The use of the waterpipe (also known as hubbly bubbly, shisha, narghile or hookah pipe) started as a cultural phenomenon . Today the use of the waterpipe has become a social phenomenon as with cigarette smoking, with hookah bars, cafés and restaurants becoming popular social gathering places for young smokers and their friends . One of the reasons for the popularity of the waterpipe is the social availability and accessibility of both the waterpipe and the tobacco used . Furthermore, waterpipe use is widely viewed as a safer alternative to cigarette smoking rather than a potential health risk . Waterpipe smoke contains significantly higher quantities of toxic heavy metals such as arsenic, nickel, cobalt, chromium, lead as compared with cigarette smoke . Research has indicated that the relationship between water pipe use and consumer risk, is dose-response related . The health effects of the waterpipe are under-studied, but users believe that as smoke is drawn through water, the filtration process removes dangerous particles in the smoke, and users would therefore consider waterpipe smoking as a safer alternative to smoking cigarettes [7, 8]. However, there are studies which suggest that the level of the nicotine does not change when the smoke is filtered [9, 10]. Thus the waterpipe could be considered to be a health risk due to the presence of nicotine and toxic heavy metals in the smoke of the waterpipe. Studies suggest that smoking the waterpipe has long-term health effects which include cancer [11, 12], respiratory health issues , acute increased heart rate and systolic and diastolic blood pressure .
Besides the smoke of the waterpipe being a health risk owing to tobacco use, additional health risks have been noted in studies. Sharing a waterpipe is a contributing factor to the spreading of tuberculosis, mononucleosis, viruses and bacteria when an infected individual shares a mouthpiece with none-infected individuals because of the transmission of oral secretions . The humid closed hose may act as a source of tuberculosis infection among waterpipe users and the common use of one waterpipe amongst a group of users . Poor sanitation, inadequate cleaning of the waterpipe and lack of public health oversight contribute to the spread of infectious diseases. In addition, hookah bars are not required to sterilise or replace the waterpipe mouthpieces after use .
Prevalence studies suggest that waterpipe use amongst school children in Middle Eastern countries and among university student groups of Middle Eastern descent in Western countries have the highest rates . In addition, the use of the waterpipe often takes place during social activities between family members and friends, in and out of the home. Smoking the waterpipe predicts regular and increased cigarette smoking .
Research focusing on the waterpipe in South Africa is limited. To our knowledge, only two studies focusing on the waterpipe have been conducted in South Africa. The first study focused on secondary school learners in a disadvantaged community in Johannesburg. The results indicated that 60% of participants used the waterpipe, which included 20% daily use . The second study focused on university medical students in Pretoria. The prevalence of waterpipe use was 18.6%. The results suggested that South African medical students used alternative tobacco products and this could be considered to be part of a pattern of risk-taking behaviour .
According to the results of the South African Youth Risk Behaviour Survey 2008 conducted by the Medical Research Council , the Western Cape Province (36.7%) has a significantly higher prevalence of current tobacco smoking and current frequent tobacco smoking (14.6%) than the national average of 21.0% and 5.8% respectively. Although the South African government has implemented legislative action to discourage tobacco use by increasing taxation and banning advertising, tobacco consumption still remains a public health concern [18, 19]. The South African Tobacco Control policy prohibits tobacco smoking in public spaces, but prohibiting waterpipe smoking has not been effected. Although, studies provide sufficient evidence that waterpipe use is a potential health risk, young people in South Africa may not necessarily be aware of the health risks of smoking the waterpipe. The purpose of this study therefore was to determine the risk perceptions and behaviours of university student waterpipe users in the Western Cape in South Africa.