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‘When I smoked it, it was like a slap in the face but it felt really good’: exploring determinants of midwakh use among young adults in Lebanon
  1. Rima T Nakkash1,
  2. Noor El Boukhari1,
  3. Rima A Afifi2
  1. 1 Health Promotion and Community Health Department, American University of Beirut, Beirut, Lebanon
  2. 2 Community and Behavioral Health Department, University of Iowa College of Public Health, Iowa City, Iowa, USA
  1. Correspondence to Dr Rima A Afifi, University of Iowa College of Public Health, Iowa City, IA 52242, USA; rima-afifi{at}


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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  • 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.