Factors contributing to the upsurge of water-pipe tobacco smoking among Saudi females in selected Jeddah cafés and restaurants: A mixed method study : Journal of Family and Community Medicine

Secondary Logo

Journal Logo

Original Article

Factors contributing to the upsurge of water-pipe tobacco smoking among Saudi females in selected Jeddah cafés and restaurants

A mixed method study

Abdulrashid, Ola A.; Balbaid, Omar1; Ibrahim, Adel2; Shah, Hassan B. U.2

Author Information
Journal of Family and Community Medicine: Jan–Apr 2018 - Volume 25 - Issue 1 - p 13-19
doi: 10.4103/jfcm.JFCM_3_17
  • Open



Tobacco-related diseases are leading causes of preventable global deaths, the reason behind the death of one in ten adults worldwide.[1] Alarmingly, tobacco use is increasing among women and young people in several regions of the world.[2] The preferred method of tobacco use in this group is the water-pipe (WP) tobacco smoking water tobacco smoking (WTS) locally called as mo’assel/shisha. The habit once considered that of old men of low socioeconomic level is now gaining popularity among women and young people mostly of high socioeconomic level.[34] Compared to cigarette smoking, WTS is not considered a social taboo in Arab culture anymore, resulting in the smoking of WP by Arab females in the open without embarrassment or shame.[5] It is widely accepted and many restaurants and cafés in the Eastern Mediterranean Region (EMR) serve it.[56] The reasons for preferring this method include peer pressure, pleasant smell of the smoke, ambience in the café, and especially the perception that it is less harmful.[67]

Realizing the harmful health effects of smoking, the Saudi Government launched an anti-smoking campaign for the first time in 2003.[5] With the growing phenomenon of WTS in public areas, particularly in enclosed places, the Saudi Government issued the smoke-free law in 2012 that applied to indoor restaurants, coffee shops, supermarkets, and shopping malls.[57]

Previous studies indicated that the prevalence of WTS among Saudi females ranged from 18%–37% and highlighted it as a public health concern that required immediate attention to limit a further increase of this phenomenon.[8] The main reasons indicated for the increase WTS use in these studies were peer pressure and psychosocial factors.[89] The use of a mixed method study (combined quantitative and qualitative methods) will give a complete understanding of the problem and develop a complete picture,[10] important for the development of properly structured prevention and policy interventions as recommended by several health organizations.[1112] Together with the quantitative analysis, there is a need for qualitative research to highlight the factors contributing to the increase in frequency of WTS among females, types of tobacco used, and depth and frequency of inhalation. The objective of this survey was to examine the prevalence and analyze in-depth the factors and reasons for Saudi females’ addiction to WTS. It would help explain its impact on health and provide a sound basis for policy makers and programmers.

Materials and Methods

This study was conducted in Jeddah city, considered a hub for cafés and restaurants serving the WP. The participants were adult Saudi females WTS, aged 15 years and above (The selection of this age group, willing to complete the interview, was done in accordance with the WHO report on global tobacco epidemic, 2011).[1] The study adopted a mixed method design, constituting quantitative cross-sectional study to determine the factors potentiating WTS, followed by focus group discussions (FGDs) and in-depth interviews (qualitative design). The total duration of the study was 5 months, from June 1, 2014, to November 1, 2014. The sample size was calculated using Epi Info version 6.4 statistical package (Centers for Disease Control and Prevention, Atlanta, Georgia, USA). The expected proportion (P) was substituted by 0.22 according to the findings of Bassiony (smoking in Saudi Arabia).[8] The worst expected frequency was set at ±0.05, confidence interval of 95%, and power of (80%), and the sample size accounted for a minimum of 264 individuals. Interviews in the qualitative method stopped on reaching “stage of saturation” (when no new or relevant information emerged).

There was no clear distinction of the cafés assigned only for families; therefore, the researcher had to pursue a convenient sampling for cafés for families and restaurants that served WP. Around 14 restaurants were chosen, permission from the restaurants’ management, approval from Institutional Review Board/Ethics Committee of Ministry of Health Jeddah secured, and oral consent from the participants were obtained. Four restaurants refused us permission to interview their customers.

The Arabic version of the questionnaire with slight modification was adopted from literature review (Bassiony and Lebanon WP) having internal consistency (Cronbach's alpha coefficients equal to 0.83).[813] As the participants were females, the researcher added questions on smoking WP during pregnancy, marital status, and permission for their children to smoke.

In the qualitative method, the participants were recruited from the WP cafés and restaurants in Jeddah through the Snowball Technique. To enroll the participants, the researcher visited the selected restaurants, approached the females smoking WP, and after explaining the purpose of study, requested them to invite their friends to the same place for FGDs. The researcher obtained oral consent from each participant and assured them of the confidentiality of data. Some of the participants refused to have a voice recording, so notes were taken instead. Each FGD involved 5–6 participants, usually friends of the same age group. The aim of this was to allow the females to freely discuss their attitudes and perception of WTS without any embarrassment. FGD was organized as a semi-structured interview with a set of predetermined open-ended questions, encouraging new themes that would emerge from the dialog between the researcher and the participants. Each session took 60–90 min, stopped when saturation was reached, i.e., no new themes were being generated from the discussions. In-depth interviews were conducted with heavy WP smokers (daily smokers), mainly aimed at delving deeply to understand their WTS experiences. Each session of the in-depth interview took 30–40 min and stopped when saturation was reached.

Data entry and statistical analyses were done using SPSS (version 16.0, SPSS for Windows, Chicago, USA). Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables while mean and standard deviation were used for quantitative variables after ensuring normality of the distribution. Chi-square test was used to establish the association for categorical variables. Binary logistic regression was used to find out factors predicting binomial outcome, namely tendency to be addicted to WTS. Since the WP is not as portable and accessible as cigarettes, its users may engage in more intensive behavioral adaptations to ensure access, such as relating it to mood and weather, carrying one's own WP to places, and selecting cafés based on the availability of WP. Similarly, smokers’ perception of smoking more than before and being addicted to it (categorized as daily, weekly, and monthly smoker) was considered as a factor related to dependence on WP.[67]

Key themes were identified and built upon for the qualitative part. It is a process of coding qualitative data using a list of themes or patterns found in the transcripts, ranging from a simple description of observation to an interpretation of the phenomenon.


A total of 332 adult WTS Saudi females, with a mean age of 32.5 ± 11.9 years, visiting Jeddah restaurants and cafés completed the questionnaire. Most (57%) were highly educated, slightly <one-half (42.1%) were employed, and around one-quarter (24.3%) were students [Table 1]. The mean age at which they started smoking WP was 24.8 ± 8.2 years. The majority of the study participants were either single (36%) or married (44%). Around 39.6% of the women were addicted to WTS [Table 1].

Table 1:
Demographic characteristics of the study participants (n=332)

The results demonstrate that an overwhelming majority n = 309 (93%) used mo’assel and almost two-thirds n = 196 (59.0%) consumed one head per session. Of the total, only 17.1% (n = 57) were concurrently cigarette smokers. It was noted that the older women were more likely to smoke daily [Figure 1]; the frequency ranged from 12.5% of the women aged 16–20 years to about two-thirds of the smokers aged 41 + years. This increase was statistically significant, p < 0.05 (Chi-square). The frequency of daily smoking was found to be significantly higher among married and widowed than with single and divorced women. Furthermore, the students were the least to smoke daily [Figure 2].

Figure 1:
Frequency distribution of Water tobacco smoking by age
Figure 2:
Water tobacco smoking (a) frequency and marital status (b) frequency and occupation

Those who smoked daily used significantly more heads per session (P < 0.001); the frequency of their smoking increased when the weather was pleasant, which related to their mood and WTS [Table 2]. This study showed that students and working women were more addicted to WTS (p < 0.001). Those who smoked daily preferred to smoke at home especially when they were alone (p < 0.001) while the preferred place for those who smoked weekly was restaurants in the company of friends (p < 0.001).

Table 2:
Factors related to addiction to water tobacco smoking

Table 3 demonstrates the model of the regression analysis for the factors that predict addiction of smokers to WTS. The results showed that increased frequency (sessions) of WTS, perception that WTS improved mood, and insistence on taking one's own WP to restaurants and cafés were the most significant predictors addiction to WTS, p < 0.05. It was evident that those who smoked daily were almost three times (odds ratio; 2.8) as likely to be addicted than those who smoked weekly.

Table 3:
Factors predicting addiction to water tobacco smoking

A total of 32 participants in the FGD and in-depth interviews were recruited by the snowball method. The participants of the in-depth interview were the regular (daily) and heavy (more than three WP per day) smokers.

The main categories and themes identified in the FDGs and interviews are given in Table 4 and details are provided in the following text.

Table 4:
Categories and key themes of qualitative analysis

Factors influencing/contributing to water tobacco smoking use

Motivations for water tobacco smoking

The reasons identified for the increase in WTS use include entertainment, having a good time with peers, especially in pleasant weather and different festive occasions. The main reason for starting WTS included peer company and imitation of friends and celebrities (66.7%). One participant commented:

“… I started WTS as result of my friends; all of them smoke when we get together. After smoking a few times, I got into the habit.”

Mood is another trigger for the women to crave WTS. The misconception that it could counter stress and provide a false sense of feeling relaxed increases WTS use as one respondent said:

“… Smoking WP gives a great feeling, relieves my tensions and helps me to relax. I just want to smoke in a quiet environment and enjoy my WTS session.”

Sensory characteristics of water-pipe

Around (100%) participants were attracted to the smell and taste of the fruity mo’assel, which is available in different attractive flavors such as cappuccino, bubble gum, cheesecake, and many more.

“… I tried many flavors of mo’assel. it's nice to try different flavors every time.”

Most of the participants agreed that the smell of smoke pleased and relaxed them. The more smoke they exhaled, the happier they felt (91.7%).

“… I get annoyed if the smoke is little. I want it to be dense, so I like more coal at the head of the WP”.

Sociocultural norms

Smoking WT by a woman, especially in the restaurants, was not acceptable in this reserved culture a few years ago. However, of late, the stigmatization relating to WTS has disappeared and Saudi females now smoke freely without any feeling of shame. Most of the participants were of the opinion that WTS was not forbidden by religion, so they had no guilt smoking WP (79.2%).

Parents and other family members

Many young participants go to cafés and restaurants to smoke WP without their parents’ knowledge and permission as one participant told us:

“… My parents don’t know that I smoke; I usually go with my friends to cafés after sneaking away from college.”

Even though stigmatization of WTS has minimized as a whole in our culture, parents fear that if their daughters use WTS, getting a good spouse for them would be difficult.

With regard to married women, it is necessary to get the permission of their spouses for them smoke WP. Smoking without a spouse's knowledge is sometimes the reason for marital problems. As one participant stated:

“My husband doesn’t allow me to smoke WP although he himself is a smoker. Actually, he doesn’t like the image of women smoking WP.”

The image of females smoking cigarettes and young girls smoking WP is not acceptable even among the women who use WT.

Frequency and availability

Most of the participants in the FGD and interviews were students and women in employment. The preferred time for the working women to smoke WP was early in the morning before work and late at night after completing their daily chores.

“… I prepare my WP at night, so that after Al-Fajr prayers I have time to smoke one head of mo’assel.” “After I return from my work my maid would have already prepared my WP, so I smoke before I have a nap.”

“… My friends and I schedule our lectures at the beginning of the study semester, so they fit in with the time when restaurants serve WP in the morning.”

The frequency of WTS varies among the participants, but the daily (heavy) smokers can use as many as seven or eight heads per day. The participants showed that they were so obsessed with WTS that they could go without food, abandon their work, or even social gathering just to smoke WP.

Health believes about water tobacco smoking

Health effects of water tobacco smoking

Even though most participants of the FGD and in-depth interviews knew that WTS was harmful and could cause fatal diseases, they still indulged in it.

“… My mother died from smoking-related disease. She was a heavy smoker, but it doesn’t matter; as I enjoy WTS.”

Advantages and disadvantages of water tobacco smoking

From the perspective of the participants, WTS helps one to relax, increases concentration, and decreases appetite. WT smokers have the misconception that it is better and less harmful than cigarette smoking. They think that it is hygienic as it does not cause bad mouth odor and does not leave a smell on the hands and clothes. Moreover, since it is not easily accessible at all times such as in the car or when walking, it is less used. Another misperception is that the water in bowl filters the nicotine making it less harmful than cigarettes.

Beauty concerns

The only thing which some of the participants were concerned about was the effect of smoking on their beauty. They were afraid of an increase in wrinkles on the face, especially around the mouth, and the effect on the color of their teeth.

“… I am a heavy WP smoker, I smoke 5–8 heads per day, but of late I have been trying to reduce WTS because of the discoloration of my teeth and some shortness of breath.”


Worldwide, WTS by women has become a public health issue. In this study, we used the mixed method technique to better understand increased WTS trends. Quantitative methods were used to determine the factors behind it, and the qualitative approach to give more in-depth understanding of this social phenomenon.

The influence of religion and the conservative society should have made the prevalence of WTS lower in EMR than other countries. However, reports indicate an increase in WTS consumption.[1415] Quantitative part of the current study highlights an increase in the WTS use when the weather is good. The women are in a good mood and want to enjoy the company of their friends. Similar findings have been recorded in Lebanese and other Arab populations.[1314] Choosing cafés that serve WP or bringing their own WP increase the likelihood of WTS consumption. This was also seen in the population of studies conducted by Dar-Odeh et al.[14] and Khalil et al.[16]

The qualitative part highlighting factors that increase WP use includes encouragement by seeing successful and highly educated females use it, perception of smoking in public as a status or a fashion symbol, enjoyment of the weather and company, enjoyment of the different flavors, means of entertainment/enjoyment, and smoking as a means of rebelling against parent's opposition. Similar findings were highlighted in studies conducted by Khalil et al.[16] Nakkash et al.[17] and Mandil et al.[18] However, the most important reason was peer pressure, which was also seen in different studies conducted in Egypt, Sharjah, and India.[1119202122]

Parents who themselves smoke were not in favor of their children indulging in this habit.[161723] As explained by the outcome of the FGDs, parents often oppose and discourage the use of WTS, especially in unmarried girls, believing that it may ruin their reputation and decrease their marriage prospects.

The misconception of WTS being less harmful and better than cigarettes because of the fallacy that water filters nicotine and other toxins is unintentionally increasing its dependency. This point was raised and discussed in our FGDs. In contrast to studies conducted in Egypt[24] and USA,[25] where around 74% thought cigarette to be more dangerous, most of our participants knew that WTS is as harmful as cigarette to health but was not strong enough reason to stop it.

Feeling of pleasure and being relaxed with the all tension released are other contributory factors that lead to dependency. Studies conducted in Lebanon, Saudi Arabia, and Syria have also recognized the dependency of WP smokers.[5131723] The present study also shows trends of increased dependency on WTS. Studies show that the important steps toward dependence include choosing restaurants and cafés that provide WP, taking one's own WP when going out, desire to smoke as soon as they wake up and high frequency (number of heads) per day.[2526] Age is also a factor of dependency. The students were mostly occasional smokers (weekly and monthly) while the older women were generally regular (daily) smokers.[2728]

What can encourage them to quit WTS are either the deleterious effect of the smoke on their skin and face and the discoloration of their teeth or the hazard it poses to their children. That is why they usually discourage their children from smoking. Similar findings were seen in a study conducted in Dammam.[27] Some Lebanese women consider WTS to be attractive and that it attracts men's attention.[13] The participants of our study had contrary views on this. They did not think that smoking attracted men, but that women tended to lose their femininity with smoking.

One limitation of our study was the sampling in the quantitative method, which provided a convenience sample because of the unavailability of the list of WTS restaurants and cafés from Jeddah Municipality.


WTS among Saudi young girls/women is spreading fast threatening the health of this group, making it a public health concern. Peer pressure, perception of it as a fashion symbol, carrying one's own WP, and the wrong belief that WP was less harmful, improved mood, and effect of the weather are main factors that lead to unintentional dependency/addiction to WTS. Understanding these factors behind the upsurge of WTS can encourage appropriate prevention/cessation programs. In this way, we can protect our new generation from the dangers of WTS. Health education through multisectorial institutions (e.g., Ministry of Health, Ministry of Education, Jeddah Municipal) can improve knowledge, change attitudes, and correct the misconceptions on the habit of WTS, especially in vulnerable groups.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

1. WHO Report on the Global Tobacco Epidemic: Warning about the Dangers of Tobacco. Global Tobacco Epidemic. 2011Last accessed on 2017 Jan 173rd ed World Health Organization Available from: http://www.who.int/tobacco/global_report/2011/en/
2. Samet JM, Yoon SY. Gender, Women and the Tobacco Epidemic 2010Last accessed on 2017 Feb 19 World Health Organization Available from: http://www.whqlibdoc.who.int/publications/2010/9789241599511_eng.pdf
3. Bowler S. Reducing Hookah use, a Public Health Challenge for 21st Century 2013. The BACCHUS Network 2013Last accessed on 2017 Feb 19 Available from: http://www.tobaccofreeu.org/pdf/HookahWhitePaper.pdf
4. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: A re-emerging strain in a global epidemic Tob Control. 2004;13:327–33
5. Haseebullah MA. Smoking in Saudi Arabia and its control measures Brit J Human Soc Sci. 2012;5:69–75
6. Maziak W. The global epidemic of waterpipe smoking Addict Behav. 2011;36:1–5
7. Jawad M, McEwen A, McNeill A, Shahab L. To what extent should waterpipe tobacco smoking become a public health priority? Addiction. 2013;108:1873–84
8. Bassiony MM. Smoking in Saudi Arabia Saudi Med J. 2009;30:876–81
9. Daffa R. An Exploratory Study on the Impact of Acculturation on Waterpipe Smoking Practices among Arab Americans in San Diego 2010 California
10. Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best Practices for Mixed Methods Research in the Health Sciences 2011 Maryland, Bethesda National Institutes of Health
11. . Gender and Tobacco in the Eastern Mediterranean Region. Women in Health and Development 2010Last accessed on 2017 Feb 21 World Health Organization Available from: http://www.ksu-symposium-2010.sa-tcp.com/pdf/Gender_and_Tobacco_07.pdf
12. Maziak W, Ward KD, Eissenberg T. Factors related to frequency of Narghile (waterpipe) use: The first insights on tobacco dependence in Narghile users Drug Alcohol Depend. 2004;76:101–6
13. Salameh P, Waked M, Aoun Z. Waterpipe smoking: Construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11) Nicotine Tob Res. 2008;10:149–58
14. Dar-Odeh NS, Abu-Hammad OA. The changing trends in tobacco smoking for young Arab women; Narghile, an old habit with a liberal attitude Harm Reduct J. 2011;8:24
15. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review BMC Public Health. 2011;11:244
16. Khalil J, Afifi R, Fouad FM, Hammal F, Jarallah Y, Mohamed M, et al Women and waterpipe tobacco smoking in the Eastern Mediterranean region: Allure or offensiveness Women Health. 2013;53:100–16
17. Nakkash RT, Khalil J, Afifi RA. The rise in Narghile (Shisha, Hookah) waterpipe tobacco smoking: A qualitative study of perceptions of smokers and non smokers BMC Public Health. 2011;11:315
18. Mandil A, Maqsoud SA, Tayel K, Shama M. Tobacco use among population subgroups: A gender analysis Open J Prev Med. 2012;2:468–77
19. Mandil A, BinSaeed A, Ahmad S, Al-Dabbagh R, Alsaadi M, Khan M, et al Smoking among university students: A gender analysis J Infect Public Health. 2010;3:179–87
20. Mandil A, Hussein A, Omer H, Turki G, Gaber I. Characteristics and risk factors of tobacco consumption among university of Sharjah students, 2005 East Mediterr Health J. 2007;13:1449–58
21. Pomerleau CS, Marks JL, Pomerleau OF. Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology Nicotine Tob Res. 2000;2:275–80
22. Kakodkar PV, Bansal SS. Hookah smoking: Characteristics, behavior and perceptions of youth smokers in Pune, India Asian Pac J Cancer Prev. 2013;14:4319–23
23. Mandil AM, Bahnassy AA, Aboul-Azm SM, Bashawri LA. Knowledge, attitude and smoking patterns among nursing and laboratory technology students, Dammam, Saudi Arabia J Family Community Med. 1999;6:51–8
24. Labib N, Radwan G, Mikhail N, Mohamed MK, Setouhy ME, Loffredo C, et al Comparison of cigarette and water pipe smoking among female university students in Egypt Nicotine Tob Res. 2007;9:591–6
25. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE, et al Prevalence of and associations with waterpipe tobacco smoking among U.S. University students Ann Behav Med. 2008;36:81–6
26. Chaouachi K. Hookah (Shisha, Narghile) smoking and environmental tobacco smoke (ETS). A critical review of the relevant literature and the public health consequences Int J Environ Res Public Health. 2009;6:798–843
27. Koura MR, Al-Dossary AF, Bahnassy AA. Smoking pattern among female college students in Dammam, Saudi Arabia J Family Community Med. 2011;18:63–8
28. Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J, et al Motives, beliefs and attitudes towards waterpipe tobacco smoking: A systematic review Harm Reduct J. 2013;10:12

Female smokers; hokkah; hooking; mo’assel; water tobacco smoking

© 2018 Journal of Family and Community Medicine | Published by Wolters Kluwer – Medknow