The first part of this research project that includes the screening of university students according to their smoking status and precipitating factors for smoking shisha has been published by Saravanan C et al., [8]. The data presented here focuses on predictors of intention and non-intention to quit shisha smoking and this data has not been published before.

In this cross sectional study, a total of 633 students pursuing any undergraduate program in UOS during the academic year September 2017 to August 2018 participated in an online survey that was administered through university website to collect the data. This study was conducted from October 2017 to May 2018 in Sharjah. The present study includes data of the students who opted to answer the questionnaires based on their shisha smoking habits. The mean age of these participants was 20.9 years. Out of 633, 349 (55.13%) students were current shisha smokers. Out of 349 shisha smokers, 103 (29.5%) students were addictive and dependent on shisha smoking based on Fagerstrom test for nicotine dependence (FTND) test score. These 103 students were categorised into two groups: intend to quit, and not intend to quit based on their response in the Transtheoretical model questionnaire (TTM) scale.

Socio demographic information sheet: It was used to measure student’s age, gender undergraduate program registered and smoking status.

Shisha smoking status: A shisha smoking status is measured based on criteria. “Current shisha smokers” is one who has smoked shisha in last 30 days prior to this survey. “Ever shisha smoker” is the one had not smoked shisha in last 30 days prior to survey but had tried in the past (even a puff). This criterion is based on the previous studies [32,33]. The criteria of shisha smoking facilitate to distinguish between ever and current shisha smokers; however, no criteria is available to identify former shisha smokers. The present study includes data of the students who opted to answer the questionnaires based on their shisha smoking habits.

Fagerstrom Test for Nicotine Dependence (FTND) [34]: This scale consists of 6 items. FTND score ranges from 1 to 2 indicate low dependence, 3 to 4 indicate low to moderate dependence and 5 and above indicate high dependence. Fagerstrom K and Furberg H, identified that smokers who secure 5 and above in FTND are considered as highly dependent on shisha dependency and they need treatment immediately [34]. In the current study, shisha dependency was considered in those participants who scored 5 and above in FTND. The test-retest reliability of FTND is 0.67 and has been used in previous researches [35,36].

Knowledge and beliefs scale: The Global Adult Tobacco Survey (GATS) [37] was used to measure the knowledge and beliefs about shisha smoking. The participants answer to this scale “yes” specifies adequate knowledge and belief, and “no” and “don’t know” specify that they have lack of knowledge and beliefs about shish smoking. Previous researchers [38,39] had used this scale to measure the knowledge and beliefs about smoking. Based on the previous study, the Cronbach alpha value of 0.85 [40].

Transtheoretical Model Questionnaire (TTM) [41]: This scale was used to measure participants’ intention to quit and not having any intention to quit shisha smoking. Intentions to quit smoking items were adapted from the Transtheoretical model of change questionnaire. The items included: no intention to quit shisha and intention to quit shisha in next 30 days. Participants were asked to mention their intention to quit or not intention to quit their shisha smoking habit in the ‘yes’ or ‘no’ type questions. Students who answered ‘yes’ indicated their intention to quit and those who answered ‘no’ indicated no intention to quit. Further, participants were asked to mention their level of intention to quit on a five point Likert scale where 1 indicated “intention to quit” and 5 indicated “extremely high intention to quit”. Similarly, students who did not have intention to quit wherein the measure on a five point Likert scale 1 indicated “no intention to quit” and 5 indicated “extremely no intention to quit”. The Cronbach alpha coefficient reliability ranged between 0.60 and 0.84 [42].

The Brief Wisconsin Inventory of Smoking Dependence Motives (BWISDM) [43]: This scale is used to measure the reason for no intend to quit shisha smoking. The subscales are affective enhancement, cognitive enhancement, craving (addiction), social/environment goals, cue exposure, tolerance, weight reduction and taste. The good internal consistency with Cronbach’s alpha value is 0.87 [43].

The Smoking Effects Questionnaire (SEQ) [44]: This scale was used to measure negative effect of shisha smoking. It consists of 33 items load on seven sub scales with two higher-order factors (positive and negative). This study used only negative expectancy sub-scales (negative physical effects, negative psychosocial effects and future health concerns) and did not use the positive sub scale. Negative psychosocial effects and future health concerns subscales focus on health issues. Therefore, these two subscales were merged for scoring purpose [45-47].

After obtaining the research and ethical approval (REC No:17-01-09-03-17-P) from University of Sharjah, the researchers invited all undergraduate students through official UOS email IDs to participate in this study. Some participants may smoke others substances in addition to shisha. Therefore participants had been instructed to answer the questionnaires based on their frequency of smoking habits such as shisha, dokha and cigarettes. This study included only the participants who had responded that they were shisha smokers and their answer to the questionnaire is based on their shisha smoking habits. Remaining students who had responded that they were cigarette and dokha smokers were excluded from this study. Current shisha smokers were instructed to mention either they have any intention to quit or not having any intention to quit shisha smoking. Those participants who had described themselves as not having intention to quit were asked to rate their level (1 to 5) of intention to not quit shisha smoking. Similar method was used to measure the participants who were intend to quit shisha smoking. Students who had mentioned themselves not having intention to quit, and intention to quit in few months were asked to fill the knowledge and belief scale. In addition, students who were not intend to quit shisha smoking were asked to complete the BWISDM scale to measure the reasons for not intend to quit smoking. Similarly, students who were intend to quit shisha were asked to fill the SEQ scale to measure the reasons for intend to quit smoking. Participants were instructed to clarify their doubts through the email address of the authors stated in the information sheet.

SPSS version 24 was used to analyse the data [48]. Cross tabulation was used to identify knowledge and belief differences between students who had intention and those who did not have intention to quit shisha smoking. Pearson correlation was used to measure the relationship between predictive factors (affect-mood enhancement, cognitive enhancement, craving, social/environment, cue response, taste, tolerance and weight control) and the level of intention to not quit shisha smoking. In addition, stepwise multiple regression analysis was used to identify the best predictor factors of intention to not quit shisha smoking among shisha dependency students.

Prevalence of shisha smokers: Out of 349 shisha smokers, 103 (29.5%) students were addictive and dependent on shisha smoking based on FTND test score. Out of 103 students, 59 (57.3%) had the intention to quit shisha smoking, and 44 (42.7%) had no intention to quit shisha smoking.

Differences in knowledge and beliefs about shisha smoking between students who had intention to quit and those who did not have intention to quit shisha smoking: [Table/Fig-1] highlights that participants who have intention to quit shisha smoking have more knowledge about the consequences of shisha smoking such as smoking leads to heart diseases and hypertension, and believe that shisha smoking is addictive than cigarettes and there is lot of nicotine in shisha smoking than students who have no intention to quit shisha smoking.

Relationship between the levels of no intention to quit shisha smoking and psychosocial variables: [Table/Fig-2] shows there was a significant positive relationship between affective (mood) enhancement, craving, social environment, cue experience, tolerance and levels of not having intention to quit shisha smoking measured by using five point Likert scale among current shisha dependency students. This study could not find significant correlation between cognitive enhancement, taste, weight control and no intention to quit shisha smoking.

Predictors for not having intention to quit shisha smoking: [Table/Fig-3] presents the factors that predict no intention to quit smoking among students who are addictive for shisha dependency. A stepwise multiple regression model was run with the independent (predictor) variables including affective enhancement, craving, social environment, cue experience and tolerance that significantly correlated with dependent (criterion) variable of not having intention to quit shisha smoking in students, but the result of the stepwise multiple regression excluded all variables except tolerance. So, the simple regression analysis was done, which indicates 10.6% (R²=0.106, F(1,42)=4.96; p=0.031) of affective enhancement; 11.1% (R²=0.111, F(1,42)=5.22; p=0.027 of craving; 14.8% (R²=0.148, F(1,42)=7.28; p=0.010) of social environment; 9.6% (R²=0.096, F(1,42)=4.46; p=0.041) of cue experience and 17.5% (R²=0.175, F(1,42)=8.88; p=0.005) of tolerance is significantly predict students levels of not intend to quit shisha smoking behaviour.

Relationship between psychosocial factors and intention to quit shisha smoking: [Table/Fig-4] shows that factors including dangerous to health; addiction and waste of money were significantly correlated with level of intention to quit smoking among university students. Reputation and waste of time was not statistically correlated with the level of intention to quit smoking.

Predictive factors for intention to quit shisha smoking: A stepwise multiple regression model was run with the independent (predictor) variables including dangerous to health, addiction, and waste of money that correlated significantly with level of intention to quit shisha smoking as the dependent (criterion) variable in students. [Table/Fig-5] shows that 65.2% (R²=0.652, F (1,57)=106.6; p=<0.001) of dangerous to health and 83.3% (R²=0.833, F (2,56)=139.47; p=<0.001 of addiction significantly predicted participants intention to quit shisha smoking. Waste of money was excluded from the model.

This study was conducted to identify the knowledge and beliefs about shisha smoking between students who intend and not intend to quit shisha smoking, at what extent affective (mood) enhancement, cognitive enhancement, taste of shisha, craving, social environment, cue experience, tolerance predict an intention to quit shisha smoking and also at what extent dangerous to health, addiction, waste of time and waste of money predict the reasons for intend to quit shisha smoking among students in one of the largest universities in the UAE.

In this study, 44 (42.7%) expressed no intention to quit and 59 (57.3%) reported the intention to quit shisha smoking. Comparatively, the intention to not quit shisha smoking was higher among university students in USA 83% [20], Pakistan 50% [49] and Qatar 45.9% [6]. Most of the students did not have the intention to quit shisha smoking due to its cultural acceptance and misbelief that shisha pipe filters all the nicotine content [16]. On the other hand, in this study most of the shisha dependents 59 (57.3%) were intend to quit their shisha habits. Similar findings were reported from Qatar 54% [6] and Saudi Arabia 57.4% [50]. The students intention to quit shisha smoking is most likely due to awareness about smoking consequences or experience of its complications such as throat irritation, headache etc., [6,27]. In addition, Government of UAE is promoting more awareness about smoking and its complications and University of Sharjah strictly prohibiting any form of smoking inside the campus and shisha smoking throughout the Emirate of Sharjah.

In this study, overall student knowledge and belief about the detrimental effects of smoking such as cardiac problem, hypertension, shisha contains more nicotine and is more addictive than cigarettes was higher among students who had the intention to quit compared to the students who did not have intention to quit shisha smoking. This finding is consistent with previous studies that students intend to quit shisha as they experience various health problems such as dry throat, headache and nausea [6,27]. Students were willing to quit when they believe water pipe smoking was harmful [20]. This study could not find significant difference between, students who had intention to quit and non-intention to quit shisha on the detrimental effect of smoking leads to cancer, sexual dysfunction, gum infection, stroke and shisha pipe filters the toxic substance. This indicates both group students did not have adequate knowledge and belief about the detrimental effect of shisha smoking. This could be one of the reasons for the students to continue their smoking habit. Though the university warns the consequences of smoking, students tend to smoke shisha as they have insufficient knowledge about shisha and strongly believe that shisha is not harmful to them. So there is a need to educate and promote awareness by conducting workshop and incorporating health awareness programs in the curriculum.

In this study, students were not intending to quit shisha smoking as they believed that shisha smoking enhanced their positive mood and social relationship. In addition, their tolerance, craving and friends’ smoking behaviour were significant predictors for not intend to quit shisha smoking. These findings are consistent with previous studies that smoking environment, both at home and at work, reduced their stress, enhanced their pleasure and strongly associated with not intend to quit shisha smoking among students [22,51,52]. On the contrary, smoking is not an effective way to tackle stress, nor enhances pleasure; in fact, it leads to detrimental effect on health. Smoking habit in students is aggravated by their peer smoking behaviour [51]. Consequently, more interaction with friends enhances their smoking behaviour and increases their motivation to continue their smoking behaviour despite of health complications. Though the government of UAE warns that shisha smoking is hazardous, but smokers are stimulated by media advertisement of smoking and celebrities smoking behaviour in the movies. However, this study could not find cognitive enhancement, weight management or taste of shisha as significant predictors for not intend to quit shisha smoking. Smokers believed that smoking helps them to reduce their body weight [53]. Pragmatically, shisha smoking impairs the attention and concentration, and increase the weight gain [54,55]. There is an immediate need to educate these smokers as they believe smoking is beneficial for them.

Dangerous to heath and fear of addiction factors were the significant predictors to quit shisha smoking among this study population. Previous studies also found that students intend to quit smoking due to health concern and fear of shisha addiction [20,52]. Warnings on the tobacco boxes and other negative effects of shisha smoking advertisements could also be one of the reasons to quit shisha smoking [56]. This study could not find that the cost of shisha is not the major reason to quit smoking, but [52] found in their study that the high cost cigarettes is one of the reasons to quit smoking. Shisha is not very expensive in UAE and most of the people keep the shisha pipe at their home would be one the reasons for not quitting shisha smoking [57]. Shisha smokers do not feel smoking affects their reputation as it is accepted culturally [57]. Unpleasant smell of smoke and that smoking waste their time were not major factors associated with quitting smoking among this study participant. However, previous studies established that these factors also contributed to quitting smoking [48,52]. Shisha is available in different flavors and smoke from the shisha gives good fragrance. Thus motivate the shisha smokers to smoke more when they interact with their friends and others, continuing their shisha smoking habit [58].

Educational institutions need to conduct the anti-smoking workshop for all students during their orientation week. Students should be guided where to seek intervention for their shisha smoking behaviour as some students wish to quit, but they are not sure to whom they can approach. University needs to provide e-lecture and videos about the complication of substance abuse which include shisha, cigarettes etc., Students who renounced smoking habit can be invited to share their experience in quitting smoking with current smokers. This will further motivate the shisha smokers to quit shisha smoking. Intervention and educational workshop has to focus on the precipitating factors for their smoking and how to tackle the precipitating factors.

This study data had been collected by using convenience sampling method and this may led to sampling bias. This study had used FTND to measure the shisha dependency, but this may not warrant that these students are clinical addictive for shisha smoking. This study had excluded students who were not addictive for shisha smoking and included students who were addictive for shisha smoking based on FTND. This limits the generality of this study. This study did not measure the correlation between duration of shisha smoking and intention to quit. Students who smoked shisha for a longer duration are postulated to be reluctant to quit shisha smoking due to addiction. Due to the cross sectional nature of this study, there was no follow-up to reassess the status of shisha smoking among those students who reported that they had intention to quit shisha smoking.

It will be relevant to measure the duration of shisha smoking in relation to the intention to quit shisha smoking. Second, future study can focus on western university in UAE as the prevalence and predictors of intention to quit and not quit may vary. This study had used FTND to measure the shisha dependency, but this may not warrant that these students are clinical addictive for shisha smoking. So this study recommends to assess the dependency by using questionnaire and also clinically interview the students, will reconfirm the shisha addiction and substance abuse disorder.

Overall students who had intention to quit shisha have adequate knowledge that shisha leads to heart diseases and hypertension, and shisha is more addictive and harmful than cigarettes. We found that health impact of shisha and fear of addiction to shisha smoking were the major predictors of intention to quit shisha smoking. On the contrary, students who were reluctant to quit shisha smoking believed that shisha enhances their mood and interpersonal relationship with their peers, and reduces their tolerance and craving. Student counseling units at the universities need to conduct anti-smoking campaign to enhance their knowledge and modify beliefs about the biopsychosocial consequences of shisha smoking and reduce the predictive factors of not intent to quit shisha smoking among students.

We obtained informed consent from all participants before they fill the questionnaire in the study. The research protocol was approved by the Ethics and Research Committee (REC-17-01-29-02) at University of Sharjah.

The data that support the findings of this study are available on request from the corresponding author.