Shisha Smoking Habit among Dental School Students in the United Arab Emirates: Enabling Factors and Barriers

Objectives The objective of the present study was to assess shisha smoking among dental school students in Sharjah, United Arab Emirates (UAE). In addition, the role of suggested barriers and enabling factors in shisha smoking was also evaluated. Methods A cross-sectional questionnaire-based survey was conducted at the College of Dental Medicine, University of Sharjah, between February and May 2016. The questions were adapted from previously published water pipe smoking studies. The collected data were analyzed to identify the relationship between shisha smoking and sociodemographic characteristics. Relevant questions were further categorized as enabling factors and barriers for shisha smoking. Results Three enabling questionnaire items related to social environment were significantly associated with an increased risk of being a current smoker. The most powerful is peer pressure (“friends smoke shisha”), which increased the odds ratio of shisha smoking 11.3 times, followed by smoker sibling with increase in odd ratio by 4.52 times, then the belief of social acceptance with increase in odd ratio by 4.31 times. Conclusion Shisha smoking is a serious problem among university students. Any intervention program in the university curricula should consider teaching students that shisha is no less risky than cigarettes and is addictive.


Introduction
Tobacco smoking is one of the ten leading health indicators proposed by the WHO Healthy People 2020 objectives [1]. According to the UN organization, by 2020, the current smoking pattern will cause about 10 million deaths every year [2]. It is estimated that death rate due to smoking will reach 8.3 million per year by the year 2030, where 70% of these deaths will occur in developing countries [3].
Tobacco consumption trend has been found constant over the past 3 decades in the Eastern Mediterranean region, especially in Iran; however, water pipe smoking was increasing in females and young people and decreasing in older people [4].
Shisha is another method of smoking that is attracting new younger customers, especially in the Middle East region. Worldwide, more than 100 million people are reported to smoke shisha [5]. e typical smoking session lasts between 45 and 50 minutes and may last for several hours [6]. Young people are attracted to shisha as the experience comes in a variety of avors and is popular as a group activity. Many shisha users are under the misconception that shisha is less harmful than cigarettes. e reason for the drastic increase in shisha use is the false assumption that it is environmentally friendly and less harmful than cigarettes. Nevertheless, nicotine intake per shisha session has been reported as the equivalent of more than one pack of cigarettes [7]. erefore, the type and magnitude of health adverse e ects associated with shisha are prone to be di erent from those of cigarette smoking. Hadidi and Mohammed [7] stated that "smoking one head of avored (Ma'assel) tobacco (204 mg/pack), containing an average of one-third of the nicotine present in 20 cigarettes, resulted in a 20% higher plasma nicotine level." Shisha smoking has been associated with a variety of diseases, like infertility [8], decreased respiratory function [9], infectious disease [10], and esophageal cancer [10]. e increased popularity of shisha could be attributed to its wide availability, low cost, and sociability. About 50% of university students report having used shisha, and about 25% of men currently smoke it [11]. Mohamed et al. in their study reported that around 9% of 5066 medical students in Cairo smoked both shisha and cigarettes. e prevalence of smoking was observed to be increasing from the rst year through the nal year despite an awareness of the hazards [12]. In Kuwait, more than 57% of men and 69% of women had used a water pipe at least once in their life [13]. In Lebanon, weekly use of water pipe was reported in 30.6% of male students and 23.4% of female students at Beirut Universities [14]. Medical student use is an example of the increased popularity of shisha smoking among educated peoples.
Among Iranian university students, 11.5% of females and 28.7% of males have been reported to smoke water pipe, compared to 2.5% of females and 18.3% of males who smoke cigarettes [15]. e sense of relaxing and energizing and a part of their culture are the main reasons behind water pipe smoking.
A systematic review of the prevalence of water pipe smoking from 38 studies found rates of current water pipe     [16]. Most water pipe smokers in Ghafouri et al. study cited that social and fun aspects are the primary motivators for their continuing use of water pipe [17].
A few articles have been published about shisha or water pipe smoking among university dental students [11,18,19]. Questionnaire-based study among Iranian dental students revealed that 23% are current cigarette, pipe, or water pipe users [20].
However, the authors are unaware of published studies assessing shisha smoking among students of dentistry in the UAE. e aims of the present study were to estimate the prevalence rate of shisha smoking (current and ever) among students categorized by grade and sex, the nicotine dependence among current shisha smokers, and the association between the suggested barriers and enabling factors, and the shisha smoking habit was also studied.   (1) How soon after you wake up do you smoke your rst shisha: (i) Within 5 minutes 3 (ii) 6-30 minutes 2 (iii) 31-60 minutes 1 (iv) After 60 minutes 0 (2) Which shisha smoking would you hate most to give up?
(i) e rst one in the morning 1 (ii) Any other 0 (3) How many Hager/week? (i) 1 per week 0 (ii) 2-4 per week 1 (iii) More than 5 per week 2 (4) Do you smoke more frequently during the rst hours after waking than during the rest of the day?
(i) Yes 1 (ii) No 0 (5) Do you smoke if you are so ill that you are in bed most of the day?

Methods
A cross-sectional survey was conducted on students of the College of Dental Medicine at the University of Sharjah, UAE, between February and May 2016. All students from the dentistry baccalaureate program were included in the study. Students were informed about the aim of the study before the survey questionnaire was distributed. e survey instrument was developed from a literature review and questions adapted from previously published water pipe smoking studies [19,21].
Informed consent was obtained from each participant, and the study was approved by the research and ethics committee of the University of Sharjah. e survey questionnaire is categorized into ve sections: e rst section was about sociodemographic data (such as sex, age, marital status, family education, and nationality). e second section was information about the social environment like whether the student's parents, siblings, and friends smoked shisha. e third section of the questionnaire was about knowledge and awareness of shisha smoking. e fourth section consisted of questions about psychological factors involved in shisha smoking, such as stress, family and friends, and nancial problems. e last section of the questionnaire addressed the personal smoking behavior of those who smoked shisha. e Modi ed Fagerström Test for Nicotine Dependence (MFTND) questionnaire with 5-item responses was used in this study to determine the level of dependence among the shisha smokers. e MFTND total score was calculated as the sum of the individual items, with a score of 5 or more indicating signi cant dependences and a score of 4 or less indicating low to moderate dependence. e completed questionnaire was then collected and coded for data entry. Data were analyzed using IBM SPSS version 23 (IBM statistical package of social sciences program). e odds ratio was used to assess the strength of association between an independent categorical variable and an outcome dichotomous one.

Results
Out of 410 questionnaires distributed among all dental students (82 males and 328 females), only 397 students answered the questionnaire with a response rate of about 96.8%. Women constituted the highest proportion (83.1%) of the respondent students. Most of the students in the study sample were unmarried (92.7%), non-Emirati (64.6%), and had highly educated parents and high income (Table 1). e majority of participants (83.4%) mentioned that shisha was more harmful than cigarettes and that shisha smoking was addictive (76.7%), but only about one-third (37.6%) agreed that shisha was more addictive than cigarettes (Table 2). More than two-thirds of the participants acknowledged that women were more comfortable smoking shisha than cigarettes (71.3%). Most participants also acknowledged that friends could in uence the shisha smoking habit (87.8%) ( Table 3). Stress was found to be the most important factor in uencing the start of shisha smoking (72.3%), followed by family problems (55.9%) ( Table 4).
e prevalence rate of current shisha smoking among women was 8.2%, which is signi cantly lower than that of men (43.3%). In both sexes, the prevalence was lowest for third-and fourth-year students and varied signi cantly among the 3 grade categories. Among women, the prevalence was highest for the fth and sixth years (17.9%), while among men, the prevalence was high for both the rst and second and the fth and sixth years (Table 5). e prevalence of ever smoking shisha was much higher, being double in men compared with their current habit and triple in women. e prevalence rate of ever smoking shisha was signi cantly higher in men (82.1%) than in women (27.9%). Among men, the prevalence was slightly but not signi cantly higher among the lower grades (93.1% in the 1st to 2nd grade) and was lowest in the highest grades (72.2% in the 5th to 6th grades) ( Table 6).
Of the 56 current shisha smokers, 48 completed the Modi ed Fagerström Nicotine Test for Dependence International Journal of Dentistry  6 International Journal of Dentistry questionnaire (less than 20% nonresponse rate) ( Table 7). A signi cant level of dependence was observed, which was signi cantly higher among men (15.4%) than among women (4.5%) ( Table 8). Some knowledge items were perceived as barriers, since they referred to the detrimental health consequences of shisha smoking and the toxic chemicals in the product. Other knowledge items were classi ed as enabling factors, since they encouraged shisha smoking behavior. e role of these barriers and enabling factors was tested for association with the current shisha smoking habit. is test was categorized by sex, since the perception of these knowledge items was di erent between the sexes.
All the 11 barrier knowledge items were more frequent among female nonsmokers than current smokers. However, only the rst 2 items "shisha is more addictive than cigarettes" and "shisha is addictive" were positively identi ed and agreed upon by the interviewees as signi cantly reducing the risk of being a current shisha smoker by 5.85 and 2.38 times, respectively (Table 9). In men, 10 barriers were more frequent among nonsmokers than current shisha smokers. However, only 1 item "shisha contains nicotine" when positively identi ed signi cantly reduced the risk of being a current shisha smoker by 7.02 times. Only 3 enabling factors (items 1, 2, and 4) clearly increased the risk of being a current shisha smoker in men.
ese were "friends can in uence shisha smoking," "shisha is more socially acceptable compared to cigarettes," and "people smoking shisha look cool" all of which signi cantly increased the risk of being current smokers by 11.08, 5.06, and 3.6, respectively (Table 10).
Among women, only 10 enabling factors clearly increased the risk of being current shisha smokers. e most powerful of these factors was item number (1) "friends smoke shisha," which signi cantly increased the risk of being a current smoker by 11.32 times. e next 4 items (items 2, 3, 5, and 6) increased the risk of current shisha smoking by more than four times. ese positive knowledge items included: "smoker sibling, father, and mother," believing that "friends can in uence smoking," and feeling that "shisha smoking is more socially acceptable than cigarettes." In addition, agreeing that "girls are more comfortable smoking shisha compared to cigarettes" and feeling that "people smoking shisha look cool" signi cantly increased the risk of current shisha smoking as an outcome by more than three times. e remaining 2 knowledge items (9 and 10) "shisha smoking is our cultural heritage" and "people who smoke shisha have more friends" marginally increased the risk by between 56% and 63%. For women, the remaining 10 items originally classi ed as enabling factors not only did not increase the risk of current shisha smoking but also were inversely associated with this habit. ese factors included stressful situations as a possible cause of smoking, including the life burden in university, the problems with friends, couple problems, and nancial problems, "stress leads to shisha smoking." Advertising about shisha was not perceived by women as an enabling factor for shisha smoking (Table 9).
Tables 11 and 12 summarize the participants' smoking habits and personal smoking behavior.

Discussion
In the present study, men with a current shisha smoking habit comprised 43.3% of the male sample, which was nearly the same percentage reported among medical students in central Saudi Arabia (44.1%) [22]. e prevalence rate was the highest in senior year students.
is high prevalence could be attributed to a common belief that shisha smoking is less harmful than cigarette smoking [23]. However, in the present study, most of the male participants (86.8% nonsmokers and 79.3% current smokers) acknowledged that shisha was more harmful than cigarettes. e increasing prevalence in shisha smoking among university dental students despite the high perception of its harmful e ects and the increasing trend in shisha smoking is due to other factors, including peer pressure. Akers et al. [24] have stated that "the single most direct in uence on smoking among young people is how many of their 5 best friends smoke." Initial cigarette workout occurs in the presence of other adolescents who are smoking [25,26]. In the present study, 86.1% of surveyed nonsmokers and 96.3% of current shisha smokers supported this concept. e number of students  Tables 5 and 6. More than 55.3% of nonsmokers and around 86.2% of male current smokers in the present study believed that shisha was more socially acceptable than cigarettes. Similar ndings also showed that smokers do not see themselves as addicts and feel they can quit whenever they wish [27,28]. Worldwide, more than 100 million people reported smoking shisha [4]. Young people are attracted to the water pipe as it comes in a variety of avors and is popular as a group activity. For many years, the water pipe was considered less harmful than cigarettes; even worse many users did not consider it as a form of tobacco smoking. e use of the water pipe for smoking tobacco is a tradition in the Middle East region that goes back centuries. Since the early 1990s, however, its use has surged among new groups such as women, teenagers, and wealthy people. Shisha smoking is usually between 1 and 4 sessions/day, but with much more intense exposure per session when compared to cigarettes. Public health education and better informing health practitioners about the facts of water pipe tobacco exposure might correct the false concept of "safe smoking." In the present study, the overall prevalence of shisha smoking was 14.1% among dental students. A lower prevalence rate (5.6% and 7.3%) was reported among other nonmedical students at the University of Sharjah, UAE [1], and university students in Riyadh, Saudi Arabia [29].
A study conducted in the United Kingdom on 181 dental students showed that more than 90% of dental students had moderate or good knowledge and more than 80% had an appropriate attitude towards smoking [30]. However, appropriate knowledge and attitude alone cannot result in a proper behavior, and other confounding factors like socioeconomic and family issues [31,32] should also be taken into account [3].
e Modi ed Fagerström Nicotine Test of Dependence (MFNTD) questionnaire with 5-item responses was used in the present study to determine the level of dependence (Table 7). e total score was calculated as the sum of the individual items; a signi cant level of dependence was observed in 15.4% of men with a current shisha habit (Table 8). Ghafouri et al. [17] found that 17.2% of their studied sample felt that shisha smoking was addictive.
Stress was found to be one of the enabling factors that leads to shisha smoking (22/29 men and 17/27 women) among current shisha smokers as shown in Tables 9 and 10. e high perception of the harmful e ect of shisha smoking among participants does not prevent them from practicing this habit. is may be contributing to the widespread of this type and other types of tobacco use. Similarly, a study done at the American University of Beirut [32] reported that most students are aware about the e ects of smoking on health but lacked detailed information about how these e ects happened. ese discrepancies re ect the failure of university curricula in this region to teach students about the harmful properties of tobacco e ectively.
In addressing the concept of barriers, acknowledging the addictive nature of shisha and the fact that it is more addictive than cigarettes was found to reduce the risk of being a current shisha smoker among women. ese barriers did not a ect the male habit, in fact their knowledge about the nicotine content of shisha increased the risk of the habit. Among the factors that promote the habit of smoking shisha, both sexes agreed on the positive peer e ect. However, current female shisha smokers were more likely to have a friend with the shisha smoking habit. In addition, both sexes were signi cantly a ected by the positive social image of shisha. ey used the word "cool" to describe the habit. In addition, they thought that shisha smoking was more acceptable than cigarettes. Socially, women are more comfortable with shisha smoking than cigarette smoking. Finally, the role of family members (father, mother, and siblings) was an important promoter for women.
If dental students are to become advocates for reducing smoking, the dental schools' curricula should stress more about the awareness of tobacco-related diseases. e positive social image of shisha for both sexes and the role model of family members in fostering this habit among women should be addressed to prevent its spread. e increasing number of women smoking water pipes may become an epidemic unless robust health education programs are designed to combat water pipe smoking, especially in these age groups.

Conclusion
Water pipe smoking among university students is of growing concern. Acknowledging the addictive nature of shisha and the fact that it is more addictive than cigarettes is an important barrier for the habit among women users. Among the factors that promote the habit in both sexes were the positive peer e ect and the positive social image of shisha. e in uential role model of other family members smoking shisha was an important promoter only for women. An intervention program to prevent this health problem must teach the public that water pipes are no less risky than cigarettes. Water pipe smoking should be bound by the same regulations and laws as cigarette smoking, including banning it in public places.  International Journal of Dentistry Furthermore, teachers and faculty at schools and universities should be engaged to include tobacco and water pipe prevention programs in their curriculum.

Conflicts of Interest
e authors declare that they have no con icts of interest.