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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 779-785

Knowledge and sociodemographic predictors of shisha smoking among students in a Nigerian university


1 Department of Oral Pathology and Oral Medicine, Faculty of Dentistry, University of Nigeria Enugu Campus, Enugu State, Nigeria
2 Department of Preventive Dentistry, Faculty of Dentistry, University of Port Harcourt, Rivers State, Nigeria
3 Department of Preventive Dentistry, University of Nigeria/University of Nigeria Teaching Hospital, Enugu State, Nigeria

Date of Submission15-Apr-2021
Date of Acceptance22-Apr-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. B B Osagbemiro
Department of Preventive Dentistry, Faculty of Dentistry, University of Port Harcourt, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1424_21

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   Abstract 


Background: There is a global rise in shisha smoking amongst the youths. Information on the prevalence and knowledge of the constituents and the harmful effects of shisha smoking is important for the development of prevention strategies and policies. Aim: This cross-sectional study aimed to assess the knowledge and sociodemographic predictors of shisha smoking among the university students. Subjects and Methods: A structured 12-item questionnaire was administered to the university students at the University of Port Harcourt, Rivers State. The prevalence, knowledge, and predictors of shisha smoking and the association between sociodemographic factors were studied. A P value of <0.05 was considered statistically significant. Results: Among the 546 university students studied, 24.7% (135) had smoked shisha. The percentage of those knowledgeable about the constituents and its ill effects of shisha smoking was 14.8% (81), those with poor knowledge was 94.1% among shisha smokers. Females and social sciences students demonstrated statistically significant better knowledge of shisha (P = 0.007, and 0.027, respectively). The main predictors of shisha smoking were: poor knowledge (odd ratio, OR = 4.48, 95% confidence interval, CI [2.02, 9.93], P = 0.001), being in 400 level of study (OR = 2.63, 95% CI [1.12, 6.13], P = 0.724) and being in the faculty of social science (OR = 1.25, 95% CI [0.50, 3.09], P = 0.638). Conclusions: The prevalence of shisha smoking in this study was 24.7%, and the most influential factors were the level of study, type of faculty, and knowledge of the constituents and harmful effects of shisha. Lecturers and administrators of different faculties of the university should be engaged to include shisha smoking prevention programs in their curriculum.

Keywords: Knowledge, predictors, prevalence, Shisha, university students


How to cite this article:
Otakhoigbogie U, Osagbemiro B B, Akaji E A. Knowledge and sociodemographic predictors of shisha smoking among students in a Nigerian university. Niger J Clin Pract 2022;25:779-85

How to cite this URL:
Otakhoigbogie U, Osagbemiro B B, Akaji E A. Knowledge and sociodemographic predictors of shisha smoking among students in a Nigerian university. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 2];25:779-85. Available from: https://www.njcponline.com/text.asp?2022/25/6/779/347600




   Introduction Top


Shisha is one of the methods of smoking tobacco invented as far back as in the sixteenth century by a physician named Hakim Abul-Fath Gilani.[1] It is a form of tobacco smoking that involves the use of a waterpipe also known as arguileh, hookah and shisha, an ancient form of tobacco consumption indigenous to the eastern Mediterranean region.[1],[2] Shisha smoking (water-pipe smoking) is a method of tobacco use that involves passing smoke through water before inhalation.[2] It was invented supposedly as a safe method of tobacco use.[2]

The purpose of the instrument used was to pass the smoke through water (an attempt to filter the smoke), though this has been grossly questioned for validity.[3] The device consists of a compartment (head) that contains the tobacco to be smoked and separated from coal which burns the tobacco. The next compartment is an airtight pipe that draws the smoke from the tobacco into another portion containing water. Finally, the user draws in the smoke which has passed through the water using the connected hose.[3]

There has been a remarkable global spread of water-pipe tobacco smoking in recent times.[4] In times past, shisha use, in the eastern Mediterranean region has been relatively prevalent among adults, but recently, it is gaining popularity among younger age groups particularly the university students[5],[6] and teenagers.[7],[8],[9] In Nigeria, water-pipe smoking is rapidly gaining popularity, especially among young adults and teenagers.[10]

Several misconceptions exist about shisha smoking in our society presently. For example, shisha smokers erroneously believe that water can bind or retain toxins as the smoke passes through it. Also, compared to cigarette smoking, shisha is believed to be less irritating with a less adverse effect on the mucosa of the oral cavity.[10],[11] The fruit juice flavors added to shisha is also believed to be good for health.[11] Also, water-pipe tobacco smoke is believed to be produced at a much lower temperature than cigarette smoke, hence is believed that the toxins are different and are less harmful when compared with cigarette smoke.[1],[10],[11]

According to the World Health Organization, shisha also contains harmful toxins just as cigarettes.[12] It has been reported that Water-pipe tobacco smoking is considered a serious public health threat. Hence, the American Lung Association has labeled it the “emerging deadly trend”.[13] Water-pipe smoking has been implicated as a risk factor for several tobacco-related diseases such as lung cancer, esophageal cancers, cardiovascular disease, and adverse pregnancy outcomes[1],[12],[13],[14] Some studies have shown that there is an association of water-pipe smoking with communicable diseases such as hepatitis C and tuberculosis resulting from shared mouthpieces and repetitive use without disinfection.[11],[14] Apart from the smoke from tobacco, there is also the smoke that comes from the burnt coal. These contain polycyclic aromatic hydrocarbons (PAH), volatile aldehydes, carbon monoxide, nitric oxide, nicotine, furans, and nanoparticles. All these have adverse effects on the health of smokers.[3],[14] Smoke from shisha for 60 min is 100–200 times more than inhaling one pack of cigarette.[15] Some oral mucosal changes such as xerostomia, gingivitis, and leukedema have been found in shisha smokers.[16]

A study in the North-western part of Nigeria found a poor knowledge of the harmful effect of water-pipe smoking among those who indulge in it.[17] There is, however, a dearth of literature on the major predictors of shisha smoking among students in our environment. Also, to our knowledge, there has been no study on how shisha smoking is perceived among university students in the south–south of Nigeria. Hence, this study aimed to investigate the knowledge and predictors of shisha smoking among the students at the University of Port Harcourt in southern Nigeria. The outcome of the study will generate useful information for health policy and public health interventions toward shisha smoking.


   Subjects and Methods Top


This cross-sectional survey was conducted among undergraduate students of the University of Port Harcourt, Rivers State, Nigeria, between July and November 2019. Sample size was calculated using the formula (N = Z1 − α/22 p (1 − p)/d2) for sample size determination for a cross-sectional study using qualitative variable. Where Z1 − α/2 = 1.96 [standard normal variate at 5% type 1 error (P < 0.05)], p is 40% (prevalence of shisha smoking among university students in a previous study24) and d is 0.05 (precision error of 5%). To give allowance for 10% attrition, the adjusted sample size was 410. There were 12 faculties in the university (Humanities, Social Sciences, Education, Engineering, Management Sciences, Health Sciences, Basic Medical Sciences, Sciences, Dentistry, Pharmacy, Agriculture, Law). Seven faculties were randomly picked using simple random sampling. The name of the different faculties was written on different sheet of paper, folded one by one, and placed in a box. An independent observer helped to pick seven folded papers. The students from the picked faculties were recruited at the ceremonial pavilion at the Abuja campus and various departmental lecture rooms of the University of Port Harcourt. Students from various departments of the University often congregate at the pavilion to receive lectures. The lecture time of the various level was considered to ensure fair distribution in the levels of study before recruiting the students. Participation was voluntary and the participants that gave consent were selected consecutively. The objective of the study was explained to the participants, and informed consent was obtained before administering the questionnaire. Participants were assured of anonymity and confidentiality. The questionnaires were completed by the students at the point of administering and retrieved immediately after completion. Those who declined to participate in the study were excluded from the study. Ethical clearance was obtained from the Research and Ethics Committee of the University of Port Harcourt Teaching Hospital.

The tool for data collection was a self-administered structured questionnaire that elicited information on demography and knowledge of constituents and health effects of shisha. The questionnaire was adapted from literature reviews and pretested among nursing school students of the University of Port Harcourt not selected for the study. Necessary modifications were made to the questionnaire before data collection to ensure the validity and reliability of the questionnaire. The knowledge of the respondents on Shisha was assessed by 12 questions and a correct response was assigned 1 mark, while an incorrect/do not know response scored 0. The total knowledge score was 12, with a higher score indicating better knowledge. Respondents with a knowledge score >60% were regarded as having good knowledge, while those who scored <60% were considered to have poor knowledge based on Bloom's cut-off point.[18] Data were entered into the Statistical Package for the Social Sciences (SPSS, IBM New York, USA) version 25.0 for analysis. The entered data were subjected to descriptive statistics and results were presented in the form of frequency, percentages, and cross-tabulation. Chi-square statistics and binary logistic regression analysis were performed to detect the sociodemographic variables association and predictors of shisha smoking respectively; P < 0.05 was considered to be statistically significant.


   Results Top


A total of 546 students completed the questionnaire comprising 243 males and 303 females. Their age ranged from 15 to 34 years with a mean age of 20.55 ± 3.57. Most of the students were in the Faculty of Science (19.6%), followed by Faculty of Education (18.1%), Social Sciences (17.0%), Humanities (16.3%), Health Sciences (11.5%), Law (9.5%), and Engineering (7.9%). Up to one-third of the students were in their first and second year of study, respectively, while the rest were between 300 and 500 level [Table 1].
Table 1: Distribution of the sociodemographic variables of study participants

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Of the 546 students, 135 (24.7%) had smoked shisha. [Table 2] showed that the proportion of those that indulge in shisha smoking increases with age, however, this was not statistically significant (P = 0.10). Up to 39% of those >30 years had smoked shisha compared to 21.6% of students <20 years. The proportion of males (25.1%) that had smoked shisha was marginally higher than the females (24.4%). However, this was not statistically significant (P = 0.855). The relationship between the faculty of the students and their previous indulgence in shisha was statistically significant (P = 0.037). The percentage of students that had smoked shisha was the highest among the students in the Faculty of Law, followed by those in the Social Sciences and the least was found among students in the Faculty of Health Sciences. A higher percentage of those in the upper level of their study had smoked shisha compared to those in their first year. This observation was statistically significant. Nearly 41% of 400 level students had smoked shisha compared to 20.3% of 100 level students. However, none of the 500 level students had indulged in shisha smoking.
Table 2: Prevalence of shisha smoking and its distribution among the students

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[Table 3] showed that 85.2% of the students had poor knowledge of the constituents and health effects of shisha. The results also showed that the relationship between the knowledge of shisha and the different age groups of the students was not statistically significant (P = 0.185). The older age group had good knowledge of shisha compared to the younger age groups. The female students (18.5%) had good knowledge of shisha compared to the males (10.3%) and this was statistically significant (P = 0.007). More students from the Faculty of Social Sciences (23.7%) showed good knowledge of shisha followed by the students in the Faculty of Engineering (20.9%). The students with the least knowledge of shisha were found in the Faculty of Humanities (6.7%). There was no statistically significant difference (P = 0.333) between the level of study and the knowledge of shisha. However, the association of knowledge and previous shisha smoking was statistically significant (P = 0.001). Around 127 (94.1%) of those that had previously smoked shisha showed poor knowledge of the constituents and the health effects of shisha.
Table 3: Knowledge of shisha smoking among the students

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Predictors of shisha smoking

Binary logistic regression analysis demonstrated that students in the 30–34 years age group were 3 times more likely to have smoked shisha compared to students that were <20 years old, however, this was not statistically significant (odd ratio, OR = 2.78, 95% confidence interval, CI [0.87, 8.93], P = 0.084). Likewise, females were more likely to have smoked shisha compared to males (OR = 1.18, 95% CI [0.76, 1.84], P = 0.456), though this was not statistically significant. Interestingly, students in the faculty of Health Sciences were less likely to have smoked shisha compared to students in the other faculties (OR = 0.16, 95% CI [0.05, 0.54], P = 0.003). However, students in the faculty of Social Science were more likely to have smoked shisha compared to students in the other faculties. Also, students in the 200 and 400 level were twice and thrice more likely to have smoked shisha, respectively, compared to other levels. Students with poor knowledge of the constituents and health effects of shisha were four times more likely to have smoked shisha (OR = 4.48, 95% CI [2.02, 9.93], P = 0.001). [Table 4].
Table 4: Logistic regression of predictors among students who previously smoked shisha (n=546)

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   Discussion Top


Shisha smoking is a worldwide public health risk. Although it was most prevalent among young adults in Eastern Mediterranean and European countries, it is becoming more prevalent among young adults in sub-Saharan Africa.[19],[20] The increasing popularity of shisha as a tobacco product among young adults in Nigeria is attributed to the attractive flavors and the misconception that it is safer than traditional cigarettes.[19],[20] Shihadeh and Saleh identified a greater quantity of chrysene, phenanthrene, fluoranthene, anthracene, and pyrene apart from tar and nicotine in shisha smoke from a single smoking session.[21] These toxins increase the risk for numerous harmful health consequences such as cancer, cardiopulmonary diseases, and periodontitis.[19],[20],[21]

The prevalence of shisha smoking among the university students in this study was 24.7%. This was higher than the prevalence in other studies. A prevalence of 8.4% was reported among the university students in the USA, 13.3–18.9% in Middle Eastern and North African countries, and 16% in 28 countries of the European Union.[22] It was, however, close to 26.1% reported by Omotehinwa et al.[23] among the private university students in Rwanda. The prevalence of shisha smoking among the university students in South Africa was between 18.6% and 40%.[20],[24] The insignificant difference in gender indulgence of smoking shisha in this study corroborate the findings of other studies.[20],[23],[24] However, the 24.4% prevalence rate among female students in this study was high compared to 1.7–16.8% reported in the Asian countries.[21],[22] Shisha has been reported to be increasingly popular among females due to the attractive flavors such as strawberry, pineapple that mask the harsh effects of conventional cigarettes.[25],[26] The increasing global prevalence of shisha smoking among university students have been attributed to peer pressure, inadequate regulation policies in café and restaurants, social acceptability, and the negative influence of social media and celebrities.[22],[23],[24],[25],[26] Media reports have shown the increasing advertisement of shisha as part of hotels and restaurants available services.[25] Students are also seen posting pictures of shisha competition on social media.[20],[25],[26]

The lack of knowledge about the harmful effects of shisha smoking among university students was shown by the results of this current study. It revealed that 85.2% of the students had poor knowledge about the impact of shisha smoking on both general and oral health. Similarly poor knowledge was reported by Muzammil et al.[19] and Omotehinwa et al.[23] among university students in Saudi Arabia and Rwanda, respectively. This showed that the ignorance of the health hazards of shisha was common. Interestingly, students of the Faculty of Health sciences showed poorer knowledge of shisha compared to other Faculties in this study. Al-Naggar and Bobryshev also reported poor knowledge about shisha impact on health among medical students.[27] In contrast, a study conducted by Clareboets et al.[28] in the United Kingdom among the dental students showed that >90% of dental students had moderate or good knowledge of shisha. It appears that medical education does not have any influence on the knowledge of the constituents and health effects of shisha in our clime. The lack of an updated syllabus that incorporates this topic into health sciences and other university programs, along with the absence of awareness programs and intervention policies contributed to the poor knowledge and misconception among the university students in this present study.[19],[20],[21],[22] It is important to improve anti-smoking education in the curricula of all medical and nonmedical schools.

In terms of the predictors of shisha smoking, Bashirian et al.[29] demonstrated that the knowledge of the harmful effects of shisha smoking is one of the most important factors in reducing shisha smoking among students. This supports our observation that knowledge has a significant impact on whether one will start smoking shisha or not. Peer pressure and social interactions were other predictors of shisha smoking reported in the literature apart from the desire and curiosity to try a shisha.[28],[29],[30] Students are likely to smoke shisha with their peers when they are in social gatherings, cafeterias, and birthday parties where the pipe is exchanged between them. Students are less likely to smoke in public places due to religious and social stigma against substance abuse in our environment. However, this study was limited in obtaining data related to the association of friends and social gatherings in having smoked shisha by the students.

Another study by Ziaei et al.[30] found that females were less likely of being shisha smokers (OR = 0.45; 95% CI [0.30, 0.70]). This contradicts the report of this current study where females were more likely to have smoked shisha though not statistically significant. Global statistics point to the increasing rate of hookah smoking among women compared to men. A systematic review by Dadipoor et al.[31] showed that women have a more positive attitude toward shisha and are more dependent on it than men. Shisha smoking among women is accompanied by a higher risk of preterm menstrual pause, lung cancer, reduced bone mineral density, infertility, and ectopic pregnancy. It is also associated with a higher rate of infant mortality and chromosomal birth defects.[32],[33] Moreover, women play an important educational and constructive role within the families. Hence, it is essential to prevent and reduce shisha smoking among women to maintain a healthy society and to protect future generations.

This study shows that nonmedical students were more likely to have smoked shisha compared to medical students. Our findings corroborate with similar studies conducted by Maziak et al.[34] and Mahfouz et al.[35] in Syria and Saudi Arabia, respectively, in which students from art, law, and humanities were more likely to have smoked shisha. This may be attributed to an increase in coursework with each passing year giving less opportunity for social gatherings among medical students. Though students think shisha has positive effects in reducing stress, depression, creating oblivion, and improving their concentration.[35] The increase in the number of shisha smoking establishments around universities also increases the likelihood of smoking shisha among the students.[35],[36] Thus, health planners and policymakers should consider the growing number of hotels and shisha-smoking establishments that provide shisha services around Nigerian universities.

Strengths and limitations

To our knowledge, the present research is the first study to look into the knowledge and determinants of shisha smoking among the university students in South–south Nigeria. The present findings can form the basis for future qualitative and quantitative studies and aid in the design of effective interventions to reduce the rate of shisha smoking among university students.

There were also some limitations in the present study. First, a convenience sampling technique was used, this will cast doubts on the scientific validity of the findings. However, the present information helps understand the trends of emerging tobacco products at a major Nigerian university. Data collection was based on a self-reporting questionnaire, which may raise the possibility of recall and response bias. This was resolved by emphasizing the confidentiality and anonymity of the information obtained through the questionnaire. Also, causality cannot be inferred from this study because of the cross-sectional design. Moreover, other potential predictors like peer pressure, dual-use of shisha and other tobacco products, and use of shisha by friends, siblings and parents were not examined in this study.


   Conclusion Top


The prevalence of shisha smoking in this study was 24.7%; the habit was common amongst students in the Faculty of Law and those in 400 level. The most influential factors were level of study, type of faculty, and poor knowledge of the constituents and harmful effects of shisha.

Recommendations

Lecturers and administrators of different faculties of the university should be engaged to include shisha smoking prevention programs in their curricula. Also, there is a need to incorporate measures to enhance both knowledge and awareness of the dangers of shisha smoking among the university students and the population at large as it is done for cigarette using mass and social media.

Acknowledgments

The authors are thankful to all the study participants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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