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Embed code for: Hookah smoking article_REvised _Darby June 17_2010
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Knowledge of Hookah Smoking Effects on Oral Health among University Students
Rowaidah Al-momani, BSc;Hanan Hassa, BSc; Sultan DayfAllah , BSc; Zakaryah Mahasneh, BSc; Ensherah Jamal, BSc; Baha' Al-shdooh Rawan Sulaiman, BSc; Raad Al-hindi , BSc; Osama Kana'a, BSc; Ranya Al-dhoon, BSHanan Barahmeh, BSc Waid Jararwah, BSc; Ra'fat Daqamseh, BSc; Ayat Al-adama, BSc; Suhair Ref’at Obeidat, BS, MSDH, Instructor; and
Arwa Mahasneh, BS, MSDH, Lecturer
Jordan University of Science and Technology
Faculty of Applied Medical Sciences
Department of Applied Dental Sciences
June 17, 2010
This study determined the prevalence of water pipe smoking (also known as hookah, gouza, narghile, hubble-bubble, or shisha among university students and measured students’ knowledge about its effects on oral health. A self-designed questionnaire was used to survey a convenience sample of 249 males and 217 females students at Jordan University of Science and Technology during the spring 2010 semester. More than half of the participants (76.0%) were between the ages of 20 and 24 years. Fourth year students made up about 46.8% of the sample, and 47.4% of them reported having a "good" academic achievement level. Descriptive and inferential statistics including Chi-square tests and the SPSS system were used to analyze data. The p-value was set at 0.05.
Results revealed that about 35% of the participating students were narghile smokers and that there was a statistically significant difference in narghile smoking prevalence between male and female students (52.2% vs. 16.1%; p = 0.000). A lack of awareness about narghila smoking’s harmful effects on oral health was documented among narghila smokers versus non-smokers (p < 0.05). About 70% of the students started narghile smoking between the ages of 17 and 20 years, 60% of them have at least one person in the family who smokes narghile, and 63% of the respondents were encouraged to smoke narghile by their friends. First narghile use was reported to have occurred most commonly in cafes (60%). Emotional stress and only to try it" were the main reasons for narghile smoking as reported by the participants. Unfortunately, narghila smoking is prevalent among university students and narghila smokers are uninformed about its effects on oral health. Public education and stronger, enforced public health laws are needed to protect the public against the detrimental effects of nargile smoking in the smoker and in those who breathe secondhand smoke. Furthermore, universities in the Middle East need to develop healthier stress reduction programs for students like intramural athletics and students organizations so that less student time is spent in cafes and more time can be invested in health promoting behaviors.
Hookah, gouza, narghile, hubble-bubble, waterpipe or shisha, smoking is an old and deep-rooted tradition in the world. The practice originated in India1 eand reached Jordan via the Ottomans who carried it from Turkey. The practice has increased in polularity and is ubiquitous in the Middle East among both genders and in public areas. The purpose of this survey was to investigate the prevalence of narghile smoking among university students and to assess their knowledge of its effects on oral health. This study answered the following questions:
Do students know the detrimental effects of narghile smoking on oral health?
Is narghile smoking wide spread among students?
Do both male and female students smoke narghile?
Is there a relationship between socioeconomic status (SES) and narghile smoking?
At what age do students start to smoke narghile?
Of those who smoke, what factors motivate students to start smoking narghile?
Significance of the Study
Given the negative effects of narghile smoking on oral health, the current study is important to explore the prevalence of narghile smoking among university students and the level of their health awareness about its damaging effects on oral tissues. Limited information was found on the prevalence of narghile smoking among Jordanian college students and on their knowledge about its effects on oral health.
A study of the beliefs and attitudes related to narghile smoking among university students in Syria indicated that family was more permissive toward narghile smoking by females, and toward narghile compared to cigarettes in general.2 Dental hygienists have a key role to play in educating the public and can participate in the promotion of oral health, safer communities, and public health policies. Given that some people view water pipe smoking as a safe alternative to cigarette smoking, dental hygienists need to be alert to patient’s water pipe smoking behaviors throughout the process of care and encourage these patients to participate in smoking cessation programs.
Review of the Literature
Smoking in Jordan
Tobacco use is a growing problem in Jordan. Jordan’s Global Youth Tobacco Survey, last conducted in 1999, showed that 19.3% of students between the ages of 13 and 15 years (25% males and 14.5% females) were smokers. In 2004, a survey of 2457 students in Jordan, (females constituted 50.3% of them). found that male students (19.2%) were significantly more likely than female students (6.6%) to have smoked cigarettes on one or more days. The proportion of smokers in Jordan within the age group 13-15 years is 25% males and 15% females. About 12% of them start smoking by the age of nine and 48% start smoking between the ages of 10 to 13 years.3 In November 2001, the Ministry of Health (MOH), through its tobacco control program, started a three month media campaign to fight tobacco use in the country but its effects were short lived. Visitors to Jordan notice that smoking behavior is universally accepted and practiced, even in areas where smoking is prohibited.
Prevalence of Water Pipe Smoking
Water pipe smoking is common among young people in Middle Eastern countries, with prevalence rates of regular smoking in the range of 11%–32%4, 5, and evidence of recent increases in prevalence.6,7 Data on the prevalence of water pipe smoking in western societies is limited. A survey of American military showed only 0.3% had used water pipes in the last years8, while a recent survey of two universities in the US found that 15%–20% of the student population had smoked a water pipe .9
A convenience sample of regular water pipe users in the US revealed that the majority were young and university educated.10 The data for this study were collected via the web-based version of the National College Health Assessment from the American College Health Association..Results also revealed that 41% of the respondents (N = 647) reported ever smoking tobacco from a water pipe, 31% reported water pipe smoking over the past year, and 9.5% reported using water pipes smoking over the past 30 days. In this study, lifetime water pipe use was as common as lifetime cigarette use. Intention to smoke tobacco from a water pipe was substantial among users as well as non-users. Many in this sample who smoked tobacco from a water pipe had never smoked cigarettes.
A cross-sectional survey was conducted on a representative sample of 587 students (278 males, 309 females; mean age 21.8-2.1 years) at Aleppo University in Syria using an interviewer-administered questionnaire.11 With a response rate of 99%, results showed ever narghile smoking in about 63% of men and 30% of women. The researchers concluded that narghile smoking is prevalent among university students in Syria, where it is mainly practiced by men in the context of social activities with friends.11
trial took place with a member of the immediate family, even though 58.2% initiated with a A study was conducted in Beirut to measure the prevalence and determinants of water pipe or narghile use among students in Beirut's southern suburbs.
To determine the prevalence of smoking (cigarettes and/or narghile) among Lebanese university students and to examine multiple correlates of smoking behavior the researchers______________________. The prevalence of smoking was 40% (21.1%, 7.6%) and 11.3% of the students were smoking only narghile, only cigarettes and both cigarettes and narghile, respectively.
The objective of the study was to assess tobacco smoking practices (water pipe and/or cigarette) among public and private adolescent school students in Beirut.
To assess the prevalence of water pipe smoking among university students in Jordan., a cross-sectional survey of students was conducted at four prominent universities in Jordan (Jordan University of Science and Technology, Yarmouk University; National University; and Jerash Private University) using an interviewer-administered questionnaire. The study also determined the association between water pipe tobacco smoking and major sociodemographic factors such as age, gender, income, and marital status. A representative sample of 548 students participated, and of these, 61% (N = 335 ) had ever smoked tobacco from a waterpipe. This finding was slightly higher than the 57% of participants (N =309) in the same study who had ever smoked a cigarette. Use of water pipe at least monthly was reported by 43% (N = 227) of the students who participated. Of those who had smoked tobacco from a waterpipe, use was approximately equal across categories: yearly (25.6%), monthly (24.3%), weekly (30.5%), and daily (19.7%). First use of the waterpipe was most commonly with friends (60.7%) or family (30.9%), and is least commonly used alone (8.4%). Place of first use was most commonly at home (37.3%) or a café (32.6).12
Effects of Water Pipe Smoking on Oral Health
Smoking cigarettes, pipes and cigars is a risk factor for all cancers associated with the larynx, oral cavity and esophagus. Although little research exists on the health risks of hookah smoking, preliminary evidence suggests that hookahs are not any safer than cigarettes, and as with cigarettes, effects may include a higher chance of developing heart disease or lung cancer. Over 90% of patients with oral cancer use tobacco by either smoking or chewing it. Although the most common use of tobacco in the United States is a cigarette smoking, the use of smokeless tobacco, or chew, is also associated with oral cavity cancers.13 There has been some decrease in the overall numbers of oral cavity cancers and deaths from the disease noted in the last 20 years, the decrease has not been dramatic.14
Ali, et al. studied the histopathologic changes in the oral mucosa on a sample of 33 Yemenis who were addicted to waterpipe and cigarette smoking, and takhzeen al-qat using. Subjects were grouped by chronic qat users,heavy cigarette smokers, nonsmokers and water pipe smokers and two biopsies one from the buccal mucosa at the chewing side, and the other from a similar mucosa at the contra lateral (none exposed) side were taken on each subject. The results showed that the association between takhzeen al-qat and cigarette or water pipe smoking may increase the risk of epithelial dysplasia. (Please add something like this-
Compared with cigarettes, narghile smokers inhale about 48x greater amounts of smoke, have 3x the carbon monoxide and 1.7x the nicotine in their blood plasma. I know you have other health effects of narghila smoking in your large paper…please pull some of that back into this paper)
RESULTS AND DISCUSSION
About 47% of the participants were recently smokers; about 33.3% were cigarette smokers; and 35% were narghile smokers. There was a significant difference in narghile smoking behaviors among male students comparing to female students (52.2% vs 16.1%) (p = 0.000). About 47.5% of the respondents have an “acceptable" academic achievement level, and 26.1% of them smoke narghile daily
About one third of the study sample were narghila smokers, of whom 13% reported frequent use (more than 7 times/week) suggesting that water pipe tobacco smoking is highly prevalent among the university students surveyed. In contrast, the study of Lebanese university students reported a waterpipe smoking frequency of less than 7 times/week.15
Approximately 70% students started narghile smoking between the ages of 17 and 20 years, about 63% of the respondents were encouraged to smoke narghile by their friends, 60% smoking narghile at narghile cafes, and 30% of respondents smoke anrghile because of emotional stress (see Figure 1 ), parents was more permissive when their sons / daughters smoked narghile at home than in public, 48.2% of those who tried to stop smoking narghile want to because they have a disease that is caused by smoking.
Regarding the sociodemographic variables, gender was the most significant with male students reporting significantly more frequent narghila smoking. This supports the finding of Azab et al16 who reported that male students used nargila more than females. The academic discipline of the smokers is another significant factor where surprisingly, nursing students reported the highest prevalence among the disciplines represented. Also students with "acceptable" academic averages were the most prevalent smokers as compared to those with stronger academic averages. The students’ sociodemographic factors of year in college, age, and income level showed no significant relationship to narghila smoking behavior..
Most of the smoking students reported starting narghile use between the ages of 17 and 20 years suggesting that they may have started at the time they entered the university. This result differs slightly from the Lebanese university study findings where the mean age for nargila smoking was 16 years15. Most of the nargila smoking students had at least one person in the family who smokes narghile, while more than half of them were encouraged to smoke narghile by their friends. This is likely due to the fact that most young people, especially university students, spend more time with their friends and colleagues; and peer pressure requires them to imitate each others. In addition, more than half of students who smoke narghila experienced their first narghila smoking in cafes. Suggesting that they mostly enjoy this practice when socializing with friends. When asked about the reasons for narghile smoking, 30% of the students reported "to avoid emotional stress", while 20% of them reported "to try it". Stress is associated with the lives of students who often balance time traveling to and from school, class and study time, part-time employment, and a social life. In contrast, the Lebanese study found that the main reason for smoking narghile among university students was pleasure.15
A general lack of awareness of narghila's harmful effects on oral health was observed among narghila smokers compared to non narghila smokers. Table 1 shows the statements that tested the participant students on their knowledge of narghile smoking effects on oral health with the highest percentage among the smoking and non smoking students and its relative P-value. Most of them believed that narghila is less harmful than cigarettes. This finding was similar to a study conducted at a Lebanese university15. In general the sense that waterpipe is less harmful than cigarettes was associated with a higher prevalence of using a waterpipe suggesting that correct knowledge about narghila might influence people to not use narghila. For example, public education about smoke toxicant content and user toxicant exposure associated with waterpipe tobacco smoking may be a valuable method for intervention.
Regarding parents' reaction toward narghila smoking, it was found that 38% of the students' parents have no problem with them narghila smoking. Almost half (48%) of narghila smokers tried or contemplated trying to stop smoking because they had a disease caused by smoking or because they were aware of diseases related to smoking narghila (28%). The validity of the study might be affected by several factors:
The time given to perform this study was short and students were approached at the convenience of the researchers; therefore, the sample size and representativeness of the sample are limited. The self-designed questionnaire had no established validity and reliability. However, content validity and test-retest reliability was established to control for instrumentation effect and to increase the validity and reliability of the findings. The sample included students at Jordan University of Science and Technology; therefore, the findings cannot be generalized to students at other universities. who may have characteristics different from those students in the final sample. The use of a relatively large sample size should overcome any problems of selection bias and improve population validity.
Findings indicate an increase in narghile smoking among a population of Jordanian university students and that this behavior is related to emotional stress, and their lack of awareness about its detrimental effect on oral health. The prevalence of narghile smoking increases as the academic level increases and as academic achievement decreases. Most narghile smoking students are encouraged to smoke by their friends. Parents are more permissive toward narghile smoking compared to cigarette smoking, although narghile smoking is more harmful than cigarette smoking. There is an increase in the number of narghile cafes and the percentage of students who smoke narghile.
Policymakers and healthcare professionals should collaborate to develop strong anti-smoking policies and a program across many generations that aims to reduce the prevalence of narghile smoking, and increase awareness of its unhealthy effect. These programs may include brochures, awareness campaigns, educational programs, and lectures. To make these programs and policies more effective and better influence behaviors and attitudes of narghile smoking, a countrywide approach that is culturally sensitive should be planned and implemented. For example, legislation should be passed that prevents teenagers under 18 years of age from accessing narghile café's. The government should also fund research and programs on narghile smoking cessation to keep this phenomenon under control and monitor it's prevalence in the community,
Figure 1. Reasons for narghile smoking among University students
Table 1: University students’ knowledge of narghile smoking’s effects on oral health
Narghile smoking students
Non-narghile smoking students
Narghile smoking transfers infectious diseases
Narghile smoking causes oral cancer
Narghile smoking causes stains on the teeth and oral tissues
Narghile smoking causes halitosis
Narghile smoking may aggregate the inflammation of the gum tissues
Narghile smoking lengthens wound healing time
Narghile smoking increases the ones risk of dental decay
Narghile smoking is associated with dental implant failure
2. Maziak .W, Eissenberg Th, Rastam S. Hammal F, MD, Taghrio Asfar MD Mohamed E. Bachir, Mohamed F. FouadMD and Kenneth D. Ward PhD, Beliefs and attitudes, related to narghile (water pipe) smoking among university students in Syria, Annals of Eolume.Issue9, October 2004, pages 646-654.
3. Regular smoking in Amman; survey conducted by UNICEF and information provided by Basima Isteitieh of the Ministry of Health at the WHO Regional Office for the Eastern Mediterranean meeting on tobacco in July 1999. Youth data: Regular and occasional smoking in Amman; survey conducted by KAP, supported by UNICEF and information provided by Basima Isteitieh of the Ministry of Health at the WHO Regional Office for the Eastern Mediterranean meeting on tobacco in July 1999.
4-Varsano S, Ganz I, Eldor N: Water-pipe tobacco smoking among school
children in Israel: frequencies, habits, and attitudes. Harefuah 2003, 142(11):736-741, 807.
5-Maziak W, Fouad FM, Eissenberg T, Ward KD: Prevalence and characteristics of narghile smoking among university students in Syria. Int J Tuberc Lung Dis 2004, 8:882-889
6-Momenan AA, Etemadi A: The Rising Prevalence of Waterpipe Smoking among Iranian Adolescents: Tehran Lipid and Glucose Study. 2006.
7-Chaaya M, El Roueiheb Z, Chemaitelly H: Argileh smoking among university students: a new tobacco epidemic. Nicotine and Tobacco Research 2004, 6:457-463.
8 -Ward KD, Vander Weg MW, Klesges RC: Waterpipe smoking among American military recruits. Prev Med 2006, 43:92-97.
9 -Smith-Simone S, Maziak W, Ward KD, Eissenberg T: Waterpipe smoking on two US college campuses. 2007.
10- Ward KD, Eissenberg TE, Gray J, Srinivas V, Wilson N, Maziak W: Characteristics of American waterpipe users: a preliminary report. Nicotine and Tobacco Research 2007, in press.
11- W. Maziak, F. M. Fouad, T. Eissenberg, K. D. Ward: Prevalence and characteristics of narghile smoking among university students in Syria. Int J Tuberc Lung Dis 2004, 8:882-889.
12-Omer khabour J.U.S.T, Medical Laboratory Science, Mohamed Azab, M.D,Ph, Almuthanna K. Alkaraki,M.Sc,Thomas E . Eissenberg ,ph.D,Karem H. Alzoubi.ph.D ,Brian A. Primack,M.D, Ed.M, M.S.Waterpipe Tobacco Smoking Among University Students in Jordan .2008, NTR-2010-001.R1
13. American Head and Neck Society, oral cavity cancer
14. Tobacco or oral health an advocacy guide for oral health professionals
15. Khabour O. Azab M, , Alkaraki Almuthanna, Essenberg Thomasm, Alzoubi Karem , Primack Brian, Waterpipe tobacco smoking university students in Jordan
16. Water-pipe (narguila) smokers in Lebanon: a pilot study
M.Waked , P.Salameh and Z.Aoun
Special thanks to the administrators at Jordan University of Science and Technology who approved the implementation of this study in the student population, and to Michele Darby, Fulbright Distinguished Scholar at Jordan University of science and Technology for her expertise in research methods, critical reviews, and enthusiasm in seeing this study go to publication.
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What categories are you referring to?
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Also in this section, discuss some of the periodontal effects found in smokers.
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