⁵. The prevalence of current smokers of Shisha among Palestinian students was 36.11% and 34.17% among Jordanian students²⁶.

There are no studies conducted so far examining the predictors of shisha use among young adults in Oman. The Oman-GYTS 2003 report has mentioned that “nearly four in ten of current users of shisha (44%) and one third of non-users of shisha think that shisha is less harmful than cigarettes with no significant difference between boys and girls. This lead to a conclusion that there is misunderstanding and ignorance of the consequent hazards of smoking especially shisha. The problem is compounded by the lack of research on shisha and its wider acceptance and popularity in the eastern societies. Moreover the presence of many shisha cafes in Oman testify the fact that waterpipe smoking is becoming increasingly popular. Consequently, there is an urgent need for an epidemiologic study that would assess the prevalence as well as the predictors of shisha use among young adults in Oman. This study was conducted to assess the prevalence and predictors of waterpipe (shisha) use among Omani and Non-Omani Pre-medicine and Pharmacy students of Oman medical college (OMC).

The study was designed with the following objectives:

1. To estimate the prevalence of waterpipe (shisha) use among Omani and Non-Omani Pre-medicine and Pharmacy students of OMC.

2. To identify significant predictors for use and heavy use of shisha in this target population.

3. To test the internal consistency of the survey instrument and perform the reliability analysis by calculating the Cronbach’s alpha.

4. To obtain valid estimates of ever use and current use of shisha in this population.

MATERIAL AND METHODS:

Study Design:

This was a descriptive cross-sectional study conducted among Pharmacy and Pre-medicine students of OMC in Muscat.

Ethical Approval:

The study was conducted after receiving ethical approval from Research and Ethics Committee (REC) of College of Pharmacy, National University of Science and Technology (formerly Oman Medical College; reference number: OMC/IRRB/2015/008/C).

Study Population:

The Pharmacy and Pre-medicine college students were stratified by the year of study. A sample target of 140 students was chosen. The inclusion criteria included students above 18 years of age and their willingness to participate in the study after taking consent from them.

The questionnaire was distributed to around 180 students. 144 students (response rate 80%) responded and filled the questionnaire.

Study Procedure:

The self-administered questionnaire was designed based on a subset of questions from the GYTS-2010 questionnaire pertaining to water pipe smoking and the demographics of the respondent. The questionnaire was slightly modified to suit college students. The validation of the questionnaire was done by distributing the questionnaire among 5 students to express their opinion and perception about the appearance and clarity of the questionnaires. The suggested changes were incorporated. These subjects selected for the validation of the questionnaire were excluded from the study.

The modified questionnaire consisted of 32 questions on shisha use, knowledge and attitudes concerning shisha use, cessation and initiation trends and exposure to second hand smoke. The questionnaire was administrated to the subjects in the presence of one or two investigators. The outcome variables used in the study included: An ‘ever used’ waterpipe is defined as one who has used shisha at least once in his/her lifetime. A current user of waterpipe is defined as one who has used a shisha in the last 30 days. The predictor variables included a number of covariates including personal details (age, gender, education level), social (family Income per month, family smoking status -Have parents and siblings who smoke, Health Perceptions (Is shisha harmful to health? Is shisha less harmful than cigarettes?), etc.

Data Analysis:

All statistical analyses were conducted using IBM SPSS ver. 23. It included questions on socio-demographics variable, current shisha smoking and smoking pattern differentiated for male and female respondents, as percentages with 95% confidence intervals (CIs). A p-value ≤ 0.05 was considered to be statistically significant.

RESULTS:

Out of 180 questionnaires distributed to students, 144 students participated by responding with a response rate of 80%. The incomplete questionnaires (4 in number) were not included in the study. 140 responses were included in the results analysis. The study population included 123 females and 17 males. 108 students were in the age range of 18-21 years and 32 students were 21 years and above. Participants included 73 Omani students and 67 non-Omani students.

Demographics:

The majority of the students in the sample were females (87.86%). Approximately half of the students (52.14%) were Omanis. A large number of students (77.14%) were in the age group of 18-21 years and the rest were above 21 years. The data is provided in the figure 1. About one third (32.14%) of the students received a daily allowance of RO 5.

About one-fifth of the students, (22.86%) felt that smoking makes them more comfortable in social gatherings. Surprisingly, only 5.9% male and 4.9% female students believe that shisha is less harmful (figure 5). 5% of the study population think that boys and girls who smoke look more attractive. 47.1% males and 9.0% females responded that if best friend offered, they would smoke. About 50% male students and 19.7% females felt that smoking makes them more comfortable.

Exposure to Second Hand Smoke (SHS):

About 6.43% students in the study group lived in homes where other members smoked in their presence. A large number of the students, (21.42%) were around others who smoke in places outside their homes. About 73.57% students rightly thought that smoking should be banned in public places. Almost all the students (97.86%), thought that smoke from others is harmful to them. 7.86% students had one or more parents who were smoking. About 8.57% students had most or all friends who were smoking (figure 6).

1	Students live in homes where other members smoke in their presence
2	Students who were around others who smoke in places outside their homes
3	Students thought that smoking should be banned in public places
4	Students think that smoke from others is harmful to them
5	Students who have one or more parents who smoke
6	Students who have most or all friends smoke.

Figure 6: Exposure to Second Hand Smoke (SHS).

Media and Advertising:

Almost half of the respondents (46%) admitted to have seen anti-smoking media messages in the past 30 days.

Internal Consistency and Reliability Analysis:

The Cronbach’s alpha for 32 questions covering the practice, knowledge, and attitude towards tobacco, was found to be 0.862 which indicated high reliability.

DISCUSSION:

Waterpipe (shisha, hubble-bubble or hookah) is one of the ancient methods of tobacco use. This alternative method of tobacco smoking is gaining popularity among youth including college students worldwide and is matter of growing concern. The GYTS and the WHO report 2013 have shown an alarming level of tobacco use among youth and young adults in Oman. Use of shisha is becoming increasingly popular, supported by the misconception that it is safer than smoking cigarettes. Moreover, the 2012 Health facts released by the Ministry of Health (MOH), Sultanate of Oman clearly showed high morbidity related to diseases of the respiratory system²⁷. Also studies indicated high morbidity related to respiratory symptoms, mainly asthma²⁸ among children. Furthermore, few clinical and animal studies have shown a link between waterpipe and development of cardiovascular diseases⁷. Hence, it is critical for the growth and development of Oman that the health of young adults be safeguarded especially from behavior like shisha smoking which would contribute to the increase of the health burden of the Sultanate of Oman. The prevalence and predictors of waterpipe (shisha) use among Pharmacy and Pre-medicine college students in the age group of 18 years and above were assessed using a validated self-administered questionnaire. A total of 140 responses were analyzed to obtain the data which indicated that shisha smoking is more prevalent among males. Although, the prevalence of current and ever smokers among students in Oman was comparatively lower than the prevalence rate reported in other gulf countries. The prevalence of current and ever waterpipe use among Taibah University students in Medina, Saudi Arabia was 24.2% and 36.04%, respectively²³. The prevalence of smokers among university students in Kuwait was reported to be 42% while in Saudi Arabia it was 35%^{29, 30}. The reason for the lower number of smokers among Omani students can be attributed to lower number of male students who participated in the study (12.2%). The percentage of female students studying in many professional colleges in Muscat is significantly very high.

Data pertaining to second hand smoke showed that only one in 12 students have parents and friends who smoke and one in five were exposed to smoking by others around their homes. These findings were far better than studies carried out in some other Middle East countries. The knowledge level of OMC students appeared to be quite high. Almost 100% of the students felt that exposure to SHS was harmful to them and three quarters of the students were in favor of banning smoking from public places. About half of the students claimed to have seen anti-smoking messages in the past 30 days. Figure 7 illustrates the changes in the prevalence of tobacco use over periods; 2003, 2007, and 2010 as recorded by the GYTS studies and was compared with the current 2016 OMC pilot study. The percentage of current shisha smokers decreased from 8% in 2003 to 1.5% in 2010 but has increased to 2.85% in 2016, which was almost doubled in comparison to 2010. This clearly showed that the trend of shisha smoking is increasing in the Sultanate. The similar growing trends for shisha smoking has also been reported by studies carried out in Saudi Arabia. A study conducted in Qassim University revealed that the total prevalence of waterpipe use was 40%³¹, which was higher than the studies conducted earlier. The overall prevalence of shisha and cigarette smoking was 12.6% with a prevalence of 8.6% for shisha smoking only⁷ which was higher than that reported by Almutairi study of 7.3% among university students in Riyadh³². Also, the percentage of current cigarette smokers fell down from 6.9% in 2003 to 1.8% in 2010 but has again increased to 4.29 % in 2016. However, the current use of smokeless tobacco has consistently dropped from 5.2% in 2003 to 1.4% in 2016. These data suggest that shisha and cigarette smoking maybe gaining popularity among young adults whereas the popularity of smokeless tobacco appears to be waning.

Table 1 shows the practice of Shisha with respect to various characteristics. Males were more likely to have smoked shisha at least once as compared to females (47.05% vs. 14.63%, P < 0.05). Also, males were more susceptible to initiate smoking within a year as compared to females (64.7% vs. 17.2%, P < 0.05) which is higher than a study conducted among medical students in China that reported the prevalence of susceptibility to smoking was 23.0% (95% CI: 20.4–25.8%). The unadjusted logistic analysis showed those who were older and male were more likely to be susceptible to smoking³³.When analyzed by nationality it was found that Omanis were more likely to have been never users of shisha as compared to non-Omanis (95.9% vs. 62.1%, P <0.05). In fact 6.1% of non-Omanis were current users of shisha.

Figure 7: Trend of Shisha Smoking, Cigarette Smoking in 2003, 2007, 2010 Oman GYTS study and the 2016 OMC Pilot study

Table 1: Shisha Use and Practice by Gender, Nationality & Age Category

Characteristics	Gender	Ever Use	Current Use *	First tried shisha at age <10	Have most friends use shisha	Never smokers susceptible to initiate smoking within a year.
Gender	Boys	47.05%** (23.3 –70.8)	5.88%	5.9%	17.6%	64.7%** (42.0 –87.4)
Gender	Girls	14.63%** (8.5 –21.1)	2.44%	1.6%	7.4%	17.2 %** (10.5 –23.9)
Nationality	Omani	2.7% **	0	o	1.4%**	5.5%**
Nationality	Non-Omani	36.4%** (24.8 –48.0)	6.1%	4.5%	16.7%** (7.7 –25.7)	42.4%** (30.4 –54.3)
Age category	<21 Yrs	24.2%** (15.4 –32.9)	3.3%	2.2 %	9.9%	26.4%
	>= 21 Yrs	10.2%** (1.7 –18.7)	2.0%	4.1%	6.1%	16.3%

* Students who used tobacco at least one day during the past 30 days

** Corresponding column Proportions differ significantly at P-value < 0.05.

Figures in brackets are 95% confidence intervals

Note: Cells in which confidence intervals are not shown have np<5

Also, non-Omanis were more likely to have most friends smoking shisha and were more susceptible to initiate smoking within a year as compared to Omanis (42.4% vs. 5.4%, P<0.05). Demographics suggest that the population of expatriate students is on the rise. This trend is disturbing, since expatriate students could influence their Omani counterparts negatively towards shisha smoking. However more research needs to be done with larger sample size to confirm this trend.

Finally, when analyzed by age category it was found that students less than 21 years were more likely to have ever used shisha as compared to students 21 years or older (24.2% vs. 10.2%, P < 0.05), which is correlated with the factors associated with the smoking frequency^34,35. According to the National Survey on Drug Use and Health, nearly 80 percent of all adult smokers begin smoking by age of 18³⁶. Also, among never smokers, younger students appear to be more likely to initiate smoking shisha within a year as compared to older students (26.4 % vs. 16.3%), although the difference was not found to be statistically significant. The reliability analysis of the questionnaire produced a Cronbach’s alpha of 0.862 which is considered quite high. This shows that the survey instrument is indeed very reliable with high internal consistency and hence ready for administration in the target population.

CONCLUSION:

The pilot study indicated that shisha and cigarette smoking are on the rise among young adults. The prevalence of shisha and cigarette smoking in the pilot study were found to be 2.85% and 4.29% respectively which were higher than the GYTS estimate in 2010 (1.5% and 1.8% respectively). The male gender was found to be positively associated with shisha use. Non-Omani students were found to be significantly positively associated with shisha use. Also, younger students (< 21 years) were more likely to initiate smoking as compared to their older counterparts. Thus necessary steps need be taken to educate these specific groups of students about the harms of shisha smoking. This could not only help current smokers to quit smoking but also protect the never smokers from being initiated into this vicious habit. Steps to educate young budding population of the Omani society will ultimately help in reducing the impact of non-communicable disease on their families and will also reduce the financial burden on the Oman health infrastructure. A city-wide larger study with higher sample size is urgently needed to confirm the findings of this pilot study.

LIMITATIONS:

This was a pilot study which had a sample size of 140 students. The selection of the students was non-random. Hence, the results cannot be generalized to the whole population of college students in Oman. Moreover, since all the students in the study were from the health field, the attitudes could be skewed.

ACKNOWLEDGEMENT:

Authors are grateful to National University and Oman Medical College for the award of the internal research grant to conduct this study. We are grateful to Mr. Ahmad Al Abri, former lecturer of English at the Oman Medical College, Bowshar Campus for all the hard work done in translating the questionnaire from English to Arabic.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

AUTHOR CONTRIBUTIONS:

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work.

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Received on 22.12.2021 Modified on 07.02.2022

Research J. Pharm. and Tech 2022; 15(12):5841-5848.

DOI: 10.52711/0974-360X.2022.00986