INTRODUCTION

Waterpipe tobacco smoking (WTS) (Shisha, Hookah & Narghileh) is a centuries-old form of tobacco smoking intuitive to the Middle East and South Asia countries [1]. It is becoming a serious public health problem globally, especially among youth, many of whom believe that WTS is safer than cigarette smoking [2-4] Health is a significant factor in human beings’ life [5]. Waterpipe tobacco smoking (WTS) is associated with several harmful health indicators and outcomes like lung cancer [6-10].  Studies have shown that the use of WTS among adolescents and young adults has increased and was not prioritized as a curtail use [11-14].

Not much is known about the harbingers of smoking Shisha in the Malaysian community. As for the recent decades of the twentieth century, it has become noticeable within the Malaysian society with the beginning of the millennium facilitated by the influx of Middle Eastern people into Malaysia [15]. Previous studies indicated that smoking Shisha has become a culture in urban communities, especially among adolescents [16, 17]. However, most of the early information about the Shisha smoking phenomenon in the country is anecdotal. There is a high prevalence of Shisha smoking among Malaysian university students [18].

Research is needed since the prevalence of WTS has become a common practice adopted by the Malaysian youth and younger population. Hence, this study was designed and carried out to estimate the prevalence of Shisha smoking in Malaysia and to evaluate the familiarity and perception of Shisha smokers towards Shisha smoking. The study also aimed at identifying the socio-demographic characteristics associated with Shisha smoking in Malaysia.

MATERIALS AND METHODS

Study Design

A cross-sectional survey was carried out using a validated self-administered, bilingual (English & Bahasa Malaysia) questionnaire for approximately one year, until the end of 2016, among Shisha smokers in the two cities of Pulau Penang (Penang Island) and Kuantan, Malaysia, throughout Shisha cafes around both cites. A random sample of 500 participants has been targeted conveniently, divided equally between the two cities. Inclusion criteria included: participants above 18 years old either speak/understand English or Malay language. Those who did not meet any of those criteria were excluded from the study. Participants were briefed about the topic of the survey before the distribution of questionnaires. The confidentiality of the study participants was guaranteed, and informed consent was obtained.

Development of the Questionnaire

A 43-item questionnaire was used for data collection and was piloted with 30 general public for testing its validity and reliability. Experts at Discipline of Social and Administrative School of Pharmaceutical Sciences, Universiti Sains Malaysia, Department of Pharmacy Practice, The Kulliyyah of Pharmacy, and International Islamic University Malaysia assessed the validity (face & content) of the questionnaire. Furthermore, the internal consistency was assessed using Cronbach's alpha. With the recommendation of minor changes, reliability testing was conducted for the attitudes and perception responses from the pilot testing. The results showed that the internal consistency of the items tested with Cronbach's α value of 0.76.

The results of the pilot study were not included in the final analysis. The questionnaire was adopted from previous studies and modified to suit the local population [18-20]. The questionnaire was designed in two language versions: English and Malay (the national language of Malaysia).  The English version of the survey was developed initially and was translated into the Malay language.  Face and content validation of the questionnaire was done by three senior faculty members (two with expertise in survey & pharmacy practice research and one with clinical expertise & teaching experience in smoking cessation) and two registered pharmacists (both are clinical pharmacists with expertise in public health). Modifications were made based on the feedback provided, and the consensus was reached following a meeting with all experts who were involved in revising the subjects randomly selected from the study site.  From the pilot study, participants were found to be able to understand and answer the questionnaire provided.

Consequently, no further modification of the questionnaire was done before the actual survey. The final draft of the questionnaire contained three parts. Part 1 obtained the demographic characteristics of the respondents. Part 2 was designed to assess the knowledge of the participants about Shisha smoking. Participants were requested to choose between two options provided: "true" or "false."

Additionally, three statements were addressing the health effect, addictive effects, and nicotine contents in the water pipe (Shisha) comparing to the regular cigarettes. Part 3 of the questionnaire consisted of 14 statements to evaluate the perception of the general public of Shisha smokers. A three-point semantic differential scale ranging from "Yes", "No," or "Not decided" was used to assess the responses of the participants.

Ethical Approval

The Institutional Review Board of Management Services Division (MSD), IIUM approved the study. The confidentiality of the study participants was ensured, and informed consent was obtained. However, the subjects that completed and returned the questionnaire were considered as providing consent to participate.

Statistical Analysis

The data were computed and analyzed using Statistical Package for Social Sciences (SPSS version 19.0, SPSS Inc., Chicago, IL, USA). The results of each item on the questionnaire were reported, the mean (+SD) was calculated for continuous variables, and frequencies were measured for categorical variables. The Kolmogorov-Smirnov test was used for normality assessment, and non-parametric tests were used accordingly. Any association between groups was examined by the X² or Fisher exact tests as appropriate for categorical variables. Data, which emerged from domains using a Likert scale as a measurement, was analyzed statistically as non-parametric data [21]. A p-value of <0.05 was considered to be of statistical significance.

RESULTS AND DISCUSSION

A total of 500 questionnaires were distributed to the general public at the Shisha cafes in both cities (Pulau Penang & Kuantan), from which 297 (55.8%) agreed to participate in the study. However, 23 of the questionnaires were found incomplete and therefore were excluded from the analysis to avoid fallacious results. The overall usable responses were (59.4%, N=274). Respondents were from Pulau Penang and Kuantan (n=103, 37.6%, n= 171, 62.4%, respectively).

Socio-demographic Characteristics of the Study Respondents

The majority of the study participants were male (n=225, 82.1%), Malay (n=227, 82.8%) with university or college qualification (n=185, 67.5%), and with an average age of 22.55 years (SD = 4.48). The demographic information of the participants is presented in Table 1.

Familiarity about Shisha

The prevalence of Shisha smoking among study participants was found to be about half (n=135, 49.3%). The vast majority of respondents (n=200, 73%) were under 20 years old when they first smoked tobacco from a Shisha. Most of the respondents (n=215, 78.5%) had smoked Shisha at least once in their lives at Shisha café.

More than half of respondents (n= 159, 58%) had tried Shisha for the first time with more than one friend. The vast majority of Shisha users (n=145, 52.9%) had smoked Shisha almost always in a café or restaurant, while more than one-third of them (n= 104, 38%) smoked Shisha sometimes in café or restaurants and sometimes at home. The vast majority of respondents (n=238, 86.9%) usually shared Shisha with others and had smoked Shisha in the last six months (n=220, 80.3%). About half (n=117, 42.7%) of respondents revealed that they smoked Shisha for more than 60 minutes per session.

Although, about 60% (n=163) of respondents were not curious about tobacco used in Shisha, a large proportion of respondents had started smoking Shisha because they liked the smell and taste of tobacco (n= 172, 62.8% & n=174, 63.5%, respectively). However, about half (n=141, 52.2%) of the respondents had started smoking Shisha because they liked the crafting way of the water pipe as shown in Figure 1.

*Chi square test; **R= residency, A= age, G= gender and LE=Level of education

Safety and Health Aspects of Shisha Smoking

The vast majority of study respondents (n=226, 82.5%) thought that Shisha was purified of harmful substances as passing through the water filter.  Regarding the question of whether smoking Shisha irritates the airways or not as it contains natural products, a more substantial proportion of study respondents (n=177, 64.6%) answered negatively to this statement. Furthermore, nearly half (n=136, 49.6%) of respondents believed that Shisha smoking might not cause lung cancer. A great statistically significant difference between the two cities' residents' perceptions about the relationship of Shisha smoking to lung cancer was noticed (p<0.001). About half (n=99, 57.9%) of Kuantanies believed that Shisha smoking causes cancer. On the contrary, almost two-thirds (n=64, 62.1%) of Penangites believed that there is no association between Shisha smoking and lung cancer.

Nearly half of the surveyed respondents (n= 124, 45.3%) believed that Shisha smoking caused damage to the respiratory system and transmitted hepatitis infection (n=116, 42.3%). It is worth noting that more than half (n=90, 52.6%) of Penangites believed that Shisha smoking might not transmit hepatitis infection (p=0.030). However, a large proportion of respondents did not believe that Shisha smoking could transmit infection, which caused gastric ulcer or coronary heart diseases (60.6%, 63.5%, respectively). There was moderate evidence of a statistically significant relationship between current education level and the fact that Shisha smoking caused damage to the respiratory system (p=0.028). Slightly more than half of the respondents who had non-formal education (n=13, 52%) agreed that Shisha smoking caused damage to the respiratory system. There was a statistically significant relationship between the current education level and the fact that Shisha smoking might transmit hepatitis infection (p=0.021). Slightly less than half of the respondents who had non-formal education (n=12, 48%) agreed that Shisha smoking might transmit hepatitis infection followed by the university or college-educated respondents (n=85, 45.9%). The complete information about the beliefs towards the health risks of Shisha among study participants is mentioned in Table 3.

*Chi square test; **R= residency, A= age, G= gender and LE=Level of education

Perceptions of Shisha Smoking   

The study revealed that nearly half (n=121, 44.2%) of respondents believed that cigarettes were more harmful than water-pipe. Analogously, the same percentage of respondents believed that they had the same harmful effects. A statistically significant difference between the two cities' residents concerning the harmful effect of water pipe comparing to compostable cigarettes has been noticed (p<0.001), where only a few (n=3, 2.9%) of Penangites believe that water pipe is more addictive than cigarettes compared to Kuantanies.  The vast majority of respondents considered that cigarettes had more addictive effects and more nicotine content than water-pipe. At the same time, about one-quarter of them believed that they were the same regarding addictive effects and nicotine content (69%, 67.5%, 27%, & 27.7%, respectively). There was moderate evidence of a statistically significant relationship between the current education level and comparing the nicotine content of Shisha and combustible cigarettes (p=0.018). The vast majority of respondents with secondary school education (n=50, 80.6%) agreed that cigarette smoke had more nicotine than Shisha smoke. However, more than one-third of non-formal educated respondents (n=9, 36%) considered that nicotine content was the same, while less than one-fifth of them (n=4, 16%) considered that Shisha smoke had more nicotine than cigarette smoke (Table 4).

*Chi square test; **R= residency, A= age, G= gender and LE=Level of education

About two-thirds of respondents agreed that Shisha smoking was socially acceptable in Malaysia compared to cigarettes and offered a good opportunity to meet friends and families (66.1% & 58.4% respectively). There was a statistically significant difference between both cities' residents where more Kuantanies perceived that Shisha smoking was an opportunity to meet family and friends (p<0.001).  About half of the respondents (n=139, 50.7%) agreed that their parents did not object to their smoking of Shisha compared to cigarettes. Kuantan respondents agreed that there was no objection from their parents of Shisha smoking (p=0.025).   About one-third of respondents (n=86, 31.4%) disagreed that their parents allowed them to smoke Shisha at home but not cigarettes. Half of the respondents disagreed that smoking Shisha is considered a sign of maturity (n= 137, 50%).

The vast majority of respondents (n=80, 77.7%) agreed that smoking of Shisha relieved stress and tension, while a low percentage of them (n= 12, 11.7%) disagreed. There was a statistically significant difference between the two cities' residents, where more Kuantanies thought that Shisha smoking could relieve stress and tension (p=0.002).  About one-third of respondents (n=34, 33%) agreed that Shisha smokers had more friends than non-smokers, while slightly more than one third (n=38, 36.9%) disagreed. More than half of respondents (n=151, 55.1%) agreed that women smoking Shisha were not as odd as those smoking cigarettes. However, Study findings showed that only the minority of Penang island was not decided (p<0.001). There was solid evidence of a statistically significant relationship between gender, and a statement that women smoking Shisha was not odd as those smoking cigarettes (p<0.001). The vast majority of female respondents (n=41, 83.7%) agreed that women smoking Shisha were not as odd as those smoking cigarettes compared to (n=110, 48.9%) males. About less than half of respondents agreed that movie stars smoking Shisha were less offensive than those smoking cigarettes, and respondents preferred smoking Shisha over normal cigarettes because it was easy to get (46.4% & 44.9%, respectively).

There are wide variations of whether the ease of access is the reason for the preference of smoking Shisha over cigarettes among the two cities' populations. A large number of Kuantanies disagreed with the statement (p=0.005). There was strong evidence of a statistically significant relationship between gender and preferring Shisha smoking over cigarettes because it was easy to get (p=0.006). About two-thirds of female respondents (n=32, 65.3%) agreed that they preferred Shisha smoking over cigarettes because it was easy to get compared to (n=91, 40.4%) males. However, less than half of male respondents (n=93, 41.3%) disagreed that they preferred Shisha smoking over cigarettes because it was easy to get compared to (n=13, 26.5%) females. 

Study results showed that there was robust evidence of a statistically significant relationship between gender and a statement that movie stars smoking Shisha were less offensive than those smoking cigarettes (p<0.001). More than two-thirds of female respondents (n=34, 69.4%) agreed that movie stars smoking Shisha were less offensive than those smoking cigarettes compared to (n=93, 41.3%) males.

About two-thirds of respondents (n=185, 67.5%) agreed that the use of Shisha to smoke tobacco would be more popular in Malaysia in the next five years, while a low percentage of them (n=33, 12%) disagreed. Almost all of the Penangites agreed with the statement compared to about half of Kuantanies (p<0.001). There was a statistically significant relationship between the current education level and the statement that in the next five years the use of Shisha smoking to smoke tobacco in Malaysia would be more popular (p=0.006). The vast majority of respondents with secondary school education (n=47, 75.8%) agreed that in the next five years, the use of Shisha smoking to smoke tobacco in Malaysia would be more popular, followed by the university or college-educated respondents (n=124, 67%) (Table 5).

*Chi square test; **R= residency, A= age, G= gender and LE=Level of education