ISSN: 2455-5479
Archives of Community Medicine and Public Health
Research Article       Open Access      Peer-Reviewed

Water pipe smoking among female in Iran : A survey Pattern of use, risk perception and environmental factors

Saeed Bashirian1, Majid Barati1, Manoochehr Karami2, Behrooz Hamzeh3 and Elahe Ezati4*

1Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
2Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran.
3Research Center for Environmental Determinacies of Health, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
4Department of Public Health, School of Health, Hamadan University of Medical Sciences, Hamadan, Iran
*Corresponding author: Elahe Ezati, Department of Public Health, School of Health, Hamadan University of Medical Sciences, Hamadan, Iran, Tel: +989189206695; E-mail: [email protected]
DOI: 10.17352/2455-5479.000160
Received: 09 August, 2021 | Accepted: 10 September, 2021 | Published: 13 September, 2021
Keywords: Female; Adolescents; Water pipe smoking

Cite this as

Bashirian S, Barati M, Karami M, Hamzeh B, Ezati E (2021) Water pipe smoking among female in Iran : A survey Pattern of use, risk perception and environmental factors. Arch Community Med Public Health 7(3): 191-196. DOI: 10.17352/2455-5479.000160

Copyright

© 2021 Bashirian S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background: Considering the prevalence of water pipe smoking among female adolescents and the need to identify the components and dimensions of such behaviors, this study was conducted to investigate determinants of water pipe smoking, use pattern, risk perception and environmental factors among female in Iran.

Methods: This cross-sectional study was conducted on 1302 adolescent females in Kermanshah city, western Iran, in 2019. The method was multi-stage sampling with a systematic random approach. Data were collected using a questionnaire and analyzed using SPSS 22 software. Statistical tests included descriptive statistics and linear and logistic regression analyses.

Results: 32.4% of the participants reported ever water pipe smoking and 20.4% mentioned they used WP at the present time. 60 % of water pipe smoking believed that water pipe smoking is less harmful than cigarettes. 78 % participants believed water pipe smoking 1 h a day was not danjerous and environmental factors affect the tendency to water pipe smoking.

Conclusions: water pipe smoking by adolescents is a multi-factor and multi-level phenomenon, and the major factors for their determining existat multiple levels of individual, interpersonal and environmental factor, which should be considered for intervention, prevention, an control of water pipe smoking.

Background

WPS1 has become one of the most common methods of smoking [1]. WP was first introduced in Iran and WP is used in its present form under the influence of major changes. WPS reached Egypt and the Mediterranean region in the middle of the 16th century and in the 19th century, WPS has widespread among female in the Middle East [2]. in recent, WPS in Europe and the United States has been increasing [3]. WP is known all over the world with different names including: Hubble bubble, Shisha, Gylan, Goza [4]. WP among adolescents has been increasing in recent years [5]. According to a 2012 national survey on student smoking, 32% of male and 30% of female ever used WP [6]. In Iran, ever WPS in adolescents were estimated to be 59.16% [7]. In addition, the results of the latest survey on risk factors of Non-Communicable Disease [SuRFNCD 2007] in Iran showed that more than half of female smoke WP [8]. one reason for the increasing tendency of WPS in adolescents is misunderstanding about WPS and they think WP is less harmful than other tobacco products [9]. This is more sensitive in the Arab countries and Iran, because WPS in female is not considered harmful and it is much more acceptable in the community than other types of tobacco products [10]. there are several factors affecting the tendency to WP, including: individual factors [attitude], family factors [peer influence], environmental factors [easy access], political, etc [11]. studies show that the smell and flavours of WP has increased adolescents’ tendency to WP compared to other tobacco products [12,13]. new types tobacco producte including WP have gained popularity because of attractive advertising and financial sponsors [14]. more access to more modern types of tobacco products and marketing strategies by tobacco manufacturers has caused tobacco control laws less effective[15]. the purpose study of investigate determinants of waterpipe smoking, use pattern, risk perception and environmental factors among female in Iran and using Sociocological [SEM] model to clearer perception determinants of use.

SEM

Using the SEM is a useful method for examining health-related behaviors, however, this model has not been used about WPS in women. This model examines the interpersonal and environmental relationships and indicates that although individual factors play an important role in health-related behaviors, but examining other factors and levels gives the researcher a clearer understanding about doing or not doing a behavior, especially in high-risk behaviors such as smoking [16,17]. [form1].

Materials and methods

Study design and setting

This cross-sectional study was carried out on 1302 middle and high school females aged 12–18 years in Kermanshah, one of the largest cities with the highest prevalence of tobacco use in Iran, between January and August 2019. The method applied was multistage sampling with a systematic random approach. Initially, a list of schools in the three districts of Kermanshah was prepared. In total, 12 schools were then selected by systematic random sampling (two middle schools and two high schools). At the school level, systematic random sampling was also selected based on the number of students and the proportion of the total sample size. Written informed consent was obtained from students aged ≥16 years, and from parents of students aged < 16 years. The names of the participants in the questionnaire were not recorded and other information was kept confidential and used only for this study.

Instrument

The formal and content validity of the questionnaire was assessed using the opinion of 15 health education and promotion specialists. The Content Validity Ratio (CVR) and Content Validity Index (CVI) for each question was extracted . Also, for the reliability of the questionnaire, in a preliminary study, the questionnaire was givento 30 students who had characteristics similar to the main study samples. Cronbach’s alpha coefficient was then calculated.

The questionnaire consisted of two parts: demographic and water pipe-related behaviors. The questionnaire was completed on a self-report basis and took approximately 20 minutes to complete.

Demographic factors: Included age, grade, father’s and mother’s job, father’s and mother’s education, living conditions.

WPS -related determinant: Including never having been a ever WPS, having friends who smoke WP [Yes/No] and having friends who offer WPS [Yes/No], perceptions of cigarette smoking associated with WP, perceptions of harm associated with WP, environmental factors associated with WP, reasons of WP use , prototype images about WPS.

Statistical analysis

The data were entered into IBM SPSS 22 software after collection. Logistic regression was used to investigate and predict factors affecting WP. Chi-square and logistic regression were performed to identify statistical diffrences and analyze factors associated with WP.

Ethical consideration

This reserch received ethics approval from the Ethics Committee of Hamadan University of Medical Sciences. [IR.UMSHA.REC.1397.696]. All participants were given an informed consent form to participate in the study.

Results

Individual determinants of use

The results were obtained after completion of 1302. A total of 883 (67.8%) participants reported that they had never smoked WP, 419 (32.3%) had a single experience of WP during their lifetime, and 265 (20.4%) were current consumers of WP. Also, the likelihood of an increase in WPS in students whose fathers were self_employed and un-employed was 3.85 and 3.23 times more likely than those whose fathers were employees Table 1.

Table 1: Characteristics of the students based on waterpipe ever use and non-use.
Characteristics Never water pipe smoking[n=883][%] ever water pipe smoking [n=419][%] AOR [95% CI] P-value Past-month water pipe smoking [n= 265][%] AOR [95% CI] P-value
Age a[yr]            
13-Dec 200 [15.3] 86 [6.6] 0.94[.069 to 1028] 0.7 53 [20] 1.05[0.73 to 1.5] 0.7
14-15 273[20.9] 147[11.2] 1.18[0.91 to 1.5] 0.2 106[40.] 1.5[1.15 to 2.1] 0.04**
16-17-18b 410[31.5] 186[14.3] 1 - 106[40] 1 --
High school gradea              
Seventh 137[10.6] 54[4.1] 0.69[0.46 to 1.04] 0.08 31[11.7]  0.74[0.45 to 1.2] 0.24
Eighth 168[12.1] 66[5.1] 0.88[0.69 to 1.28] 0.5 48[18.1]  0.98[0.62 to 1.5] 0.95
Ninth 126[9.7] 97[7.45] 0.75[0.51 to 1.1] 0.1 68[25.6]  1.68[1.09 to 2.5] 0.01*
Tenth 164 [12.6] 45 [3.4] 0.56[0.31 to 0.84] 0.006*** 33[12.4] 0.71[0.43 to 1.17] 0.945
Eleventh 154 [12.4] 64 [5] 0.55[0.35 to 0.87] 0.004*** 38 [14.3] 0.82[0.5 to 1.31] 0.673
Twelfthb 134[10.5] 93[7.1] 1 --- 47[17.8] 1 ----
Father's Educationa              
Illiteracy 39 [2.1] 26 [2.00] 1.95[1/1 to 3/4] 0.01* 16 [6.4] 1.37[0.73 to 2.50] 0.3
Under the diploma 176 [13.6] 109 [8.5 1.81 [1.27 to 2.50] 0.001*** 72 [27.1] 1.40 [0.96 to 2.1] 0.07
Diploma 442 [34.0] 207 [15.9] 1.37 [1.01 to 1.84] 0.04* 119 [45] 0.71 [0.66 to 1.33] 0.73
Collegeb 226 [17.4] 77 [6.0] 1 - 58 [21.9] 1 -
Mother's Educationa              
Illiteracy 55 [4.2] 20 [1.5] 0.78[0.4to 1.4] 0.4 12 [4.5] 0.60[0.29 to 1.26] 0.1
Under the diploma 326 [25] 159 [12.2] 1.03 [0.68 to 1.55] 0.83 97 [12.7] 0.79 [0.51 to 1.25] 0.32
Diploma 411 [31.5] 197 [15.2] 1.01 [0.68 to 1.54] 0.94 124 [46.8] 0.81 [0.52 to 1.27] 0.37
Collegeb 91 [7.0] 43 [3.3] 1 - 32 [12.1] 1 -
Father’s joba              
Unemployed 489 [37.5] 288 [22.12] 3.23[2.3 to 4/3] 0.001*** 184 [69.5] 2.62[1.7 to 3.6] 0.00***
Self-employed 114 [8.8] 80 [6.3] 3.85 [2.52 to 5.81] 0.000*** 46 [17.4] 1.48 [1.63 to 4.21] 0.00***
Employeeb 280 [21.5] 51 [4.00] 1 -. 35 [13.1] 1 -
Mother’s joba              
Housewifeb 819 [33.8] 382 [33.7] 1 - 234 [24.4] 1 -
Employed 64 [3. 4] 37 [2.7] 1.23[0.81 to 1.81] 0.31 31 [1.9] 1.83 [1.17 to 2.86] 0.008**
CI: Confidence Interval, AOR: Adjusted Odds Ratio. a: Categorical variables, b: Reference group, *p<0.05, **p < 0.01, ***p < 0.001
Socialecological factor

Table 2 shows perception of the comparison between WP and cigarette smoking, those who ever WPS compared to those never WPS, believe that WP access is 1,08 times easier than cigarette.

Table 2: Logistic regression examining perceptions of cigarette smoking associated with waterpipe ever use.
In comparison to cigarette ever use Study participants 1302  Waterpipe ever use  AOR [95% CI]
Yes 419  No 883
Harm perception waterpipe vs. cigarette*         2.29[1.73 to 2.80]
Less harmful 655[51] 253[60] 494[56]
More harmful [reference] 647[49] 166[39] 389[44]
Accessibility cigarette vs. waterpipe? *         1.08[0.84 to 1.39]
Easier access 902[69.2] 295[70.4] 607[68.7]
Difficult to access [reference] 400[30.7] 124[29.5] 276[31.3]
Cost cigarette vs. waterpipe? *         1.5[1.3 to 1.63]
Less expensive 962[73] 264[63] 564[64]
More expensive [reference] 340[27] 155[37] 319[36]
Smell waterpipe vs. cigarette? *         2.2[1.7 to 2.8]
Much better 832[64] 317[75] 515[59]
About the same [reference] 470[36] 102[26] 368[41]
CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.05

Most participants believed that the smell of WP is more pleasant than cigarette. Th odds of ever use WP were 2.2 times higher for those who had much better smell to WP than cigarettes. Nearly 60% of them believe that WP is less harmful than cigarettes. 73% femal adolescent believed cost WP less expensive than cigareettes.

The students that their friends WPS, they were more likely to smoke WP and those that their friends had suggested WP smoking , were 7 times more likely than others to smoke (Table 3).

Table 3: Logistic regression examining peer pressure factors associated with Waterpipe ever use.
Peer pressure Study participants 1302  Waterpipe ever use  AOR [95% CI]
Yes 419  No 883
Have friends who smoke waterpipe regularly*     4.9[3.87 to 6.31]
Yes 445[74] 247[58] 198[23]
No[reference] 857[26] 172[42] 685[77]
If your friends invite will you smoke* waterpipe?       7.27[5.4 to 9.7]
Yes 319[25] 227[55] 92[11]
No[reference] 983[75] 192[45] 791[89]
If your friends insist will you smoke* waterpipe?       5.07[4.3 to 8.2]
Yes 158[12] 108[26] 50[6]
No[reference] 1144[88] 311[74] 833[94]
 CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.05

78% female students believed WPS 1h daily was not danjreous and ever users WP had 5.07 times a higher odd of believing that WPS makes users cool and fit .ever WPS had 4.4 time a higher odd of believing that WP smoking maks users theeth damaged (Table 4).

 Table 4: Logistic regression examining perceptions of harm associated with Waterpipe ever use.
Harm perception Study participants 1302  Waterpipe ever use  AOR [95% CI]
 YES 419  NO 833
Waterpipe smoking makes theeth damaged*        
Yes 940[72] 214[51] 726[82] 4.4[3.87 to 6.31]
No[reference] 362[28] 205[49] 157[18]
Smoking waterpipe for an hour daily is harmful*        
Yes 284[21] 192[46] 92[11] 7.27[5.4 to 9.7]
No[reference] 1018[78] 227[54] 791[89]
Waterpipe smoking makes users fit*        
Yes 158[12] 240[57] 703[80] 5.07[4.3 to 8.2]
No[reference] 1144[88] 204[43] 180[20]
 CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.05

Table 5 shows WPS in relation to environmental factors. tendency to smoke WP, including easy access to WP, the existence of different WP tobacco flavours, and the acceptance of WP in the community which increases odd of smoking 1.6, 2.8, and 1.46, respectively. But there is no significant relationship between the lack of facilities for healthy recreational activities and WPS.

Table 5: Logistic regression environmental factors associated with Waterpipe ever use.
Enviromentl factors Study participants  Waterpipe ever use AOR [95% CI]
Yes No
1302 419 883
Acceptance of WP smoking in the community*        
Yes 1013[78] 344[82] 669[75] 1.46[1.09 to 1.96]
No[reference] 289[22] 75[28] 214[25]
Easy access to hookah*        
Yes 1094[84] 370[88] 724[82] 1.6 [1.7 to 2.3]
No[reference] 208[16] 49[12] 159[18]
Various flavors*        
Yes 1091[84] 385[92] 706[80] 2.8[1.9 to 4.2]
No[reference] 211[16] 34[8] 177[20]
No other facilities        
Yes 990[76] 323[77] 667[76] 1.09[0.81 to 1.4]
No[reference] 312[24] 96[23] 216[24]
 CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.05

The 5 most frequently recorded reasons of WPS from students’ viewpoints are shown in Table 6. take pleasure and sense relax and increase focus were common reasons of WPS from students viewpoints OR estimates of becoming an ever WPS was 2.6, 2.1 and 2.2 for students who mentioned sense of realax, take pleasure and increase focus as the main reason of WP use compared to those who did not mention it, respectively. As well as, the likelihood of WPS was higher among those who mentioned these reasons as the main reasons of WPS compared to those who did not mention to such reasons.

Table 6: Reasons of water pipe use in the female students.
Cause of smoking Never WP smoking [n=883][%] Former WP smoking [n=419][%]  AOR [95% CI]
 		 P-value
Frequency  percent[%] Frequency  percent[%]
sence realax            
NO 671  [76] 113  [27] 2,6[1.8 to 3.6] 0.001  
YES 212  [24] 306  [73]  
Take pleasure          
NO 634  [72] 115  [28] 2,1`[1.5 to 2.4]   0.001  
YES 249  [28] 304  [72]  
Increase focus          
NO 752  [85] 165  [40] 2,2[1.3 to 2.9] 0.001  
YES 131  [15] 254  [60]  
Forggtive problem          
NO 745  [84] 171  [41] 1.7 [1.1 to 2.4] 0.001
YES 138  [16] 248  [59]  
control violence             0.001
NO 670  [76] 275  [66] 1.7[1.2 to 2.4]
YES 213  [28] 144  [34]  
 CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.01

Table 7 presents the important positive and negative images of typical WPS in the students. It was hypothesized that students prototypes of daily smoking peers would differ among WP users and non-users. In this regard, comparison to non-users,WPS evaluated a typical WP user as more clever,Less immature, more popular, more attractive, more self-confident,more independent and less selfish [P< 0.001].

Table 7: Prototype images about waterpipe users among female students.
Images of WP users Never WP smoking [n=813][%] Former WP smoking [n=409][%]  AOR [95% CI] P-value
Frequency  percent  Frequency[%]  percent [%]
Immature             0.001
NO 595  [68] 170  [41] 2,1[2.3 to 3.2]
YES 288  [28] 249  [59]  
popular             0.001
NO 624  [70] 129  [30] 5.1 [4.2 to 6.9]
YES 259  [30] 290  [70]  
Attractive             0.001
NO 639  [72] 140  [34] 3.1[3.6 to 5.5]
YES 244  [28] 279  [66]  
clever             0.001
NO 673  [76] 151  [36] 5.1[4.4 to 7.3]
YES 210  [24] 268  [64]  
Self-confident             0.001
NO 528  [60] 137  [33] 1.6[1.2 to 2.1]
YES 355  [40] 282  [67]  
Independent             0.001
NO 458  [52] 146  [35] 1.9[1.5 to 2.5]
YES 455  [48] 273  [65]  
Selfish             0.001
NO 428  [49] 139  [33] 1.89[1.4 to 2.3]
YES 453  [51] 280  [67]  
CI: Confidence Interval, AOR: Adjusted Odds Ratio. *p<0.01

Discussion

32.2 % of the female adolescent had ever WPS and 20.4 % were current WPS, Our findings were similar to those of other studies in other countries [1,18]. for example, in a study in Turkey, the prevalence of WPS was 32.7%. [19]. in this study showed that the job and education the play a significant role in the increase of WPS, in such a way that , the probability of WPS in students whose fathers are unemployed and self_employed is 3 times more than students whose fathers are employee which is similar to the results of study [19-22], ever WPS believed that WPS makes them cool and fit compared to cigarettes which is similar to the results of study [16].

Female reported WPS to be less harmful than cigarettes,in line with finding from other studies [2,4,23-25]. WP, like cigarettes, has many disadvantages and especially in female it causes oral diseases, infectious diseases, menstrual disorders and infertility [26-28] .female adolescents believed cost WP less expensive than ciggaret. We worry that students believe that WP is cheaper than cigarettes, and this is one of the most effective reasons about the tendency to smoke WP [29].

The results showed that the smell of WP is one of the incentives for students to smoke WP and this is consistent with the results of study [30]. findings showed that the influence and offer friend to smoke WP increased the probability of WPS 7 times more among students, which is similar to the results of study [31-33]. It seems that lack of sufficient people skills, such as the ability to say ‘no’ to the suggestion of friends, is one of the main reasons for the tendency to smoke WP. the result demonstrated that sense of realax , take pleasure and increasing focuse, are the most important reasons on starting tobacco smoking as reasons for WPS was higher than those who did not mention to such reasons. which are consistent with results of similar studie [34,35].the findings indicate that positive and negative images of typical WP lead to WP use, in line with other study [36-38]. our study showed that female students believed that WP was more acceptable and less harmful than cigarette[39, 40]. flavored tobacco smell, environment friendly, easy access to WP some of it is attributable to the significant expansion, which is similar to The results of study [15,41]. Also, Iranian females often face many restrictions with regard to cigarette smoking, but family members approve of WPS as traditional entertainment with no trouble, and females are allowed to use them inside and outside the home. WPS is a major threat for female adolescent. WP is a multi-factor and multi-level phenomenon, and the major factors for their determining existat multiple levels of individual, interpersonal and environmental factor, which should be considered for intervention, prevention, an control of WP.

Consent to publish

The manuscript has been read and approved by all authors.

Availability of data and materials

Data used in this study is analyzed and the data is available any time you had request.

Funding

This study was supported by Hamadan University of Medical Sciences in Iran, and funder did not play a role in research design, data collection, analysis, and manuscript writing. [reference number: 9711026633].

Ethical consideration

Written informed consent was obtained from students aged 16 years and over and parents of students under 16 years of age. The names of the participants in the questionnaire were not recorded and other information was kept confidential and used only for this study. The Ethics Committee of Hamadan University of Medical Sciences approved this study (reference number: (IR.UMSHA.REC.1397.696).

Authors’ contributions

SB, MB, MK, participated in the study designing. EE participated in data collection. SB, MB,MK and EE participated in the data analysis and SB and EE and BH wrote the manuscript. The manuscript has been read and approved by all the authors.

This study was adapted from a PhD thesis at Hamadan University of Medical Sciences. Moreover, the authors would like to thank the participants.This study was supported by Hamadan University of Medical Sciences [reference number: This work was supported by Hamadan University of Medical Sciences [reference number: 9711026633].

  1. Primack BA, Walsh M, Bryce C, Eissenberg T (2009) Water-pipe tobacco smoking among middle and high school students in Arizona. Pediatrics 123: e282- e288. Link: https://bit.ly/3hrKN9n
  2. (2009) Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis 5: 16. Link: https://bit.ly/394hC7L
  3. (2004) Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria. Prev Med 38: 479-484. Link: https://bit.ly/3A8TmNI
  4. (2011) Examining hookah smoking among a cohort of adolescent ever smokers. Nicotine Tob Res 13: 1202-1209. Link: https://bit.ly/395kO3b
  5. et al. (2016) Characteristics of Iranian hookah smokers aged 15 and above: a primary report. Health Scope 5. Link: https://bit.ly/3nsqDAe
  6. (2012) Predictors of waterpipe smoking among secondary school adolescents in Al Hassa, Saudi Arabia. Int J Behav Med 19: 324-335. Link: https://bit.ly/3htoLmV
  7. (2007) Patterns of WP smoking among adolescent students: a cross-sectional study in district 13 of Tehran. Payesh 6: 135-144.
  8. (2010) Pattern of tobacco use among the Iranian adult population: results of the national Survey of Risk Factors of Non-Communicable Diseases [SuRFNCD-2007]. Tob Control 19: 125-128. Link: https://bit.ly/3C5pLoX
  9. Bashirian S, Barati M, Sharma M, Abasi H, Karami M (2019) Water Pipe Smoking Reduction in the Male Adolescent Students: An Educational Intervention Using Multi-Theory Model. J Res Health Sci 19: e00438. Link: https://bit.ly/3tzuEUr
  10. (2012) Lower prevalence of cigarette and waterpipe smoking, but a higher risk of waterpipe dependence in Lebanese adult women than in men. Women & Health 52: 135-150. Link: https://bit.ly/3hmzkbl
  11. (2003) The impact of individual and interpersonal factors on perceived news media bias. Polit Psychol 24: 101-117. Link: https://bit.ly/2XgGxCk
  12. (2011) Young adults’ perceptions about established and emerging tobacco products: results from eight focus groups. Nicotine Tob Res 14: 184-190. Link: https://bit.ly/3k2H1VI
  13. (2010) Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav 34: 275-285. Link: https://bit.ly/3C3odMk
  14. (2013) WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship: World Health Organization. Link: https://bit.ly/3A9NVy5
  15. (2004) The importance of a minimum age law for the possibility of purchase of tobacco by adolescents: a study based on Swedish experiences. Scand J Soc Med 32: 68-74. Link: https://bit.ly/3tF6TKv
  16. (2015) Determinants of waterpipe use amongst adolescents in Northern Sweden: a survey of use pattern, risk perception, and environmental factors. BMC Res Notes 8: 441. Link: https://bit.ly/3E7HFcN
  17. McQuiston C, Choi-Hevel S, Clawson M (2001) Protegiendo nuestra comunidad: Empowerment participatory education for HIV prevention. J Transcult Nurs 12: 275-283. Link: https://bit.ly/3lks8O8
  18. Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, et al. (2015) The global epidemiology of waterpipe smoking. Tob Control 24: i3-i12. Link: https://bit.ly/2Xa3Uh2
  19. (2010) Waterpipe [narghile] smoking among medical and non-medical university students in Turkey. Ups J Med Sci 115: 210-216. Link: https://bit.ly/3lidt5X
  20. (2007) Cigarette and nargileh smoking practices among school students in Beirut, Lebanon. Am J Health Behav 31: 56-63. Link: https://bit.ly/3z0NNQh
  21. (2006) Which sociodemographic factors are important on smoking behaviour of high school students? The contribution of classification and regression tree methodology in a broad epidemiological survey. Southampt Med J 82: 532-541.
  22. et al. (2003) Early adolescent smoking and a web of personal and social disadvantage. Int J Pediatr Child Health 39: 580-585. Link: https://bit.ly/3Ef343u
  23. (2005) Water-pipe [narghile] smoking: an emerging health risk behavior. Pediatrics 116: e113-e119. Link: https://bit.ly/3hpcmjC
  24. Jackson D, Aveyard P (2008) Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health 8: 174. Link: https://bit.ly/3nzoZfQ
  25. et al. (2007) Characteristics of US waterpipe users: a preliminary report. Nicotine Tob Res 9: 1339-1346. Link: https://bit.ly/3noh70V
  26. (2008) Waterpipe-associated particulate matter emissions. Nicotine Tob Res 10: 519-523. Link: https://bit.ly/3nsqHzY
  27. et al. (2015) Harmful effects of nicotine. Indian J Med Paediatr Oncol 36: 24-31. Link: https://bit.ly/2YVcm4R
  28. (2014) Harmful effects of shisha: literature review. Int Arch Med 7: 16. Link: https://bit.ly/3hrcbo0
  29. Morris DS, Pawlak R (2012) Peer Reviewed: Opportunities for Policy Interventions to Reduce Youth WP Smoking in the United States. Prev Chronic Dis 9.
  30. (2008) Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two US samples. Nicotine Tob Res 10: 393-398. Link: https://bit.ly/3z3IvDl
  31. (2015) An extended theory of planned behavior [TPB] used to predict smoking behavior among a sample of Iranian medical students. Int J High Risk Behav Addict 4: e24715. Link: https://bit.ly/3k3vt4v
  32. Lazuras L, Eiser JR, Rodafinos A (2009) Predicting Greek adolescents’ intentions to smoke: A focus on normative processes. Health Psychol 28: 770-778. Link: https://bit.ly/2VEasEk
  33. (2011) The role of parents, friends and teachers in adolescents' cigarette smoking and tombak dipping in Sudan. Tob Control 20: 94-99. Link: https://bit.ly/3nvj8Iy
  34. (2004) Explaining adolescents' smoking and drinking behavior: The concept of smoker and drinker prototypes in relation to variables of the theory of planned behavior. Addict Behav 29: 1615-1622. Link: https://bit.ly/2YQcd2u
  35. Rahimi T, Javadi A (2018) Using Prototype Willingness Model to Predict Waterpipe Smoking among High School Adolescents in Birjand, Iran. J Psychiatry Behav Sci 12: e11255. Link: https://bit.ly/38Z5TaE
  36. (2016) Factors associated with hookah use among male high school students: the role of demographic characteristics and hookah user and non-user prototypes. J Res Health Sci 16: 217-223. Link: https://bit.ly/3tzIRR4
  37. Bashirian S, Barati M, Abasi H, Sharma M, Karami M (2018) The role of sociodemographic factors associated with water pipe smoking among male adolescents in western Iran: A cross-sectional study. Tob Induc Dis 16: 29. Link: https://bit.ly/3lgk40F
  38. Barati M, Allahverdipour H, Hidarnia A, Niknami S (2015) Predicting tobacco smoking among male adolescents in Hamadan City, west of Iran in 2014: an application of the prototype willingness model. J Res Health Sci 15: 113-118. Link: https://bit.ly/3C4lWQR
  39. Fakhfakh R, Hsairi M, Maalej M, Achour N, Nacef T (2002) Tobacco use in Tunisia: behaviour and awareness. Bull World Health Org 80: 350-356. Link: https://bit.ly/3z4sI7p
  40. et al. (2015) Waterpipe [hookah] smoking among youth and women in Canada is new, not traditional. Nicotine Tob Res 18: 757-762. Link: https://bit.ly/3k3LfMQ
  41. Martinasek MP, McDermott RJ, Martini L (2011) Waterpipe [hookah] tobacco smoking among youth. Curr Probl Pediatr Adolesc Health Care 41: 34-57. Link: https://bit.ly/3C3Xkb4
© 2021 Bashirian S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 

Download as


Article Alerts

Subscribe to our articles alerts and stay tuned.


Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 International License.

Help ?

Submit your next article Peertechz Publications, also join of our fulfilled creators. Submit a Manuscript

© Peertechz Publications Inc., 10880 Wilshire Blvd., Suite 1101, Los Angeles, California, 90024, USA