**Abstract**

The use of tobacco products is a modifiable risk factor for non-communicable diseases. The aim of the study was to determine the prevalence of waterpipe tobacco product use and associated risk factors amongst University of Limpopo students aged 17–43 years. This cross-sectional study comprises 916 (415 males and 501 females) University of Limpopo students aged 17–43 years. The questionnaire was validated for the University of Limpopo student population before it was used. Logistic regression was used to determine the associated risk factors for waterpipe tobacco product use among the University of Limpopo students. Staying on campus (OR 2.54 95%CI 1.87 3.44) or off-campus (0.39 95%CI 0.29 0.54) was significantly (p<0.05) associated with using waterpipe tobacco products even after adjusting for age and gender and receiving a bursary (on Campus OR=3.8095%CI 2.59 5.57) off-campus (0.26 95%CI 0.18 0.39). Our results demonstrate that waterpipe smoking was more prevalent among university male students than female students. Liking the taste and difficulties to refuse were significantly (p<0.05) associated with the use of waterpipe amongst University students. Future research should investigate the association of waterpipe use with risk factors for non-communicable diseases over time.

**Keywords:** waterpipe, NFSAS, current use, lifestyle, tobacco products university students

#### **1. Introduction**

Tobacco products have been widely reported all over the world in various populations with health effects as risk factors to non-communicable diseases [1]. By 2030, more than 80% of the deaths in developing countries could be accounted for by tobacco-related implications [2]. There are emerging methods of tobacco use that have become alarmingly common in specific population groups which include waterpipe tobacco use also referred to as hubbly bubbly, hooker, narguileh and shisha which

comes in a variety of flavours such as mint, liquorice, strawberry, cappuccino and chocolate [3, 4]. Waterpipe (Hubbly bubbly, hooker, narguileh and shisha) is known by different titles depending on the segment of the globe it is being used as a form of tobacco delivery [4]. Briefly, 'the waterpipe instrument is set up with charcoal, filters, a bowl of water, rubber pipe and varying flavours'. The delivery of tobacco smoke moves through the rubber pipe attached to the bowl that directs large volumes of smoke inhaled into the mouth. Waterpipe smokers are exposed to the noxious materials of the tobacco smoke such as carbon monoxide, nitric oxide, nicotine, polycyclic aromatic hydrocarbons, nanoparticles, volatile aldehydes and furans [5]. Aboaziza and Eissenberg [6] reported that waterpipe smoking is associated with nicotine dependence and smoking-related diseases including cancer, cardiovascular disease, lung disease and adverse pregnancy outcomes. Students are knowledgeable about harmful health effects associated with waterpipe tobacco product use but continue to use it for a variety of reasons which include taste, peer pressure and easy availability [7]. Furthermore, university students regard waterpipe tobacco as a socially acceptable, popular, pleasant social experience and looks cooler than smoking cigarettes [8–10].

The prevalence of waterpipe smoking varies with areas of the world in student communities due to multifactorial influences [4]. A student study at the University of Beirut, Lebanon, reported 43% ever user and 28% of current smoking [2], while another study in the same country contrastingly reported current waterpipe use at 21% [11]. Kilic and Kasap [12] found in the American region 10% ever user and a 41% current use of waterpipe tobacco product use. In North Africa, it was found that men were four times most likely to report waterpipe smoking, with 64% of the sample investigated reporting long-term consumption [7]. In South Africa, waterpipe tobacco product use was reported to be 40% amongst Western Cape university students [7]. Van der Merwe *et al*, [13] reported 11% waterpipe tobacco product use among University of Cape Town students with social settings as the main reasons for using it. Furthermore, Miri-Moghaddam et al., [14] reported that friends played crucial roles in the high prevalence (78%) of waterpipe smoking amongst medical students in Iran.

University environments across the globe provide a unique opportunity for students to experiment with waterpipe tobacco smoking which can eventually become a lifelong use. However, little is known about the prevalence of waterpipe tobacco use amongst University of Limpopo students in the Limpopo province of South Africa. The study aimed to determine the prevalence of waterpipe tobacco products use and to investigate the associated risk factors amongst among University of Limpopo students aged 17–43 years.

### **2. Materials and methods**

#### **2.1 Geographical area**

This cross-sectional study was carried out at the University of Limpopo, South Africa. The University of Limpopo is situated in the foothills of the Hwiti (Wolkberg range) in Mankweng Township (23.8837° S, 29.7079° E), midway between Polokwane and Magoebaskloof. It is a predominantly African ethnicity dominated student community. Most students come from low- and middle-income families and are receiving funding in the form of a government bursary called South African National Student Financial Aid Scheme (NSFAS). The students rely mostly on this NSFAS bursary scheme to cover their university expenses and other essentials.

*The Use of Waterpipe Tobacco Products and Its Associated Risk Factors among University… DOI: http://dx.doi.org/10.5772/intechopen.105130*

#### **2.2 Sampling procedure**

Using STATA, the sample size required for the study was calculated based on a power of 80% and a two-tailed significance level of 5%, the prevalence of waterpipe smoking was 0.24% amongst university students with an alternative proportion of 20% [3, 15, 16].

A convenient sample of 916 students (415 males' mean age is 22.02 years, sd 2.97, and 501 females' mean age is 21.16, sd 2.71) aged 17–43 years, who were enrolled in all the faculties (Humanities, Health Sciences, Management and Law and Science and Agriculture) of the University of Limpopo in 2019 participated in this study.

#### **2.3 Data collection**

The questionnaire used in the present study was based on questions which have been used in the Ellisras Longitudinal Study and other studies [3, 15–17]. The questionnaire was shared with experts to ensure content, face and construct validity. It was then revised and piloted with a sample of students to make sure it was valid, reliable, acceptable and accurately understood.

The questionnaire comprised three sections. The first part of the questionnaire included information on age, sex, acquisition of NSFAS bursary, place of residence, the field of study, year of entering the university and the level of study. Briefly, current waterpipe smoker was defined as anyone who uses waterpipe tobacco products regularly or every day during the time of the survey. The following question was asked: 'Do you NOW use waterpipe regularly, at least once every day?' Ever waterpipe users were those who answered that they tried to use waterpipe tobacco products before the survey and have stopped, or they use them occasionally. The question used was: 'Have you ever used waterpipe to smoke (at least once)?' Those who had never used waterpipe tobacco products at the time of the survey were considered non-smokers., 'The onset (initiation age) age for waterpipe use was determined by the question "If yes, indicate how old you were when you first tried this\_\_\_\_", How old were you when you first started using waterpipe tobacco everyday/regularly \_\_\_\_\_\_.'Onset age was the group as less than 20 years, between 21 and 25 years and over 26 years.

#### *2.3.1 Educational achievements*

Participants were asked to indicate their academic status ('first-year undergraduate' through to the third year, fourth year, master's and PhD). First and second-year undergraduates were combined to form 'lower level undergraduate' and third-year study was moderate to high level while fourth year, master's and PhD were grouped as a postgraduate level.

#### *2.3.2 Social factors*

Social factors for waterpipe tobacco products use were assessed with the following question: 'One smokes waterpipe tobacco products because I went with others having a good time and felt like inhaling and exhaling together (yes/no), One smokes waterpipe tobacco products because it is difficult to refuse (yes/no), waterpipe tobacco smoking helps me face a difficult situation with confidence (yes/no), One smokes waterpipe tobacco products because it gives me energy (yes/no), One smokes waterpipe tobacco products because I like the taste (yes/no)'.

The study received an ethical clearance from the University of Limpopo Ethics committee (TREC/61/2019: IR) before the data collection process commenced.

#### **2.4 Statistical analysis**

Descriptive statistics including frequency distributions and percentage frequencies were used to determine the prevalence of waterpipe tobacco product use among University of Limpopo students. A Chi-squared test was used to compare sets of nominal data that had larger frequency counts while the Fisher's exact test was used when frequency cells were small (less than five or ten) between genders [18, 19]. Logistic regression was used to determine the associated risk factors for waterpipe tobacco product use among the University of Limpopo students. All statistical analyses were performed using SPSS version 25. The statistical significance was set at P< 0.05.

#### **3. Results**

**Figure 1** shows the prevalence of ever and current waterpipe use amongst University of Limpopo students. The prevalence of current waterpipe use was significantly (p<0.05) high (6.7%) for boys as compared with girls (3%) amongst the University of Limpopo students.

**Table 1** shows the onset age and number of quitting attempts for water pipe use amongst University of Limpopo students aged 17–43 years. The prevalence of waterpipe tobacco product use for ever use in the onset age ranges between 1.6 and 3.9% for the age less than 20 years and between 17.8 and 26.7% for ages between 21 and 25 years. For the current waterpipe user, the prevalence was significantly (p<0.05) high 4.6% for boys as compared with 1.8% for girls between the ages of 21 and 25 years. It was clear from **Table 1** that 1.2% of the current boys who quit the use of waterpipe smoking lasted for more than a year. 4.6% of boys and 2.0% of girls never tried to quit using waterpipe smoking.

**Table 2** presents the frequencies and percentage frequencies for a positive response for associated risk factors in using waterpipe tobacco amongst University of Limpopo students aged 17 to 43. A total of 70.6% of boys and 77% of girls stay on campus for the duration of their study while 29.4% of boys and 23% of girls stay


#### *The Use of Waterpipe Tobacco Products and Its Associated Risk Factors among University… DOI: http://dx.doi.org/10.5772/intechopen.105130*

#### **Table 1.**

*Onset age and number of quitting attempts for waterpipe use amongst University of Limpopo students aged 17–43 years.*


#### **Table 2.**

*Frequencies and percentage frequencies for a positive response for associated risk factors in using waterpipe tobacco amongst University of Limpopo students aged 17–43.*

off-campus. A total of 5.8% boys and 1.6% girls who are currently using waterpipe smoking reported that it was difficult to refuse using waterpipe smoking while 7.0% of boys and 1.8% of girls reported that they like the taste of using waterpipe tobacco products, and the difference was significant (P<0.05).

**Table 3** shows the logistic regression (odds ratio, 95%CI and P-value)) for the association between waterpipe tobacco product use and associated risk factors amongst University of Limpopo students aged 17–43 years. Older onset age (between 21 and 25 years (OR= 6.7 95%CI 3.63 13.05) and above 26 years (OR= 5.57 95%CI 2.77 11.21) was significantly associated with using waterpipe tobacco products even after adjusting for age, gender and receiving a bursary (21–25 years (OR- 6.98 95%CI 3.60, 13.54 and above 26 years (OR= 5.92 95%CI 2.81 12.49). Staying on campus (OR 2.54 95%CI 1.87 3.44) or off-campus (0.39 95%CI 0.29 0.54) was significantly (p<0.05)


#### **Table 3.**

*Logistic regression (odds ratio, 95%CI and P-value)) for the association between waterpipe tobacco use and associated risk factors amongst University of Limpopo students aged 17–43 years.*

*The Use of Waterpipe Tobacco Products and Its Associated Risk Factors among University… DOI: http://dx.doi.org/10.5772/intechopen.105130*

associated with using waterpipe tobacco products even after adjusting for age, gender and receiving a bursary (on Campus OR=3.8095%CI 2.59 5.57) off-campus (0.26 95%CI 0.18 0.39). Liking the taste (OR= 7.84 95%CI 1.66 28.33) and difficult to refuse (OR= 12.25 95%CI 5.06 29.65) were significant (p<0.05) using the waterpipe even after adjusting for age gender and receiving bursary (Liking the taste (OR= 6.54 95%CI 1.76 24.21) and difficult to refuse (OR-11.25 95%CI 4.59 27.58).

#### **4. Discussion**

This cross-sectional study aimed to investigate the prevalence of waterpipe tobacco product use and associated risk factors among University of Limpopo students aged 17–43 years. The current study confirms a high prevalence (40%) of ever waterpipe smoking and low prevalence of current (6.7%) waterpipe users. Daradka et al. [16] reported the prevalence of 24.2 and 36.04% for current and ever using waterpipe smoking, respectively, amongst University students. The prevalence of ever water smoking was almost 60.7% among Iranian medical students with the current waterpipe smoking prevalence reaching 18.7 and 51% for Iranian medical students and health science students [20]. Waterpipe smoking has become a global public health problem and requires serious attention [21].

In the current study, the prevalence of ever (40.2 vs 26.3%) and current (6.7 vs 3.0%) waterpipe user was significantly (p<0.05) high for boys compared with girls amongst University of Limpopo students in each group. Male participants were more likely to report current waterpipe smoking and higher frequencies than their female counterparts as reported by Salloum et al. [22]. However, the current use of waterpipe is not consistent with that of studies in Western Cape Universities, Pretoria Universities and Johannesburg as researchers reported proportion of both males and females being high for both the current and ever water pipe users in these universities [7, 13, 23–25]. An effective waterpipe tobacco control is needed to curb the spread of this dangerous epidemic among both genders in university communities.

In the current study, older age at onset (21–25 years) appeared to be significantly associated with waterpipe smoking usage compared with younger age onset (less than 20 years). Similar findings were reported in other studies [21]. These associations are suggestive and reflect more dependence on waterpipe smoking which may be reflective of social behaviour in university environments. These findings are not surprising given that the older onset of tobacco use is associated with higher nicotine dependence [26]. Furthermore, older students are more conversant with the university environment than first and second-year entering students.

Having friends who are smokers and enjoying the taste were the highest risk factors for waterpipe use among the University of Limpopo students. Similar findings were reported amongst dental students at King Saud University in Riyadh [27]. Student residences were the main factor associated with waterpipe smoking among university students in the current study. University campuses are an ideal setting to reach waterpipe tobacco users and those who may initiate this while on campus [28]. Evidence-based interventions, including tobacco-free campus policies [28] are essential to decrease the initiation and continued use of all forms of tobacco products among university students and across the lifespan [29]. There is a need to further understand factors which may motivate university students to initiate waterpipe tobacco in order to develop prevention intervention [30].

Research had generated a consistent picture of the health risks of waterpipe smoking in the past. Waterpipe smokers clearly show exposure to nicotine, toxicants and carcinogens associated with smoking-induced disease [6, 31]. Waterpipe smoking acutely decreases heart rate variability and elevates CO, plasma nicotine, blood pressure and heart rate [14]. Furthermore, waterpipe smoking can cause or accelerate the rate of pulmonary and cardiovascular complications as well as cancer [32, 33]. Children exposed to waterpipe smoking have been shown to have higher levels of carcinogenic tobacco-specific nitrosamines [34]. It is suggested that several educational and consultation courses could improve habits and the attitude of students regarding the detrimental effects and dire consequences of waterpipe usage amongst the university community. It is also suggested that implementing strict surveillance on the behaviour of students in the hostel and residential places of students, along with direct cooperation of students' families, is important in reducing, if not completely eradicating, waterpipe usage. Furthermore, the university should provide enough recreation facilities for students as they spent most of their time on campus than at home.

This study has some limitations. First, data collection was based on convenience samples, without systematic regulation of sampling factors. As such, findings may not be generalizable to a broader population, including those who have never tried waterpipe smoking. Sampling was limited to university students and did not include other nonuniversity youth and adult sub-populations around the university. Thirdly, we did not consider health risk factors related to smoking including respiratory complications the students may have ever experienced. Fourthly, the study was cross-sectional; therefore, a change in tobacco use over several years was not examined.

A comprehensive questionnaire which covered almost all aspects of daily lives was another positive point of this survey. The findings from the current study can serve as a basis for additional research to document the public health impact of waterpipe smoking and guide regulatory efforts for waterpipe smoking control in the Limpopo Province of South Africa. Future research would generate new evidence to advance waterpipe tobacco control policies.

#### **5. Conclusions**

Our results demonstrate that waterpipe smoking was more prevalent among university male students than female students. Staying on campus or off-campus was significantly (p<0.05) associated with using waterpipe tobacco products. Liking the taste and difficult to refuse were possible risk factors significantly associated with waterpipe usage amongst university students. Future studies should investigate the relationship of waterpipe use and the development of chronic diseases lifestyle over time.

#### **Acknowledgements**

The authors are obligated to the administrators of the Ellisras Longitudinal Study for administration of the study project.

#### **Funding**

The study received funding from the South African National Research Foundation (Reference: RA18092336171, Grant No: 127507) and the University of Limpopo (Account number: N533) for the Ellisras Longitudinal Study is acknowledged with

*The Use of Waterpipe Tobacco Products and Its Associated Risk Factors among University… DOI: http://dx.doi.org/10.5772/intechopen.105130*

gratitude. Any opinions, findings and conclusions or recommendations expressed in this material are those of the authors and therefore the funding sources do not accept any liability in regard thereto.

## **Conflicts of interest**

The authors declare no conflict of interest.
