AJTCCM VOL. 29 NO. 1 2023 6
RESEARCH
Background. e tobacco epidemic is one of the biggest public health threats the world has ever faced. Shisha use has recently been gaining
increased popularity in many developed and developing countries.
Objective. To determine the prevalence of shisha use among students in Ouagadougou, Burkina Faso, and associated knowledge, smoking
practices and beliefs about health eects.
Method. A total of 443 students were selected for this cross-sectional study, using a stratied sampling method. Data on shisha use, knowledge
about shisha, shisha smoking practices, and factors associated with use of shisha were collected via a questionnaire. e association between the
independent variables and shisha use was assessed using a χ2 test (p<0.05). Binary logistic regression analysis was used to determine variables
that were independently associated with shisha smoking.
Results. Of the 421 respondents, 162 (38.5%) indicated that they had smoked shisha; 14.0% were regular smokers. We found that 183students
(43.5%) had poor knowledge about the health eects of shisha. e main reasons for shisha smoking were being in the company of friends
who were users (57.4%), the pleasant avour and fragrance of shisha (25.9%), and fashion (22.2%). Ninety-nine shisha smokers (61.1%) also
consumed alcohol. Factors associated with shisha smoking included age <20 years (p<0.001), gender (p=0.034), and educational level of the
respondent’s father (p=0.0001) and mother (p=0.0004).
Conclusion. We found a relatively high prevalence of shisha smoking among the students, and that 43.5% of them had poor knowledge about its
eects on health. Developing surveillance, intervention and regulatory/policy frameworks specic to shisha has become a public health priority.
Keywords. Prevalence, knowledge, practices, shisha smoking, university students, Ouagadougou, Burkina Faso.
Afr J Thoracic Crit Care Med 2023;29(1):e246. https://doi.org/10.7196/AJTCCM.2023.v29i1.246
e tobacco epidemic is one of the biggest public health threats the
world has ever faced, killing >8 million people a year.[1] Tobacco
is used in various forms, including cigarettes, cigars, chewable
tobacco, bidis, kreteks (also known as clove cigarettes), and shisha
smoking, also known as hookah, waterpipe, goza, nargile and
hubble-bubble.[2] e shisha is a traditional oriental pipe with a long,
exible hosethrough which the user inhales smoke from a tobacco
preparation, avoured or unavoured, burned by charcoal embers.
e smoke is cooled through water before it is inhaled.[3]
According to the World Health Organization (WHO), >100
million people worldwide use shisha daily.[1] e WHO has taken
up this problem, and reports that the use of shisha poses a serious
Knowledge, practices and beliefs of students regarding
health eects of shisha use in Ouagadougou, Burkina Faso:
Across‑sectional study
A R Ouédraogo,1,2 MD ; K Boncoungou,1,3 MD; J C R P Ouédraogo,4 MD; A Sourabié,5 MD; G A Ouédraogo,6 MD;
G Bougma,7 MD; E Bonkian,3 MD; G Ouédraogo,1,3 MD; G Badoum,1,3 MD; M Ouédraogo,1,3 MD
1 Unité de Formation et de Recherche en Sciences de la Santé, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
2 Service de Pneumologie, Centre Hospitalier Universitaire de Tengandogo (CHU-T), Ouagadougou, Burkina Faso
3 Service de Pneumologie, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
4 Département de Médecine et Pharmacopée Traditionnelles, Pharmacie (MEPHATRA-PH), Institut de Recherche en Sciences de la Santé (IRSS),
Ouagadougou, Burkina Faso
5 Service de Pneumologie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
6 Service de Pneumologie, Centre Hospitalier Universitaire Régional de Ouahigouya, Ouahigouya, Burkina Faso
7 Service de Pneumologie, Centre Hospitalier Régional de Kaya, Kaya, Burkina Faso
Corresponding author: A R Ouédraogo (oarisgou@yahoo.fr)
Study synopsis
What the study adds. e study provides additional data from resource-poor settings such as Burkia Faso, where there is an overall high
prevalence of Sisha smoking, and also among students who are poorly informed about the health eects of smoking.
Implications of the ndings. e data informs advocacy and intervention strategies to combat smoking and decrease overall tobacco use
in an African setting.
AJTCCM VOL. 29 NO. 1 2023 7
RESEARCH
healthrisk for both active and passive smokers.[1] There is an
erroneous perception that shisha is less hazardous than tobacco
cigarettes,[4-6] although mounting evidence indicates that it is
even more harmful.[4-6] Like tobacco cigarettes, shisha has been
shown to be associatedwith a wide range of detrimental eects on
health such as cancer, heart disease, lung disease, and many other
illnesses.[4-6] Moreover, sharing of shisha pipes has been linked
to the spread of infectious diseases such as hepatitis B, herpes,
tuberculosisandinuenza.[4-6]
Shisha has recently been gaining increased popularity in many
developed and developing countries.[4,7] It has been documented
that shisha smoking is common among young people, mainly high-
school children and college and university students.[7] For example,
according to a survey involving >100 000 students from 152 colleges
and universities in the USA, current shisha smoking was reported
by 8.4% of students, second only to cigarettes.[7] Two recent studies
in 15 secondary schools in London, UK, and on the campus of the
University of Florida in the USA have documented for the rst time
a higher prevalence of use of shisha than of cigarettes.[7] In Africa,
shisha smoking has rapidly become increasingly popular in major
cities. e vogue is pervading society, and smoking is commonly
practised by university undergraduates, adolescents and the older
population in restaurants and hotels and at social gatherings.[8-10] Lack
and/or weakness of regulations have also contributed to its increased
consumption. A high prevalence (36.4%) of shisha smoking and poor
knowledge regarding its eects on health was reported in youths
attending bars in Kampala, Uganda.[9] In Nigeria, the prevalence of
shisha smoking in nightclubs was 7.1%.[10]
Burkina Faso has not escaped this trend, and despite the growing
popularity of shisha, to date there has been no study on the prevalence
of shisha consumption in a student environment. e present study
aimed to determine the prevalence of shisha use among university
students in Ouagadougou, Burkina Faso, and associated knowledge,
practices and beliefs about health effects, to generate helpful
information for interventions against shisha smoking.
Methods
Design and study population
Burkina Faso is a landlocked country located in the heart of West
Africa. Ouagadougou, the capital city, has a population of 2637 303.[11]
We conducted a cross-sectional study from October to December 2019
at UniversitéSaint omas d’Aquin (USTA) in Ouagadougou. USTA
is the biggest private university in the country, with 2 442 students
during the 2019/2020 academic year. It currently has ve faculties
(Legal and Political Sciences, Economics and Management, Health
Sciences, Science and Technology, Human Sciences and Society), one
institute (Higher Institute of Tertiary Trade) and one doctoral school
(Graduate School of Science, Health and Technology).
e study population was students from dierent faculties at USTA
enrolled during the 2019/2020 academic year, who consented to
participate in the study.
Sample size and sampling technique
A stratied sampling method was used, as students were stratied
into faculties. e number of students per stratum was proportionally
allocated. Students were selected by simple random sampling
using a student list made available by each department on request.
Studentswere approached in lecture rooms shortly before or aer
a class.
We determined the minimum sample size (no=385) using the
Cochrane formula for estimating a single proportion:
where p is the anticipated shisha prevalence in the population,
is the percentage of the standard distribution corresponding
to the two-sided signicance level (for the signicance level of 5%,
=1.96), and =0.05 is the level of precision.
A 10% non-response rate gives a total sample size of N=424 for
data collection.
Data collection
The questionnaire was adapted from previous studies on the
prevalence of shisha use conducted in Kampala, Uganda, and Kigali,
Rwanda.[8,9] We used CSpro soware, version 7.1 (US Census Bureau
and ICF International, USA), through CAPI (Computer Assisted
Personal Interviewing) using a mobile phone for data collection.
is soware allows administration of a face-to-face questionnaire in
which the interviewer uses a tablet on an Android system to conduct
the interview. e questions were closed, open or dichotomous.
Dependent variable
e dependent variable was shisha smoking. e information sought
on prevalence was based on the participants’ response to the question
‘Have you ever smoked shisha?’ We dened three types of smokers:
regular (an individual who smoked daily or at least once a week),
occasional (an individual who smoked less than once a week), and
experimenter (an individual who had smoked only once or twice
during their lifetime).
Independent variables
Our independent variables included sociodemographic characteristics
(including age, sex, marital status, level of education and place of
residence), smoking status of the parents and youths, educational
level of the parents, and knowledge about and attitudes of the youths
towards shisha smoking.
We dened knowledge about the health eects of shisha smoking as
the respondent’s ability to identify diseases associated with the practice
based on a list of eight diseases, knowledge about the harmfulness
of shisha to health, and knowledge about the harmfulness of shisha
compared with cigarettes. Correct responses to questions were
allocated 1 point, giving a possible total of 10 points for the questions.
Participants were then categorised as having satisfactory knowledge,
with a score ≥5, or poor knowledge, with a score of 0 - 4.
Data analysis
e data generated were entered into the system and analysed using
SPSS Statistics soware for Windows, version 25.0 (IBM Corp., USA).
At the univariate level, we calculated proportions for categorical
variables and summarised age using means and standard deviations
(SDs). A forward stepwise-ordered logistical regression model
established the factors independently associated with shisha smoking
AJTCCM VOL. 29 NO. 1 2023 8
RESEARCH
at the multivariable level. A binary logistic regression analysis was
also performed to determine the independent factors accounting
for the participants’ knowledge. We set the signicance level (α)
at 5%.
Ethical considerations
The study was carried out with respect for the anonymity and
condentiality of the information collected. It was authorised by
the board of USTA (ref. no. 2019-202/CNEC/SN/USTA/R/VR). We
obtained informed consent from all participants before enrolment.
Results
Sociodemographic characteristics of the respondents
A total of 443 students were approached for an interview, of
whom421consented to participate (response rate 95.0%). e mean
(SD) age of the respondents was 20.9 (2.3) years, and 213/421 (50.6%)
were aged <21 years. Females represented 243/421 (57.7%) of the
respondents. Most respondents (97.1%) were single, and 57.0% did
not live with their parents. Of the participants’ fathers, 312 (74.1%)
had secondary or tertiary education, and more than half of the
participants’ mothers (64.6%) had secondary or tertiary education
(Table1).
Prevalence of shisha use
Of the 421 respondents, 162 (38.5%) indicated that they had smoked
shisha. Of the 162 shisha users, 14.2% were regular smokers, 77.2%
were occasional smokers, and 8.6% were experimenter smokers.
Legal and Political Sciences (54.1%) and Economics and Management
(42.4%) were the most affected faculties. There was a significant
dierence in prevalence between faculties (p=0.0042).
Table 2 shows the sociodemographic characteristics of the
respondents stratified by shisha use and the association with
shisha use. Age (p=0.0001), gender (p<0.001), educational level of
father (p=0.0001) and educational level of mother (p=0.0004) were
signicantly associated with shisha smoking. Students aged <20years
had 2.63 times higher odds of smoking shisha than those aged
≥20years, while males were 3.5 times more likely to use shisha than
females. Students whose fathers and mothers had at least secondary
education had 2.60 and 2.20 higher odds of shisha use, respectively,
than students with less educated parents.
Knowledge about shisha smoking and beliefs about
health eects
Nearly all the respondents (95.2%) stated that shisha is harmful to
health, and more than half (67.5%) thought that shisha is less hazardous
than tobacco cigarettes. Responses to the questions about diseases
associated with shisha smoking were as follows: bronchopulmonary
cancers 24.5%, tuberculosis 19.5%, hepatitis 18.5%, cancers of the
larynx 16.1%, cardiovascular disease 15.4%, chronic bronchitis 14.0%,
labial herpes 5.5%, and peptic ulcer 5.5%. On further classication of
knowledge into poor and satisfactory, less than half of the students
(n=183; 43.5%) had poor knowledge about the health eects of shisha
smoking. ere was no signicant dierence in knowledge between
shisha smokers and non-smokers (p=0.213). However, there was
a signicant dierence in knowledge between faculties (p=0.017)
(Table3). Students from the Health Sciences faculty had 80% increased
odds of having satisfactory knowledge.
Shisha smoking practices
e mean (SD) age of initiation of shisha smoking was 18.15 (2.40)
years, and the mean (SD) duration of shisha use was 18.03 (17.06)
months. The main reasons for shisha smoking were being in the
company of friends who were users (57.4%), the sweet and pleasant
avour and fragrance of shisha (25.9%), and fashion (22.2%). Shisha
was consumed with alcohol in the tank by 21% of smokers. Nearly
all shisha smokers (90.7%) smoked over the weekend, and the mean
(SD) time spent smoking shisha on a day when it was used was 42.60
(10.20) minutes. e majority (n=155; 97.5%) of the respondents
smoked shisha in the company of friends, and 100 respondents (61.7%)
shared a shisha pipe. Mean (SD) monthly expenditure on shisha was
USD6.6 (10.1). More than half (n=99; 61.1%) of shisha consumers also
consumed alcohol, 6.8% smoked other forms of tobacco, and 4.3%
also used drugs. Table4 shows the shisha smoking practices reported
by the students.
Discussion
Prevalence
e prevalence of shisha use varies across countries. In the present
study, 38.5% of the respondents had smoked shisha at least once.
Table1. Sociodemographic characteristics of the respondents
(N=421)
Variable n (%)
Faculty
Health Sciences 97 (23.0)
Legal and Political Sciences 85 (20.2)
Economics and Management 99 (23.5)
Science and Technology 80 (19.0)
Human Sciences and Society 60 (14.3)
Gender
Male 178 (42.3)
Female 243 (57.7)
Age (years)
<21 213 (50.6)
21 - 24 170 (40.4)
≥25 38 (9.0)
Marital status
Single 409 (97.1)
Married 12 (2.9)
Lives with parent(s)
Yes 181 (43.0)
No 240 (57.0)
Educational level of father
None 84 (20.0)
Primary 25 (6.0)
Secondary 52 (12.3)
Ter ti ar y 260 (61.7)
Educational level of mother
None 117 (27.8)
Primary 32 (7.6)
Secondary 138 (32.8)
Ter ti ar y 134 (31.8)
AJTCCM VOL. 29 NO. 1 2023 9
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This finding is similar to those of Aanyu
etal.[9] in Uganda and Sutn etal.[12] in North
Carolina, USA, who reported prevalences of
36.4% and 40.3%, respectively.
Our prevalence of shisha use was higher
than rates reported by Omotehinwa etal.[8]
in Rwanda (26.1%) and Wachinou etal.[13]
in Cotonou, Benin (13.8%). Burkina Faso
has a higher prevalence of smoking than
Benin and Rwanda, which may explain the
higher prevalence of shisha use. However,
the prevalence of shisha use in our study was
lower than that in the United Arab Emirates
(44.9%),[14] Saudi Arabia (44.1%)[15] and
Pakistan (53.6%).[16] The high prevalence
rates in these countries could be explained by
the cultural and social acceptance of shisha.
We found that the prevalence of regular
shisha consumption in our study (14.0%)
was higher than that of tobacco smoking
in Burkina Faso.[17] e WHO has declared
shisha to be a real public health problem,
because of the increase in consumption
among young people.[18] Shisha could be a
gateway to smoking for many young people
who would otherwise never have started
smoking.[18] ese gures should challenge
public health practitioners to implement
an intervention strategy to reduce shisha
consumption among young people.
Knowledge about the health harms
of shisha and associated factors
Most of the respondents in our study (95.2%)
stated that shisha was harmful to health.
is gure is similar to those reported from
Uganda (86.7%)[9] and South Africa (91.0%).[19]
More than half of our respondents (67.5%)
thought that shisha was less harmful than
cigarettes. According to the literature, the
aerosol of shisha smoke contains higher
concentrations of carbon monoxide, nicotine,
tar and heavy metals than those in cigarette
smoke. A shisha session exposes the user to
~100 times the volume of harmful substances
compared with smoking a cigarette.[2,20]
Many of our respondents (56.5%) had
satisfactory knowledge. Students in the
Health Sciences faculty were 1.80 times more
likely to have satisfactory knowledge than
those in other faculties. e same nding was
reported by Jawaid etal.[16] in Pakistan. ese
observations could be explained by the fact
that medical students have better knowledge
about the health eects of tobacco use than
students in other elds.
Shisha consumption practices
Reports indicate that shisha is usually
consumed with water in the tank. Young
people sometimes replace the water with
alcoholic beverages out of curiosity and in
search of excitement.[21] is practice was also
Table2. Association of sociodemographic characteristics with shisha use (N=421)
Variable n Shisha users, n (%) OR (95% CI) p‑value
Age (years)
≥20 109 25 (22.9) Ref.
<20 312 137 (43.9) 2.63 (1.6 - 4.3) 0.0001*
Gender
Female 243 65 (26.7) Ref.
Male 178 97 (54.5) 3.5 (2.3 - 5.4) <0.001*
Study faculty
Other faculties 324 129 (39.8) Ref.
Health Sciences 97 33 (34.0) 0.79 (0.5 - 1.3) 0.382
Lives with parent(s)
No 240 86 (35.8) Ref.
Yes 181 76 (42.0) 1.48 (0.9 - 2.3) 0.073
Educational level of father
None or primary 109 25 (22.9) Ref.
Secondary or tertiary 312 137 (43.9) 2.60 (1.6 - 4.3) 0.0001*
Educational level of mother
None or primary 149 40 (26.8) Ref
Secondary or tertiary 272 122 (44.9) 2.2 (1.4- 3.4) 0.0004*
OR = odds ratio; CI = condence interval; Ref. = reference category.
*Signicant (p<0.05).
Table3. Association of sociodemographic characteristics with a satisfactory
knowledge about the health eects of shisha smoking (N=421)
Variable n
Satisfactory
knowledge, n (%) OR (95% CI) p‑value
Gender
Female 243 148 (60.9) Ref.
Male 178 90 (50.6) 0.68 (0.5 - 1.0) 0.056
Age (years)
≥20 109 68 (62.4) Ref.
<20 312 170 (54.5) 0.79 (0.4 - 1.3) 0.390
Study faculty
Other faculties 324 173 (53.4) Ref.
Health Sciences 97 65 (67.0) 1.80 (1.1 - 2.9) 0.017*
Lives with parent(s)
No 240 133 (55.4) Ref.
Yes 181 105 (58.0) 1.11 (0.7 - 1.6) 0.615
Educational level of father
None or primary 109 68 (62.4) Ref.
Secondary or tertiary 312 170 (54.5) 0.83 (0.5 - 1.3) 0.450
Educational level of mother
None or primary 149 91 (61.1) Ref.
Secondary or tertiary 272 147 (54.0) 1.3 (0.9- 2.0) 0.190
Shisha smoking
Yes 162 81 (50.0) Ref.
No 259 157 (60.6) 0.76 (0.5- 1.2) 0.213
OR = odds ratio; CI = condence interval; Ref. = reference category.
*Signicant (p<0.05).
AJTCCM VOL. 29 NO. 1 2023 10
RESEARCH
observed in the present study, with 21.0% of respondents stating that
alcohol was used in the tank.
Respondents in the present study reported that they smoked
most oen at their friends’ homes (54.3%), in bars and restaurants
(36.4%) and at home (16.0%). Other studies report similar smoking
venues.[19,22] e majority (97.5%) of our respondents smoked in the
company of their friends. e above observations testify to the social
and recreational aspect of shisha use and illustrate that it has become a
way of identifying with peers. In a sense, shisha has become an object
of aliation rather than liation.
We found that the primary motivations for smoking shisha were
spending time with friends (57.4%), avour and fragrance (25.9%),
fashion (22.2%), curiosity (9.9%), stress management (6.2%) and
media inuence (2.5%). Our review of the literature found additional
reasons that motivate young people to use shisha, including boredom,
lack of alternative leisure activities, and an expression of cultural
identity for people in the Middle East.[21,23]
Simultaneous use of shisha and other tobacco products (cigarettes
3.7%, cigars 2.5%, pipes 0.6%), alcohol (61.1%) and narcotics (4.3%)
was found in our study. Other studies have made the same observation.
Van der Merwe etal.[19] found that 11.0% of shisha users also smoked
cigarettes, and that 30.0% smoked drugs and consumed alcohol. ese
ndings could indicate that participating in risky behaviour increases
the likelihood of experimenting with other risky behaviours. As a
springboard to smoking alone, shisha would increase health risks for
its users.
Conclusion
is study found a relatively high prevalence of shisha smoking among
university students, while knowledge about its eects on health was
relatively satisfactory, although more than half of the respondents
(67.5%) thought that shisha was less harmful than cigarettes. Regular
medical education and health promotion targeting young people
could improve their knowledge about shisha use and hence their
practices. In addition, laws and regulations should be enacted, such as
banning the shisha bars in Ouagadougou or throughout BurkinaFaso,
and even the importation of shisha equipment and material.
Declaration. e research for this study was done in partial fullment of
the requirements for EB’s MD degree at USTA.
Acknowledgements. e authors thank all the research participants who
contributed to the study.
Author contributions. ARO conceptualised the study, and participated in
its design, performance and co-ordination, in statistical analysis, and in
draing and revising of the manuscript. KB and JCRPO participated in the
study design and co-ordination, in statistical analysis, and in draing and
revising of the manuscript. AS and GAO participated in the study design,
and in revising of the manuscript. GB, EB and GO participated in the study
design and performance, in data collection and statistical analysis, and in
draing and revising of the manuscript. GB and MO conceptualised the
study, and participated in its design and co-ordination and in revising of
the manuscript. All authors read and approved the nal manuscript.
Funding.None.
Conicts of interest.None.
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Table4. Practices with regard to shisha smoking among
students (N=162)
Variable n (%)*
Age of initiation (years)
≤15 16 (9.9)
16 - 20 106 (65.4)
≥20 40 (24.7)
Reasons for smoking shisha
Being with friends who are users 93 (57.4)
Shisha is sweet and pleasantly avoured 42 (25.9)
Fashion 36 (22.2)
Curiosity 16 (9.9)
To manage stress 10 (6.2)
Media inuence 4 (2.5)
Consumption habits
With water in tank 137 (84.6)
With alcohol in tank 34 (21.0)
Smoking venue
Friend’s home 88 (54.3)
Bars/restaurants 59 (36.4)
Own home 26 (16.0)
Shisha smoking partner
Friends 158 (97.5)
Alone 5 (3.1)
Family 1 (0.6)
Sharing shisha pipe
Yes 100 (61.7)
No 62 (38.3)
*Totals are sometimes more than 162, because some students gave more than one response to
the question.
AJTCCM VOL. 29 NO. 1 2023 11
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Accepted 17 January 2023.
