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Abstract
Background Dokha (‘dizziness’ in English) is a type of alternative tobacco product (ATP) increasing in popularity in the Arab world; and smoked in a pipe called a midwakh. Midwakh use is common among nationals in the United Arab Emirates (UAE); yet, evidence indicates its spread among expats in the UAE as well as beyond the UAE. Research on midwakh use is nascent, and no qualitative research has been published. This paper explored the context and determinants of midwakh use among young adults in Lebanon using qualitative methods.
Methods We conducted four focus group discussions with 18 midwakh ever smokers aged 18–25 years in Lebanon. Discussions were recorded, transcribed and thematically analysed using the Pragmatics, Attraction, Communication, Expectations framework.
Results ‘Pragmatics’ was evident in participants’ comments about availability of a supply of dokha. For ‘attraction’, participants described why they prefer midwakh smoking and compared it to other ATPs. Regarding communication, participants shared terms used to describe their use of midwakh (eg, ‘buzz’/taking a hit). Participants also described expectations from smoking midwakh, including stress relief.
Conclusion Midwakh smoking is appealing to young adults due to factors such as the ‘buzz’, perceived harm reduction, stress relief and its ability to satisfy nicotine craving with small amounts of tobacco. As a result, despite experiencing negative effects on first use, young adults choose to continue to use midwakh, and find it hard to quit. These results have implications for prevention and control of midwakh smoking among young adults. Framework Convention on Tobacco Control guidance documents to address ATPs are critically needed to prevent the global spread of yet another tobacco product.
- non-cigarette tobacco products
- global health
- public policy
- addiction
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Introduction
Tobacco use is responsible for more than 7 million deaths annually.1 While cigarettes are the most common type of tobacco used,2 other forms are on the rise.3 4 Dokha, a form of dried tobacco leaves smoked in a pipe called a midwakh, is increasing in popularity in the Arab world.5 Research on the epidemiology, determinants and health effects of midwakh use is nascent, but provides evidence that midwakh smokers may be at risk of tobacco-related diseases comparable to that of cigarette smoking.4 6 7 Midwakh use has been documented mostly in the United Arab Emirates (UAE),8–12 among nationals and expatriates,10 12 with higher prevalence among males. Midwakh smoking has also spread beyond the UAE, as evident by ever smoking rates among 7th-12th graders in Lebanon.13 This study aimed to explore the context and determinants of midwakh use among young adults in Lebanon using qualitative methods.
Methods
We conducted mixed gender focus group discussions (FGD) in 2018 with a purposive sample of midwakh ever smokers, 18–25 years, recruited through the distribution of flyers at young adult hang-outs, and then snowball sampling. Informed consent was obtained from participants. The interview guide can be found in the online supplementary material. FGDs were conducted in English after providing Arabic or English options, and lasted up to 1 hour. Four FGDs with 18 ever midwakh users were sufficient to reach data saturation. All FGDs were recorded and transcribed verbatim in English and analysed following the PACE framework concepts: Pragmatics, Attraction, Communication and Expectations.14 15 These concepts interact to influence use. With intent to minimise subjectivity in coding, all three authors read through all the transcripts and highlighted themes prior to the in-depth PACE analysis conducted by author NEB.
Supplemental material
We describe our findings supported by a quote to illustrate the theme. Table 1 includes description of the PACE concepts with illustrative quotes.
PACE concepts and additional quotes under each
Results
Table 2 describes the sociodemographic characteristics of participants in each of the FGDs. Participants had been smoking midwakh from 3 months to 9 years; their frequency of smoking ranged from once/week to up to 20 times/day.
Sociodemographic characteristics of participants in each FGD
Pragmatics
Pragmatics involves whether one can access an addictive object, is aware of it and knows how to obtain it.14–17 Identifying the pragmatic aspects of an addictive object often occurs through description of its initial use. Communication about the addictive objective also leads others to understand the pragmatic aspects of it. In the FGDs, participants reported that their initiation of midwakh use was due to curiosity, peer pressure and its availability among peers or family members, in school and university settings, at home or social gatherings. Almost all (17/18) first tried midwakh between the ages of 13 and 18 years. The majority of participants were exposed to midwakh while living in the UAE.
I was introduced to it by my cousins that live in Saudi. So my cousins would come to Lebanon with their pipe and midwakh and I thought ‘oh cool, it’s a cool concept let me try it’. (Former midwakh smoker, female, 23 years old)
Participants who initiated midwakh use in the UAE reported it could be found almost everywhere there; in Lebanon, dokha tobacco was not easily found. Non-regular midwakh smokers borrowed from family members or friends. When midwakh use became more regular, participants reported purchasing a device. Participants who were residing in or visited the UAE brought dokha tobacco with them because the tobacco found in Lebanon was perceived to be of poorer quality.
I know a guy who was with me in school, now he is in AUB (American University of Beirut) and … he gets midwakh that costs around 150$ with him from Dubai…he brings it to Lebanon and sells it in small amount…. (Regular midwakh smoker, male, 18 years old)
Participants were very well versed in dokha tobacco brands and prices. Prices depended on the brand, quality, quantity and location of purchase.
Attraction
Attraction describes aspects of the addictive product that lead to initiation and continued use.14 15 Factors affecting initiation are described in the section on pragmatics. The majority of participants characterised their first experience of midwakh use as negative, due to experiencing unpleasant symptoms such as vomiting and passing out. Others reported their initial midwakh trial to be pleasant as they enjoyed the feelings of dizziness, numbness and relaxation.
The first time I tried it, I was I think 15 years old and I was in Dubai visiting my friends. I was sleeping at my friend’s house, there was a house party so his other friends got with them Dokha and they were smoking it. I was like ‘What is this? I have never seen it before’ and they were like ‘You want to try?’ I took one puff or 2 puffs and it hit me and it was like a slap in the face but it felt really good. (Former midwakh smoker, male, 20 years old)
Participants who had an initial negative experience with midwakh reported enjoying their second trial. The dizziness, numbness and relaxation feelings were reported to be key positive aspects of continued use. Participants reported those feelings were strongest when smoking within minutes of waking up, after eating and before bedtime, or while drinking alcohol.
Midwakh is an acquired taste, it is not something you would like from the first time you try midwakh, so you need to do it a couple of times for it to really like resonate with you. (Former midwakh smoker, female, 23 years old)
Participants also noted other factors that attracted them to midwakh, including its lack of odour, ease to smoke, its fast delivery of nicotine to the blood system and the social context in which it is smoked. These characteristics made it possible to smoke discreetly, without attracting attention. The majority of participants reported preferring smoking midwakh over cigarettes and e-cigarettes but they still perceived midwakh smoking as harmful.
Communication
As one becomes more involved in the addiction object, a system of communication about it will develop.14 15 Participants were knowledgeable about the language associated with midwakh use. The feelings of dizziness, numbness and light-headedness were referred to by all participants as the ‘Buzz’; smoking midwakh was referred to as a ‘taking a hit’, ‘smoking a head’, ‘taking a buzz’ and ‘Aam Doukh’ (‘I am getting dizzy’ in Arabic).
X was one of the first people I ever saw smoke midwakh. She kept saying ‘I need a buzz, I need a buzz’ and I never understood what the concept is and then when I started smoking, I started understanding what it was. (Regular midwakh smoker, female, 18 years old)
Participants also used terms to describe types of dokha tobacco; cold/light, warm/mild and hot/heavy were used to describe the extent of harshness of the dokha tobacco. They had a common understanding of when each type was to be used, for example, cold dokha tobacco was usually smoked during initiation.
Expectations
Expectations are beliefs that the addiction object provides solutions to experiential desires.14 15 Expectations are influenced by and influence both attraction and communication. Participants expected that smoking midwakh would relieve stress during exam period or tense situations, feel good, result in a feeling of relaxation, alleviate fatigue and boredom as well as satisfy nicotine and ‘buzz’ cravings.
I cannot leave the house without smoking a head, especially if I have an exam, exams are stressful so I need to relax a bit. (Regular midwakh smoker, male, 18 years old)
An additional aspect of ‘expectations’ was the social image associated with its use. Midwakh use was seen as a ‘trend’ and contributed to a positive image, such as to look ‘cool’ and ‘different’. Participants wanted to be seen smoking it in public places. Yet, a few stated that they avoided smoking midwakh in public in Lebanon, as it might be mistaken for marijuana (due to the colour of the tobacco and the shape of the device).
It makes you like stand out from the crowd, you are not just smoking cigarettes, it is like ‘oh you are smoking midwakh’… It would make you appear as cool or have something that’s different. (Former midwakh smoker, female, 23 years old)
Participants perceived midwakh as addictive for a variety of reasons, including experiencing withdrawal symptoms and inducing nicotine and ‘buzz’ cravings. ‘Buzz’ cravings caused users to transition to different types of dokha tobacco (cold, warm, hot), and to different products (e-cigarettes, marijuana).
Also, dokha leads to people smoking marijuana because dokha if you are always doing it then the buzz is going to become less and less and they would want something different so it would lead to smoking hash or weed. (Former midwakh smoker, female, 23 years old)
Participants also decreased midwakh use, and tried to quit using midwakh when expectations were no longer met or when concerns about health issues overtook the pleasure of the ‘buzz’.
First time I stopped smoking midwakh I stopped for 50 days and I willingly went back to it. I reached a phase where I stopped craving it but I willingly went back to it…. I was not willing to quit it. (Regular midwakh smoker, male, 18 years old)
Discussion
Our study explored experiences of midwakh use among young adults in Lebanon using qualitative methods. We used the PACE model to guide our analysis. Findings from this study suggest that the emergence of midwakh smoking in Lebanon may be fuelled by the large number of Lebanese expatriates who used to (or still) live in the UAE, where midwakh smoking is common.11 However, since the majority of the population of the UAE is expatriate, midwakh may spread globally.12 13 Evidence indicates prevalence of midwakh smoking is similar among nationals and expatriate students.12
Our findings also point to lack of enforcement of tobacco control laws. As adolescents and young adults (under 18 years), participants were able to access dokha tobacco despite laws in both UAE18 and Lebanon19 that prohibit the sale of tobacco products to minors.
Our results confirmed findings of a previous study6 regarding the reasons why midwakh ever users prefer midwakh over other forms of tobacco products. These include the ‘buzz’, lack of odour, ease of smoking and satisfying nicotine cravings. Furthermore, unique to our study, using midwakh to feel good and to relieve stress was a major factor that influenced use. Consistent with other studies,20–22 we also found that curiosity, family and peer influence played a central role in midwakh smoking initiation and continuation.
Our participants shared negative effects related to their midwakh use, such as throat and chest irritations, numbness, nausea, passing out and heart palpitations. Yet, although they seemed to expect some of these, the attraction (‘buzz’, social) of midwakh use balanced out the negative effects in favour of use. Previous research on cigarettes found that smokers are more likely to downplay negative outcomes than non-smokers .23 Daily e-cigarette users were able to list reasons for liking and not liking e-cigarettes, including significant health effects in the latter category.21 Despite these effects, participants still tended to erroneously5 7 24 perceive midwakh smoking as a healthier alternative to cigarettes.
Our findings should be interpreted with caution. This study focused on young adults; results are not generalisable to different age groups. In addition, although we achieved saturation of themes within four FGDs, the convenience sample may lack representativeness. Also, the results describe the perceptions and experiences of midwakh users in Lebanon, a location relatively naïve to midwakh.
A comprehensive and robust research programme to understand the biological, social and behavioural determinants and consequences of midwakh use should be developed. Also, understanding the complex polytobacco use patterns among young adults over time is critical to developing comprehensive interventions. In the meantime, awareness campaigns are urgently needed to increase knowledge and amplify attitudes about the harmful health effects of midwakh smoking while highlighting its addictive nature. Countermessaging campaigns could potentially use quotes similar to those provided by some of our participants. In addition, enforcement of current tobacco control laws should be strengthened. Finally, both Lebanon and the UAE have ratified the Framework Convention on Tobacco Control. Although technically applicable to all tobacco products, concerns about the lack of a guidance document to support application of FCTC articles to alternative tobacco products have been noted elsewhere.25 Such guidance is urgently needed for Midwakh use.
What this paper adds
Dokha is an alternative tobacco product (ATP) that is mostly used in the United Arab Emirates and is gaining popularity among the large expatriate population, including young adults.
Few studies have investigated the determinants of midwakh use in general, and even fewer from a qualitative perspective.
Midwakh use initiation is influenced by friends and family members; it appeals to young adults due to the ‘buzz’, lack of odour, ease to smoke, low cost, perceived harm reduction, stress relief and its ability to satisfy nicotine craving with small amounts of tobacco.
Our findings extend understanding on midwakh use by explaining the determinants and context of use, thus informing regulatory action to prevent and control midwakh smoking among young adults.
A key recommendation is for stronger Framework Convention on Tobacco Control guidelines for application of articles relevant to ATPs including midwakh smoking.
Ethics statements
Ethics approval
The Institutional Review Board at the American University of Beirut approved the study (SBS-2018-0435).
Acknowledgments
The authors thank the research participants who provided the data reported on in this manuscript. The authors also thank Sara Kassas for her contribution to the proposal writing and Abeer Al Halabi for contributing to the early analysis of data. The authors thank the reviewers who provided critical comments that strengthened the manuscript.
References
Footnotes
Twitter @rimanakkash
Contributors All authors contributed to the conceptualisation of the research and the development of the methodology. NEB conducted the focus group discussions. All authors read the transcripts and developed the code book. NEB conducted the preliminary analysis. All authors contributed to writing the paper and approved the final version.
Funding The University of Iowa College of Public Health funded this research.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.