Water Pipe as Growing Public Health Challenge Among School Children in the Federation of Bosnia and Herzegovina.

INTRODUCTION: The water pipe is a form of tobacco smoking that recently become very popular among youth in many countries all over the globe. AIM: To highlight recent data collected through Global Youth Tobacco Survey (GYTS) in the Federation of Bosnia and Herzegovina (FBiH) 2019, related to knowledge, attitudes and behavior of school children and youth to water pipe consumption.
METHODS: The GYTS questionnaire for the Federation of BiH 2019 contained 60 multiple-choice questions. The GYTS 2019 in the Federation of BiH was conducted in a total of 73 of the 75 sampled primary and secondary schools with a school response rate of 97.3%. From the 6,972 sampled students a total of 6,415 participated as eligible students in grades 8-9 of primary and 1st grade of secondary school, with a response rate for students of 92.0%.
RESULTS: Survey findings show that almost half (44.1%) of the school children confirm ever smoking the water pipe, while Current smoking of water pipe is confirmed by 16.1% school children.
CONCLUSION: There is a substantial need for implementing of systematic and inter sectorial tobacco control measures that involves a water pipe as new public health challenge among youth.

INTRODUCTION

The water pipe is not a new tobacco product, it is present in the society since centuries under different names: “narghile” in East Mediterranean countries including Turkey and Syria, “shisha” in Egypt and North African countries and “hookah” in India, or “water pipe” frequently used in World Health Organization documents (1). After so many surveys and evidence based proofs on all health consequences caused by water pipe, there are still belief widespread among water pipe consumers that smoking water pipe is safe or less harm than other tobacco products (2). While consumption of cigarettes among adolescents decreases in several countries, consumption of other tobacco products increase, particularly water pipe, that become global public health issue which have to be considered as priority in the planning and design of national and international tobacco control measures (3).

Regionally, there are some historical or cultural differences in water pipe design device, but all water pipes have similar segments: a head, body, water bowl, hose and mouthpiece. In the bottom of the head there is holes that allow smoke to pass into to body central conduit, submerged in the water in the water bowl (4). It is proof that smoking of one cigarette take usually 5 to 7 minutes, with 40 to 75 ml puffs and inhale 0, 5 liters of smoke while water pipe smoking takes 20 to 80 minutes, with 50 to 200 puffs and inhale 0,15 to 1,0 liters of smoke. This is reason for statement that related to quantity of inhaled tobacco smoke, consumption of one water pipe is equal to 100 or more cigarettes (5).

Laboratory analyzes of water pipe smoke revealed measurable levels of carcinogenic compounds such as: nitrosamines, polycyclic aromatic hydrocarbons (PAHs), formaldehyde, benzene, toxic compounds nitric oxide and heavy metals, and high concentrations of carbon monoxide (6).

In comparison to cigarette smoke, water pipe smokers consume higher amounts of arsenic, lead and nickel, 36 times more tar, 15 times more carbon monoxide and polyciclic aromatic hydrocarbons (PAH) (7, 8).

The water pipe smoking acutely leads to increased heart rate, increase of blood pressure, impaired pulmonary functions and carbon monoxide infections (9, 10). Long term complications of water pipe smoking is associated with chronic bronchitis, emphysema, lung, gastric and oesophageal cancer, obstetrical complications, coronary artery disease and mental health problems (11, 12). Water pipe smoking is hazard to oral health and has been associated with periodontitis, dry socket, premalignant lesions and oral cancer (13).

Consumption and sharing of water pipe among consumers could be connected with wide spreading of different communicable diseases, due to lack of disinfection and properly cleaning of a hose. There are many surveys that show the water pipe smoking has been associated with tuberculosis, herpes, hepatitis, infection with H. pylori, toxoplasmosis, as well limphocytic dysfunction (14).

Until recently, national surveys of tobacco use rarely involved water pipe smoking prevalence. Surveillance of web-based searches show that popularity of water pipe smoking increased over the past decade in the USA, Australia, Canada and UK (15, 16). International studies indicate that adolescent consumption of other tobacco products than cigarettes particularly water pipe increased in last two decades, in several European countries, also in the United States, Canada and Australia. About 30% of college students in USA have smoked water pipe currently smokers 12,4% (17).

AIM

Aim of this paper is to highlight recent data collected through Global Youth Tobacco Survey (GYTS) in the Federation of BiH 2019, related to water pipe consumption among school children and suggest some preventive measures.

METHODS

The United States Centers for Disease Control and Prevention (CDC) together with World Health Organization (WHO) developed the Global Youth Tobacco Survey (GYTS) to present comprehensive tobacco prevention and control information on young people. The GYTS is a nationally representative comprehensive school-based survey related to smoking knowledge, attitudes and behavior in schoolchildren of eligible classes age 13-15 (18).

GYTS was conducted four times in the Federation of BiH, in the year 2003, 2008, 2013 and 2019 with the support of the Federal Ministry of Health who authorized the surveys. All four GYTS surveys in the Federation of BiH were conducted by the Institute for Public Health of the Federation of Bosnia and Herzegovina as the implementing agency (19). For the purpose of this article, were used data collected from last GYTS survey in the Federation of BIH 2019.

The GYTS questionnaire for the Federation of BiH 2019 contained 60 multiple-choice questions, included all 43 core questions from the GYTS Standard Core Questionnaire and 17 questions added from the optional modules. Within questions from the optional modules, 11 questions related to attitudes and behavior of school children in line to water pipe were added.

The GYTS is a school-based survey, which involve a two-stage cluster sample designed to produce a representative sample of students in 8th and 9th primary school grades and 1st grade of secondary school. In the Federation of BiH two-stage cluster sample design was used to produce a representative sample of students. Schools were selected with probability proportional to school enrollment size. All classes in the selected schools were included in the sampling frame. All students in the selected classes were eligible to participate in the survey.

The GYTS 2019 in the Federation of BiH was conducted in a total of 73 of the 75 sampled primary and secondary schools with a school response rate of 97.3%. All of the 290 sampled classes participated in GYTS resulting in a 100.0% response rate. From the 6,972 sampled students a total of 6,415 participated as eligible students in grades 8-9 of primary and 1st grade of secondary school, with a response rate for students of 92.0%. Finally, the overall response rate was 83,3%.

A weighting factor was applied to each student record to adjust for probability of selection, non-response, and post-stratification adjustment to population estimates. SUDAAN, a software package for statistical analysis of complex survey data, was used to calculate weighted prevalence estimates and standard errors (SE) of the estimates (95% confidence intervals [CI] were calculated from the SEs). A weight has been associated with each questionnaire to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of no response.

RESULTS

Almost half (44.1%) of the school children confirm ever smoking the water pipe, this is more common among boys (48.6%) than girls (39.90%) (Table 1). Current smoking of water pipe is confirmed by 16.1% school children, 17.7% of boys and 14.4% of girls (Table 2). Survey findings show early initiation of smoking the water pipe among schoolchildren in the Federation of BiH. Over third of ever smokers (35.7 %) start to smoke at the age of 12 to 15 (Table 3).

Table 1.

Percentage of school children ever smoked water pipe, Federation of BiH, 2019

	Total	Male	Female
%Lower 95% limit	44.140.7	48.644.8		39.936.2
Upper 95% limit	47.6	52.3		43.6

Table 2.

Percentage of school children who currently smoke water pipe, Federation of BiH, 2019

	Total	Male	Female
%Lower 95% limit	16.113.7	17.714.5		14.412.1
Upper 95% limit	18.9	21.3		17.1

Table 3.

Age when start to smoke water pipe, Federation of BiH, 2019

	Total	Male	Female
Never smoke water pipe%Lower 95% limit	57.153.7	52.949.2		61.457.5
Upper 95% limit	60.5	56.4		65.1
7 years old or younger%Lower 95% limit	1.41.1	1.91.3		0.90.6
Upper 95% limit	1.9	2.8		1.4
8 or 9 years%Lower 95% limit	1.31.0	2.11.5		0.60.3
Upper 95% limit	1.7	2.8		1.1
10 or 11 years%Lower 95% limit	4.53.5	5.54.2		3.62.6
Upper 95% limit	5.7	7.0		4.9
12 or 13 years%Lower 95% limit	20.618.5	23.320.8		17.815.5
Upper 95% limit	22.8	26.1		20.4
14 or 15 years%Lower 95% limit	14.812.4	14.111.3		15.512.9
Upper 95% limit	17.5	17.4		18.5
16 years or older%Lower 95% limit	0.20.1	0.20.1		0.20.1
Upper 95% limit	0.4	0.4		0.4

Only 5.4% school children are refused to get water pipe because their age, more likely boys (7.0%) than girls (3.6%) Almost 2 in 10 schoolchildren (17.3%) confirm age did not keep them from being served water pipe in last 30 days, more boys (18.0%) than girls (16.7%) (Table 4).

Table 4.

Percentage of school children have been refused to serve them water pipe, Federation of BiH, 2019

	Total	Male	Female
Did not try to get water pipe in last 30 days%Lower 95% limit	77.374.6	75.071.6	79.776.8
Upper 95% limit	79.8	78.1	82.3
Refused because their age in last 30 days%Lower 95% limit	5.44.6	7.05.8	3.62.8
Upper 95% limit	6.2	8.4	4.6
Age did not keep them from being served water pipeIn last 30 days%Lower 95% limit	17.315.1	18.015.3	16.714.1
Upper 95% limit	19.9	21.0	19.5

Almost half of all children surveyed (46.7%) definitely think other people’s water pipe smoke is harmful to their health, without any difference among boys and girls, while over third of them (38.1%) think that other people’s water pipe smoke is probably harmful for them, more likely girls (40.8%) than boys (35.5%) (Table 5).

Table 5.

Percentage of school children who think other people’s water pipe is harmful for them, Federation of FBiH, 2019

	Total	Male	Female
Definitely not%Lower 95% limit	6.35.5	8.6 7.2		3.83.0
Upper 95% limit	7.1	10.1		4.7
Probably not%Lower 95% limit	8.97.8	9.27.8		8.57.4
Upper 95% limit	10.0	10.8		9.8
Probably yes%Lower 95% limit	38.136.3	35.533.2		40.837.8
Upper 95% limit	40.1	38.0		43.9
Definitely yes %Lower 95% limit	46.744.8	46.744.3		46.943.8
Upper 95% limit	48.7	49.0		50.1

Almost a half of all children surveyed (46.2%) think that smoking water pipe helps people feel more comfortable at celebrations, parties and social gatherings, this opinion was more common among boys (51.4%) than girls (41.1%) (Table 6).

Table 6.

Percentage of school children who think smoking water pipe helps people feel more or less comfortable, Federation of BiH, 2019

	Total	Male	Female
More comfortable %Lower 95% limit	46.244.4	51.448.8	41.138.7
Upper 95% limit	48.1	53.9	43.6
Less comfortable %Lower 95% limit	10.18.5	10.99.1	9.37.3
Upper 95% limit	12.1	13.0	11.9
No difference %Lower 95% limit	43.641.9	37.835.4	49.547.0
Upper 95% limit	45.4	40.2	52.1

DISCUSSION

This is the first longitudinal study comparing cigarette and water-pipe smoking among young adolescents in a Middle Eastern setting. This study shows that smoking is widespread and quickly increasing among this young population. The Global Youth Tobacco Survey (GYTS) performed in the Federation of BiH in 2019 shows that smoking of water pipe among school children become a significant public health challenge.

Almost half (44.1%) of the school children confirm ever smoking the water pipe, more common among boys (48.6%) than girls (39.90%), while current smoking of water pipe is confirmed by 16.1% school children, 17.7% of boys and 14.4% of girls. Results collected through GYTS in the Federation of BiH are similar to trends of water pipe smoking in several European countries, including the United States (20). Also, water pipe smoking is now more likely in younger age groups, particularly adolescents. Findings from cross-sectional survey conducted 2014 on a random sample of 4,576 schoolchildren in Australia aged 12-17, show 13% of adolescent had used the water pipe, with 2% using the water pipe exclusively while 67% of water pipe consumers had also used cigarettes (21). Data from surveys conducted in Germany show that in period between 2007 and 2016 decrease of consumption of cigarettes among adolescents and increase of water pipe consumption (22).

Through GYTS findings 46.7% school children in the Federation of BiH definitely think other people’s water pipe smoke is harmful to their health, while many international studies show belief among youth that smoking water pipe is safe or less harm than other tobacco products (23-25). GYTS findings in the Federation of BiH show only 5.4% school children are refused to get water pipe because their age, and 17.3% confirm age did not keep them from being served water pipe in last 30 days, that is contrary to the last tobacco control law in the Federation BiH that bans the sale of tobacco products to minors still under age 15 (26)

In looking for real predictors for water pipe popularization among youth in the Federation of BiH, more attention should be raised on social image of water pipe smoking, as 46.2% school children think that smoking water pipe helps people feel more comfortable at celebrations, parties and social gatherings, similarly to other survey results conducted in Sweden (27) and the United States (28).

CONCLUSIONS

The water pipe consumption among school children is new public health challenge in the Federation of BiH.

Related to smoking prevention of water pipe, a variety of measures needed from policy-level interventions, such as enforcement of new tobacco control law that enrolled water pipe as any other tobacco products, ban of smoking of water pipe in enclosed public places, regulatory inspection monitoring of facilities that serves water pipe, ban of serving water pipe to minors under age of 18, ban of advertisement and promotion of water pipe in media, social network and public events. There should be greater focus on effective water pipe smoking prevention programs particularly in earlier grades of primary and secondary schools as a part of regular school curriculum with more youth sensible information’s on health consequences of water pipe.