INTRODUCTION
Smoking is one of the most serious global health issues in modern times and has resulted in substantial disability, morbidity, and mortality1. Moreover, tobacco consumption has become the sole leading cause of preventable death; accounting for the loss of more than 7 million lives annually as well as 1.4 trillion US dollars in economic losses2. Additionally, tobacco use afflicts personal health and impacts societies by reducing productivity, burdening the healthcare system, impoverishing families, and damaging the environment3. Today, the majority (80%) of the world’s one billion smokers reside in middle- and low-income countries, which carry the bulk of the tobacco burden. To further jeopardize the situation, most of the world’s nations lag behind on smoking surveillance, smoke-free laws, cessation services, anti-tobacco campaigns, advertising restrictions, and tobacco taxation4.
One form of tobacco use, shisha (waterpipe), has amounted to a global health issue due to several factors such as the manufacturing of flavored tobacco (maassel), the social appeal of shisha and its link to the growing café culture, the emergence of social media, and the lagging of the implementation of relevant regulations and policies5. In addition, shisha use is prevalent in the Eastern Mediterranean Region. An earlier systematic review on the subject has revealed that the prevalence of smoking shisha among adults was highest in the previously mentioned region (7.2%). Also, the rate of waterpipe use among the youth was similar across the European (10.6%) and Eastern Mediterranean (10.3%) regions6.
Moreover, there is a prevailing misconception among smokers that waterpipe use is safe and poses no significant harm to human health. A recent systematic review regarding the knowledge and perceptions towards shisha use among university students has revealed that shisha is perceived as less harmful and less addictive when compared to cigarette smoking. Furthermore, despite the students’ knowledge of its harms, waterpipe use was still prevalent7. Another study among shisha users in Malaysia showed that the waterpipe was perceived as a ‘cool’ and ‘trendy’ activity. Also, shisha users reported that the most harmful health effects were dry throat, headache, and nausea8. A qualitative study among young adults attending shisha cafés and smoking waterpipes in the United Kingdom revealed that the participants believed the social benefits of shisha outweighed its health hazards9. Nevertheless, evidence has linked shisha use to several health problems such as respiratory diseases, oral cancer, lung cancer, low birthweight, metabolic syndrome, cardiovascular diseases, and mental illness10. Another concern is the common belief that smoking shisha is not linked to nicotine dependence and tobacco addiction. However, the literature has shown that the waterpipe is a nicotine delivery system and any abstinence from its use is associated with withdrawal symptoms11.
In Qatar, the Global Adult Tobacco Survey in 2013 has shown that 3.4% of adults in the country were current waterpipe users. The use of shisha was more prominent among males (4.9%) than females (1.6%) and most men (85%) smoked shisha at cafés while women (63%) smoked at home12. An earlier study among self-reported waterpipe users in the country revealed that less than half (44%) perceived waterpipe smoking to be safer than cigarette use and over half of the current smokers intended to quit smoking shisha at a certain time13. Despite the fact that the country has witnessed a flourishing of shisha cafés since 2013, there remains a scarcity of data on shisha smokers. In addition, studying the knowledge and practice of shisha smokers in Qatar will help identify gaps for the implementation of more effective tobacco control strategies in the country.
METHODS
Study design, setting and population
This was a cross-sectional study across three primary healthcare (PHC) centers in Qatar. The three health centers were chosen by convenience from the list of all 28 operational health centers in the country. Adult clients (aged ≥18 years) who spoke Arabic or English and were attending the chosen health centers were approached for enrollment in the study between September and December 2020. If consenting, an interview was conducted in the waiting areas of the three health centers.
Sampling and sample size
A convenient sampling (non-probability) technique was employed to recruit the participants. The sample size was calculated to obtain a sufficient number of participants that ensures the study’s power. The estimated sample size was 236 individuals based on a 95% CI, a precision of 5%, and assuming that the prevalence of shisha use among the general public in Qatar was 19% (based on an unpublished study)13.
Data collection
Upon consenting, each participant was interviewed using a structured questionnaire. The questionnaire included five sections and entailed 38 questions. The first section (6 items) collected demographic information (age, gender, education level, marital status, nationality, and employment status). The second section (4 items) generated data on the patient’s smoking history (duration of tobacco use, type of tobacco currently in use). The third (13 items) and fourth (6 items) sections encompassed questions about the participants’ practice and knowledge of shisha smoking, respectively. The final section (9 items) included questions about the participants’ smoking cessation history. The face validity of this questionnaire was based on a thorough literature review of relevant research as well as the review of community medicine and smoking cessation specialists. The questionnaire was piloted among a small number of participants (n=6) from the target population. Most of the participants acknowledged that the questionnaire was reader-friendly and comprehensible. Two participants (each) recommended adding a question each, such as the effect of taxation on shisha use and the perception of the smoker towards the safety of shisha use. However, the investigators decided to defer such questions to a future study because they were not concordant with the study’s objectives.
Outcome measures
Regarding the level of knowledge on shisha among the participants, it was measured through a 12-point scale. Each correct answer scored 1 and an incorrect answer zero. Then, the level of knowledge among respondents was classified into two categories based on a cutoff score of 6, where a value ϛ6 denoted inadequate knowledge and >6 denoted adequate knowledge. In regard to shisha use among the attendees of the three primary health centers, descriptive statistics were calculated such as the age of initiation of shisha use (mean and SD), frequency of current shisha use, duration of each shisha use session (mean and SD), ownership of a shisha at home (%), sharing shisha with another person (%), importing tobacco products (%), effect of taxation on shisha use (%), and use of electronic shisha (%). Similar statistics were calculated on smoking cessation among the respondents such as having heard of Public Health Care Corporation smoking cessation clinics (%), been asked about smoking status by primary care physician (%), been counseled on smoking by primary care physician (%), having attended a s Public Health Care Corporation smoking cessation clinic (%), previous quit attempts (mean and SD), duration of quit attempt (mean and SD), readiness to quit in the next year (%), and readiness to participate in group smoking cessation (%).
Statistical analysis
Descriptive statistics, frequencies and percentages, were calculated for categorical variables while means and standard deviations (SD) were calculated for numerical variables. For analytical statistics, Student’s t-test and chi-squared were applied to assess the association between the background characteristics and the participants’ shisha knowledge level.
Factors identified through the univariate analysis with p<0.1 were included in a backward stepwise logistic regression analysis to identify the independent factors of adequate shisha knowledge. All of the tests for significance were two-sided. The p-values of multiple logistic regression analysis <0.05 were considered statistically significant. The data were analyzed using the IBM SPSS Statistics for Windows (version 28, IBM Corp., Armonk, N.Y., USA).
RESULTS
Nearly half of the participants (47.8%) reported currently using shisha. Moreover, the mean age of initiating shisha use among the study respondents was 19.2 ± 7.5 years. Nearly two-thirds (62.4%) of the participants mentioned a friend as the person with whom the first shisha was smoked. Regarding their frequency of shisha use, nearly one-third (34.8%) stated smoking once every few months while about one-quarter (24.1%) smoked shisha once every week. Also, more than a third of the participants (35%) smoked from 30 minutes up to one hour per session and nearly half (48.7%) smoked at a shisha cafe. When attending a cafe/restaurant for shisha, most respondents (70.7%) were accompanied by a friend. In addition, less than half of the study participants (41.7%) owned a shisha at home and a higher proportion (55.7%) frequently shared a shisha with someone else. Moreover, almost half (53%) of the study subjects brought tobacco products with them when returning home from a vacation and a similar percentage (50.4%) denied any effect of increased tobacco taxation on their smoking behavior. Regarding the electronic shisha, nearly a third (29.3%) of the participants reported ever use of such a product and a smaller percentage (13.6%) were currently using it (Table 1).
Table 1
Frequency distribution of smokers attending primary healthcare centers, Qatar 2020 (N=281)
| Characteristics | n (%) |
|---|---|
| Current use of shisha | |
| Yes | 120 (42.7) |
| No | 161 (57.3) |
| Age of initiation of shisha use (years), mean ± SD | 19.2 ± 7.5 |
| Person with whom the first shisha was shared | |
| Alone | 25 (21.4) |
| With a family member | 19 (16.2) |
| With a friend | 73 (62.4) |
| Frequency of shisha use | |
| Once every few months | 39 (34.8) |
| Once every month | 14 (12.5) |
| Once every week | 27 (24.1) |
| 2–5 times per week | 20 (17.9) |
| Once every day | 12 (10.7) |
| Duration of shisha smoking session (hours) | |
| <0.5 | 32 (27.4) |
| 0.5–1.0 | 41 (35) |
| >1.0 to 2.0 | 28 (23.9) |
| >2.0 | 16 (13.7) |
| Place of smoking shisha | |
| At home | 28 (23.9) |
| In a shisha cafe | 57 (48.7) |
| In a restaurant | 12 (10.3) |
| Outdoor area (e.g. beach or sand dune or park) | 20 (17.1) |
| People who accompany you to restaurant/cafe when smoking shishaa | |
| Alone | 30 (25.7) |
| Wife/husband | 23 (20.0) |
| Wife/husband and children | 8 (7.0) |
| Friends | 82 (70.7) |
| Not applicable | 4 (3.5) |
| Owning a personal shisha at home | |
| Yes | 48 (41.7) |
| No | 67 (58.3) |
| Sharing a shisha with someone | |
| Yes | 64 (55.7) |
| No | 51 (44.3) |
| Bringing tobacco products when returning from a vacation | |
| Yes | 62 (53.0) |
| No | 55 (47.0) |
| Effect of increased tobacco taxation on your smoking | |
| It made me decrease my smoking | 31 (27.0) |
| I tried to quit but couldn't | 23 (20.0) |
| It didn't affect my smoking | 58 (50.4) |
| I switched from one type of smoking to another | 3 (2.6) |
| Ever use of electronic shisha | |
| Yes | 34 (29.3) |
| No | 82 (70.7) |
| Current use of electronic shisha | |
| Yes | 16 (13.6) |
| No | 82 (86.4) |
Regarding their knowledge of shisha, over half (56.1%) of the study subjects agreed that shisha contains tobacco. Also, participants correctly associated certain diseases with the use of shisha such as lung cancer (72.7%), heart disease (66.4%), and colon cancer (30.9%). Most participants (69%) associated shisha use with the risk of transmitting infections between users. On the other hand, less than half of the respondents (45.5%) reported shisha use to be addictive and a similar percentage (46%) considered its nicotine content to be higher than regular cigarettes. Moreover, almost a third of the study participants (33%) denied the presence of an efficient filtration system in a shisha. Furthermore, the study subjects’ mean shisha knowledge score was 4.85 points (SD=3) and nearly three-quarters (n=186; 72.9%) had inadequate knowledge in this regard (Table 2).
Table 2
Participants’ knowledge of shisha among smokers attending primary healthcare centers, Qatar 2020 (N=281)
| Characteristics | n (%) |
|---|---|
| Tobacco content of shisha | |
| Yes | 148 (56.1) |
| No | 45 (17.0) |
| I don’t know | 71 (26.9) |
| Diseases associated with smoking shishaa | |
| Lung cancer | 189 (72.7) |
| Colon cancer | 81 (30.9) |
| Heart disease | 172 (66.4) |
| Type 2 diabetes | 29 (11.2) |
| Ectopic pregnancy | 32 (12.4) |
| Liver cancer | 72 (27.7) |
| Vision loss | 38 (14.8) |
| None of the above | 24 (8.5) |
| Shisha as a source of infection between users | |
| Yes | 180 (69.0) |
| No | 9 (3.4) |
| I don’t know | 72 (27.6) |
| Shisha is addictive | |
| Yes | 121 (45.5) |
| No | 69 (25.9) |
| I don’t know | 76 (28.6) |
| Shisha contains more nicotine than cigarettes | |
| Yes | 122 (46.0) |
| No | 54 (20.4) |
| I don’t know | 89 (33.6) |
| Shisha has an efficient filtration system | |
| Yes | 78 (29.2) |
| No | 88 (33.0) |
| I don’t know | 101 (37.8) |
Regarding the participants’ smoking cessation history, nearly half (53.4%) had heard of the smoking cessation services at primary healthcare centers. A similar percentage of respondents (50.2%) reported ever being asked about their smoking status by a primary care physician. Moreover, almost two-thirds (59.2%) of the study subjects had never been counseled on smoking cessation by their primary care physician. When asked about attending the smoking cessation clinics at the primary healthcare centers, a minority (19.5%) of participants conveyed doing so. As a result, a quarter (25%) of the respondents managed to quit smoking before relapsing. In addition, 42.7% of the smokers in this study reported an intention to quit smoking in the coming 12 months and 28.4% were willing to attend group therapy sessions for this purpose (Table 3).
Table 3
Smoking cessation history among smokers attending primary healthcare centers, Qatar 2020 (N=281)
Upon bivariate analysis (Table 4), there was a statistically significant association between the study subjects’ shisha knowledge level and their nationality, employment status, smoking status, and duration of smoking. In addition, it was found that being a Qatari, unemployed, current smoker, and with a longer duration of smoking, were more likely to have adequate knowledge of shisha compared to their peers (Table 4).
Table 4
The association between the participants’ background characteristics and their shisha knowledge level among smokers attending primary healthcare centers, Qatar 2020 (N=281)
| Variable | Inadequate knowledge n (%) | Adequate knowledge n (%) | p |
|---|---|---|---|
| Age (years), mean ± SD | 35.8 ± 11.0 | 38.3 ± 12.8 | 0.061 |
| Gender | 0.946 | ||
| Male | 165 (73.0) | 61 (27.0) | |
| Female | 21 (72.4) | 8 (27.6) | |
| Nationality | 0.002* | ||
| Qatari | 38 (58.5) | 27 (41.5) | |
| Non-Qatari | 148 (77.9) | 42 (22.1) | |
| Education level | 0.999 | ||
| Illiterate | 3 (75.0) | 1 (25.0) | |
| Preparatory | 9 (75.0) | 3 (25.0) | |
| Primary | 6 (75.0) | 2 (25.0) | |
| Secondary | 33 (71.7) | 13 (28.3) | |
| University | 128 (71.9) | 50 (28.1) | |
| Marital status | 0.081 | ||
| Single | 60 (75.0) | 20 (25.0) | |
| Married | 118 (71.5) | 47 (28.5) | |
| Divorced | 3 (100) | 0 (0) | |
| Widowed | 0 (0) | 2 (100) | |
| Employment | 0.02* | ||
| Employed | 149 (74.1) | 52 (25.9) | |
| Unemployed | 14 (53.8) | 12 (46.2) | |
| Self-employed | 12 (100) | 0 (0) | |
| Retired | 9 (64.3) | 5 (35.7) | |
| Smoking status | <0.001* | ||
| Yes | 103 (62.4) | 62 (37.6) | |
| No | 83 (92.2) | 7 (7.8) | |
| Duration of smoking (years), mean ± SD | 7.8 ± 10.2 | 15.5 ± 11.7 | <0.001* |
Multiple logistic regression analysis showed that being smokers and employed were the independents factors of knowledge about shisha (OR=7.4; 95% CI: 3.2–17.3) and (OR=0.38; 95% CI: 0.18–0.83) (Table 5).
Table 5
Multiple logistic regression on factors significantly associated with adequate shisha knowledge among smokers attending primary healthcare centers, Qatar 2020 (N=281)
DISCUSSION
The current study presents the prevalence, knowledge, and practice of shisha use and smoking cessation among three Public Health Care Corporation health center attendees in Qatar. It was found that almost half of the participants were currently using shisha and about three-quarters had inadequate knowledge about this topic. Also, only one-fifth of participants attended smoking cessation clinics at the primary healthcare centers and a quarter of the respondents managed to quit smoking before relapsing. Upon further analysis, a significant association was identified between adequate shisha knowledge and nationality (Qatari), employment status (unemployed), smoking status (current smoker), and duration of smoking.
Regarding the prevalence of shisha use among the study subjects, it was found to be 47.8%, which is high compared to a study (20.9%) conducted among university students and governmental employees in Qatar during 2019. This could be possibly explained by the variation of the participant characteristics in each study, where nearly half of the participants in the earlier study were female (41.6% vs 11.8%), Qatari (47.6% vs 25.3%), and younger (53.9%; aged 18–34 years)14. These differences might entail different smoking behavior and preferences. Moreover, the knowledge of shisha among our study respondents was mainly inadequate (72.9%). Similarly, a survey among Ugandan youths found that the majority (86.4%) possessed a low level of knowledge on shisha15. The decreased shisha knowledge can be attributed to a prevalent misconception that its use is safer than other tobacco products16.
Furthermore, only 19.5% of study subjects consulted the smoking cessation clinics at the primary healthcare centers and a quarter of them quit smoking before relapsing. The decreased uptake of the smoking cessation services at the primary care level can be explained by several factors such as the lack of awareness about the availability of this service. Another explanation could be the lack of motivation among smokers to attempt quitting or seeking help in this regard. Also, a deficient or absent community engagement strategy of attracting smokers to the smoking cessation clinic might be another barrier in this regard17. In addition, the 25% quit rate among participants in the current study was similar to that of adult smokers attending smoking cessation services in primary healthcare centers in Thailand18. Similarly, a cross-sectional study of smokers attending a university smoking cessation service in South Korea reported a quit rate of 28.8%19. The smoking cessation services provided at the primary care level in Qatar encompass a combination of strategies by certified tobacco treatment specialists such as counseling, motivational interviewing, behavioral modification, and pharmacological treatment. Also, smokers can access this service through self-referral, contacting a dedicated phone line, and referral from family and community medicine physicians20. The aforementioned factors possibly contribute to an increased quit rate among smokers in this study.
The subsequent analysis yielded a significant association between adequate shisha knowledge and nationality (Qatari), employment status (unemployed), smoking status (current smoker), and duration of smoking. Similarly, a study among Jordanian university students uncovered that good knowledge of shisha was significantly associated with increased age, type of education (non-health sciences), and being a current smoker21. In addition, a community survey of Lebanese waterpipe smokers found that higher shisha knowledge was associated with male gender, a higher education level (university degree holders), higher income, and low waterpipe dependence22. Moreover, the association between nationality (Qatari) and adequate shisha knowledge could be attributed to an effective national school health program that began mainly across governmental schools that are mainly attended by Qatari nationals23. In addition, being a current smoker and having a lengthier duration of smoking were associated with higher shisha knowledge. Such findings could be explained through the fact that smokers are exposed to various information about tobacco use and its harmful effects from label warnings, peer discussions, physician consultations, anti-tobacco advertisements, and other sources. So, the level of awareness regarding the types and adverse health effects of different tobacco products might increase with time as smokers are further exposed to various sources of information in this regard.
Strengths and limitations
To the best of our knowledge, the present study was the first to generate evidence on shisha use and knowledge among attendees of primary healthcare centers in Qatar. Also, a high response rate was attained among the target population that encompassed a diversity of nationalities as seen in the country. Moreover, the employment of an interview-based questionnaire ensured a high level of data completeness and integrity. Nevertheless, this study was not without limitations. The use of a convenience sampling technique might affect the generalizability of the study results. In addition, the inclusion of self-reported variables in the survey could have introduced social desirability bias into the study. Additionally, the cross-sectional study design prevented the researchers from interpreting the temporality of the association between shisha knowledge and its associated factors.
CONCLUSIONS
The study results convey a high prevalence of shisha use (47.8%), inadequate shisha knowledge (72.9%), and lack of awareness about available smoking cessation services (46.6%) among the participants. Further research is recommended to generate evidence on the determinants of shisha use and knowledge among the attendees of primary healthcare centers in Qatar. The results could enable smart decision making and inform the development of awareness campaigns on shisha and smoking cessation services in the country.
