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Year : 2023  |  Volume : 20  |  Issue : 1  |  Page : 143-153

Prevalence and epidemiological characteristics associated with hookah smoking and alcohol consumption among medical students in Najaf, Iraq

Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, University of Kufa, Kufa University Campus, Kufa City, An-Najaf Governorate, Iraq

Date of Submission05-Dec-2022
Date of Acceptance03-Jan-2023
Date of Web Publication29-Apr-2023

Correspondence Address:
Ali Mohammed Abd Alridha
Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, University of Kufa, Kufa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_313_22

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Background: Reporting patterns of hookah smoking (HS) and alcohol consumption (AC) in Iraq are limited. Objectives: This study aims to investigate the prevalence of HS and AC among medical undergraduates in Najaf, Iraq. Materials and Methods: A pilot-tested online self-administered questionnaire was used to conduct a descriptive cross-sectional study. The sampling followed the “snowball” technique. The associations of HS and AC with the participants’ characteristics, perceived risk of harm, motives, and consequences were tested. Results: The preceding month’s prevalence of HS and AC (at least once) was 13.8% and 2%, respectively. The age at initiation was mainly <15 years (59.3% of smokers and 92.3% of drinkers). The presence of a friend who drinks or smokes and skipping life problems were statistically significant motives for the habits (P-value < 0.05). Smoking mainly caused problems with parents (10.1%) and poor performance at school or work (7%), whereas AC mainly caused problems with teachers (8.5%) and fights (5.2%). Conclusion: In conclusion, the prevalence of HS and AC among medical undergraduates in Najaf, Iraq, was reported, and several associated characteristics were discerned. The findings help develop targeted interventions to protect future generations of medical professionals from the hazards of HS and AC.

Keywords: Alcohol, hookah, Iraq, Najaf, prevalence

How to cite this article:
Abbood SK, Abd Alridha AM, Al-Gburi KM, Ali Mohsin N, Ismael AS, Ali AB, Salih AT. Prevalence and epidemiological characteristics associated with hookah smoking and alcohol consumption among medical students in Najaf, Iraq. Med J Babylon 2023;20:143-53

How to cite this URL:
Abbood SK, Abd Alridha AM, Al-Gburi KM, Ali Mohsin N, Ismael AS, Ali AB, Salih AT. Prevalence and epidemiological characteristics associated with hookah smoking and alcohol consumption among medical students in Najaf, Iraq. Med J Babylon [serial online] 2023 [cited 2023 Jun 11];20:143-53. Available from: https://www.medjbabylon.org/text.asp?2023/20/1/143/375141

  Introduction Top

Annually, nearly five million people die from tobacco smoking, and 76.3 million suffer from alcohol abuse.[1],[2],[3] There are various types and sizes of tobacco products, including cigarettes, hookahs, and electronic cigarettes. Hookah, also called “shisha” or “nargileh,” gained popularity in the 19th century.

Lung cancer is the most common cancer-causing death. This menace is associated with the carcinogenic substances contained in cigarette smoke.[4],[5] Nicotine was found to suppress the immune system’s response to cancerous development.[6] Numerous investigations have established that hookah smoking (HS) includes potentially hazardous substances.[7],[8],[9] A 45-minute hookah session exposes the user to up to 48.6 times the smoke produced by a cigarette.[10],[11]

Several studies have investigated the pattern of HS. For instance, males smoked hookah at a greater rate than females.[12] HS is popular in the Middle East, particularly among teenagers. Flavored shisha tobaccos are the most popular tobacco flavors.[13],[14] Numerous variables have been identified as contributing to HS, including the effects of friends and family and poor self-esteem.[15],[16],[17] Smokers were predisposed to a higher prevalence, greater severity, and faster progression of periodontal disease than never- or former smokers.[18]

Alcohol consumption (AC) can cause a wide range of physical and social problems, from mild embarrassment to long-term effects. Alcohol abuse is the third most significant cause of death worldwide.[1] Students with AC habits took longer to complete their studies, and others were ejected from colleges. AC may have significant, long-term, and costly repercussions, including drunk-driving arrests, car accidents, sexual assault, child abuse, suicidal tendencies, and murders.[19],[20] Moreover, their link to poor academic performance will be a growing problem as the number of undergraduates rises.

Despite their importance, studies on HS and AC among Iraqi students are scarce. This study aims to investigate the prevalence and the associated epidemiological characteristics of HS and AC among medical undergraduates in four universities in Najaf, Iraq.

  Materials and Methods Top

Study design, sample, and data collection

A descriptive cross-sectional study was conducted using an anonymous pilot-tested questionnaire. The link to the semi-structured, online, self-administered questionnaire was shared with students from Najaf, Iraq’s four universities (two government-aided and two private-aided). The sampling of the participants followed the snowball technique. Recruiter students approached other students in the target medical schools during break time and asked them to fill out the questionnaire and recruit their colleagues.

The recruiters were undergraduates who agreed to take part in the research to help identify other students who may be willing to participate in the study. The students who came forward themselves and agreed to take part and fill out the study questionnaire became the new participants, and they were asked to recruit other students. The recruiter students were informed and trained on how to perform survey research.

The sample size was determined using an online sample size calculator (https://www.surveysystem.com/sscalc.htm). However, the recruitment continued to identify as many students as possible.

The anonymous nature of the online questionnaire was important to secure as honest a response as possible to sensitive questions such as engagement in unprotected sex or AC. The human research committee at Kufa University, Faculty of Pharmacy, approved the research (Reference No. 2987). The data collection period was from January to May 2021.


The questionnaire was designed after a review of the literature for similar studies.[12],[17],[21],[22],[23]

Arabic and English were the languages used in writing the questions and answer options. Content and face validity were performed by pharmacists and academics with experience in survey research. The first section of the questionnaire was the demographics section. The hookah section involved asking the respondents two questions about HS. The third section’s questions (n = 2) were relevant to AC.

Inquiries about the motives, perceptions, and consequences of HS and AC were included in the third section. The participants were free to select yes or no responses to the motives’ questions (n = 13). Five-point Likert choices (no risk, slight risk, don’t know, moderate risk, and great risk) were provided to answer questions on the perception of harm risk from HS and AC (n = 5). For the consequences questions (n = 15), the participants were asked to tick a single answer from the following options: “Never,” “Yes, because of my HS,” “Yes, because of my alcohol drinking,” or “Yes, for other reasons.”

The questionnaire was initially piloted with a sample of 31 students. The students in the pilot study were excluded from this survey.

Statistical analysis

Descriptive statistics (frequencies and percentages) were used to summarize the categorical data (demographics, HS, AC, place, motives, and consequences of HS and AC).

Numbers from one (which corresponds to “no risk”) to five (which corresponds to “great risk”) were used to code responses to the perceived risk of harm. The mean of the responses from each respondent was calculated and compared to Likert scale intervals to categorize the perceived risk of harm toward HS and AC into “perceived low risk,” “don’t know,” or “perceived high risk.” The results were described using frequencies and percentages.

The χ2, or Fisher’s exact, test was conducted to analyze the association of being a hookah smoker or alcohol consumer with the participants’ demographics, perceived risk of harm, motives, and consequences of HS and AC.

Ethical approval

The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. The study protocol, the subject information, and the consent form were reviewed and approved by a local ethics committee on August 15, 2020, according to document number 2987.

  Results Top


The response rate was 84%. Of the 890 participants, about 55% were from the 21–24-year-old group. More females responded to the questionnaire than males (n = 529, 59.4%). Approximately nine-tenths of the respondents were single and city residents [see [Table 1]]. The most frequent university of the study was the University of Kufa (61%). Pharmacy and medicine were the most frequent colleges (30.6% and 38.1%, respectively), while the most frequent students were second- and fifth-year students (35.1% and 25.7%, respectively). About nine-tenths of the students lived at home with satisfactory relationships with their parents and family members.
Table 1: Demographical characteristics of the study participants

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HS and AC

About 14% of the participants (n = 123) smoked hookah at least once in the previous month. More than half of the smoker students (n = 73/123) started HS at an age of less than 15 years old [see [Table 2]]. A total for 18 students (2%) reported AC at least once in the previous month. The majority of the students who claimed AC had an age at initiation (AI) of less than 15 years old (n = 24/26). HS (at least once in the previous month) was significantly associated with age, gender, the participant’s father’s education and relationship to parents and family members, the university of study, and the place of stay during study life [see [Table 3]]. AC, however, was significantly associated with only two factors: gender and college of study (P-value < 0.05).
Table 2: Characteristics of hookah smoking and alcohol consumption among the study participants

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Table 3: Association of the participants’ demographics, hookah smoking, and alcohol consumption

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Smoking and AC locations and motivations

Outside the house was the predominant place for HS and AC (n = 83 and n = 24, respectively). The presence of a family member and a friend who smoke was noticed in 48.8% and 60.2%, respectively. A total of 42 participants reported having a family member who drinks. The presence of a friend who consumes alcohol was confirmed in 18.9% of the responses [see [Table 2]].

The presence of a friend who smokes or drinks and a family member who drinks were statistically significant associating factors with both HS and AC [see [Table 4]]. The motives significantly associated with HS were skipping life events, psychological stress, academic performance difficulties, entertainment, emotional reasons, and peer pressure (P-value < 0.05).
Table 4: Association of the place of use, motives, hookah smoking, and alcohol use among the participants

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Perceptions toward tobacco smoking and AC

Following categorization, 11.8% of participants perceived low harm from tobacco smoking. Furthermore, 4.5% of respondents perceived a low risk of harm from AC [see [Figure 1] and [Figure 2]]. The perceived harm risk of tobacco cigarettes was significantly associated with HS and the AI of HS (P-value < 0.05) [see [Table 5]].
Figure 1: Perceptions of the study participants toward cigarette smoking and alcohol consumption (The question was how much do you think people risk harming themselves (physically or in other ways), if they do the following?)

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Figure 2: Perceived risk of harm toward cigarette smoking and alcohol consumption among the study participants

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Table 5: Association of the perceived risk of harm toward cigarette smoking and alcohol consumption among the study participants

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Consequences due to smoking and AC

Some students reported having problems in their relationships with their parents (10.1%), damage to objects or clothing (8.9%), and poor performance at school or work (7%) due to smoking [Figure 3]. AC caused problems in student-teacher relationships for 8.5% of participants and fights or scuffles for 5.2%. Both HS and AC were significantly associated with several consequences, including, for example, getting into a scuffle or fight; problems with parents, friends, and teachers; and poor performance at school or work (P-value < 0.05) [see [Table 6]].
Figure 3: Consequences of hookah smoking and alcohol consumption and the responses of the study participants (The question was have you ever had any of the following problems due to smoking or alcohol consumption?)

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Table 6: Association of the consequences with hookah smoking and alcohol consumption

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  Discussion Top

To our knowledge, this is the first study to investigate the prevalence of HS among medical undergraduates in Najaf, Iraq. The prevalence of HS (at least once in the previous month) was 13.8% (31% in males and 2.1% in females). This rate of HS was lower than that reported in a Qatari study (40%).[24] Similarly, it is lower than that found in other countries of the region, such as Lebanon, Syria, and Jordan, yet higher than that in Saudi Arabia, Iran, Egypt, and a previous Iraqi study.[25],[26]

The variation in findings could be attributed to a methodological discrepancy, such as the characteristics of the students involved. Alternatively, the difference may be realistic and reflect the incremental trend of HS among university students who are of particularly predisposed age. The study underlined a statistically significant association between the age of students and the university of study, among others, which might explain the difference in the prevalence patterns. Furthermore, previous studies in Iraq and the region revealed that cigarette smoking was the most frequent form of tobacco smoking.[10],[27]

The trend of rising rates of HS revealed by this study could indicate a concerning change in the prevalence pattern of tobacco smoking. This could be related to the common public misperception that HS causes less harm and less addiction than cigarette smoking and is socially more acceptable.

This study also found that the perceived risk of harm from cigarette smoking was significantly associated with HS and the AI of HS. Consistent results were also found in Iraq, Qatar, and the US.[10],[24],[28] These findings are indications that urgent action to address and combat HS is timely to limit the public health and financial ramifications of HS, which, by reasonable expectation, is growing over time in Iraq.

Furthermore, 94% of study participants (n = 116/123) began HS before the age of 18. This percentage was considerably higher than that found in another Iraqi study.[29] The absence of restrictions on hookah sales to younger adults and advertisements for HS, in combination with affordable hookah prices, could contribute to the early initiation of smoking.

HS was significantly associated with age and the father’s education. A similar finding was identified in a previous Iraqi study.[26] In the same vein, entertainment reasons, as well as the presence of a family member or a friend who smokes or drinks, stress-promoting events, and peer pressure, were significantly associated with HS. Similar motive themes have been discovered in other studies.[10],[24]

Understanding how these conditions contribute to the prevalence of HS among students may stem from their independence in terms of finances and living situation during study life. This could provide both the socioeconomic ability and freedom to indulge in HS, particularly when it coincides with distressing or entertaining occasions.[30]

The present study findings are essential to expanding our knowledge of the factors associated with tobacco smoking and equipping public health initiatives with properly targeted interventions.

Regarding the consequences of HS among medical undergraduates, problems in relationships with their parents (10.1%), damage to objects or clothing (8.9%), and poor performance at school or work (7%) were mostly reported. In this regard, the findings help promote awareness about the socio-cultural risks of HS, which is a key component of the interventions devised to tackle tobacco smoking.

In terms of the prevalence of AC (at least once in the previous month), eighteen students [2%, with 0.4% in females (n = 2) and 4.4% (n = 16) in males] were reported. A consistent result to a study in Karbala (2.2%) but a lower prevalence in comparison to AC in Erbil (23.7%) and Baghdad (9.7%). Higher prevalence rates were identified in Iran and Lebanon (6.9% and 11%, respectively).[22],[31] The difference in findings may be related to variations in socio-cultural and religious restraints in different regions, as well as the various methods used for sampling.

Most participants in the study (n = 24/26) started AC at an age younger than 15 years old. To our knowledge, only one Iraqi study reported an AI of AC (12 years old) among students in Kirkuk (no indication of mean or median).[32] A result that is related to our findings.

Additionally, gender and college of study were significantly associated with AC (P-value < 0.05). Male predominance has been reported consistently in similar Iraqi and regional studies, possibly due to the conservative nature of raising the female students to uphold the religious and socio-cultural beliefs and norms that prohibit AC or due to under-reporting from female consumers.[21],[22],[31]

In Erbil, the prevalence of occasional drinking among medicine undergraduates (10.5%) was higher than that among dentistry, nursing, and pharmacy students (5.3%, n = 0, and 3.5%, respectively).[21]

Clinical training in medicine was linked to increased substance use and dissatisfaction with academic performance.[33] However, the prevalence of AC was lower in medicine undergraduates in our study (1.5%) as compared to undergraduates of other majors. It is possible to consider the scarcity of leisure time available for medicine undergraduates to indulge in AC due to the thorough, packed, and difficult academic programs in comparison to the undergraduate programs of colleges of other medical sciences.

Educational interventions about the risks of AC and the confidential management of the students in need of help are essential components in the design of alcohol-tackling policies. Furthermore, routine assessment of the student’s learning experience, personality, and professionalism, as well as optimization of the feedback delivery to the undergraduates, have been shown to aid in facilitating the medical learning and training processes.[34],[35],[36]

In this study, skipping life problems and the presence of a drinking family member or friend were identified as significant associating motives. A similar finding was reported in Iran.[37] The findings regarding the encountered consequences add to the strength of the study. Problems in relationships with parents and engagement in unprotected intercourse were also reported in previous similar studies.[38],[39],[40]

This study is limited by the fact that, despite the inclusion of students from all medical colleges in Najaf, Iraq, the generalizability of the study findings was hindered by the study design, which was based on self-reported responses from students who were approached without prior random selection from all the medical undergraduates. The questionnaire was anonymous, semi-structured, and pilot-tested to improve the responses’ validity. However, the participants’ inclination to under-report their smoking or AC cannot be excluded due to the self-reporting nature of the questionnaire and the social and religious unacceptability of the studied habits. In summary, this study reported the prevalence of HS and AC among undergraduates of medical colleges in Najaf, Iraq, and discerned several associating characteristics.

  Conclusion Top

The public health authorities in Iraq need to adopt and implement preventive measures to mitigate the spread of HS to the younger generations and protect the community’s future from the hazards of tobacco smoking. The data gathered can also be utilized to develop targeted intervention strategies and awareness-raising initiatives to protect future medical professionals from indulging in risky behaviors due to HS and AC.


The authors would like to extend their gratitude to the students and their universities and colleges for their cooperation and facilitating the recruitment of participants for the study.

Financial support or sponsorship


Conflicts of interest

The authors had none to declare.

Author contribution

SKA developed the study design, and wrote the manuscript. AMAA conducted the data analysis and contributed to writing of the manuscript. KA contributed to the data collection and data entry into SPSS and Microsoft Excel. AB, AT, NAM, and ASI contributed to the questionnaire distribution and data collection. All authors approved the final version of the manuscript.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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