INTRODUCTION

The rapid spread of the new coronavirus that causes COVID-19 infection in various parts of the world has caused concern worldwide, especially after the World Health Organization (WHO) classified it as a global pandemic¹. Smoking in general kills directly or through diseases related to smoking, as the World Health Organization stated that about 7 million people die annually as a result of smoking¹. Smoking any type of tobacco reduces lung capacity, increases the risk of many respiratory infections, and can increase the severity of respiratory diseases². COVID-19 is an infectious disease that primarily attacks the lungs and impairs lung function, and research indicates that smokers are more likely to develop serious complications from COVID-19 and die³. Smoking hookah (also named shisha, waterpipe, narghile or argileh)³, is a habit that has spread all over the world, known in India, Africa, the Arabian Peninsula, Canada, the United States, Malaysia, South-East Asia, and Turkey^4-12. People use different types of tobacco with hookah, that can include opium and hashish. The hookah consists of a bowl containing water, a heating rod, and a long hose (pipe) for extracting smoke. It may have more than one pipe to share, or more than one person may use the same pipe. Hookah smoke contains dangerous chemicals that affect the respiratory system, weaken the lungs, and expose the body to the risks of viruses, tuberculosis, bacterial infections, fungi and other diseases, including the COVID-19⁵. In addition to the risk of transmission of the COVID-19, smoking hookah has many long and short-term effects starting with the reaction that the body automatically produces when smoking hookah such as dizziness, dehydration, and coughing⁸. The World Health Organization explains that hookah contains less nicotine, which may cause an individual to smoke more and not know when to stop, and this may lead to an upset stomach or nausea⁹. The majority of hookah smokers believe that the smoke of hookah tobacco is filtered by the water at the base of the hookah bowl and that many harmful substances and toxins have been removed making it less harmful to health¹⁰.

Hookah smoke enters the respiratory system, and thus viruses in the chest can pass onto the hookah pipe and subsequently to whoever uses it. Microbes colonize the hookah device, particularly the mouthpiece and handle. Hookah cafes worldwide are known for overcrowding and poor ventilation, which lead to poor air quality (e.g. high levels of particles, tobacco-specific nitrosamines, and polycyclic aromatic hydrocarbons). Social distancing and educating the public about the possible link between smoking (cigarettes, hookah, or roll-your-own) and the risk of transmission of COVID-19 is the most important measure to take. Also, smoking cessation programs should be activated during this period in conjunction with the fight against the spread of COVID-19. Hookah smoking is a widespread habit in Saudi Arabia and a prominent social activity in cafes and daily gatherings of people¹³. Sharing hookah pipes with others is very common among people in Saudi Arabia^14,15, which is a risk for spreading COVID-19. Inadequate cleaning of hookah utensils, especially trumpets, increases this risk. Non-participation, use of clean and sterile equipment, adherence to hygiene practice and COVID-19 prevention measures can reduce the transmission risk. This study aims to assess participants awareness of the risks of hookah use during the pandemic and the risks of sharing hookah pipes and their impact on the spread of COVID-19, in Saudi Arabia.

METHODS

RESULTS

A total of 490 participants joined the study using the Google Form Survey via a link sent to them via email and WhatsApp, as shown in Table 1. Among the participants, 52% were of Saudi nationality (n=255) while 48% were non-Saudis (Egyptian, Sudanese, Palestinian, Qatari, Chadian, Yemeni, Kuwaiti). Most (72%) participants were male. A quarter of them were aged 21–30 years (35.3%), 202 were single, and 51.4% of the participants had a Bachelor’s degree. Nearly a quarter of the participants were healthcare workers. Regarding hookah smoking, as shown in Table 2, a total of 33.3% of the participants smoked hookah (n=163), and 55.1% said they knew the content of hookah; 49.6% did not know if the toxic substances in hookah smoke are filtered out by the water in the hookah bowl. Fifty-seven percent of the participants said they did not know if the cold, wet smoke from the pipe was less harmful, and 173 (35.3%) said hookah smoking is less addictive than cigarette smoking. The participants’ awareness level is low based on our cutoff point; if participants’ awareness is <60% then this is considered a low level of awareness (Table 2).

Most of those who smoke hookah were aged <30 years, as shown in Table 3. Hookah smokers were 34.6% male and 29.9% female, and 27.1% of Saudi participants (n=255) and 40% of non-Saudi participants (n=235) smoked hookah (p=0.002). About 37.7% of singles and 29.9% of married couples smoked hookah (p=0.067). Also, 33.3% of those with less than secondary education smoked hookah, and 33.2% of those in universities and higher education smoked hookah. We also found that 37.55% of the health worker participants smoked hookah.

The answer to the question: ‘Are the toxic substances in the smoke filtered out by the water in the hookah bowl?’, the response was variable, as shown in Table 4. We found that more than 40 participants aged >40 years answered that toxins are not filtered by the water in the hookah bowl, but the majority of ages responded ‘don’t know’ (p=0.005). Those who answered that toxins do not filter out in in the water in the hookah bowl were 40% government employees. Most of those aged <30 years believe that hookah is less addictive than cigarettes (47.9; p<0.001), while 46.2% of singles believe that hookah is less addictive than cigarettes. Workers in the health sector thought that it was less addictive (40.8%), but the majority of other job holders thought the opposite, as shown in Table 4. When we asked, ‘Do you think stopping sharing a hookah hose could prevent the spread of COVID-19?’ (Table 4), most of the answers were ‘yes’ and with a high percentage, among them: 69.1% men, 75.2% women, 71% Saudis, 70.6% non-Saudis, 72.6% single and 69.4% married, and 67.4% with a high school diploma or less, and 72.3% of university degree holders or higher, government employees 78.2%, health workers 75.7%, educators 64.4%, unemployed 62.7%, and retired 65.5% (Table 4).

The participants who shared hookah pipes with others before the outbreak of the COVID-19 pandemic were 22.7% and the participants who shared hookah pipes after the outbreak of the COVID-19 pandemic were 8.4% (Pearson chisquared p<0.001). A total of 70% of participants said that stopping the sharing of hookah may reduce the risk of the spread of COVID-19 among people; 78% of them supported setting policies that prevent people from gathering in cafes, restaurants, and homes to smoke hookah and suggested that these policies may limit the spread of COVID-19; and 95.1% of them believe that stopping smoking will improve the general health of people and reduce the risk of spreading diseases, as shown in Table 5. The participants’ knowledge is high in our study based on our cutoff point; if participants know ≥60%, they are considered to have high knowledge. The knowledge of participants about the risk of sharing hookah with others is shown in Table 5.

DISCUSSION

In this study, we found that 33.3% of the participants smoked hookah, while those who smoked hookah and cigarettes together were 44.7%. These results can be compared with the results found in Jackson et al.¹¹ who found that 33.3% of participants were regular hookah smokers. Ami et al.¹² in their article, found that the proportion of participants who smoked cigarettes and hookah together was 16.5% which is less than our study result. Also, Barnett et al.¹³ in the USA found that hookah smoking exceeded cigarette smoking (46.4% vs 42.1%)¹⁸. While Kalan et al.¹⁴ in Iran found that the participants who smoked hookah were less likely to smoke than those who smoked cigarettes.

In this study, we examined 490 participants (mean age = 35.3 ± 18.7 years), predominantly men, with a high education level (69.5% university degree or higher). These findings align with previous research conducted in Iran¹⁵, Saudi Arabia^16,17, the UK¹⁰, and the systematic review by Itumalla et al.¹⁷ in Saudi Arabia.^. Our study revealed that the majority of participants do not smoke hookah. However, among the respondents who do smoke hookah, it is evident that this behavior has become a habit across different ages, education levels, occupations, and marital statuses.

Several articles have reported prevalence rates of smoking, particularly hookah smoking, in Saudi society. Hassan et al.¹⁸ in their study at Al-Ghad International College (Male-Riyadh) in Saudi Arabia, noted that the prevalence of cigarette smoking among students was 34.8%, hookah smoking was 21.2%, and individuals who smoked both cigarettes and hookah accounted for 40.9%. Alkhalaf et al.¹⁹ found that hookah smoking prevalence among medical students in the College of Medicine, Jazan, was 12.4%. Furthermore, the prevalence of passive smoking among all medical students was 39.9%, with 18.6% of male and 5.9% of female medical students being active smokers. These findings align with our study, which revealed that 33.2% of individuals with higher education smoked hookah.

Amin et al.¹² conducted a study among secondary school students aged ≥18 years in Al Hassa, Saudi Arabia, and found that 21.7% were current smokers, with 46.1% smoking only cigarettes, 37.4% smoking only hookah, and 16.5% smoking both cigarettes and hookah. Similarly, in our study, we observed that 40% of participants who reported hookah smoking were young individuals. Abdulrashid et al.¹⁵ in their study conducted in various cafés and restaurants in Jeddah, found that 39.6% of women participants were hookah smokers. Their study also highlighted higher hookah addiction rates among students and working women. In our study, 29.9% of women participants were hookah smokers.

Our findings regarding hookah smoking align with an international study by Wong et al.⁸, which found that the majority of hookah users were young people aged 21–30 years in Malaysia. Additionally, Grekin et al.²⁰ reported that 1 in 5 American college students had used hookah in the past year. Another study by Kalan et al.¹⁴ in Iran revealed that 64% of participants were male, with high education levels (76%), and had a prevalence of hookah smoking (70%), cigarette smoking (89%), and dual smoking (86%).

The aim of this study was to assess the level of awareness among participants from Saudi Arabia regarding the risks associated with hookah use. Overall, the study found that the level of awareness varied based on sociodemographic characteristics, but was generally low among the study group.

Prior to the COVID-19 pandemic, 22.7% of participants reported sharing hookah with others. However, the majority (70.8%) believed that ceasing to share hookah could reduce the risk of COVID-19 transmission. Following the outbreak of the pandemic, the percentage of people sharing hookah decreased to 8.4%. Additionally, 95.1% of participants believed that quitting smoking would improve overall health and reduce the spread of diseases. Furthermore, 90% of participants were aware that COVID-19 transmission could occur through sharing hookah pipes.

It is important to note that smoking, including hookah use, has been identified as a source of increased risk and severity of COVID-19³. The design of hookahs, with long pipes that are challenging to clean, and the presence of a cold-water bowl, create an ideal environment for COVID-19 transmission^21,22. Hookah tobacco smoke contains harmful chemicals that can infect the respiratory tract and increase susceptibility to infectious diseases, including COVID-19²³. Controlling hookah-serving establishments is crucial, as they contribute to exposure to PM2.5, which heightens the risk of respiratory and cardiovascular diseases among hookah smokers²⁴. Government efforts, regulations, and policies can help curb the spread of COVID-19 in hookah-serving venues. In fact, 78% of participants believed that government-imposed policies on sharing hookah would reduce COVID-19 transmission.

Addressing the issue of hookah smoking in home environments is particularly challenging, as many studies indicate that almost half of hookah smokers believe that smoking at home is safe. However, it is encouraging that 95.1% of participants acknowledged that people’s health would be better without smoking. Awareness campaigns through social media platforms are necessary to educate smokers, emphasizing the link between smoking and the spread of COVID-19, highlighting the risks of sharing hookah, and promoting smoking cessation.

CONCLUSIONS

The level of awareness and knowledge differed according to some sociodemographic characteristics of our study group, but generally, the level of awareness of the risks of hookah use during the pandemic and the risks of sharing hookah pipes and their impact on the spread of COVID-19 was low in the study group.