A Comparison of Shisha Smoking among University students in Palestine, Jordan and Turkey

Background: Smoking is one of the main causes that is related to lung cancer. It was estimated that tobacco smoking may kill 10 million people annually in the next 20– 30 years, and Shisha smoking was very common habit worldwide during the last 20 years, especially in the Middle East. This study aimed to determine the prevalence of shisha smoking and make a comparison between three different countries in the Middle East, and establishing factors associated with shisha smoking among students in universities in Palestine, Jordan and Turkey. Methods: An online cross-sectional study was carried out among university students from 3 different Middle East countries; Palestine, Jordan, and Turkey. A total of 812 students were selected for the study. They were asked to answer an online structured questionnaire consisted of questions concerning prevalence and patterns of Shisha smoking, and associated factors. Data was analyzed by Statistical Package for Social Sciences. Results: The overall prevalence of Shisha smoking was 31.77%. Less than quarter of university students (21.67%) had smoked shisha before. The highest percentage of current Shisha smokers were Palestinians (36.11%), and lowest percentage was from Turkey (20.23%). Approximately 43% of Shisha smokers believe that they will be addicted to Shisha smoking and almost half of them smoke Shisha daily. Approximately, 66% of Jordanian students’ current Shisha smokers were smoking shisha at least once daily while the 44% of Turkish students’ current shisha smokers were smoking shisha once monthly. The highest percentage of Shisha smokers were university students aged 25 years old and above. However, highest percentages of university students who are Shisha smokers were low monthly income’s students.

The university students living with their families were smoking Shisha less frequently than students' living in private residencies.
Conclusions: There was a high prevalence of Shisha smoking among university students. The highest percentage of university students smoking Shisha were Palestinians. High percentage of smokers between the students believes that they will be addicted to Shisha smoking. The majority of current Shisha smokers was smoking Shisha daily; especially in Jordan and followed by Palestine. The monthly income was affecting the prevalence of Shisha smoking.

Background
The tobacco smoking is one of the main behavioral factors related to increase the rsik of cancer worldwide, which is one of the leading causes of death globally so far [1]. Shisha smoking with different names water pipe, Narghile or Hookah is one of the main social habits and behaviors which is becoming more common day by day especially among adolescents. It was claimed that more than one hundred millions of people worldwide smoke shisha [2]. Smoking Shisha is less harmful than cigarette; because the water is useful in the Shisha to purify the toxins or the heavy metals. However, the Shisha smokers might inhale much more smoke as compared to cigarette smoking due to the longer duration of Shisha smoking. In addition, one session of Shisha smoking is found to be equivalent to smoking 100 cigarettes [3][4][5]. High concentrations of Nicotine, tar, Carbon Monoxide, and heavy metals are present in the Shisha smoke [3,6].The Shisha's country of origin is thought to be India, but others stated that it was Ethiopia, South Africa, or Persia [7,8].
After reviewing many published studies concerning the prevalence of Shisha smoking; one of these studies was targeted adolescents in developing countries, with title "Knowledge, attitude and perception of water pipe smoking (Shisha) among adolescents aged 14-19 years", the targeted sample was collected in Karachi city of Pakistan. They observed that Shisha is more addictive as compared to cigarettes in the same time they were confirmed that Shisha is being more socially acceptable for that culture [2]. However, a study done in different Pakistani cities indicated that the prevalence of Shisha smoking was 19.7%, more common in males than females. Furthermore, the highest percentage of Shisha smoking was observed in Islamabad the capital of Pakistan (28.1%), and the lowest was in Peshawar (11.2%). Also, the highest percentage was observed in professional and private educational schools with almost 29% of students [5]. While the following study which is also done in Pakistan, focused on the frequency of Shisha smoking found that 36% of students were smoking shisha in different frequencies, 45% of them were smoking Shisha rarely, 25% of smokers smoked sometimes, 13% were smoking always, 6% were smoking it often and 10% just smoked it once [9].
Data concerning Shisha use, attitude, knowledge, and factors associated with Shisha smoking was collected in a cross-sectional study conducted in Rwanda. The prevalence of the students who smoked Shisha in the last month was approximately 21%, and the students ever smoking Shisha was 26%. It was observed that the highest percentage of Shisha smokers were in ages between 20-24 years [10].
Another cross-sectional study was conducted among a sample of 371 students recruited from medical schools in eastern region of Saudi Arabia. The overall prevalence of Shisha smoking was 12.6%, more than 63% of smokers started smoking Shisha in ages between 16-18 years, and 15% of them smoked Shisha daily [11]. Another study titled "Smoking, Awareness of Smoking Associated Health Risks, and Knowledge of National Tobacco Legislation in Gaza, Palestine" that targeted the university students in the Palestinian city of Gaza had focused on the prevalence of Cigarette and Shisha smoking, health risks, and knowledge. They observed that 55% of students ever smoked before, 36% were smoking Shisha only, and 31% were smoking cigarette [12]. A newly research conducted in Palestine from different Palestinian universities in the West Bank and Gaza Strip, had focused on the gender differences in tobacco smoking prevalence (both cigarette and Shisha), and sociodemographic characteristics. It was indicated that the overall prevalence of current tobacco smoking was 30% of the study participants, and men were more likely to be current Shisha and cigarette smokers compared to women [13].
The current study focused on the prevalence of Shisha smoking among university students in three different Middle East countries; Palestine, Jordan, and Turkey, which have different cultures and races, and associated factors such as the educational level for students and parents, age, income, and residency. Furthermore, we also tried to measure the addiction of smoking Shisha between the university students through questions concerning Shisha smoking frequency and addiction that make the study unique in comparison with other studies.

Research Design and Population
An online cross-sectional study was carried out among university students from 3 different Middle East countries; Palestine, Jordan, and Turkey. A total of 812 students were selected for the study, and this study was cross-sectional. The data concerning the prevalence of Shisha use and the associated factors was collected from students in different universities in Palestine, Jordan, and Turkey; which are Middle East countries. The Middle East is a transcontinental region centered on Western Asia. Geographically, the largest Middle East countries are Turkey, Egypt, and Saudi Arabia, and the smallest is Bahrain. But, Palestine, Jordan, and Turkey are pivotal in the Middle East ;due to their respective privacy [14]. Palestine is under Israeli occupation, Jordan is a fairly stable country, but it is surrounded by countries full of conflict, including Iraq, Syria and Palestine [15]. Turkey is a country that grows economically and politically, but is exposed to conspiracies. Main universities included in the study are An-Najah National University-Nablus, Palestine, Al-Zaytoonah University of Jordan-Amman, Jordan, and Girne American University, North Cyprus.
An-Najah National University is the largest Palestinian university that has 300 Professors and 23,345 enrolled students in 19 faculties posing multiple disciplines.
Al-Zaytoonah University of Jordan is a private Jordanian university with 8000 enrolled students, from which 14% of them are students from 28 countries. The Girne American University was the first private university in North Cyprus, and the total number of students registered in various disciplines provided by the university was up to 18,000 according to the 2016 statistics [16,17]. The questionnaires were formulated using Google forms and the online copy is available as a Google™ document (https://docs.google.com/forms/d/e/1FAIpQLSdwebHFniEECLYshw2CWpSV0EDdIP9Mx 1nhP4y03BdAe88D1A/viewform?usp=sf_link ). This type of forms were used in other studies before to collect the sample's answers online [18]. The process of contacting the students was facilitated using official Facebook pages of student's associations and unions.

Ethical Consideration
The study was approved by Institutional Review Board (IRB;17.06.2019) at the Faculty of Medicine and Health Sciences of An-Najah National University, and the Ethical Research Committees of Al-Zaytoonah University of Jordan and Girne American University. Thus, the participants were students from different faculties in the universities included in the study. The questionnaires were distributed after students were informed by the researchers about the study objectives and outcomes. They were assured that the collected data would be kept confidential and would be used for the research purposes only, as well as the study participation was voluntary. Furthermore, the study took into account the maximum privacy level, and the students may refuse not to participate in the study.

Sample Size Calculation and Sampling Technique
Raosoft Sample Size Calculator (www.raosoft.com) was used to calculate the minimum sample size based on that the population size was 49,345 [19]. The counted population size included the total number of students enrolled in An-Najah National University (i.e. up to 23,345 enrolled students), Al-Zaytoonah University of Jordan (i.e. up to 8,000 enrolled students) and Girne American University (i.e. up to 18,000 enrolled students) was 49,345 enrolled students. Thus, the estimated minimum sample size for a 95% confidence level and margin error of 5% was 334 university students. Stratified random sampling method was used [20], the students were stratified into 3 different universities from 3 different Middle East countries.
The students were chosen using a student's list made available by each department on request. Subsequently, random selection was done using the Statistical Package for Social Sciences (SPSS) version 20. Students were approached in lecture rooms before or after a class. The questionnaires were distributed online to the selected students, Subsequently, student participation was based on their self-selection and their willingness to accept the study participation. Consequently, the absent students were replaced by running the SPSS again in order to provide an opportunity to keep random selection of the students to get the sample required for the study.

Data Collection
The researchers invited all male and female students in different faculties to participate in the study. Self-administered questionnaire was distributed online. The questionnaire was the sum of questions extracted from various questionnaires used in previous studies [18,[21][22][23]. This study collected data concerning sociodemographic and economic characteristics of the study participants, the affiliated university, the prevalence and patterns of Shisha smoking, and attitude towards Shisha addiction [10,24]. Subsequently, the study will be based primarily on the questions concerning Shisha smoking status "Are you smoking Shisha" and/or "have you ever smoked Shisha". A current Shisha smoker was defined as those who had smoked Shisha for at least 1 time during the past one month. The questionnaire had been translated to Arabic and Turkish languages and validated for both languages.
The researchers carried out the survey during the period from July to September 2019. The study participants completed the self-administered questionnaires and submit it online to the supervisor of the data collection. Completing the questionnaire took an average of 2 to 3 minutes.

Data Analysis
Before starting the data analysis process (i.e. pre-analysis phase), data were coded to maintain the participants privacy and confidentiality. Next, data were entered and analyzed using the SPSS program version 20. Descriptive and comparative statistics were carried out for all variables which were expressed as frequency and percentage for categorical variables. Chi-square test was done to establish relationships between the independent variables and the dependent variables.
Binary logistic regression was used to assess statistical significance of the difference in the prevalence of Shisha use (i.e. total prevalence of Shisha smokers, prevalence of current Shisha smokers, and prevalence of those who never/ever smoked Shisha), and students' attitude of Shisha smoking addiction according to independent variables.  over the total prevalence of overall students, the prevalence of shisha smokers in the Turkish students (20.23%) was the lowest between the other nationalities.

General Characteristics of the Sample
While, half of Turkish students had been smoked Shisha (n =84, 50.0%). Figure.1 shows that the Palestinian and Jordanian students has almost very close percentage of current, ever or never smoking shisha, and this might be because of very close culture, but the percentages among the Turkish students was totally different. Approximately half of Shisha smokers answered that they are daily smoking Shisha will be addicted to shisha smoking, 58.5 % and 44.2% of Jordanian and Palestinian respectively answered "yes" they will be addicted to Shisha smoking, while 58% of Turkish students answered "no" for the same question ( Table 2).
The bivariate analysis showed that the country to which student belongs to was significantly associated with shisha smoking frequency (P = 0.000), the time of smoking Shisha, and attitude concerning addiction to Shisha smoking (P = 0.006). The differences among the prevalence of Shisha smoker's students of different universities can be observed in Figure. 2. The highest percentage was among the other Palestinian universities (40.8%) and lowest percentage was in Girne American university (16.7%). However, the highest percentage of daily smoker Shisha between the students who are current smokers was in Al Zaytoona University (75.5%), and approximately 64% of current smokers in this university believe that they will be addicted to smoking Shisha ( Figure.2).   (Table.3) The prevalence of Shisha smokers according to the age differences and different country, and the total results showed that the highest percentage for the current Shisha smokers' students was an age more than 25 years old category (i.e. total 75 students 32 of them were smokers approximately 43%) ( Figure 3).   (Table 4). According to the results of the bivariate analysis, the faculty to which the student affiliates was significantly associated with Shisha smoking (P = 0.000). * Percentage of current smokers was calculated for each category individually (example 138/465 X 100% = 29.67%), P Value was 0.000 Table 5 shows that almost half of the sample (n = 411students) was from the students within first-third year level of study, 42.98% of students were within fourth-sixth years level of study, 5.54% were master degree students and less than 1% of students were PhD degree students (n =7 students). We found that the majority of students were within bachelor degree, and their prevalence of smoking Shisha was very close to the mean average, while 52 students were graduated students ,master and PhD degree, and their prevalence of smoking Shisha (44.23%) was over the mean average and 23 of them were current Shisha smokers (Table.5).
Approximately two-thirds of students were living with their families (n = 534) and their prevalence of smoking Shisha was very close to the mean average while the prevalence of smoking Shisha of students who leaves in Private Students' dormitory or apartments was higher than the mean average (n = 194, 35.05%). Table 5 shows that there were no significant associated between Shisha smoking and both study level (P = 0.502) and current residency (P = 0.183). Palestine and Jordan, and higher than the prevalence rate of Shisha smoking among university students in Turkey [25]. The prevalence of Shisha smoking among university students in Lebanon was 22.1%, 21.5% in Pakistan, and 8% among university students in the United Kingdom, respectively [26]. However, a high prevalence of Shisha smoking was also shown by other studies from the Gulf and Eastern Mediterranean countries [27], a study in Syria indicated that 25% of male university students were Shisha smokers [25].
Despite the disparity in results between different countries, but all agree that the main factors leading to the wide spread of Shisha smoking among university students globally are the provision of flavored tobacco, the thriving coffee shop, and Shisha home delivery, as well as weak roles and regulations to limit the spread of Shisha smoking [28]. Shisha smoking is more prevalent among students due to severe stress, very busy schedules, the lifestyle of university hostiles, friendships between students, and distance from parents, and increasing responsibilities [31] Thus, this explains the highest percentage of Shisha smokers among Master's students and those living in private hostiles surrounding the universities. There is a social stigma associated with Shisha smoking among them [32]. Therefore, the study results in comparison with others which were in favor of Turkey had shown that the culture of the Turkish community concerning Turkish students' lifestyle is full of study and provision of work opportunities during the university life to fill their leisure time and keep them away from all health risks caused. Furthermore, Turkey might implement strategies of medical schools and residency training programs that have additional benefits of reducing prevalence of Shisha smoking in the general population [33].

Conclusion
There was a high prevalence of Shisha smoking among university students in the Arabian countries in compression with Turkey especially in Palestine. Different factors affect the prevalence of Shisha smoking like the age, monthly income, residency and level of education. High percentage of smokers between the students believes that they will be addicted to Shisha smoking. The majority of current Shisha smokers was smoking Shisha daily; especially in Jordan and followed by Palestine.

Abbreviations:
SPSS: Statistical Package for Social Sciences, n: number of students, IRB: Institutional Review Board.

Ethics approval and Consent to Participate
We declare that all authors approve the submission of the manuscript to this journal. We assure in quality of authors of the manuscript that we own the copyright for the entire manuscript including all art work and tables. The study was approved

Consent to publish
Not applicable. the total prevalence of shisha smokers, and the prevalence of current, ever, never smokers a Figure 2 the percentage differences of shisha smoker's prevalence, daily smokers, and students answ