Abstract
Objective:
To compare patterns of water pipe and cigarette smoking in an eastern Mediterranean country.
Methods:
In 2008, 1781 out of 1877 seventh graders enrolled in 19 randomly selected schools in Irbid, Jordan, were surveyed.
Results:
Experimentation with and current water pipe smoking were more prevalent than cigarette smoking (boys: 38.7% vs 26.8%; 20.2% vs 9.0%, girls: 21.2% vs 9.5%; and 7.5% vs 2.3%, P<0.05 for all). Parent- and peer-smoking correlated more strongly with water pipe than with cigarette smoking.
Conclusion:
Water-pipe smoking is more prevalent than cigarette smoking at this early age.
Keywords: adolescent, cigarette, smoking, tobacco, water pipe
Tobacco use is a global epidemic that kills more than 4 million people each year.1 This annual toll is expected to exceed 8 million by 2030, most of which will occur in developing countries.2 Smoking is distressingly common among adolescents across the eastern Mediterranean region (EMR).3 Current smoking of tobacco products among middle/high school students was reported to be 19.8%, 25.3%, and 48.5%, in Jordan (2007), Kuwait (2005), and Lebanon (2005), respectively.4 Moreover, and despite the fact that smoking prevalence in school girls is much lower than that of boys, evidence shows that girls’ smoking, especially water pipe, appears to be increasing.5,6
Water-pipe use (also known as hookah, shisha, narghile) is increasing among youths in the EMR.7,8 Data from the Global Youth Tobacco Survey (GYTS) involving more than 90,000 students (13–15 years) from 20 countries in the EMR suggest that water-pipe use may be surpassing cigarette smoking among EMR adolescents.9 This shift in tobacco use patterns towards increasing prevalence of water pipe smoking, especially among youth, does not seem to be confined to the EMR region but is spreading worldwide.10,11 Moreover, recent research suggests that water pipe smoking is addictive and associated with significant adverse effects on health.12,13 These findings highlight the new and serious challenges to tobacco control efforts posed by the resurgence of water-pipe smoking.
Understanding the patterns and determinants of tobacco use in youth is crucial to curb the tobacco epidemic. Adult cross-sectional surveys are valuable for establishing tobacco use prevalence.14,15 However, understanding who uses which tobacco product, and why, requires longitudinal follow-up of youth, especially given that adolescence is a critical period for tobacco use initiation.16 Moreover, data on factors influencing water-pipe smoking initiation and maintenance in the EMR are scarce. This manuscript presents the rationale and design of the first longitudinal study of cigarette and water-pipe smoking patterns among young students in a country from the EMR region (Jordan). It also reports findings from the cross-sectional analysis of the baseline survey performed in school year 2007–08 among a representative sample of seventh-grade students in the Jordanian city of Irbid.
METHODS
Development of the Survey Instrument
The survey questionnaire development was guided by international guidelines17 and other instruments validated in Arabic.18,19 The questionnaire was comprised of 4 modules. The first module included socio-demographic questions. The second included questions about cigarette smoking. The third included questions about water-pipe smoking, and the fourth included questions about tobacco ads and smoking warnings, family and school environment, peer influences, and students’ attitude to quitting smoking. Special attention was devoted to the clarity of items to allow for similar cognitive processing by the respondents. Concept- or linguistic-laden questions were avoided (eg, to assess peer pressure, we asked about “smoking among close friends” rather than “peer pressure”). The questionnaire was piloted in 86 boys and 67 girls from 4 schools in Irbid and further modified to address issues revealed by the piloting.
The following definitions of smoking status were adopted: ever smoking is ever experimentation with tobacco; current smoking is reported tobacco use (cigarette, water pipe) in the past 30 days; regular smoking is smoking at least once a week in the past 30 days; ex-smoking is regular smoking in the past but none in the past 30 days; and never smoking is reporting never having experimented with tobacco. Information on number of items smoked per day for current and regular smoking was obtained from a separate question: “During the days in which you smoked in the past month, how many cigarettes per day did you usually smoke?” A similar question was asked for water-pipe smoking. This approach was used because it is more suitable for assessing tobacco use patterns among youth, where it is important to establish meaningful gradients of smoking behavior within mostly intermittent use patterns (especially for the water pipe).19
The questionnaire was group-administered by one of the study personnel. In each classroom, a study staffer explained the purpose of the study to students, showed them how to answer the questionnaire, and answered their questions. To improve the validity of students’ responses, no teachers or other school personnel were allowed in the classroom.
Source Population and Sampling Method
The school system in Jordan comprises 2 stages: basic (grades 1–10; ages 6–16 years) and high (grades 11–12; ages 16–18 years). This study enrolled students at the 7th grade and will follow them up yearly until the 10th grade. This range was selected to include students young enough to be at the experimentation and initiation phase of smoking and follow them during the phase of establishing and maintaining the habit. Therefore, the source population was all students who were registered in the 7th grade, in fall 2007, in Irbid, Jordan (population ~300,000). There were 5287 seventh-graders in 60 schools in Irbid. A stratified, cluster random sample was used: a list of city school names and number of students was obtained from the Department of Education and verified for accuracy and completeness by the study staff. The schools were stratified by gender (male schools, female schools, and mixed-gender schools) and by type (public, private) to ensure the representativeness of the sample. Within each gender/type stratum, a random sample of schools was selected from the roster of school names with probability proportional to size (PPS). Briefly, the schools were ordered according to their size in increasing order and each school was assigned a range of numbers proportional to its 7th-grade student population. For example, if school (A) had 250 students and school (B) had 500 students, school (A) was assigned numbers 1 to 250, and school (B) was assigned numbers 251 to 750. A random number between 1 and the total sum of students in all schools in each stratum was generated by computer. The school in whose range the generated number fell was selected. If a school was selected more than once, the random number was discarded and another number was generated. Nineteen schools (6 private, 8 male, 9 female, and 2 mixed) were selected. All 7th graders in the selected schools were invited to enroll in the study.
Data were collected in the spring of 2008 after parental consent and students’ assent were obtained. The informed consent document, together with a letter describing the study, was sent home with the student because mail service is unreliable in this setting. The study was reviewed and approved by the Jordan University for Science and Technology (JUST) and the University of Memphis IRBs.
Sample Size and Power
Sample size calculations were performed for the primary outcomes (eg, comparing factors associated with cigarette vs water-pipe smoking). Preliminary information available about cigarette and water-pipe use from previous surveys among high school and university students5,20 was used to calculate the sample size needed. It was estimated that 480–500 students would be needed to detect an odds ratio (OR) of 2 or more at a 2-sided alpha level of 5% and an 85% power.21 Considering an expected loss to follow-up of 30% during the 4 years of the study and a design effect of 2 (loss of power due to cluster sampling), a baseline sample size of approximately 1430 students is needed to detect that effect size [n = (500/0.7) * 2 ~1430].
Statistical Analysis
Data were summarized as number and percent of total. Chi-square test was used to assess the associations between smoking status and socio-demographic variables. Multivariate associations were examined by logistic regression models. Separate models were constructed for cigarette and water pipe and in male and female students. First, all variables that were significantly associated with smoking status in the bivariate analyses were included in the logistic models to assess their relative influence. Next, the back-ward elimination method was used to remove insignificant variables. To detect multicollinearity in logistic regression analyses, we used multiway frequency analysis among the categorical independent variables to evaluate intercorrelations. Alpha level was set at 0.05. All statistical tests were performed using SPSS software (SPSS Inc, Chicago, IL).
RESULTS
All 19 randomly selected schools agreed to participate in the study. Out of a total of 1877 students in these 19 schools, parental consents and student assents were provided by 1781 (95%), and they were enrolled in the study. Of these 1781 students, 915 (51.4%) were boys and 866 (48.6%) were girls. The median age was 13 years. Their socio-demographic characteristics are shown in Table 1.
Table 1.
Anthropometric and Socio-demographic Characteristics (N=1781)
| Variable | n | % |
|---|---|---|
| Gender | ||
| Boys | 915 | 51.4 |
| Girls | 866 | 48.6 |
| Age (year) | ||
| 11–12 | 580 | 32.6 |
| 13 | 1097 | 61.6 |
| 4–15 | 104 | 5.8 |
| Daily pocket money (JD)a | ||
| <0.25 | 898 | 50.4 |
| 0.25–0.50 | 548 | 30.8 |
| 0.50–0.75 | 225 | 12.6 |
| >0.75 | 110 | 6.2 |
| Father’s education | ||
| ≤high school | 863 | 48.5 |
| >high school | 917 | 51.5 |
| Mother’s education | ||
| ≤high school | 941 | 52.9 |
| >high school | 839 | 47.1 |
| Household size | ||
| <8 | 1275 | 71.7 |
| ≥8 | 504 | 28.3 |
Note.
JD: Jordanian Dinar (1 JD = US $1.4)
Prevalence of Smoking
Of a total of 1781 students, 18.4% had tried cigarette smoking, 30.2 % had tried water-pipe smoking, and 35.1% had tried either. About 9.0% of boys and 2.3% of girls were current cigarette smokers, and 20.0% of boys and 7.5% of girls were current water-pipe smokers. Overall, 16.1% of students were current smokers of either cigarettes or water pipe (Table 2). Of those who had never smoked cigarettes, 8.3% (9.3% for boys and 7.4% for girls) reported being likely to start smoking in the next year. The prevalence of current cigarette smoking and current water-pipe smoking according to socio-demographic characteristics is shown in Table 3 and Table 4.
Table 2.
Gender Patterns of Smoking Among Seventh-Grade Students in Northern Jordan, Middle East (n, % of total)
| Smoking Status | Boys | Girls | Total |
|---|---|---|---|
| Ever-cigarettes smoking | 245 (26.8) | 82 (9.5) | 327 (18.4) |
| Ever-water-pipe smoking | 354 (38.7) | 184 (21.2) | 538 (30.2) |
| Ever smoking (cigarettes or waterpipe) | 421 (46.0) | 204 (23.6) | 625 (35.1) |
| Current cigarettes smoking | 82 (9.0) | 20 (2.3) | 102 (5.7) |
| Current water-pipe smoking | 185 (20.2) | 65 (7.5) | 250 (14.0) |
| Current smoking (cigarettes or water pipe) | 213 (23.3) | 74 (8.5) | 287 (16.1) |
Table 3.
Current Smoking Prevalence Among Seventh-Grade Students by Socio-demographic and Relevant Characteristics
| Boys (n, %) | Girls (n, %) | |||||
|---|---|---|---|---|---|---|
| Cigarette Smoker | No | Yes | P | No | Yes | P |
| Age (year) | ||||||
| 11–12 | 214 (95.5) | 10 (4.5) | 354 (99.4) | 2 (0.6) | ||
| 13 | 553 (91.0) | 55 (9.0) | <0.01 | 475 (97.1) | 14 (2.9) | <0.01 |
| 14–15 | 66 (79.5) | 17 (20.5) | 17 (81.0) | 4 (19.0) | ||
| Father’s education | ||||||
| ≤high school | 360 (88.0) | 49 (12.0) | 440 (96.9) | 14 (3.1) | ||
| >high school | 473 (93.7) | 32 (6.3) | <0.01 | 406 (98.5) | 6 (1.5) | 0.11 |
| Mother’s education | ||||||
| ≤high school | 413 (88.6) | 53 (11.4) | 461 (97.1) | 14 (2.9) | ||
| >high school | 419 (93.5) | 29 (6.5) | 0.01 | 385 (98.5) | 6 (1.5) | 0.17 |
| Daily pocket money (JD)a | ||||||
| <0.25 | 420 (92.1) | 36 (7.9) | 436 (98.6) | 6 (1.4) | ||
| 0.25–0.50 | 239 (91.6) | 22 (8.4) | 0.34 | 278 (96.9) | 9 (3.1) | 0.09 |
| 0.50–0.75 | 116 (87.2) | 17 (12.8) | 90 (97.8) | 2 (2.2) | ||
| >0.75 | 58 (89.2) | 7 (10.8) | 42 (93.3) | 3 (6.7) | ||
| Smoking status of parents | ||||||
| no one smokes | 433 (92.1) | 37 (7.9) | 391 (98.5) | 6 (1.5) | ||
| one of them smokes | 344 (90.1) | 38 (9.9) | 0.47 | 402 (97.6) | 10 (2.4) | 0.03 |
| both of them smoke | 56 (88.9) | 7 (11.1) | 53 (93.0) | 4 (7.0) | ||
| Smoking status of brothers/sisters | ||||||
| no one smokes | 679 (91.9) | 60 (8.1) | 706 (98.3) | 12 (1.7) | ||
| at least one smokes | 154 (87.5) | 22 (12.5) | 0.07 | 140 (94.6) | 8 (5.4) | <0.01 |
| Smoking status of friends | ||||||
| no one smokes | 540 (94.7) | 30 (5.3) | 774 (98.2) | 14 (1.8) | ||
| some of them smoke | 264 (86.6) | 41 (13.4) | <0.01 | 69 (92.0) | 14 (1.8) | <0.01 |
| all of them smoke | 27 (71.1) | 11 (28.9) | 3 (100.0) | 0 (.0) | ||
| Do smokers have more friends? | ||||||
| more friends | 223 (88.8 ) | 28 (11.2) | 157 (94.0) | 10 (6.0) | ||
| fewer friends | 204 (91.1) | 20 (8.9) | 0.32 | 135 (100.0) | 0 (0.0) | <0.01 |
| no effect/don’t know | 406 (92.3) | 34 (7.7) | 554 (98.2) | 10 (1.8) | ||
| Are smokers more attractive? | ||||||
| more attractive | 291 (86.9) | 44 (13.1) | 304 (96.5) | 11 (3.5) | ||
| less attractive | 217 (92.3) | 18 (7.7) | <0.01 | 195 (99.5) | 1 (0.5) | 0.09 |
| no effect/don’t know | 325 (94.2) | 20 (5.8) | 347 (97.7) | 8 (2.3) | ||
| Does smoking affect weight? | ||||||
| weight gain | 145 (91.8) | 13 (8.2) | 85 (97.7) | 2 (2.3) | ||
| weight loss | 429 (93.1) | 32 (6.9) | 0.03 | 532 (98.7) | 7 (1.3) | 0.02 |
| no effect/don’t know | 259 (87.5) | 37 (12.5) | 229 (95.4) | 11 (4.6) | ||
| Does smoking harm health? | ||||||
| has no effect | 91 (88.3) | 12 (11.6) | 43 (95.5) | 2 (4.4) | ||
| has effect | 742 (91.4) | 70 (8.6) | 0.12 | 803 (97.8) | 18 (2.2) | 0.35 |
Note.
JD: Jordanian Dinar (1 JD = US $1.4)
Table 4.
Current Prevalence of Water-pipe Smoking Among Seventh-Grade Students According to Socio-demographic and Relevant Characteristics
| Boys (n, %) | Girls (n, %) | |||||
|---|---|---|---|---|---|---|
| Water-pipe Smoker | No | Yes | P | No | Yes | P |
| Age (year) | ||||||
| 11–12 | 202 (90.2) | 22 (9.8) | 334 (93.8) | 22 (6.2) | ||
| 13 | 474 (78.0) | 134 (22.0) | <0.01 | 453 (92.6) | 36 (7.4) | <0.01 |
| 14–15 | 54 (65.1) | 29 (34.9) | 14 (66.7) | 7 (33.3) | ||
| Father’s education | ||||||
| ≤high school | 320 (78.2) | 89 (21.8) | 414 (91.2) | 40 (8.8) | ||
| >high school | 410 (81.2) | 95 (18.8) | 0.27 | 387 (93.9) | 25 (6.1) | 0.13 |
| Mother’s education | ||||||
| ≤high school | 361 (77.5) | 105 (22.5) | 437 (92.0) | 38 (8.0) | ||
| >high school | 368 (82.1) | 80 (17.9) | 0.08 | 364 (93.1) | 27 (6.9) | 0.54 |
| Daily pocket money (JD)a | ||||||
| <0.25 | 379 (83.1) | 77 (16.9) | 414 (93.7) | 28 (6.3) | ||
| 0.25–0.50 | 207 (79.3) | 54 (20.7) | 0.02 | 273 (95.1) | 14 (4.9) | <0.01 |
| 0.50–0.75 | 96 (72.2) | 37 (27.8) | 77 (83.7) | 15 (16.3) | ||
| >0.75 | 48 (73.8) | 17 (26.2) | 37 (82.2) | 8 (17.8) | ||
| Smoking status of parents | ||||||
| no one smokes | 567 (85.5) | 96 (14.5) | 581 (96.2) | 23 (3.8) | ||
| one of them smokes | 134 (64.4) | 74 (35.6) | <0.01 | 178 (89.0) | 22 (11.0) | <0.01 |
| both of them smoke | 29 (65.9) | 15 (34.1) | 42 (67.7) | 20 (32.3) | ||
| Smoking status of brothers/sisters | ||||||
| no one smokes | 644 (84.8) | 115 (15.2) | 690 (96.0) | 29 (4.0) | ||
| at least one smokes | 84 (54.5) | 70 (45.5) | <0.01 | 111 (75.5) | 36 (24.5) | 0.01 |
| Smoking status of friends | ||||||
| no one smokes | 501 (88.0) | 68 (12.0) | 635 (96.1) | 26 (3.9) | ||
| some of them smoke | 196 (67.1) | 96 (32.9) | <0.01 | 154 (81.5) | 35 (18.5) | <0.01 |
| all of them smoke | 33 (61.1) | 21 (38.9) | 12 (75.0) | 4 (25.0) | ||
| Do smokers have more friends? | ||||||
| more friends | 222 (74.2) | 77 (25.8) | 183 (92.0) | 16 (8.0) | ||
| fewer friends | 237 85.6) | 40 (14.4) | <0.01 | 198 (96.6) | 7 (3.4) | 0.03 |
| no effect/don’t know | 271 (79.9) | 68 (20.1) | 420 (90.9) | 42 (9.1) | ||
| Are smokers more attractive? | ||||||
| more attractive | 229 (75.8) | 73 (24.2) | 233 (89.6) | 27 (10.4) | ||
| less attractive | 169 (80.1) | 42 (19.9) | 0.09 | 149 (95.5) | 7 (4.5) | 0.07 |
| no effect/don’t know | 332 (82.6) | 70 (17.4) | 419 (93.1) | 31 (6.9) | ||
| Does smoking affect weight? | ||||||
| weight gain | 138 (81.2) | 32 (18.8) | 87 (90.6) | 9 (9.4) | ||
| weight loss | 332 (85.6) | 56 (14.4) | 0.36 | 404 (94.8) | 22 (5.2) | 0.02 |
| no effect/don’t know | 260 (72.8) | 97 (27.2) | 310 (90.1) | 34 (9.9) | ||
| Does smoking harm health? | ||||||
| has no effect | 116 (73.9) | 41 (26.1) | 61 (83.6) | 12 (16.4) | ||
| has effect | 614 (81.0) | 144 (18.9) | <0.01 | 740(93.3) | 53 (6.7) | 0.19 |
Note.
JD: Jordanian Dinar (1 JD = US $1.4)
Of current cigarette smokers, 35.4% of boys and 35.0% of girls started cigarette smoking before the age of 10. Of current water-pipe smokers, 37.8% of boys and 24.6% of girls started water-pipe smoking before the age of 10. In boys, 24.4% of current smokers were daily smokers, and 15.8% smoked more than 10 cigarettes per day. For girls, the corresponding percentages were 15.0% and 10.0%, respectively. About 12.4% of boys and 7.7% of girls who were current water-pipe smokers smoked more than one water pipe per day.
Students’ Perceptions About Smoking
The response to the question whether cigarette smokers are more attractive than nonsmokers varied by smoking status; in nonsmokers, 35.4% believed that smokers are more attractive, compared to 53.9% of current smokers, P<0.001. The responses to the corresponding question among non- and current water-pipe smokers were 30.2% and 40.0%, respectively, P=0.003. Also, 22.6% of nonsmokers believed that cigarette smokers have more friends, compared to 37.2% of current smokers, P=0.002. The corresponding numbers for water-pipe smoking were: 26.4% vs 37.2%, for non- and current water-pipe smokers, respectively, P=0.001.
When the numbers were further broken down by gender and smoking status, similar patterns were observed for both smoking methods, where boys were more likely to believe that smokers are more attractive and have more friends.
Most students (81.6% of boys and 87.6% of girls) believed that cigarette smoking has harmful health effects, but fewer (66.6% of boys and 62.7% of girls,) believed that water-pipe smoking has harmful health effects. However, among cigarette smokers, the prevalence of current smokers was similar among those who believed smoking has an adverse effect on health and those who did not (boys: 8.6% vs 11.7%, respectively; P=0.36 and girls: 2.2% vs 4.4%; P=0.28). Among water-pipe smokers, there were more current smokers among those who believed that water-pipe smoking does not harm health (boys: 26.1% vs 19.0%; P=0.05, and girls: 16.4% vs 6.7%; P=0.01). A small proportion (17.3% of boys and 10.0% of girls) believed that cigarette smoking makes one gain weight. Similar percentages of water-pipe smokers had the same belief (18.6% of boys and 11.1% of girls). On the other hand, 50.4% of boys and 62.2% of girls believed that smoking cigarettes makes one lose weight. The corresponding numbers for water pipe were 42.4% and 49.2%, respectively. Only 8.6% of students believed that it is easy to quit cigarettes after beginning to smoke (8.5% had the same belief for quitting water pipe).
Factors Associated With Current Smoking
Table 5 shows the multivariate analysis of factors associated with current cigarette or water-pipe smoking. Boys were more likely to report cigarette smoking than were girls (OR = 2.7; 95% CI: 1.6, 4.8). Older students were more likely to be current cigarette smokers (OR = 5.4; 95% CI: 2.4, 12.2 for 14–15 years vs 11–12 years). Having more pocket money and having a father with lower education level were associated with higher odds of being a current cigarette smoker (OR = 3.0; 95% CI: 1.3, 6.6 and OR = 2.3; 95% CI: 1.5, 3.8, respectively.) Having close friends who smoke was significantly associated with current cigarette smoking (OR = 2.4; 95% CI: 1.5, 3.9), especially when all close friends were smokers (OR = 4.7; 95% CI; 2.0, 11.1). Students with water-pipe-smoking sibling/s were more likely to be current cigarette smokers (OR = 2.8; 95% CI; 1.7, 4.4). The perception that smoking affects weight was associated with decreased odds of being a cigarette smoker (OR = 0.4; 95% CI: 0.2, 0.6). The perception of increased attractiveness of smokers was associated with current cigarette smoking (OR = 2.3; 95% CI: 1.4, 3.9).
Table 5.
Multivariate Analysis of Current Cigarettes and Water-pipe Smoking in Seventh-Grade Students in North of Jordan
| Cigarette Smoking | OR (95% CI) | P | Water-pipe Smoking | OR (95% CI) | P |
|---|---|---|---|---|---|
| Gender | Gender | ||||
| Girls | 1.0 | Girls | 1.0 | ||
| Boys | 2.7 (1.6, 4.8) | <0.01 | Boys | 2.5 (1.7, 3.6) | <0.01 |
| Daily pocket money (JD)a | Daily pocket money (JD) | ||||
| <0.25 | 1.0 | <0.25 | 1.0 | ||
| 0.25–0.50 | 1.7 (1.0, 2.9) | 0.04 | 0.25–0.50 | 1.2 (0.8, 1.8) | 0.33 |
| 0.50–0.75 | 2.0 (1.1, 3.9) | 0.03 | 0.50–0.75 | 1.9 (1.2, 3.1) | <0.01 |
| >0.75 | 3.0 (1.3, 6.6) | <0.01 | >0.75 | 2.3 (1.3, 4.2) | <0.01 |
| Age (year) | Age (year) | ||||
| 11–12 | 1.0 | 11–12 | 1.0 | ||
| 13 | 2.2 (1.2, 4.3) | 0.02 | 13 | 1.7 (1.13, 2.5) | 0.01 |
| 14–15 | 5.4 (2.4, 12.2) | <0.01 | 14–15 | 3.4 (1.9, 6.1) | <0.01 |
| Father’s education | Father’s education | ||||
| high school | 1.0 | >high school | 1.0 | ||
| ≤high school | 2.3 (1.5, 3.8) | <0.01 | ≤ high school | 1.5 (1.1, 2.1) | 0.01 |
| Cigarette-smoking status of friends | Cigarette-smoking status of friends | ||||
| none smoke | 1.0 | None smoke | 1.0 | ||
| some of them smoke | 2.4 (1.5, 3.9) | <0.01 | some of them smoke | 2.0 (1.4, 2.8) | <0.01 |
| all of them smoke | 4.7 (2.0, 11.1) | <0.01 | all of them smoke | 2.9 (1.3, 6.3) | <0.01 |
| Water-pipe-smoking status of brothers/sisters | Water-pipe-smoking status of brothers/sisters | ||||
| No | 1.0 | No | 1.0 | ||
| Yes | 2.8 (1.7, 4.4) | <0.01 | Yes | 3.8 (2.7, 5.3) | <0.01 |
| Perceived effect of smoking on weight | Perceived effect of water pipe smoking on weight | ||||
| no effect | 1.0 | no effect | 1.0 | ||
| weight gain | 0.5 (0.2, 0.9) | 0.03 | weight gain | 0.8 (0.5, 1.2) | 0.32 |
| weight loss | 0.4 (0.2, 0.6) | <0.01 | weight loss | 0.5 (0.4, 0.7) | <0.01 |
| Perceived effect of smoking on attractiveness | Water-pipe-smoking status of friends | ||||
| no effect | 1.0 | nonsmoker | 1.0 | ||
| smoker more attractive | 2.3 (1.4, 3.9) | 0.01 | some of them smoke | 2.3 (1.3, 3.2) | <0.01 |
| smoking less attractive | 1.3 (0.7, 2.6) | 0.32 | all of them smoke | 2.5 (1.3, 4.6) | <0.01 |
| Water-pipe-smoking status of parents | |||||
| nonsmoker | 1.0 | ||||
| one of them | 2.4 (1.7, 3.4) | <0.01 | |||
| both of them | 3.7 (2.2, 6.3) | <0.01 | |||
Note.
a = JD: Jordanian Dinar (1 JD = US $1.4)
OR = odds ratio
CI = confidence interval
For water-pipe smoking, boys were also more likely to report water-pipe smoking than were girls (OR = 2.5; 95% CI: 1.7, 3.6). Older students were more likely to be current water-pipe smokers (OR = 3.4; 95% CI: 1.9, 6.1 for the 14–15 years vs 11–12 years). Having more pocket money and having a father with a lower education level were associated with water-pipe smoking (OR = 2.3; 95% CI: 1.3, 4.2 and OR = 1.5; 95% CI: 1.1, 2.1, respectively.) The water-pipe smoking of parents, siblings, and close friends was associated with participant’s water-pipe smoking (OR = 3.7; 95% CI: 2.2, 6.3, OR = 3.8; 95% CI: 2.7, 5.3, and OR = 2.5; 95% CI: 1.3, 4.6 for parents’, siblings’, and friends’ smoking, respectively.) The perception that water-pipe smoking causes weight loss was associated with decreased odds of water-pipe smoking (OR = 0.5; 95% CI: 0.4, 0.7.)
DISCUSSION
In general, these data point out 3 important findings: (1) experimenting with and initiation of smoking began at an early age in this sample of Jordanian students; (2) the prevalence of water-pipe smoking is considerably higher than cigarette smoking in both males and females; and (3) similar socio-demographic factors are associated with cigarette and water-pipe smoking.
Data on the prevalence and patterns of smoking in this age-group in the Middle East are scarce. The few studies that have reported the prevalence and determinants of cigarette smoking in school children4,5,22 reported higher prevalence of current cigarette smoking than this study (11.2 – 13.6% vs 5.7%), but they studied older children (13–15/16 years vs 11–13 years). However, 30.5% of those who ever tried cigarette smoking in this study did so at ≤10 years of age. These findings show that at this early age, experimentation with and initiation of cigarette smoking are already significant.
Water-pipe smoking presents a new challenge to efforts to control the tobacco epidemic worldwide.23 This is especially true in the Middle East.24,25 Warren et al26 recently reported that among the 97 sites in the GYTS survey that had data on “other tobacco use,” 34 saw an increase in the use of other tobacco products that was mainly attributable to the increase in water-pipe smoking. In 13 of these 34 sites, the increase in the use of other tobacco products was significant among both boys and girls. Jordan is one of these 13 sites where between 1999 and 2007 current water-pipe smoking in the 13-to-15-year-olds has doubled in boys and more than tripled in girls (Warren et al, Table 3, page 52–53).26 A 2004 study of university students in neighboring Syria25 found that the age of initiation of water-pipe smoking was 19.2 and 21.7 years in men and women, respectively. In a recent report from university students in Jordan, the prevalence of water-pipe smoking was 19.3%, and the majority (85.5%) of smokers started smoking water pipe at or after the age of 15 years.27 In this study, current water-pipe smoking was reported in 14.0%, with 34.4% of them having smoked their first water pipe at or before age of 10. In this context, it is evident that water-pipe smoking is spreading in the society, not only horizontally—among females, for example—but also vertically, attracting younger and younger converts. These findings are in concordance with other reports from the region.7,22,28
New evidence on harmful effects of water-pipe use on health is mounting. However, high-quality studies of the long-term health effects of water-pipe smoking are still lacking. A systematic review of the evidence concerning the health effects of water-pipe smoking shows that water-pipe smoking more than doubles the risk of lung cancer, respiratory illness, and low birth weight.13 Another systematic review found that adverse effects of water-pipe smoking on lung function are similar to those of cigarette smoking.29 Evidence of the addictive nature of water-pipe smoking also is accumulating.30,31 Taken together, these 3 factors—the rapid increase of water-pipe use, its serious effects on health, and its addictive nature— highlight the importance of this new form of tobacco use to public health. This could undermine decades of concerted work to control the tobacco epidemic—especially knowing that water-pipe smoking may also predict progression to regular cigarette smoking.32
From the prevention standpoint, longitudinal studies help in identifying predictors of susceptibility to smoking among adolescents and may yield valuable insights regarding factors that contribute to lifetime tobacco use.33–35 Although information about the initial development of tobacco dependence is beginning to emerge for cigarette smoking,36 knowledge to guide water-pipe interventions continues to be lacking. A recent Cochrane review failed to identify a single water-pipe cessation intervention.23 Moreover, longitudinal studies of youth have not yet been conducted in the EMR, whether for cigarettes or water pipe, and results from developed countries may not apply: adolescents’ knowledge, beliefs, and attitudes regarding a variety of tobacco use methods likely differ from those of adolescents in developed nations.37,38 Therefore, the EMR does not yet have the data necessary for understanding tobacco use patterns and identifying determinants of cigarette and/or water-pipe use to guide prevention efforts. This study was designed in an effort to produce the knowledge needed to understand the longitudinal pattern of acquiring the habit in this understudied population. This will help not only to guide future research in this setting but also will inform prevention programs.
In conclusion, this report shows the current status of tobacco use in the eastern Mediterranean region. More importantly, it characterizes the burden of the emergent water-pipe smoking and factors influencing its increase.
Acknowledgment
This study was supported by grants from the National Institute on Drug Abuse (R01 DA024876).
Contributor Information
Fawaz Mzayek, Division of Epidemiology and Biostatistics, School of Public Health, University of Memphis, Memphis, TN and Syrian Center for Tobacco Studies, Aleppo, Syria..
Yousef Khader, Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science, Irbid..
Thomas Eissenberg, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA and Syrian Center for Tobacco Studies, Aleppo, Syria..
Kenneth D. Ward, Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, TN and Syrian Center for Tobacco Studies, Aleppo, Syria..
Wasim Maziak, Division of Epidemiology and Biostatistics, School of Public Health, University of Memphis, Memphis, TN and Syrian Center for Tobacco Studies, Aleppo, Syria..
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