INTRODUCTION

Shisha

Shisha smoking is phenomenal problem of global health importance and the problem had been subtly bedevilling mankind for a very long time.¹ The history of shisha smoking can be traced back to around 1,400 AD when the practice began in the Middle East and Indian subcontinent.¹ However, due to the influence of civilization, the practice has spread across every part of the world.² Shisha smoking, also known as hookah/narghile/hubble, bubble/water-pipe smoking, according to the British Heart Foundation, is a way of smoking tobacco, sometimes mixed with fruit or molasses sugar, through the mouthpiece of a bowl hose or tube.³

Shisha is a rich source of smoked tobacco and tobacco is a known cause of tobacco-induced diseases in the human body.^1,4 However, there is an existing paradox about shisha smoking; many people believe that shisha smoking can cause only little or no harm.^5,6 In fact, many shisha smokers were of the opinion that shisha smoking is not as dangerous as cigarette smoking.^5,6 Scientific investigations have shown that shisha smoking is more dangerous than cigarette smoking.^7-12 The smoke from shisha contains high content of furans, nicotine, nitric oxide, carbon monoxide, volatile aldehydes (e.g. formaldehyde, acrolein, methacrolein, etc,), carcinogenic polycyclic aromatic hydrocarbons, and nanoparticles.^7-12 Furthermore, notorious infections like hepatitis B and tuberculosis can be transmitted through sharing of the mouthpiece of a shisha hose.⁸

The prevalence of shisha use is on the rise as more and more people are engaging themselves in shisha smoking habit.^13-20 As a matter of fact, shisha smoking is commonly considered as a social behaviour in many parts of the world; hence little to no social stigma is attached to shisha smoking.^18-20

Social Media

Social media is a very powerful tool for information sharing in the 21st century; be it health-related or otherwise. In fact, about 3.5 billion people are daily active users of social media; this is about 45% of the worlds’ total population.²¹ On social media, information can be widely transmitted or shared in the form of messages, videos, audios, and pictures. Among these forms, the video is the most informative of all, as it captures both audio and visual components of information, unlike the other forms.²² Also, behaviours can be formed, stopped, or modified through information obtained from social media.²³

YouTube

The most commonly used social media platforms through which videos are publicly transmitted or shared is YouTube.²⁴ YouTube has about 2 billion active users.²⁴ There are so many videos that can be watched on the YouTube without necessarily being a subscriber to a YouTube channel. YouTube media, according to it, was managed based on four key values of freedom which are: freedom of expression; freedom of information; freedom of opportunity; and freedom to belong.²⁵

Shisha smoking & social media

Based on our experience, as shisha researchers and active users of social media, we have witnessed occasions where shisha videos and pictures are transmitted or shared on social chat rooms, television stations, internet, and more. Without mincing words, sharing of shisha videos on social media is not an unpopular event.

Aims & objectives

After extensive literature search on studies ever conducted on shisha, we found no study assessing shisha-related videos on social media. Interestingly, there are numerous shisha-related videos on social media. In as much that the social media is a key influencer of human behavior,²³ it becomes imperative to conduct a study to assess the contents of shisha videos transmitted or shared on social media. Based on the above, we conducted this study with the aim of quantitatively and qualitatively assessing the 50 most viewed short English shisha videos on social media, using YouTube as a case study.

Relevance of the study

Conducting this type of study is of high relevance in the area of shisha tobacco control and tobacco-harm prevention. The data obtained from this study will provide vital information on the content of information shared on YouTube videos; hence, providing guidance on how to develop strategies in re-educating the public about shisha use.

MATERIAL AND METHODS

This study was an online cross-sectional survey assessing the metrics and content of short YouTube English videos on shisha using a mixed method approach. The tool used for the data collection was a proforma (Table 1).

An online filtered single search of all videos tagged “shisha” was done on the YouTube App of an Android phone, using the keyword “shisha”. The search was filtered by selecting “view count”, “video”, “anytime”, and “short (< 4 minutes)” options in the “sort by”, “type”, “anytime”, and “duration” tabs, respectively, under the “search filter” command (Figure 1). Out of the first 107 videos that popped up, only 50 of them were English; these videos were then downloaded for watching. Using the pro-forma, the quantitative data (on the metrics and video content) and the qualitative data (on the additional notes attached to the video) of each of the English videos was also obtained alongside. The data collection process was conducted between 2:15pm and 6:00pm (GMT +1) on January 19, 2020.

Data Analysis

Collected quantitative data was entered into SPSS version 20 software for data analysis while the qualitative data were analysed thematically. In the quotations given to support the thematic findings, we deliberately denoted brand names as well as the names of geographical areas, companies, and cultures with “[…]” for the sake of anonymity. Quantitatively, the frequency distributions of all variables were determined. The mean and standard deviation of relevant frequencies were also determined.

Ethical Considerations

This study was also conducted in accordance with the 1964 Helsinki Declaration on health research.

RESULTS

Video Metrics

A total of 50 short English YouTube videos on shisha were analysed for this study (Table 2). These 50 videos have a mean (±SD): time of upload of 5.64 (±3.348) years, view rate of 1,917,311.7 (±8,001,059.6) views, like rate of 17,953.9 (±75,945.7) likes, and dislike rate of 1,243.3 (±5,454.4) dislikes, as at the download date: January 19, 2020.

Quantitative Information Extracted from Videos

Only 10 videos, out of the entire 50, did not show person(s) smoking shisha. Among the remaining 40 videos, 35 showed a scene where male person(s) is/are smoking shisha, 34 showed scenes of indoor shisha smoking, and 3 showed scenes where shisha mouthpiece is shared among persons. Importantly, only 5 videos relayed information about the dangers of shisha smoking to viewers (Table 3).  

Additional Notes Attached to the Videos

Furthermore, qualitative analysis of the additional notes attached to the videos by the video sources showed that some of these shisha videos were uploaded to teach the viewers on how to make shisha, with no warnings given about the risk of shisha smoking in the notes:

“In this video you could learn how to make hookah out of […] bottle (or any other plastic bottle)…” Video #1: views – 52,192,309; likes – 501,000; dislikes – 38,000

“…I made this video to teach you how to make and setup a perfect hookah. I cover everything you’ll need to know like how to prepare materials, how to set up a hookah, how to pack a hookah bowl, how to light a hookah coal, and how to smoke a hookah…” Video #4: views – 2,187,894; likes – 15,000; dislikes – 1,200

“Smoking tobacco from a hookah is a major step up from smoking dry cigarettes…If you don’t have a place nearby to buy a hookah, then you can create your own out of household items…” Video #8: views – 1,180,928; likes – 9,400; dislikes – 637

However, some videos had notes on how to make shisha theoretically and further gave warnings of the dangers associated with practicing the acts in such videos in reality:

“…The hookah in this video was made only for demonstration how it works…Smoking is definitely bad for your health, so please watch this video only as entertainment…” Video #9: views – 1,119,600; likes – 6,500; dislikes – 614

“…This video is intended for educational and scientific purposes only. Every action performed in this video is done under experts’ supervision or in the presence of adult…Do not try this at home” Video #22: views – 276,165; likes – 3,300; dislikes – 304

Also, some videos were uploaded with notes on shisha brand, purposely for advertisement:

“[…] Rechargeable Electronic Shisha is the latest innovative technology in this emerging market. Used with […] e liquid, the […] is a supremely powerful device with a long-lasting battery. Choose from strawberry, apple, grape, cherry or peach shisha e liquid in either nicotine free, or 16mg nicotine content. New flavours coming soon.” Video #12: views – 916,348; likes – 3,700; dislikes – 323 

“The new shisha pen. Pretty good. Not harmful. Contains no nicotine…” Video #25: views – 226,513; likes – 215; dislikes – 69

“…The […] shisha pipe embodies all the elements of […]’s world famous and critically acclaimed artisanal heritage, hand blown glass, hand-made ceramics, a pioneering use of leather working techniques and reindeer antler carvings of the indigenous […] people. This delicate balance of traditional craftsmanship and state-of-the-art engineering is a defining feature of all […] shisha pipes.” Video #26: views – 225,499; likes – 1,300; dislikes – 58

“The […] is a highly-rated refillable electronic cigarette that employs a tank system for smoking tobacco-free e-liquid. When fully charged and filled with e-liquid, the […] e-cig will give you up to 500 puffs. This e cigarette can be charged right at your computer with the provided USB charger.” Video #44: views – 107,600; likes – 133; dislikes – 13

However, only very few videos have notes that educated the viewers on the dangers associated with shisha use:

“People may not realize just how dangerous water-pipes are; one session can be equal to 100 cigarettes.” Video #14: views – 723,900; likes – 1,900; dislikes – 77

“The toxins in hookah smoke may be different from that of cigarette smoke, but that doesn’t make it any less harmful, according to a new study.” Video #14: views – 723,900; likes – 1,900; dislikes – 77

“Similar to cigarettes, hookah smoking delivers the addictive drug nicotine and it is at least as toxic as cigarette smoking.” Video #14: views – 723,900; likes – 1,900; dislikes – 77

Table 1. Questions asked in the pro-forma used for data collection

DISCUSSION

Tobacco is an endemic and colossal public health problem causing illnesses, deaths, and impoverishments worldwide.²⁶ In fact, there are about 1.1 billion smoked tobacco users worldwide,²⁶ and its use accounts for the deaths of over 8 million people on yearly basis.²⁶  Despite the huge burden of tobacco-associated deaths in the world, tobacco control policies and laws in many countries are restricted, with so much attention placed majorly on cigarette control only.^2,27 As earlier mentioned, shisha smoking is more lethal than cigarette smoking, having much more tobacco-associated risks than cigarettes.^7-12

In this study, we analysed the most viewed 50 short English YouTube shisha videos; our analysis yielded noteworthy findings that are of public health concern. Starting with the metrics of the analysed videos, we found that these videos are viewed and liked by many people. The whole world is made up of about 7.8 billion people.²⁸ Based on our finding, it can be estimated that an average of about 1,917,311.71 people had viewed at least one of the 50 short English shisha videos on the YouTube media; hence, it can be estimated that about 1 person out of every 4,068 persons (1,917,311.71 / 7,800,000,000) in the world have viewed at least one of these videos on YouTube. 

Furthermore, it was observed that many of these videos featured male person(s) in shisha smoking scenes. This may suggest that those shisha videos were targeted at the male viewers. Also, it can be further suggested that shisha videos are more likely to influence men than women, since they commonly featured men in their scenes. Invariably, this finding also strengthens scientific literatures that reported that men are more likely to smoke shisha than women.^29-33

Table 2. Characteristics of the of top 50 short English YouTube shisha videos analysed (date of download: January 19, 2020)

N/A – Not applicable; SD – Standard deviation

Table 3. Quantitative description of the analysed shisha videos