575479

Research ArticlePredictors of Intention to Quit Waterpipe Smoking:A Survey of Arab Americans in Houston, Texas

Liqa Athamneh,1 Sujit S. Sansgiry,1 E. James Essien,1,2 and Susan Abughosh1

1Department of Pharmaceutical Health Outcomes and Policy, Texas Medical Center, University of Houston,1441 Moursund Street, Houston, TX 77030, USA2The University of Texas School of Public Health, 7000 Fannin Street, Houston, TX 77030, USA

Correspondence should be addressed to Susan Abughosh; [email protected]

Received 28 August 2014; Revised 24 January 2015; Accepted 19 February 2015

Academic Editor: Hua Yong

Copyright 2015 Liqa Athamneh et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Waterpipe smoking has been described as the second global tobacco epidemic since the cigarette. Both Middle Eastern ethnicityand having a friend of Middle Eastern ethnicity have been reported as significant predictors of waterpipe smoking. Addressingwaterpipe smoking in this ethnicminority is essential to controlling this growing epidemic in theUS.We investigated the predictorsof an intention to quit waterpipe smoking by surveying 340 Arab American adults in the Houston area. Primary analyses wereconducted using stepwise logistic regression. Only 27% of participants reported having an intention to quit waterpipe smoking.Intention to quit waterpipe smoking was significantly higher with history of cigar use, a prior attempt to quit, and not smokingwhen seriously ill and significantly lower with increasing age, medium cultural acceptability of using waterpipe among family, highcultural acceptability of using waterpipe among friends, longer duration of smoking sessions, and perceiving waterpipe smoking asless harmful than cigarettes. Educational programs that target Arab Americans in general, and specifically older adults, those whosmoke waterpipe for more than 60 minutes, those whose family and friends approve waterpipe smoking, and those with no formerattempts to quit, may be necessary to increase the intention to quit waterpipe smoking.

1. Introduction

The term waterpipe refers to any type of instruments thatinvolve passing tobacco smoke through water before inhala-tion [1]. Using waterpipe to smoke tobacco is a centuries-oldhabit that has been practiced inAsian andAfrican regions butis usually linked with the eastern Mediterranean area [2].

Waterpipe smoking is currently the object of renewedattention, as its use has been gaining popularity lately amongyoung people in western countries, such as the US, Europe,and Brazil [3]. During the past decade, it has been describedas the second global tobacco epidemic since the cigarette[4].

In the US, reports show that waterpipe smoking is rising[5] and becoming the most common type of tobacco smokedby US adults after cigarettes [6, 7]. Waterpipe smoking hasbeen reported in more than 33 states, with most reportsderiving from cities with a large university [8, 9]. In a studytargeting 6,594 students of the state of Arizona (grades 6

through 12) about 4% of the students were current waterpipesmokers (7.3% of 12th grade students) and 6% of studentshad previously used a waterpipe [10]. A survey of 411Johns Hopkins University freshmen found that about 15% ofstudents reported waterpipe tobacco smoking in the past 30days [11]. Another survey of 647 students from graduate andundergraduate programs at a large urban university in the USfound about 10% of participants reported current, and 41%had previous waterpipe smoking [12]. Another study of 2,204students at the University of Houston reported that 12.5% ofthe sample participants had smoked with a waterpipe withinthe last month [13].

Waterpipe smokers are at the same risk of smoking dis-eases such as lung cancer, oral cancer, cancer of the esoph-agus, stomach cancer, decreased fertility, and reduced lungfunction as cigarette smokers [14, 15].

Being of Middle Eastern ethnicity or having a friend ofMiddle Eastern ethnicity has been reported as significantpredictors of waterpipe smoking among US students [16].

Hindawi Publishing CorporationJournal of AddictionVolume 2015, Article ID 575479, 11 pageshttp://dx.doi.org/10.1155/2015/575479

2 Journal of Addiction

Consequently, addressing waterpipe smoking in this ethnicminority is essential in controlling this growing epidemic inthe general US population.

Arab Americans are one of the rapidly growing minoritygroups in the USA for which there seems to be little or nosmoking behavior data. The US Census Bureau categorizesArab Americans as people with descents originating fromArab-speaking areas of the world and considers them as oneof the fastest growing populations in the USA [17]. There areapproximately 1.5 million Americans (0.5 percent of the totalpopulation)who have anArab origin [17].They usually derivefrom common linguistic, cultural, and political heritages.

Smoking in Arab countries is an acceptable cultural andsocial behavior; it is a sign of hospitality to offer someonea cigarette, and it is a normal behavior to smoke inside thehome [18]. In a study that was conducted on Arab Americanadolescents, the participants described their use of waterpipein the home as an acceptable social activity by their parents[19].

The stage-based model of behavioral change was indi-cated to be effective for cigarette smoking cessation [20,21]. According to the model, the modification of addictivebehaviors includes progression through five stages: precon-templation stage with no intent to quit, contemplation stagewith starting an intention to quit, preparation for the behav-ioral change, action and change, and finally maintaining thechange [22].

As forming an intention to quit is the first step of quitting,identifying predictors of an intention to quit is integral indesigning effective intervention strategies to aid waterpipesmokers in this subpopulation in quitting and prevent furtherdiffusion into the US society.

To date, no studies have investigated the predictors ofan intention to quit waterpipe smoking among the Arab-American population. Our studys objective is to investigatethe predictors of intention to quit waterpipe smoking in thenext 12 months among a sample of Arab Americans whosmoke tobacco using a waterpipe in the Houston area.

2. Methodology

2.1. Study Design, Setting, and Area. To address the studygoals, an observational, survey-based cross-sectional studywith a convenience sample of Arab American adults wasconducted.

The study was carried out in Houston, Texas, with apopulation of more than 2,1 millions in 2013 [23]. Houstonwas chosen as it is one of the ten places in the United Statesthat have the largest Arab population, with about 41,653people from Arab origins living in Houston in 2013 [23, 24]and also because it was convenient for the investigator who isliving in this area. Data were collected by distributing surveysto willing adult participants from Arab origins in the studyarea.

2.2. Study Procedures. Adults visiting Arab congregations orhookah bars (regardless of their skin color or any physicalcharacteristics) were introduced to the study and the target

population and asked if they considered themselves to beamong this group of people. If they answered yes, they wereasked if they were willing to participate in filling out ananonymous survey regarding their waterpipe smoking habits.The basic information about the study, such as the purpose,procedures, confidentiality issues, risks, and benefits to par-ticipation both verbally and in written form, was explainedby the investigators before filling out the questionnaire.Filling out and returning the questionnaire implied the studyparticipants consent. When a qualified person refused toparticipate in filling the questionnaire, the investigator kindlyasked for the reason and noted the reason given.

Inclusion criteria for the study were adult aged 18 years orolder, fromArabAmerican descent, and smoking awaterpipein the last 30 days [25]. There was a locked box in the datacollection sites to drop off the survey upon completion. Asthe surveys were anonymous, there were no confidentialityissues.

2.3. Sample Size. The minimum effective sample size thatis required for the study was determined using GPOWER3.1 statistical software package [26]. Considering a multiplelogistic regression statistical test at 95% confidence, 80%power, and for a 1.5 odds ratio, the required sample size forthis study was estimated to be 307.

2.4. Ethical Considerations. Thestudy received approval fromthe Institutional Review Boards (IRBs) and the Committeefor the Protection of Human Subjects (CPHS) at the Univer-sity of Houston.

2.5. DataCollection Instrument. Thestudy used a self-admin-istered survey. The questionnaire consisted of five majorsections with yes/no and multiple-choice questions. Thesurvey was adopted from previously used and validatedquestionnaires [11, 13, 27, 28].

The first 6 questions cover the demographics includingage, gender, annual income, marital status, and educationlevel. Questions 630 were taken from a survey that wasoriginally developed by Smith and coworkers [11, 27] andinclude questions about tobacco use history, perception ofrisk, perceived social acceptability of smoking tobacco usinga waterpipe, and waterpipe-related practices such as theownership of waterpipe, frequency and length of smokingsessions, and age and place of first waterpipe use. Items 3141were about the addiction behavior and its four subscales: thenicotine dependence, negative reinforcement, psychologicalcraving, and positive reinforcement properties of waterpipesmoking.

2.6. Statistical Analysis. Descriptive statistics and chi-squareanalyses were used to determine the frequencies and asso-ciations of sample characteristics with the intention to quitwaterpipe smoking. The intention to quit was determinedusing the question (Do you intend to quit using a waterpipeto smoke tobacco in the next 12 months? Yes or No).

Bivariate analyses of sample characteristic were carriedout with the outcome variable (intention to quit waterpipe

Journal of Addiction 3

Table 1: Frequency of intention to quit waterpipe smoking by sample characteristics.

CharacteristicsHas intention to quit in the next 12 months

(No)frequency (%)

(Yes)frequency (%) value

Total 246 (72.57%) 93 (27.43%)Gender 0.2482Male 161 (70.61) 67 (29.39)Female 85 (76.58) 26 (23.42)

Income level 0.2685$100,000 37 (84.09) 7 (15.91)

Marital status 0.6512Single 112 (71.34) 45 (28.66)Married 124 (73.81) 44 (26.19)Divorced 8 (80.00) 2 (20.00)Widowed 3 (100.00) 0 (0.00)

Education level 0.7195


Table 2: Frequency intention to quit waterpipe smoking with perception of risk.


(No)frequency (%)


Do you believe smoking a waterpipe is harmful to your health? 0.3576Yes 202 (72.40) 77 (27.60)No 34 (79.07) 9 (20.93)

Compared to a regular cigarette, how harmful do you think waterpipesmoking is? 0.0022

More harmful than cigarettes 87 (65.55) 41 (34.45)As harmful as cigarettes 74 (67.89) 35 (32.11)Less harmful than cigarettes 90 (84.91) 16 (15.09)

Significant at < 0.05.

at the end of the data collection were 340 out of 510 surveysdistributed. Thus the overall response rate was 67%, withlack of time being the major reason reported (by 99%, =168) for not participating in the study.

3.2. Sociodemographic Data. The distribution of the sociode-mographic characteristics of the waterpipe smokers thatparticipated is shown in Table 1. The study sample consistedmainly of males (67%), married (50%), with a mean age(SD) of 30 8.5 (range 1865) years. The chi-squaretest results showed no significant association between theintention to quit waterpipe smoking in the next 12 monthsand gender, income level, marital status, or education.

3.3. Smoking Patterns. The mean age (SD) of starting tosmoke tobacco using a waterpipe was 20 (6.5) (range 355 years old). Ninety-six percent of the participants initiatedwaterpipe smoking in the company of their family mem-bers or friends. Two-thirds of participants own a waterpipeand 66% share it with others. Ninety-one percent reportedsmoking flavored tobacco in the waterpipe. Sixty percent ofparticipants smoke waterpipe tobacco at least once a week(38% smoke it at least once a day) (Table 1).

3.4. Tobacco Use History. Approximately 49% of the partic-ipants had smoked cigarettes and 31% had smoked cigars,cigarillos, or little cigars in the last 30 days. By calculating thefrequency of those who answered yes to all three questions:did you smoke waterpipe in the last 30 days? Did you smokecigar, cigarillos, or little cigars in the last 30 days? Did yousmoke cigarettes in the last 30 days? 87% of the study samplereported using cigarette, cigar, and waterpipe in the last 30days to smoke tobacco.The chi-square results listed in Table 1showed no significant association between the intention toquit waterpipe smoking in the next 12 months and cigaretteor cigars use history (Table 1).

3.5. Perception of Risk. Thirty-two percent of participantsperceived waterpipe smoking as less harmful to ones healthcompared to cigarette smoking. The chi-square test resultsindicate that the intention to quit waterpipe smoking in

the next 12 months is significantly associated with perceptionof waterpipe smoking risk compared to cigarettes ( =0.0022) (Table 2).

3.6. Perceived Social Acceptability. Few participants reportedthat their families (14.8%), friends (9.6%), and peers (10.9%)did not approve or accept their use of waterpipe tobacco.

Chi-square analyses indicated a significant associationbetween an intention to quit waterpipe smoking in the next 12months with the cultural acceptability of waterpipe smokingamong family members and friends from the same ethnicity( = 0.0028 and 0.0158, resp.). In the study sample, almosttwo-thirds of participants believed that waterpipe smokinglooks cool or very cool (Table 3).

3.7.Waterpipe-Related Practices and Beliefs. Shorter length ofsmoking session ( = 0.0004), higher number of times theparticipants stopped waterpipe smoking formore than 7 days( = 0.0137), pleasure as not a reason to smoke ( = 0.0189),and pleasing others as a reason to smoke ( = 0.0264) weresignificantly associated with an intention to quit waterpipesmoking in the next 12 months (Table 4).

3.8. Logistic Regression Results. After controlling for thecovariates, the final results for the stepwise multiple logisticregression indicated that the significant predictors associatedwith a higher intention to quit waterpipe smoking in thenext 12 months among Arab Americans are history of cigaruse in the last 30 days compared to those who did notuse cigars in the last month (OR: 4.38 CI: 1.8610.31), aprior attempt to quit waterpipe smoking for more than 7days compared to those with no previous attempt (OR: 6.60CI: 1.3232.96), and not smoking waterpipe when seriouslyill compared to those who smoke even when seriouslyill (OR: 6.50 CI: 1.4030.09). Predictors associated with alower intention to quit waterpipe smoking are increasingage (OR: 0.93 CI: 0.870.99), medium cultural acceptabilityof using waterpipe among family members compared tono-cultural acceptability among family (OR: 0.43 CI: 0.180.99), high cultural acceptability of using waterpipe amongfriends compared to no-cultural acceptability among friends


Table 3: Frequency of intention to quit waterpipe smoking with perceived social acceptability.


(No)frequency (%)


The social acceptability of using a waterpipe among your peers? 0.2031None 25 (69.44) 11 (30.56)Low 55 (73.33) 20 (26.67)Medium 79 (67.52) 38 (32.48)High 82 (79.61) 21 (20.39)

The cultural acceptability of using a waterpipe among your familymembers? 0.0028

None 28 (57.14) 21 (42.86)Low 65 (65.66) 34 (34.34)Medium 99 (81.15) 23 (18.85)High 49 (79.03) 13 (20.97)

The cultural acceptability of using a waterpipe among friends of yourethnicity? 0.0158

None 20 (62.50) 12 (37.50)Low 24 (58.54) 17 (41.46)Medium 89 (71.20) 36 (28.80)High 109 (80.74) 26 (19.26)

How often do you attend Middle Eastern gatherings where waterpipeare served? 0.2615

Daily 34 (62.96) 20 (37.04)Weekly 119 (76.77) 36 (23.23)Monthly 59 (71.08) 24 (28.92)Yearly 27 (71.05) 11 (28.95)

How cool do your peers look when they use the waterpipe? 0.1377Not at all 81 (71.68) 32 (28.32)Cool 119 (69.59) 52 (30.41)Very cool 38 (84.44) 7 (15.56)

Significant at < 0.05.

(OR: 0.13 CI: 1.0910.64), duration of smoking sessionsbetween 1 hour (OR: 0.27 CI: 0.090.77) and 2 hours (OR:0.04 CI: 0.000.93) compared to those who smoke for lessthan 30 minutes, and perception of waterpipes harm as lessthan cigarettes (OR: 0.37 CI: 0.170.80) compared to thosewho perceive it as more harmful than cigarettes (Table 5).

4. Discussion

In our study sample of 340 Arab American waterpipe smok-ers, only 27.43% ( = 93) reported having an intention to quit,a percentage similar to that reported in a Syrian study [29].

The intention to quit waterpipe smoking in this studysample was significantly lower with increasing age. Thefinding contrasts previous studies on waterpipe smoking thatreported no significant association between age and intentionto quit [13, 29, 30]. A potential explanation to our findingcould be that older participants in our sample could havespent a longer number of years using waterpipe and thusmay have a higher addiction level. To confirm this potential

assumption, we calculated the duration of waterpipe smokingby subtracting the age of initiating waterpipe smoking fromthe current age of the participants and we ran a bivariateregression between age and duration of waterpipe smok-ing (in years). The bivariate regression results indicated asignificantly higher duration of waterpipe smoking in olderparticipants for the study sample.

While no significant association between cigarette smok-ing in the last 30 days and an intention to quit waterpipesmoking was found in this study, a positive associationbetween smoking cigars, cigarillos, or little cigars in the last30 days and the intention to quit waterpipe smoking wasdetected. The predominant intermittent use pattern of bothcigar smoking and waterpipe smoking [31, 32] and the beliefsthat they are less addictive and easier to quit compared tocigarette smoking [30, 32] might contribute to the positiveassociation between being a cigar smoker and the intentionto quit waterpipe smoking.

A previous attempt to quit has been reported as asignificant predictor of an intention to quit tobacco smoking


Table 4: Frequency of intention to quit waterpipe smoking with different waterpipe-related practices and beliefs.

CharacteristicsHas intention to quit

(No)frequency (%)


The likelihood of getting addicted when using a waterpipe socially 0.6314None 49 (75.38) 16 (24.62)Low 90 (75.00) 30 (25.00)Medium 67 (68.37) 31 (31.63)High 38 (76.00) 12 (24.00)

The likelihood of getting addicted when using a waterpipe by oneself 0.2538None 57 (76.00) 18 (24.00)Low 94 (78.33) 26 (21.67)Medium 62 (67.39) 30 (32.61)High 30 (68.18) 14 (31.82)

A governmental agency should evaluate the safety of the waterpipe beforeselling it 0.3104

Yes 151 (70.89) 29 (23.97)No 92 (76.03) 62 (29.11)

How often you smoke tobacco using a waterpipe? 0.0912At least once a year but not monthly 32 (60.38) 21 (39.62)At least once a month but not weekly 55 (68.75) 25 (31.25)At least once a week but not daily 96 (75.59) 31 (24.41)At least once a day, or most days each month 59 (78.67) 16 (21.33)

How long did a typical waterpipe session last? 0.0004

030 minutes 46 (57.50) 34 (42.50)3160 minutes 84 (70.59) 35 (29.41)6190 minutes 73 (85.88) 12 (14.12)91120 minutes 24 (82.76) 5 (17.24)120+ minutes 18 (85.71) 3 (14.29)

Do you consider yourself hooked on a waterpipe? 0.7737Yes 80 (74.77) 27 (25.23)No 159 (73.27) 58 (26.73)

Number of times you could stop waterpipe for more than 7 days 0.0137

None 44 (81.48) 10 (18.52)Once 14 (48.28) 15 (51.72)Several times 83 (72.81) 31 (27.19)It always happens 98 (73.13) 36 (26.87)

Percentage of income would you spend for waterpipe smoking 0.47061% or less of your monthly income 131 (70.05) 56 (29.95)2%10% of your monthly income 79 (78.22) 22 (21.78)11%50% of your monthly income 19 (67.86) 9 (32.14)More than 50% of your monthly income 11 (73.33) 4 (26.67)

Number of days you could spend without waterpipe? 0.7587One day or less 29 (76.32) 9 (23.68)2-3 days 40 (67.80) 19 (32.20)47 days 28 (70.00) 12 (30.00)More than 7 days 145 (73.60) 52 (26.40)


Table 4: Continued.

CharacteristicsHas intention to quit

(No)frequency (%)


Number of waterpipes you usually smoke per week 0.4480


Table 5: Results of bivariate and multiple logistic regressions to predict intention to quit waterpipe smoking.

Characteristics Unadjusted OR (CI 95%)for variables with < 0.2Adjusted OR (CI 95%)a

for variables with < 0.05Age 0.96 (0.930.99) 0.93 (0.870.99)Income level$100,000 0.40 (0.161.01)

Smoked cigars, cigarillos, or little cigars in the last 30 daysYes 2.31 (1.393.82) 4.38 (1.8610.31)No Reference Reference

The social acceptability of using a waterpipe among your peers?None ReferenceLow 0.82 (0.341.98)Medium 1.09 (0.482.45)High 0.58 (0.241.37)

The cultural acceptability of using a waterpipe among your family members?None Reference ReferenceLow 0.69 (0.341.40) 2.24 (0.519.74)Medium 0.31 (0.150.64) 0.43 (0.180.99)High 0.35 (0.150.81) 0.33 (0.051.98)

The cultural acceptability of using a waterpipe among friends of yourethnicity?None Reference ReferenceLow 1.18 (0.453.04) 0.70 (0.114.16)Medium 0.67 (0.291.52) 0.20 (0.031.03)High 0.39 (0.170.91) 0.13 (1.0910.64)

How often do you attend Middle Eastern gatherings where waterpipe areserved?Daily ReferenceWeekly 0.51 (0.261.00)Monthly 0.69 (0.331.43)Yearly 0.69 (0.281.69)

How cool do your peers look when they use the waterpipe?Not at all ReferenceCool 1.10 (0.651.86)Very cool 0.46 (0.181.15)

How often you smoke tobacco using a waterpipe?At least once a year but not monthly ReferenceAt least once a month but not weekly 0.69 (0.331.43)At least once a week but not daily 0.49 (0.240.97)At least once a day, or most days each month 0.41 (0.180.90)

How long did a typical waterpipe session last?030 minutes Reference Reference3160 minutes 0.56 (0.311.02) 0.41 (0.161.06)6190 minutes 0.22 (0.100.47) 0.270 (0.090.77)91120 minutes 0.28 (0.090.81) 0.044 (0.000.93)120+ minutes 0.22 (0.060.82) 0.234 (0.022.80)

Do you usually share the waterpipe with others?Yes 1.65 (0.962.85)No Reference

Number of times you could stop waterpipe for more than 7 daysNone Reference ReferenceOnce 4.71 (1.7312.82) 6.60 (1.3232.96)Several times 1.64 (0.733.66) 2.36 (0.5510.07)It always happens 1.61 (0.733.54) 1.34 (0.335.35)


Table 5: Continued.

Characteristics Unadjusted OR (CI 95%)for variables with < 0.2Adjusted OR (CI 95%)a

for variables with < 0.05Do you smoke waterpipe when you are seriously ill?Yes, absolutely Reference ReferenceYes, probably 1.19 (0.304.67) 0.06 (0.011.42)Yes, maybe 0.89 (0.223.50) 0.15 (0.011.36)No 0.51 (0.171.52) 6.50 (1.4030.09)

Do you smoke waterpipe for pleasure?Yes, absolutely ReferenceYes, probably 1.77 (0.933.38)Yes, maybe 1.43 (0.722.82)No 3.00 (1.476.10)

Do you smoke waterpipe to please others?Yes, absolutely ReferenceYes, probably 2.01 (0.547.49)Yes, maybe 0.97 (0.263.49)No 0.58 (0.201.64)

The likelihood of getting addicted when using a waterpipe sociallyNone ReferenceLow 1.02 (0.502.05)Medium 1.41 (0.692.87)High 0.96 (0.402.28)

The likelihood of getting addicted when using a waterpipe by oneselfNone ReferenceLow 0.87 (0.441.73)Medium 1.53 (0.773.04)High 1.47 (0.643.37)

Do you believe smoking a waterpipe is harmful to your health?Yes 1.44 (0.663.14)No Reference

Compared to a regular cigarette, how harmful do you think waterpipesmoking is?More harmful than cigarettes Reference ReferenceAs harmful as cigarettes 0.90 (0.511.56) 1.16 (0.612.22)Less harmful than cigarettes 0.33 (0.170.64) 0.37 (0.170.80)

aAdjusted to all variables with unadjusted odds ratio with < 0.2.

< 0.05, < 0.01, and < 0.001.

to have an intention to quit. This is potentially related to theassociation between longer duration of smoking or smokingeven when seriously ill and higher nicotine exposure anddependence [13, 35], which has been shown to lower quitattempts among cigarette smokers [33, 34].

This study showed a higher intention to quit waterpipesmoking among those who perceived waterpipe use as moreharmful than cigarettes compared to those who did not. Thisfinding is consistent with prior research [13]. In addition,lesser harm perception compared to cigarettes has also beenidentified as a predictor of use for waterpipe smokers in anumber of studies in the US and abroad [16, 36].

As a factor influential in both initiation and continuationof waterpipe smoking, educating and informing users ofpotential harms and negative health consequences should bepart of any intervention aiming at increasing the intention toquit waterpipe smoking as an initial step to quitting.

Finally, the results of this study demonstrated the signif-icant effect of the social norms on the smokers intention toquit waterpipe smoking as previously described in literature

[29, 30]. Arab Americans whose friends and family membershave a medium or high social acceptability of waterpipesmoking had a lesser intention to quit. Waterpipe smokinghas been shown to be part of a social phenomenon as it isfrequently carried out in groups and gatherings thus makingthe habit more appealing [27, 37, 38].This social aspect has tobe taken into consideration when designing any interventionto promote quitting. Including friends and family membersin the programs and interventions that aim to increase thesmokers awareness about the negative aspects of smokingcould be beneficial.

5. Limitations and Future Research

The study suffers the limitations of the cross-sectional designas we are unable to draw causal associations with such adesign. As the study was conducted using a conveniencesample of Arab Americans in Houston, Texas area only, thegeneralizability of the finding may be limited to this geo-graphic area and not to all Arab Americans. The replication


of this study in different settings and geographic locationswould provide better generalizability of the results.

Our study did not address some important factors relatedto waterpipe smoking, such as reasons for starting smoking,history of any health complications due to waterpipe smok-ing, motivations to quit waterpipe smoking, type of productused in waterpipe smoking (herbal versus tobacco), dif-ference between herbal products smokers and tobacco prod-ucts smokers intention to quit, and the intention to quit othertobacco products if smoking any. Future research projectsthat include assessing these factors among Arab Americanwaterpipe smokers are needed.

In addition, we relied on each subjects self-reported data,which might contain some potential sources of bias, suchas selective memory (to remember or not remember expe-riences or events that occurred at some point in the past) orsocial desirability bias as a result of the tendency of smokersto base their answers on what they think is theoretically rightnot what they usually do.

6. Conclusion

Findings of this study enriched current knowledge aboutthe intention to quit waterpipe smoking with two importantadditions. First, history of cigar use, a prior attempt to quit,and not smoking waterpipe when seriously ill were found tosignificantly increase the intention to quit waterpipe smok-ing. Second, significantly lower intentions to quit waterpipesmokingwere indicatedwith increasing age,medium culturalacceptability of using waterpipe among family members,high cultural acceptability of using waterpipe among friends,longer duration of smoking sessions, and perceiving water-pipe smoking as less harmful than cigarettes.

Our findings demonstrate low levels of an intention toquit waterpipe smoking amongArab Americans in the Hous-ton, Texas area. Public health educational programs andinterventions that target Arab Americans in general, andspecifically older adults, thosewho smokewaterpipe formorethan 60 minutes, those whose family and friends approveof waterpipe smoking, and those with no former attemptsto quit, may be necessary to increase the intention to quitwaterpipe smoking as the first step of quitting.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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