Worldwide Experienced Policy and Management Interventions in Preventing and Controlling Water Pipe Smoking

Background: A review is carried out to identify management and policy interventions affecting preventing and controlling Water Pipe Smoking (WPS) worldwide. Methods: PubMed, ISI Web of Science, Embase, Scopus, Science Direct, and Ovid from 1990 to August 2018 were reviewed through a literature review process. Primary studies reported at least one intervention in preventing and controlling WPS. The surveyed studies were independently checked by two investigators and quality appraised, and relevant data were extracted. Results: Out of 4343 retrieved records from the databases, 2228 records were screened, and 38 studies were selected as the main corpus of the study. The interventions identified from the content analysis process were placed in two main categories, namely management and policy interventions. The category of management interventions was related to the prevention and control measures of WPS. The category of policy interventions focused on the enactment and implementation of legislatives and policies to control WPS in national and international levels. Most interventions focused on school-based education and lack of proper interventions in WP industry. Conclusion: Our findings indicate that governments are ignorant of this important social and health crisis, and very few measures have been taken to control WPS. Informed interventions, especially among school-based and adolescents can lead to promising results in preventing and controlling WPS. There is a need to develop and design WP-specific evidence-based interventions.


Background
Tobacco smoking is one of the main preventable causes of diseases and deaths claiming the lives of 7.2 million annually [1,2]. Water Pipe Smoking (WPS) is a culture-based method of tobacco use [3] whose history goes back to 500 years ago; however, it has experienced a worldwide re-emergence since 1990 [4], and is regaining popularity among various populations, especially school and university students. In European countries such as Latvia and Berlin, 23 and 32.2% of school students respectively smoke it. In the eastern Mediterranean Region, the prevalence of WPS is high as well where 39.0% and 31.0% of boys and girls respectively smoke WP, and Lebanon has the highest rate (37%) [5][6]. In the United States, more than 30% of university students of both genders experience WPS, and nearly 23% of high school students smoke WP [7][8][9]. Similarly, WPS is increasing among highly educated groups. Nearly 20% of health professionals in Jordan and 52% of medical students in London smoke WP [10][11]. In Pakistan, 29.5% of physicians experience WPS [12].
WPS is turning to a public health crisis. Its smoking rate compared to that of cigarette is more addictive, contains more toxic and carcinogenic substances [13][14][15] and causes a variety of diseases including cancers, syndromes, and various unfavorable health effects [16]. It has a negative impact on health costs and Gross Domestic Product (GDP) of the countries. For example, in the United States, direct and indirect cost of smoking-related diseases is up to $300 billion annually [17][18][19].
The WP business is rapidly growing and gaining popularity worldwide. There are multiple stakeholders that support its expansion [20]. In recent years, the number of WP cafes has increased worldwide. For example, in the United Kingdom, there are nearly 400 WP cafes only in London [21].
There are many reasons for the in cafes to be interested in WPS and include deceptive advertising and diversified incentive services in addition to water pipe. The main reasons include a variety of fruit-flavored tobacco, psychotropic WP, foods, drink, discounts, enjoyable settings, the proximity of WP cafe to the educational, public, sports, and home/residential settings, the opportunity to socialize with friends, tempting decoration, study places for students, live music, variety of games, and the possibility of watching live movie and sports [4,[21][22][23].
Despite the concerns about WPS outcomes as well as nearly three decades of controlling measures, the prevalence and popularity of new generation WP has been increasing in the world. Due to the unique nature of WP (multi-components), there has been rare evidence and actions to prevent and control it [24]. Thus, special rules are required to prevent and control WP [25]. WP business has remained uncontrolled, which may result in the increasing prevalence of WPS [26]. WPS is one of the main factors that can lead to the failure in tobacco control [27]. If evidence-based interventions are not implemented to control this re-emerging public health crisis, nearly three decades of advances in WPS control would be undermined [28]. This study aimed to identify the management and policy interventions which can be helpful in preventing and controlling WPS worldwide.

Methods
Disagreements were solved by discussion.

Data synthesis
Content analysis was used for categorizing the management and policy interventions which influenced controlling and preventing WPS worldwide. Coding and categorizing was done by two researchers using the following process.

1.
Reading the selected studies.

2.
Identifying the interventions from the studies.

3.
Categorizing the identified interventions into categories and sub-categories based on their conceptual similarity.

4.
Placing themes in the related categories and sub-categories The extracted interventions were organized and independently categorized by a second researcher (LD) to ensure consistency and accuracy. Disagreements were discussed among reviewers in order to reach an agreement. In case of disagreements, the identified interventions were placed in both categories.

Results
Four thousand three hundred fifty three studies were extracted based on the databases and manual searching processes. Out of 2228 screened articles (after removing duplicates), 38 articles were selected for the review through the screening process. PRISMA flow diagram was used to show the number of records in each phase (Fig. 1). The included studies were of moderate-to-high quality based on the checklists of JBI. The characteristics of the included studies are showed in (Appendix 1).
In this study, 78 management and policy interventions were identified as the influencing factors in WPS control. After combining the interventions with similar concepts, the total number of interventions decreased to 26. Via content analysis, interventions were classified into two main categories: (1) management interventions and (2)  Management and policy interventions have been shows in Table 1. Table 1 The demographic characteristics of the study participants  Table 2 The categories and sub-categories extracted from the interviews and FGDs

Discussion
In this study, the policy and management interventions affecting the prevention and control of WPS worldwide were identified through a systematic review. According to the selected studies, the World

Health Organization Framework Convention on Tobacco Control (WHO FCTC) is a global treaty
enacting the actions to control all tobacco products [63]. However, there has been rare focus on controlling cigarettes and WP-specific actions in the world, and it has been applied to some treaty articles [24,[64][65]. It is obvious that using the proposed actions by the FCTC to manage WPS can lead to a progress in WPS prevention and control. The study conducted by Erdöl et al. implies that the actions proposed by the FCTC were applicable on WPS and made significant reductions in WPS [56].
To prevent WPS, the previous studies focused on school-based educational interventions, especially first smoking in school students and adolescents, and education of community/society, which led to promising results in the prevention and control of WPS [6, 32-34, 46, 51-53, 59-60]. In a study conducted by Mason et al., it was found that most studies conducted on WPS involved the school students' training [66] accompanied by counseling [66]. Nidal Eshah et al. showed that more than 70% of smokers begin WPS in adolescence [67]. The studies conducted by Aboaziza, Stamm-Balderjahn, and Tugay showed that many adolescents became dependent after the first use of WP, which made the quitting process to be extremely hard and the educational programs to be less effective [6,[68][69].
Lack of WPS control interventions among medical and nursing students and health care professionals can lead to failure in controlling WP, and health care professionals can play an important role in WPS control programs [10, 37, and 57]. Harvey and Phan Thu confirmed that health care professionals have a key role in WPS prevention and control [62,70]. In a study conducted by Moyer VJP et al, health care professionals were found to be helping adolescents to change their behavior [71] using evidence-based counseling tools [62]. Similarly, Kumar et al. reported that the lack of WPS control programs among health care professionals can act as a positive vision to WP and cause low incentive to cooperate in WPS control programs [72][73].
Lack of proper interventions in WP industry such as packaging, labeling, advertising, fruit-flavored and sweet tobacco, settings, and diversified services can lead to a failure in WPS control programs [4, 22-23, 30, 42, 44, and 48-49]. The previous studies show that fruit-flavored and sweet tobacco play main roles in the expansion of WPS in the world and act as the main barriers for WPS control programs; therefore, urgent measures are required to restrain this global problem [4, 74, and 77].
The study of Erdöl et al. in 2008 and2012 in Turkey showed that proper warning labels can be more effective in WPS control [56]. Clear, intelligible, and evidence-based packaging and warning labels can accelerate the quitting and delay first smoking [21,48,[78][79]. Social pages and websites are the main factors in promoting WPS among adolescents, proper interventions are needed to circumvent the bans, particularly in the advertising field [80][81][82].
Some studies suggest that evidences and investigations are needed to prevent and control WPS.
Researchers and scientists, especially health experts, can help policymakers in developing and designing policy interventions to control WPS [24,43,[83][84]. Lopez et al. found that evidences and studies related to WPS control are very rare, and more investigations are required in this respect [24]. Designing control interventions compatible with their needs can be effective in controlling WPS.
Despite WHO FCTC Article 6 on the taxation of all tobacco products, WP products are still tax-exempt.
In fact, some studies reported that taxation is effective in controlling tobacco smoking [53-54, 65, and 85]. However, Jaam [53], and Maziak [86] showed that cheap or expensive prices may not be effective in controlling WPS. Several studies suggested that executive authorities have main roles in controlling WPS, and they should be supported by legislative enforcers and policy makers [21, 23, and 87].
Analysis of the literature showed that although the identified interventions affect WPS control, the absence of these interventions can increase the prevalence of WPS. National and global cooperation is needed to control this public health crisis in terms of various aspects, especially WP marketing.

Strengths And Limitations Of The Study
One limitation of this systematic review is that we only included WP meshes alone or in combination with smoking as the searching key words, and did not use smoking term separately. The purpose of our review was to identify specific studies on WPS, and searching the term "smoking" resulted in irrelevant studies. However, in specific studies of WPS, WP meshes were certainly used in their titles and abstracts or have just mentioned it.

Conclusion
Our findings indicate that governments are oblivious of this important social and health crisis, and the current poorly enforced legislations are old, unclear, and incompatible with the needs of adolescents.