2Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences/King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Received Date: October 29, 2015; Accepted Date: December 17, 2015; Published Date: December 25, 2015
Citation: Al-Nomay NS, Ahmed AE (2015) Water Pipe Use and the Awareness of its Effect on Oral Health in Riyadh, Saudi Arabia. J Oral Hyg Health 3:191. doi:10.4172/2332-0702.1000191
Copyright: © 2015 Al-Nomay NS, 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.
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Objective: Despite widespread water pipe (WP) use in Saudi Arabia, research on WP use and the awareness of its effect on oral health in Riyadh, Saudi Arabia are limited. This study attempts to calculate the prevalence of WP use and discover the awareness level regarding its effect on oral health in a sample collected from Riyadh City. Method: A total of 602 residents in Riyadh, Saudi Arabia were selected by cluster sampling from the five largest shopping malls in Riyadh. Data were collected using an Arabic questionnaire with demographic characteristics. Results: The majority of the participants were aware that WP smoking is a risk factor for oral cancer, periodontal diseases, bad taste, tooth and oral tissue staining, and bad breath. However, the prevalence rate of WP use was 16.9% with 95% confidence intervals (14.03% - 20.18%). WP use was more prevalent among the male gender (22.3% in males vs. 10.2% in females, P-value = 0.001), cigarette smokers (38.0% in cigarette smokers vs. 13.8% in non-cigarette smokers, P-value = 0.001), and people who avoided dental visits (31% never visited a dentist, 25.9% had 1-5 visits vs. 13.2% who had 5 or more visits, P-value = 0.001). Conclusion: The primary WP usage in Saudi Arabia came from the male gender, cigarette smokers, and people who avoided dentist visits. Anti-WP smoking interventions that target the male gender and cigarette smokers are needed to prevent WP use among these subjects. Future study may be warranted to move beyond oral health, thoroughly grasp the motives of WP users relative to cardiovascular risk, and lead the way toward creation and implementation of a CVD intervention program.
Adjusted Odds Ratio: Aor; KAIMRC: King Abdullah International Medical Research Center; WHO: World Health Organization; WP: Water Pipe; WPS: Water Pipe Smoking
The World Health Organization (WHO) states that forms of tobacco use, including cigarette smoking and water pipe (WP) use, cause a large and growing public health burden . Each year, universal tobacco use is estimated to kill about 5 million people, and is the cause for one in every five male deaths, and one in every 20 female deaths of individuals over age 30. By 2030, it is estimated that yearly tobacco deaths will rise to 10 million . Some argue that the public health burden caused by tobacco use in the Middle East has reached epidemic proportions.
Nicknamed “Shisha,” “Muassel,” and “Nargilha,” water pipe smoking (WPS) is especially popular among the young populations of the Arabian countries, Turkey, India, Pakistan, China, and Bangladesh [3-7]. A recent study conducted in Jordan showed that among university students, WP use was as prevalent as cigarette smoking, with current use of 30% and 56% respectively, while a survey of students from four universities in Lebanon showed that WP use was more common than cigarette smoking among university students [8,9]. Another recent study conducted in the United States showed WPS to be the second most used method of tobacco consumption . Further, WP use has been reported to be prevalent and growing in countries such as Vietnam .
Although Shari’ah law rules, the foundation of Islamic cultures considers tobacco unacceptable among both sexes, and it is often deemed more unacceptable in females. However, in some Arab countries, WP usage is less stigmatizing than cigarette smoking, and there is less gender differential in its use, perhaps in part due to its acceptance as part of cultural tradition, availability, and flavored aromatic tobacco called, “Muassel” [5-7]. However, a survey of university students from the Qassim region showed that the total prevalence rate of WP smoking was 40% and cigarette smoking was 41%. Slightly more than 30% of these university students presently smoke WP . Among Syrian university students, it was found that 62.6% of men and 29.8% of women had at one time smoked WP . A Kuwaiti study found WP usage among 57% of men and 69% of women . Due to factors such as globalization and immigration, these trends have extended to western countries such as Europe and the United States .
Unfortunately, many adolescents, the general public, and even health care professionals view WP use as less harmful than cigarette smoking. Common misconceptions include the idea that the nicotine content is less than in cigarettes that water filters out all noxious chemicals, that it is less irritating to the throat, and that the tobacco contains fruit, making it healthy . Ignorance of the health effects of WP use is thought to be one motivation for its spread.
Several important studies demonstrate the harm that cigarette tobacco causes to a person’s health, but few studies have mentioned the effects of WP smoking onoral health[15-19]. The negative effects to oral health are legion: a study conducted in Saudi Arabia found that WP smoking is associated with increased bone loss in periodontal diseases , while another study found that WP smokers are at greater risk (compared to non-smokers) to dry sockets following tooth extraction, and at greater risk for oral cancers . Given these harmful effects of WP smoking on oral health, and taken as a whole to the best of our knowledge, we assessed their oral health-related prevalence, knowledge toward, and reasons for WP smoking. We also determined the possible predictors for adoption of WP smoking in a sample of adults in Riyadh, Saudi Arabia.
The study was a cross-sectional population survey of 602 residents in Riyadh, Saudi Arabia. Research Protocol: the study has received ethical approval from the Institutional Review Board (IRB), King Abdullah International Medical Research Center (KAIMRC), National Guard Ministry, Health Affairs, Riyadh, Saudi Arabia. Signing an informed written consent was not requested from participants, but we obtained oral consent. A self-administered, anonymous survey was distributed by approaching participants in social media who were in the five largest malls in Riyadh. Three research assistants were assigned to Riyadh shopping malls. We targeted shopping malls located in the north, east, west, south, and middle of Riyadh. Each mall was selected randomly from each of the five locations. The research assistants were available during filling in of the questionnaires to address questions in case a question was unclear. The survey tool was designed to answer questions that were related to oral health awareness, WP use, and its possible related risk factors. The survey was divided into two sections. The first section included sociodemographic and smoke characteristics such as region of residency in Saudi Arabia (Central, Northern, Eastern, Western, or Southern), age (18-24 yrs, 25-34 yrs, 35-44 yrs, or ≥ 45 yrs), gender (Male/ Female), level of education (High school and less/ University), marital status (Unmarried/ Married), smoke cigarettes (Yes/No), smoke WP (Yes/No), and number of times subjects visit the dentist (1-5 visits/ 5 visits or more). The second section addressed the knowledge of WP use relative to oral health effects. In this section, participants were asked whether the following statements are true: “smoking causes stained teeth,” “smoking causes bad breath,” “smoking causes tooth decay,” “smoking causes bad taste,” “smoking can affect healing of wounds,” “smoking causes periodontal (soft and hard tissues around the teeth) disease,” and “smoking causes oral cancer.”
Demographic data are presented with n (%), (Table 1). Chi square tests were used to assess the prevalence rates of WP use across the socio-demographic variables (Table 1). A multiple logistic regression was carried out to investigate the relationship between WP use and socio-demographic data (Table 2). We assessed knowledge regarding WP tobacco use and its effects on the oral health of the participants (Figure 1).
|95% C.I.for OR|
|18 – 24 Yrs||≥ 45 Yrs||0.069||0.897||1||0.378||3.033|
|25 – 34 Yrs||≥ 45 Yrs||0.794||0.085||2.2||0.896||5.467|
|35 – 44 Yrs||≥ 45 Yrs||0.126||0.81||1.1||0.407||3.162|
|University||High sch. or less||0.26||0.495||1.3||0.615||2.737|
|Satisfied with the color shade of your teeth|
|How many times did you visit the dentist:|
|Never||5 or more||1.071||.021*||2.9||1.179||7.226|
|1-5 times||5 or more||0.514||0.059||1.7||0.981||2.853|
Table 1: Prevalence of WP use and its relation to sample characteristics *chi-squar e test is significant at α=0.05.
|95% C.I.for OR|
|18 – 24 Yrs||≥ 45 Yrs||.069||.897||1.0||.378||3.033|
|25 – 34 Yrs||≥ 45 Yrs||.794||.085||2.2||.896||5.467|
|35 – 44 Yrs||≥ 45 Yrs||.126||.810||1.1||.407||3.162|
|University||High sch. or less||.260||.495||1.3||.615||2.737|
|Satisfied with the color shade of your teeth|
|How many times did you visit the dentist:|
|Never||5 or more||1.071||.021*||2.9||1.179||7.226|
|1-5 times||5 or more||.514||.059||1.7||.981||2.853|
*Wald Chi-square test is significant at α=0.05
Table 2: Multivariate analysis: Factors associated with the prevalence of WP use.
A total of 602 participants aged ≥ 18 years (544 Saudi and 58 non- Saudi) were randomly selected. Of 602 respondents, 336 (55.8%) were males, and 13.1% were cigarette smokers.
Approximately half of the respondents were married (49.2%) and (32.6%) were satisfied with the color shade of their teeth. The majority (41%) of respondents were residents of the northern region of Riyadh, 22.3% eastern region, 16.8% central, 10.8% western, and 9.1% southern.
In our sample, the prevalence rate of WP use was 16.9% with 95% confidence intervals (14.03% - 20.18%). The prevalence rate of WP use was higher among the male gender (22.3% in males vs. 10.2% in females, χ2 = 15.6, P-value = 0.001). The prevalence rate of WP use was higher among cigarette smokers (38.0% in cigarette smokers vs. 13.8% in non-cigarette smokers, χ2 = 28.6, P-value = 0.001). The prevalence rate of WP use was higher among respondents who avoided dental visits (31% never visited a dentist, 25.9% had 1-5 dentist visits vs. 13.2% had 5 or more dentist visits, χ2 = 16.1, P-value = 0.001). We assessed knowledge regarding WP tobacco use and its effects on oral health among participants (Figure 1). Of 602 respondents, 99.3% believed that smoking causes stained teeth; 97.7% believed that smoking causes bad breath; 67.4% reported that smoking causes tooth decay; 96.2% reported that smoking causes bad taste; 84.9% reported that smoking can affect healing of wounds; 94.7% believed that smoking causes periodontal (soft and hard tissues around the teeth) disease; and 93.4% believed that smoking causes oral cancer. Table 2 demonstrates a multivariate analysis to evaluate the factors that related to the prevalence of WP tobacco use. Male respondents were two times more likely to smoke WP compared with female respondents (adjusted Odds Ratio [aOR]: 2.0, 95% confidence intervals (CI): 1.139-3.408; P-value = 0.015). Compared to non-cigarette smokers, cigarette smokers were considerably more likely to smoke WP (aOR: 3.0, 95% CI: 1.691-5.333; P-value =0.001). WP use was 3.0 times more likely in respondents who avoided dental visits (aOR: 2.9, 95% CI: 1.179-7.226; P-value = 0.021).
This study of residents of Riyadh City represents one of the few studies from the Middle East that focuses exclusively on WP use and the awareness level regarding its effect on oral health. In our current investigation, the prevalence rate of WP use was 16.9%. An earlier study conducted with 16- to18-year-old high school students in Riyadh revealed that 33% were WP smokers . The high prevalence rate of WP use reported in their study could be due to their sampling. According to their study 34.1% were females and 65.9% were males. However, in our study we have an almost equivalent number (44.2% females and 55.8% males).
According to a study conducted in a sample of medical students in Al-Hassa, Saudi Arabia, the WP use was 44% in male students and 1.8% in female students [21,22]. The low percentage of WP use reported among female students may occur because of the relative social prohibition of tobacco use for females. In addition, the access to places used for smoking WP is limited: Al-Hassa is less urbanized and people in this region constitute a traditional society, tolerating female smoking to a lesser degree. There was an influence of gender on the use of WP in our study (22.3% in males vs. 10.2% in females). For many decades WP use was dominated by males. However, re-emergence of this habit today among young adults in the Middle East is spreading among females due to social acceptability, even in traditionally conservative societies [7,23]. Previous studies in the US showed a large variation in participation of WP users according to gender [24,25].
An earlier study in the City of Riyadh found that the overall smoking prevalence was 22% but in this study 62% were cigarette smokers . Cigarettes were the predominant form of tobacco used. The introduction of Muassel in the 1990s is thought to be, in part, one of the reasons for the increased popularity of WP smoking. It may be that the widespread attention, however well meaning, focused on the dangers of cigarette smoking, and may have the unintentional effect of encouraging WP use, since WP smoking is often erroneously viewed as a less dangerous alternative. Finally, the increasing importance in Arab culture of a specific Arab identity may possibly contribute to the increase of WP smoking. From this study, it appears that cigarette smoking and WP use were associated. The WP use was more prevalent among cigarette smokers than among non-cigarettes smokes (38% vs. 13.8%). This is in line with a study conducted in Al-Hassa, which reported that cigarette smokers were more likely to smoke WP .
A study from the United Kingdom found that cigarette smoking was the primary predictor among WP smokers [27-29]. These studies can be reinforced by the inauspicious awareness of women smoking in some Arab societies, such as Syria . Conversely, WP smoking alone was more than two times (88.6% vs. 36.6%) as common among female dental students compared to male dental students, which can be reinforced by the fact that WP smoking is socially acceptable among women . This is consistent with data from several studies of Arab countries such as Syria and Lebanon, which showed an increase in WP use compared to cigarettes [8,23,29]. For example, Jradi et al. found a significant difference among gender in the percentages of WP smoking but not cigarette smoking in medical students in Lebanon, where it is more socially acceptable for females to smoke WP. Conversely, in a study conducted among medical students in Syria, males were more likely to smoke either cigarettes or WP than females .
According to our study, WP use was 31% among respondents who never visited dentists, compared to respondents who frequently visit dentists (25.9% had 1-5 visits and 13.2% had 5 visits or more). Another important aspect was the knowledge of the population regarding WP tobacco use and its effects on oral health. Our results reveal a positive attitude from non-smokers who had one to five dental visits (74.1%). Interestingly, our results showed that the knowledge of participants regarding WP use and its effects on oral health was greater than our expectations. On the strength of a questionnaire-based assessment, most of them had a knowledge rating of 93.4% and above. The majority of participants surveyed in this study reported that WP smoking was harmful to oral health, regardless of their smoking behavior. The majority of the participants were aware that WP smoking is a risk factor for oral cancer (93.4%), periodontal diseases (94.7%), bad taste (96.2%), tooth and oral tissue staining (99.3%), and bad breath (97.7%). While the participants have a basic knowledge of the relationship between WP smoking and oral health, the proportions of WP smoking among participants were high. A lower proportion of participants reported being aware that WP is associated with delayed wound healing time (84.9%).
The findings of this study could help in providing data to establish and develop educational and public health programs and interventions to fight erroneous public perceptions of the relative lack of oral health-related harm in WP use. Several limitations in our study were noted. Because the findings are based on a cross-sectional study, it is possible that non-responders had a higher smoking prevalence than those surveyed, possibly causing an underestimation of the smoking prevalence rates in this study. Longitudinal study designs are required to develop a better understanding of the conditions under which these variables operate as causal factors. This study is based on cluster sampling of residents in the capital city of Riyadh, Saudi Arabia, and it cannot be generalized to the rest of Saudi residents. Oral health-related risk factors associated with residents’ smoking behavior in a capital city may differ from Saudi residents residing in, for example, Alqassium, or in the more traditional Saudi suburban cities. Further studies should be conducted with different study designs. However, there were several strengths with our paper. This study is important as it highlights the prevalence of WP use in Riyadh City and examines their health awareness level regarding its damaging effects on oral tissues. Aside from these limitations to date, this is the first study of its nature that has highlighted the topic of evaluating the knowledge, prevalence, and attitude of the capital city of Riyadh’s population. It may also be one of the first of its nature to use social media to announce a forthcoming survey.
The primary preferences for WP use in terms of groups in Riyadh, Saudi Arabia were 1) those of the male gender, 2) those who were cigarette smokers, and 3) those who avoided dentist visits. The study found that males had a much higher prevalence of WP use than females. Anti-WP smoking interventions that target the male gender and cigarette smokers are needed to prevent WP use among these subjects. However, this study could also be foundational to initiating a future study investigating the motives for WP use and awareness in terms of cardiovascular risk.