Preventing and controlling water pipe smoking: a systematic review of management interventions

Tobacco smoking is one of the main preventable causes of diseases and deaths claiming the lives of 7.2 million annually around the world [1, 2]. Although cigarette smoking is the dominant form of tobacco use in many countries, Water Pipe Smoking (WPS) with other names such as hookah, shisha, narghile, arghile. Goza, oriented pipe, hubble bubble, Mada’s and glaze base, accounts for a significant and growing share of tobacco use globally [3, 4]. In addition, WPS is a culture-based (there are some other types of tobacco smoking behavior) method of tobacco use [5] and its history goes back to 500 years ago in Middle East, North Africa and Asia. However, it has experienced a worldwide re-emergence since 1990 [6] and is regaining popularity among different groups of populations, especially in school and university students [7, 8]. Although WPS is most prevalent in Asia (specifically the Middle East region) and Africa, it has now been changed to a rapidly emerging problem in other continents such as Europe, North, and South America [9, 10]. In recent years, there has been 6–34% increase in tobacco use among 13–15 year olds, most of whom attribute to WPS [10, 11]. In European regions such as Latvia and Czech Republic 22.7 and Estonia 21.9% of people smoke water pipe, while in the Eastern Mediterranean region, the prevalence of WPS is 39.0 and 31.0% of boys and girls, respectively [12]. In average, Lebanon has the highest reported rate (37%) in this regard [12, 13]. In the United States, more than 30% of university students of both genders and 23% of high school students have experienced WPS [14, 15]. Similarly, WPS is also prevalent among highly educated groups. Nearly 20% of health professionals in Jordan and 11% of medical students in London smoked WP [16, 17]. Based on a report, 29.5% of physicians also experience WPS in Pakistan [18].

It has been shown that WPS’ smoking rate can be more addictive compared to that of the cigarette. It also contains more toxic and carcinogenic substances [19, 20] with deleterious effects on the respiratory and cardiovascular systems, as well as oral cavity and teeth [21]. Furthermore, it has a huge negative impact on health costs and the gross domestic product of the countries. For example, the direct and indirect cost of smoking-related diseases is up to $300 billion in the United States annually [22, 23].

Considering the extension of WP businesses, some groups support its expansion [24]. In recent years, the number of WP cafes has increased over many countries. As an example, there are nearly 400 WP cafes in London [25].

Using deceptive advertising, many cafes and restaurants offer WP services along with their orthodox services in order to earn more profit and lure more customers. Moreover, several factors contribute to attracting children and adolescents to WP cafes that leads to an increase in new cases of WPS [26‐28]. These factors include the provision of flavored tobacco products or psychotropic WP, the proximity of WP cafe to the public settings such as educational or residential settings, sports clubs, and residential areas, tempting decoration, the provision of study places for students, live music, a variety of games and gambling, and the possibility of watching live movie and sport matches [6, 25, 29, 30].

All this shows that WPS has been turning to a public health crisis. WP business has remained largely unregulated and uncontrolled, which may result in the increasing prevalence of WPS [31]. Moreover, WPS is one of the main factors that can lead to failure in tobacco control [32]. Despite the concerns about WPS outcomes and nearly three decades of using control measures, the prevalence of WPS has increased over the world. Due to the unique nature of WP (multi-components), little is known about the prevention and control of WPS [33]. Thus, special actions and interventions might be required to prevent and control WP tobacco use [33]. Over the recent decade, there has been growing interest among researchers and policymakers regarding addressing the gaps in knowledge about interventions that can be useful in controlling and preventing WPS. Accordingly, this study aimed to identify the management interventions in international and national levels for preventing and controlling water pipe smoking.

The searching process resulted in 4353 studies with 2125(48.81%) of these being repetitions. Out of 2228 screened articles (after removing the duplicates), 38 articles were selected through on the title& abstract screening process. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram was used to show the number of records in each phase (Fig. 1).

The included studies were of moderate-to-high quality. The characteristics of included studies are provided in Table 1.

The selected studies were published between 1990 and 2018 and focused on 19 different countries including the United States (13.15%) [6, 29, 30, 35, 36], the United Kingdom (7.89%) [25, 37, 38], Germany (5.26%) [12, 39], Iran (5.26%) [40, 41], Egypt [42, 43] (5.26%), Malaysia (2.63%) [44], India (2.63%) [45], Dutch(2.63%) [46], Pakistan (2.63%) [47], Qatar (2.63%) [48], Jordan(2.63%) [16], Lebanon(2.63%) [49], Syria(2.63%) [50], Turkey(2.63%) [51], Bahrain [52] (2.63%), Israel(2.63%) [53], the United Arab Emirates (2.63%) [29], Saudi Arabia [54](2.63%), and Switzerland(2.63%) [55]. Additionally, the type of study design included cross-sectional (31.57%), quasi-experimental (15.78%), and qualitative types (23.68%).

Seventy eight management interventions were identified. After combining interventions with similar concepts into one category, the total number of exclusive interventions condensed to twenty seven.

In the next step, the interventions were assigned to four main subcategories including preventive interventions (18.51%) [12, 35, 40, 44, 46, 48, 54, 56] and control interventions (29.62%) [25, 30, 37, 45, 57, 58], as well as interventions at the international (25.92%) [6, 29, 39, 43, 44, 51, 53, 59, 60] and national (25.92%) [10, 16, 25, 30, 46, 49, 51, 57, 61, 62] levels. The details of the included interventions are presented in Table 2.

In this study, the management interventions affecting the prevention and control of WPS worldwide were identified through a systematic literature review. In this regard, 27 interventions were experienced in the world for WSP control that was categorized into four main themes and four sub-themes.

In general, our findings indicated WPS related social and health crisis have not come into attention in high levels of decision making. The current enforced legislations are old, unclear, and incompatible with the needs of the adolescents and are not backed by rigorous evidence. In addition, the WP industry is rapidly expanding without monitoring and controlling measures. Informing and empowering adolescents for those who have not yet experienced smoking is a sensible intervention in this regard. Besides, empowering and involving health students and professionals in WPS control programs can lead to promising results in preventing and controlling WPS. It seems that there is a paucity of evidence regarding strategies on controlling and preventing WTS, thus further research in the society is warranted in this respect.