Waterpipe smoking prevalence has been reported to be high among university students in EMR countries [12]. The results of the present study show that waterpipe smoking is common among young adults (with similar frequencies reported by men and women) studying health sciences at a university in Iran. A systematic review of prevalence of waterpipe smoking from 38 studies found rates of current waterpipe smoking in university students to be 15-28% in EMR countries, 33% in the South Asia region, 10% in the Americas, and 8% in Europe [12]. However, no studies from Iran were included in this review. Waterpipe smoking among university students in Isfahan, Iran, has been reported to be 28.7% in men and 11.5% in women [13]. Self-administered questionnaires in Iranian dental students reveal that 23% are current cigarette, pipe or waterpipe users [21]. A study of university students in South Iran found a prevalence of 18.7% for students who had used waterpipes in the previous 30 days [22] whereas state university students in Iran reported 40.3% waterpipe use [23]. The latter study included 4433 undergraduate students from 7 universities and included universities located in Tehran, Iran [23]. Our study shows that among health sciences university students in Tehran, 51% report occasional or frequent waterpipe use. Our results confirm the higher rates of waterpipe use in university students reported by others in Iran [23] compared to university students from other EMR countries [12]. Students surveyed in our study were first-year graduate students enrolled in a health sciences degree program. While it could be argued that health sciences curriculums are demanding and stressful, most current waterpipe smokers in our study cited social and fun aspects as the primary reason for their continuing use of waterpipes. Few cited stress of university or exams as a motivator for smoking. However, it is concerning that the percent of waterpipe smokers is so high at a health sciences university where students presumably have greater knowledge of the risks and dangers posed by tobacco use and will be entering a career in health care.
Despite the high waterpipe use observed in our study, the degree of waterpipe smoking intensity is likely lower. Occasional waterpipe smokers accounted for slightly more than half (55.3%) of current waterpipe users. Students who were frequent waterpipe smokers (44.7%) were defined as using waterpipes as more than once a month and included students who used waterpipes daily, a few times a week, weekly, or once every 2 weeks. However, a study of Iranian dental students reported that only 7% smoked waterpipes on a daily basis [21].
Contrary to previous studies in this population, ours shows a similar number of women (48%) and men (52%) who are occasional or frequent waterpipe smokers. An increasing frequency of female smoking has been demonstrated, especially among youth [8]. While societal taboos exist against cigarette smoking by women in Iran and other EMR countries, attitudes towards waterpipes smoking are more lax and acceptable in a social and cultural context [4, 20, 24–26]. The high frequency of waterpipe use amongst female students seen in our cohort is mirroring a trend of independence and equal rights that young women are seeking in Iran. Over the last decade, young Iranian women have been enrolling in universities in increasing numbers and currently comprise over half of its university students [27]. Tehran is a diverse, densely populated capital city where many young men and women seek a modern lifestyle. Shahid Beheshti University of Medical Sciences (SBU) is the second largest university in Iran, offering a number of medical and non-medical health sciences curriculums and accepting high-achieving students from different socioeconomic backgrounds. While the academic rigor of SBU is likely to be similar to other health science universities in Iran, its location in its capital city and the large number of women students in attendance may be a contributing factor to the high waterpipe smoking frequency observed in this study. Whether this waterpipe smoking frequency is a reflection of a larger trend occurring in well educated young women in Tehran is a subject for future studies. A recent study reported similarly high rates of waterpipe smoking in university students in Iran (including universities from Tehran), suggesting that higher waterpipe smoking rates are observed in Tehran than in other parts of the country [23]. The authors reported that waterpipe use was more common in men (OR 0.42), and reported the odds ratio for waterpipe smoking to be 26.51 for students from universities located in the west of Iran, including Tehran [23]. This lends support to our findings as our research was conducted at a health sciences university in Tehran.
Waterpipe smoking was perceived as an enjoyable social activity among friends. Indeed, this was rated as the primary motivator behind both initial experimentation and continuation of waterpipe smoking in our cohort. Respondents in our study reported that their waterpipe smoking increased during the holidays and summer months, and most smoked in the company of friends and family, consistent with previously published findings [5, 9, 13, 25]. The role of family in waterpipe smoking appears complex and contradictory. Family members are often waterpipe smokers themselves and are frequently part of the introductory waterpipe smoking experience [2, 3]. However, the apparent initial support of waterpipe smoking by the family may decrease over time, since in our study approximately half of occasional waterpipe smokers reported their family members disapproved of their continued waterpipe smoking habits. Acknowledging and understanding the connection of family in introducing and fostering waterpipe smoking is an essential element in developing strategies to curtail and reduce its use in Iran.
Our study examined student perceptions of waterpipe use. More than half of frequent waterpipe smokers perceived waterpipe smoking to be relaxing, energizing, and a part of their culture in our study. However, when questioned about the dangers of waterpipe smoking, the majority of frequent smokers reported that while they believed waterpipe smoking to be hazardous to their health, they also erroneously believed waterpipes were the healthiest choice among tobacco products. This perception is particularly worrisome as a growing body of literature reveals the negative healthcare effects of waterpipe smoking on exposure to tobacco, carbon monoxide, addiction, and second-hand smoke exposure [12, 28–30]. For example, waterpipe smoking has been associated with predicting progression to regular cigarette use in Danish adolescents [31].
The study was limited in that surveys were distributed to a proportion of first-year health sciences students, rather than all first-year health science students, possibly creating a selection bias. Students completed the survey in a paper format without assistance from trained personnel. The survey involved several conditional questions asking participants to either skip or continue with subsequent questions depending on their previous responses. However, some students interpreted these directions incorrectly and demonstrated skip patterns that were inappropriate, thus creating missing data and reducing our usable sample size. A number of questions were not answered by all respondents, which can be observed in Additional file 2, Table 1, which may have introduced bias in our findings.
This, in combination with the study's convenience sampling, may have contributed to the high frequency of waterpipe smoking that we observed. Furthermore, while the survey questions were adapted from previous studies on waterpipe smoking, the final survey instrument was not validated prior to distribution. In contrast to cigarette smoking, there is currently no consensus in the research community regarding what defines an occasional or frequent waterpipe user. We defined occasional smokers as those using waterpipes less than or equal to once a month, and frequent smokers as those using waterpipes more than once a month, while other investigators have suggested recording waterpipe patterns using categories such as 'daily', 'weekly', or 'monthly'[32]. A consistent definition is needed to allow comparison of results across study populations and outcomes of interventions to reduce waterpipe smoking.
The findings of this study reflect the responses of students at a health sciences university in Tehran, Iran, and conclusions from our study may be different than those of the general waterpipe smoker population in Iran. However, while cigarette smoking is more prevalent in lower socioeconomic and less educated populations and occurs predominantly among males in Iran [8], our study results confirm findings from similar studies [2, 13, 21–23] that waterpipe smoking has developed a surprisingly strong user base within highly educated young men and women. This suggests that waterpipe smoking has become a socially acceptable practice within this demographic.
Health promotion strategies have been developed for the EMR that urge member countries to be proactive in addressing emerging health risk factors, including smoking cessation [1]. Strategies to combat the increasing use of waterpipes among youth and young adults need to be included in these efforts. Public health authorities in Iran need to develop educational programs that reach youth in schools and young adults in universities, particularly women. Since family members were involved with the introduction of waterpipes in almost half of current waterpipe users in this study, messages targeting and involving families should be an essential component of any educational program seeking to reduce the widespread practice of waterpipe smoking in Iran. Furthermore, teachers and faculty at schools and universities should be engaged to include tobacco and waterpipe prevention programs in their curriculum. Faculty at health sciences university campuses in particular should ensure that their curriculums include the dangers and addicting qualities of tobacco use, including waterpipe smoking, and discuss prevention and treatment of tobacco addiction. University administrators should strongly discourage the use of all forms of tobacco on and off their campuses.
