Predictors of an Intention to Quit Waterpipe Smoking among Arab Americans: Application of The Theory of Planned Behavior

Introduction: As the second global tobacco epidemic since the cigarette, waterpipe smoking has been rapidly spreading among youth around the world in the past decade. Middle Eastern ethnicity or having a friend of Middle Eastern ethnicity have been reported as significant predictors of waterpipe smoking among US students. To date, no studies have investigated the predictors of an intention to quit waterpipe smoking among the Arab-Americans population specifically. Our study’s objective is to investigate the predictors of an intention to quit waterpipe smoking in next 12 months among a sample of Arab Americans who smoke tobacco using a waterpipe in the Houston area. Methods: An observational, survey-based cross-sectional study with a convenience sample of Arab American adults in Houston, Texas area was conducted to address the study goals. The questionnaire consisted of six major categories with 53 questions. The first five sections of the study consisted of 41 ‘yes/no’ and multiple-choice questions that included: socio-demographic characteristics, tobacco use history, perception of risk, and waterpipe-related practices. The last section in the survey consisted of 12 sub-questions with a seven point scale answer that cover the theory of planned behavior constructs and investigate the smoker’s intention to quit smoking using waterpipes. Stepwise Logistic regression were run to determine predictors of the intention to quit waterpipe smoking in the next 12 months. All the statistical analysis were conducted using SAS 9.2 (SAS Institute Inc., Carey, North Carolina) at a significance level of 0.05.

Results: A total of 340 participants completed the survey. Overall, the percentage of participants having an intention to quit waterpipe smoking among this study sample was 27.43%. The majority of participants (96%) initiated waterpipe smoking in the company of their family members or friends. Approximately half of the participants (49%) smoked cigarettes and 31% smoked cigars, cigarillos, or little cigars in the previous 30 days. Significant predictors associated with a higher intention to quit smoking waterpipe in the next 12 months among Arab Americans were history of cigar use in the previous 30 days [OR: 4.38 CI: 1.86 – 10.31], a prior attempt to quit waterpipe smoking for more than 7 days [OR: 6.6 CI: 1.324 – 32.968], and not smoking waterpipe when seriously ill compared to those who smoke even when seriously ill [OR: 6.50 CI: 1.404 – 30.093]. Predictors associated with a lower intention to quit waterpipe smoking were increasing age [OR: 0.933 CI: 0.876 – 0.995], medium cultural acceptability of using waterpipe among family members compared to no-cultural acceptability among family [OR: 0.434 CI: 0.188 – 0.99], high cultural acceptability of using waterpipe among friends compared to no-cultural acceptability among friends [OR: 0.130 CI: 1.09 - 10.64], duration of smoking sessions between 1 hour [OR: 0.270 CI: 0.094 – 0.772] and 2 hours [OR: 0.044 CI: 0.002 - 0.933] compared to those who smoke for less than 30 minutes, and perception of waterpipe’s harm as less than cigarettes [OR: 0.376 CI: 0.177 - 0.800] compared to those perceive it as more harmful than cigarettes. After adjusting the internal constructs of TPB to age, gender, income, marital status and education the results indicated that behavioral evaluation (OR: 1.28 CI: 0.64 -0.94), Normative beliefs (OR: 1.24 CI: 0.69 - 0.93) and motivation to comply (OR: 1.17 CI: 0.73 - 0.99) were predictors of an intention to quit waterpipe smoking in the next 12 months.

Conclusion: The study findings demonstrate low levels of intention to quit waterpipe smoking among Arab Americans in Houston, Texas area. Public health educational programs that target Arab Americans in general, and specifically older adults, those who smoke waterpipes for more than 60 minutes, those whose family and friends approve smoking waterpipe, and those with no former quit attempts may be necessary to increase the intention to quit waterpipe smoking. Interest in quitting is determined mainly by smokers’ behavioral evaluation, normative beliefs and motivation to comply. Efforts are greatly needed to design interventions and strategies that include these constructs.