PREVALENCE OF HOOKAH SMOKING AND ITS

ASSOCIATED FACTORS AMONG PROFICIENCY

CERTIFICATE LEVEL NURSING STUDENTS OF
POKHARA METROPOLITAN CITY, NEPAL

SALMAN SUBEDI

A DISSERTATION REPORT SUBMITTED TO DEPARTMENT OF

PUBLIC HEALTH
LA GRANDEE INTERNATIONAL COLLEGE
POKHARA UNIVERSITY,
KASKI, NEPAL
2024
PREVALENCE OF HOOKAH SMOKING AND ASSOCIATED
FACTORS AMONG PCL NURSING STUDENTS OF POKHARA
METROPOLITAN CITY, NEPAL

SALMAN SUBEDI

PU Regd. No: 2019-4-73-0233

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF BACHELOR OF PUBLIC

HEALTH (BPH

A DISSERTATION SUBMITTED TO

DEPARTMENT OF PUBLIC HEALTH

LA GRANDEE INTERNATIONAL COLLEGE

POKHARA UNIVERSITY

KASKI, NEPAL
 DECLARATION

It is hereby stated that the dissertation entitled “prevalence of hookah smoking and its
associated factors among PCL nursing students of Pokhara Metropolitan
city”submitted in partial fulfillment of the requirement for the award of degree of
Bachelor of Public Health in the Department of Public Health, LA GRANDEE
International College, is an original work done by me.The matter presented in the
dissertation has not been submitted by me for the award of any other degree to this
University or any other institution.

Signature:

Name: Salman subedi

PU Registration No: 2019-4-73-0233

Exam Roll No:20730138

Date:
 SUPERVISOR CERTIFICATE

This is to certify that the dissertation entitled “prevalence of hookah smoking and its
associated factors among PCL nursing students of PokharabMetropolitancity
Nepal”submitted in partial fulfillment of the requirements for the award of the degree of
Bachelors of Public Health in Department of Public Health, LA GRANDEE International
College, Kaski district, is a record of bona fide research carried out by Salman subedi
under my guidance and supervision and no part of dissertation has been submitted for
any other degree or diploma. The assistance and help received during the course of this
study have been acknowledged,

It is further certified that the declaration by the candidate, Salman subedi is correct to the
best of our knowledge.

Signature:

Name: Rajib Prasad Koirala

Designation:Professor

Date:
APPROVAL SHEET
 ACKNOWLEGEMENT

It is my pleasure to acknowledge and grant thanks to all those who has been supportive,
has given consistent advice, guidance and encouragement throughout my activities in
accomplishing this dissertation.

My utmost gratitude to my academe LA GRANDEE International college affiliated to

Pokhara University for incorporating Research as Dissertation and providing handful
opportunities to learn. At first I would like to acknowledge the respondents of my study
for their active participation and quality information. A deep and sincere gratitude to my
supervisor, Lecturer Mr. Rajib Prasad Koirala for closer supervision, guidance and advice
throughout my study.Similarly, I express my sincere appreciation to lecturer Mr. Keshav
Raj Adhikari, lecturer Mrs.Kalpana Jnawali and Mr.SandipPahari for their support and
guidance. My sincere appreciation is extended to my brother Laxman Poudel providing
guidance and consistent support.

I am indebted ton each and everyone who have supported throughout my research. In an
addition, special thanks to my colleagues ………data collection process.

Last but not the least, with due respect I express my heartfelt thank you to my parents for
their financial support, inspiration, prayer and guidance and strength which helped me a
lot to complete my study.

Salman Subedi

Pokhara, Kaski, 2024

 ABSTRACT
.
TABLE OF CONTENT
LIST OF TABLE
LIST OF ABBREVIATION
 CHAPTER I: INTRODUCTION

1.1 Background
Using tobacco products that can be smoked or smokeless is referred to as tobacco use.
According to estimates from the World Health Organization (WHO), tobacco use kills
approximately 6 million people worldwide, and by 2030, that number is expected to rise
to 8 million(1). Hookah is also known as narghile, waterpipe, and shisha(5).Smoking a
water pipe may be perceived as less risky than smoking cigarettes, but it still contains
tobacco, which means that it also contains many of the same toxicants as cigarette smoke,
including high levels of nicotine, carbon monoxide (CO), "tar," and heavy
metals(10).Due to misconceptions that suggest it is less dangerous than cigarettes,
hookahs are very popular(11). Around 8 million people died from a tobacco-related
disease in 2017(2,3). it is projected that the number of tobacco-related deaths would
increase from 6.4 million in 2015 to 8.3 million in 2030(2).Currently, developing nations
account for 80% of the world's 1 billion smokers(4).

According to the Center for Disease Control and Prevention (CDC), hookahs are water
pipe apparatuses that are used to smoke specially made tobacco that comes in diferent
favors such as apple, mint, cheery, chocolate, watermelon, strawberry, etc(5).Since its
invention some 400 years ago, hookah has gained popularity among young people in
Middle Eastern and international coffee shops and restaurants(6,7)Hookah smoking
originate in Persia and India which often mostly use by men(8).Research examining the
immediate and extended consequences of hookah pipe smoking reveals that it poses a
risk for lung cancer, cardiovascular illness, periodontal diseases, and unfavorable
pregnancy outcomes(9).

.
Public health officials have labeled it a global tobacco epidemic and identified it as an
emergent public health hazard(5).Hookah and cigarettes were the most popular forms
of tobacco in Nepal(1). among medical professionals, hookah smoking is also
growing in popularity(8)(12). Hookah smoking is primarily done in public places and
is more of a communal activity, with friends gathering in one place and sharing a
single pipe.(5,13). Medical students are vital to the industry since they will be
tomorrow's practitioners, setting an example in their usage of hookahs and perhaps
disseminating false information to the public(2).

The World Health Organization (WHO) called for a better knowledge of national and
international trends in waterpipe tobacco use in a 2005 advisory note. In 2007,
waterpipe smoking was classified as a "emerging deadly trend" by the American
Lung Association(6). A single water pipe is equivalent to approximately 70 cigarettes
on average, and smoking one for an hour involves breathing smoke from the pipe
100–200 times.
 1.2 Problem Statements

Throughout the world, hookah smoking—also known as shisha or waterpipe smoking—is

a popular method of tobacco use, particularly in the Middle East, North Africa, and South
Asia. Among the parts of the world where it is becoming more and more popular are
Australia, Europe, and North America(1).Every year, millions of people are harmed and
killed by tobacco use in any form. In 2017, almost 8 million people passed away from
diseases linked to tobacco use(3).Of the 228 participants, 66% had previously smoked a
hookah pipe, and 18% were currently smoking study conduct in SouthAfrica(9).

similarly In a study done on USA, the prevalence of lifetime water pipe smoking was
determined to be 30.5%(7).Adults of Asian and African descent have taken to smoking
hookahs in recent years, particularly in the Middle East and Arab nations. Every day,
more than 100 million people consume hookah(15). The prevalence of hookah smoking
differs substantially throughout countries and areas(16).According to the World Health
Organization (WHO), the Eastern Mediterranean region has the highest prevalence of
adult waterpipe use, with up to 36% of men and 4% of women reporting using one in the
previous 12 months. In other regions, such the Americas and Europe, adult waterpipe use
varies from less than 1% to 10%(17).Many countries have implemented laws to reduce
the use of hookahs. These include bans on flavored tobacco, restrictions on marketing
and promotion, and requirements for warning labels to be placed on hookah products(11).

Currently, developing nations account for 80% of the world's 1 billion

smokers(4).Because the water in the hookah filters out the toxic components in the
smoke, many people believe that smoking a hookah is less harmful than smoking
cigarettes. However, research has shown that this is false and that many of the same
harmful substances found in cigarette smoke are also present in hookah smoke(18).More
work has to be done to raise knowledge of the health risks connected to hookah smoking
in order to convince individuals to give up using hookahs or to entirely discourage them
from doing so(7).
Tobacco use is the number one preventable cause of mortality, taking the lives of almost
5 million people annually. In the Middle East, a large portion of youth smoke
waterpipes(19).

While there isn't much research on hookah smoking in Nepal, a 2018 study found that
many parts of the country have access to flavored hookah tobacco and that smoking a
hookah is thought to be less dangerous than smoking cigarettes. The study was published
in the Tobacco Control journal. The survey also found that the public was ignorant of the
health risks associated with hookah smoking and that hookah smoking was commonly
associated with social events and nightlife(20). a recent study in nursing in nepal shows
30% prevalence of hookah smoking among nurses in Chitwan.(2).
1.3Rational and Justification of the study

A new and growing fad that is becoming more and more popular worldwide is hookah
smoking, sometimes referred to as water pipe smoking, particularly among young people
and college students. Public health officials have identified the tobacco epidemic as a
growing threat to public health and have dubbed it a global health crisis(5).

It is commonly known that the use of tobacco products, such as hookahs, is the primary
cause of chronic illness and early mortality worldwide. The Government of Nepal has
committed to decreasing premature death from NCDs by one third through prevention
and treatment by 2030 in order to meet the Sustainable Development Goal. Thus,
lowering the usage of hookahs is crucial to the global effort to meet this SDG target(21).

College students were largely ignorant about the chemicals associated with hookah
smoking, and there was little connection between what they knew and the harmful effects
of hookah smoking(6)While there isn't much research on hookah smoking in
Nepal,2018study found that many parts of the nation have access to flavored hookah
tobacco (20).

However, despite the crucial role of public health professional students in hookah control,
very few studies have collected information regarding use of hookah among pcl nursing
students in Nepal. The study will be conducted across Pokhara metropolitan city. In this
municipality no any similar study regarding prevalence of hookah use among PCL
nursing has been found to be conducted. This study might be a contribution in planning
and implementing anti-smoking laws and regulations for different college by knowing
intensity of hookah consumption on PCL nursing in Nepal.
1.4 Research question

What is the prevalence of Hookah smoking and its associated factors among Proficiency
Certificate Level nurses students of pokhara metropolitan?

1.5 Objectives

a. General objectives
To assess the Prevalance of Hookah smoking and its associated factors among
Proficiency Certificate Level nursing students of Pokhara metropolitan city.

b. Specific objecives
• To Determine the Prevalance of hookah use among PCL nursing student .

• To identify the associated factors between prevalance of hooakah smoking and selected
variable .

• To find out the association of socio-demographic variable and Prevalence.

1.6 Study variables

a) Dependent variable
Hookah smoking

b) Independent Variables

 Age
 Sex
 Ethnicity
 Religion
 Academic year
 Residence
 Family Type
 Parent’s occupation
 Parent’s qualification
  Parental history of smoking Hookah
 Friends’ habit of Hookah practice.

1.7 Conceptual Framework

Independent variable dependent variable

Socio-demographic factors

 Age
 Sex
 Ethnicity
 Religion
 Academic year
 Residence Family
Type
Individual Factors Hookah smoking

Substance use (cigarette)

School Environment:

Friends’ habit of Hookah

practice

Family Factors

 Parental history of
smoking Hookah

Figure 1 : Conceptual framework of the study

1.8 Operational Definitions
Hookah smoking is the smoking of tobacco from the equipment of hookah that has head,
body, water, bowl and a hose attached to one another. Tobacco is placed at the head and
covered with a thin perforated aluminum plate. Lit charcoal is place on the plate to burn
the tobacco. A bowl immersed into the water through tube and the inhalation is done
from the mouth and the smoke is gone to the tip of pipe through the equipment.

PCL; proficiency Certificate Level in Nursing (PCL Nursing or SN) Program is three
years academic course, which aims to producea mid-level technical nursing workforce
equipped with knowledge and skills related to the field of nursing so as to meet the
demand of the nursing workforce in the country and abroad.

Age: Age above 16 years .

Sex: Sex was divided into Male, Female and others.

Ethnic Group: classified according to the census.

Religion: Religion was classified as Hinduism, Buddhism, Christianity, Islam and others.

Studying college : Studying colleges are PCL nursing college as under CETVT .

Academic year: student studing in nursing college 1st year, 2nd year, 3rd year.

Current Residence: It is divided into living alone, staying with family and staying with
friends.

Family Type:It is categorized into Nuclear, joint and extended type.

Parents history of tobacco: It denotes whether the participant had a parents who smoke
hookah.

Friends’ history of tobacco: It denotes whether the participant had a friend who smoke
hookah or not.

1.9 Limitation of the Study

This is a cross-sectional study, so causality of the association cannot be inferred.
CHAPTER II : LITERATURE REVIEW

2.1. Introduction
Literature review is integral part of entire research process and makes valuable
contribution to every operational step. It is an essential preliminary task in order to
acquaint with the available body of knowledge in the one area of interest. The process of
reviewing the literature helps to understand the subject area better and this helps to
conceptualize the research problem clearly and precisely. It also helps to understand the
relationship between research problem and the body of knowledge in the area.

2.2. Methodology of literature review

Sources of information

The review of literature offers an overview of published articles under the topic and helps
us to determine how the research is carried out in different aspects of topics. The
literature was reviewed using various sources like Pub Med, Google Scholar and
governmental websites. The main searching tool is Mendeley software. Some of the
articles are exported from the Google Scholar. Journal articles extracted from various
topics were reviewed to have a better in-depth of the subject and to explore what we have
learnt from others. All the articles which only written in English; related to topic were
included in the review time.

Search strategy

All the literature is search through the Mendely software and Google scholar. Since the
much literature could not be found from Mendely reference manager, I have search the
relevant literature with the help of Google scholar. For searching the literature in
Mendely, I have used different keywords so that I could find the relevant one in Pub
Med. First, search terms were used to search all database " prevalence", “hookah" ,
"nursing" "college" , "Nepal", in Mendely in different time to make library sufficient
with related articles so that it is easy to carry out the research.
 Google scholar
PubMed

Article retrieved

Article excluded due

to unmatched title

Screened retrieved

Record excluded Article reviewed

for irrelevent

Article assessd for

the full text

Full text found

Article were used

Article were used

Total article used

Literature Findings

"Prevalence, Knowledge, and Practices of Hookah Smoking Among University

Students, Florida, 2012"

54.4% of students reported having smoked a hookah at some point in their lives. 16.3%
had used a hookah in the previous 30 days. The probabilities of smoking cigarettes and
owning a hookah were shown to be substantially correlated with hookah use (OR, 4.52;
95% CI, 2.13–9.60) and 10.67; 95% CI, 4.83–23.66), respectively, but not with alcohol
use (OR, 1.73; 95% CI, 0.74–4.04). Results also indicate that many view hookah as a
safer option than smoking cigarettes. Nearly 30% of people who had never smoked
hookah said they would give it some thought in the future(18)(22).

"The prevalence of waterpipe tobacco smoking among the general and specific
populations: a systematic review"

Only four of the 38 research evaluated specific groups; the other studies were national
surveys. Among schoolchildren worldwide, the United States, particularly among Arab
Americans (12%–15%), the Arab Gulf region (9%–16%), Estonia (21%), and Lebanon
(25%), had the highest prevalence of current waterpipe smoking. Comparably, the Arabic
Gulf region (6%), the United Kingdom (8%), the United States (10%), Syria (15%),
Lebanon (28%), and Pakistan (33%), had high rates of current waterpipe smoking among
university students. The following countries had the highest rates of adult waterpipe
smokers: Pakistan (6%), the Arab Gulf region (4%–12%), Australia (11% among adults
who speak Arabic), Syria (9%–12%), and Lebanon (15%). In Lebanon (5%), group
waterpipe smoking was common; in Egypt (11%–15%), it was less. 5%–6% of pregnant
women in Lebanon reported.(6)

Prevalence and Predictors of Water Pipe and Cigarette Smoking Among Secondary
School Students in London
The prevalence of water pipe smoking was more than twice as high as that of cigarette
smoking (7.6% vs. 3.4%, p <.001). Among the students, 1 in 4 had attempted using a
water pipe, while 1 in 6 had tried smoking cigarettes (24.0% vs. 15.8%, p <.001). Being
older, belonging to a South Asian or Middle Eastern ethnic group, and smoking cigarettes
personally, with family, or with friends are all significant predictors of never using a
water pipe. Significant indicators of never having smoked include being older, White
ethnicity, and tobacco usage by friends, family, or oneself. There was a higher probability
of current water pipe users among students attending schools with more water pipe cafes
within 0.5 miles (AOR = 2.43, 95% CI = 1.33–4.42)(23).

"A descriptive study of the perceptions and behaviors of waterpipe use by university
students in the Western Cape, South Africa"

Compared to non-users (13% and 17%, p<.001), waterpipe users thought the health
concerns of smoking the pipe were exaggerated (48%) and less addicting (58%).
Furthermore, the results validate that 61% of waterpipe smokers do so in a social
environment. In this social context, smoking was prevalent in the following places:
restaurants (1%), parties (9%), family homes (11%), college campuses (28%), and
friend's houses (6%). It was concerning that 90% of users could easily obtain the tobacco
mix and that 70% of users smoked their waterpipes every day. Relaxation was the most
often stated motivation for waterpipe smoking among self-repoters(24).

"Waterpipe and Cigarette Smoking among University Students in the Western

Cape, South Africa"

63% of university students in the Western Cape said they had ever smoked a waterpipe,
9.9% said they had smoked one in the previous 30 days, and 17.7% said they had smoked
cigarettes. There is a considerable socializing component to waterpipe smoking. After
adjusting for potential confounders, the effects of current waterpipe smoking on alcohol
use, age, demographic group (Indian and mixed-race students smoke more), religion
(Muslims smoke more), faculty (medical students smoke less), and spending are all
positively correlated with each other. Similar factors are linked to current cigarette
smoking, but not age(25).
"Gender differences in waterpipe tobacco smoking among university students in
four Eastern Mediterranean countries"

In the age group of 18–22 years, ladies (80.4%) were more likely than males (66.4%,
p<0.001), and they were less likely to be current waterpipe smokers (females, 60.0%;
males, 69.5%, p<0.001). Between the ages of 15 and 19, two-thirds of students in both
genders smoked their first waterpipe, with a higher percentage of female students
beginning with family members. Approximately one-third of men and 14.9% of women
typically smoked ten or more cigarettes (p<0.001). Compared to 30.5% of men, around
half (46.6%) of women smoked for less than 30 minutes (p<0.001). Males smoked 11%
of non-flavored tobacco, but just 1% of females did so (p<0.001). Regarding the tobacco
taste that men and women typically smoke, there was a significant (p=0.05) positive
association (r=0.808), with apple/double apple being the most popular flavor among
men(26).

"The Prevalence of Smoking (Cigarette and Waterpipe) among University Students

in Some Arab Countries: A Systematic Review"

A total of 45,306 people participated in the study (33,450 men and 11,856 women). The
countries with the highest overall rates of current student smoking were Egypt (46.7%),
Kuwait (46%) and the KSA (42.3%). In Yemen (36.3% vs. 28.0%, p<0.001), Bahrain
(27.0% vs. 4.2%, p<0.001), Tunisia (38.4% vs. 3.4%, p<0.001), Egypt (61.2% vs. 18.9%,
p<0.001), Palestine (52.7% vs. 16.5%, p<0.001), Syria (26.1% vs. 9.5%, p<0.001), KSA
(32.7% vs. 5.9%, P<0.001), Jordan (54.3% vs11.1%, P<0.005), and Syria (26.1% vs.
9.5%, p<0.005), all showed significantly higher rates of smoking among men than
women. In Yemen, women's participation in another study was much higher than men's
(15.7% vs. 10.3%, p<0.001). KSA had the highest rates of waterpipe smoking among the
two genders (36.4%–36.3%). The greatest rates of cigarette smoking were seen in Jordan
(80%), Saudi Arabia (70.7%), and Libya (80.2%)(27).

The prevalence and trends of waterpipe tobacco smoking: A systematic review

355 estimations for 68 nations are reported in 129 studies. In general, the Eastern
Mediterranean region had the highest prevalence estimates for adults, whereas the
Eastern Mediterranean and European regions had roughly comparable prevalence
estimates for youth. Lebanese youth (37.2%) were the most likely to use in the past 30
days; Lebanese youth (2002, 65.3%) were the most likely to use ever; Iranian university
students (16.3% in 2005) were the most likely to use regularly or occasionally; and
Egyptian youth (10.4% in 2005) were the most likely to use daily. Although there was a
lack of trend data, the majority of studies noted that use has increased over time, with
children in the US using it between 0.3% and 1.0% year and kids in Jordan using it 2.9%
annually (both for prior 30-day use). The outcomes were comparable (28).

"Knowledge, attitudes and practice of university students regarding waterpipe

smoking in Pakistan"

The study had 450 individuals in total, of which 40.4% were female (n = 182) and 59.6%
were male (n = 268). Of the participants, about half (n = 241, 53.6%) said they had ever
smoked shisha. Curiosity was shown to be the most common cause (n = 148, 61.4%) for
beginning to smoke shisha, followed by pleasure-seeking (n = 113, 46.9%), peer pressure
(n = 55, 22.8%), boredom (n = 43, 17.8%), and tension (n = 26, 10.8%). The majority (n
= 149, 61.8%) of the 241 participants who had ever smoked a waterpipe were active
smokers. The majority of participants (n = 269, 60%) believed that smoking a waterpipe
was less harmful than smoking cigarettes. Peer pressure, waterpipe use during leisure
activities, and childhood boredom were found to be the most frequent causes(16).
"Knowledge, Attitude and Practice Regarding Hookah Smoking Among Nursing
Students in Chitwan, Nepal: A Cross-Sectional Study"

Of the 373 students, 30.6% had smoked a hookah in the past, 52.3% were determined to
have insufficient information, and 53.4% had a favorable opinion of hookah smoking. A
noteworthy statistical correlation was observed between the family's monthly income and
the history of hookah smoking in the family and the attitudes people had toward the
practice(2).

"Prevalence of Hookah Smoking and its Associated Factors among Undergraduate

Engineering Students of Khwopa College of Engineering, Nepal"
The minimum and maximum ages of the responders were 18 and 24, respectively, with a
mean age of 20.83. Hinduism accounted for 96.1 percent of the student body, with
Buddhism coming in second at 1.9% and Christianity third at 1.9%. Male participants
made up more than two-thirds (78.1%), however few of the There were 21.9% female
responses. Janajat contributed 45.2% of the responses, with Brahmins (30.3%) and
Chhetri (20.6%) following closely after. Just 18.1% of pupils were from joint households,
compared to over two-thirds (81.9%) who came from nuclear families. The faculty of
civil engineering made up more than half of the sample (51.6%), with the electrical and
computer faculties coming in second and third, respectively, at 25.2% and 23.2%. Only
22.6% of respondents were from rural areas, compared to over two-thirds (77.4%) from
metropolitan areas(5).
 CHAPTER III: METHODOLOGY
3.1. Study Design
The study design will be cross-sectional design.

3.2. Study Method

The study method will be Quantitative method.

3.3. Study Population

Study population will be PCL level nurses.

3.4. Study Area

The study will be carried out in Pokhara Metropolitan .

3.5. Sample size calculation

For Quantitative Study

 Sample size of this study was determined by using the formula for infinite
population.
2
Nz α /2 pq
Where, n ˳= 2 ( N−1) + zα /2 pq
2 (29)
d

no=Initial sample size

Z = Standard normal variable at 95% confidence level (1.96)

 p = Proportion = 0.306(2)
q = (1-p) = (1-0.306) = 0.694
d = Desirable error 0.05 (5% margin of error)
Now putting the values,
= 172

Also applying non response rate 10% then

n= n+(n*10 %) = 172+172*10/100 = 190

Therefore final sample size will be 190

 3.6 Sampling Technique

Pokhara metropolitan

3 colleges

Charak Academy Fishtail

Fewa city

proportionate
sampling
1st 2nd 3rd 1st 2nd 3rd
year 1st 2nd
ye yea year year year 3rd
year year
ar r yea
r

22
21 22 20 20 21 22 20 21

Figure 3 : Sampling Technique

3.7. Selection Criteria:

3.7.1 Inclusion Criteria:

The study included adolescents above 16 year.
3.7.2 Exclusion Criteria
 Respondent absent the day of data collection would be a part of the study.
 Participant with no consent were excluded.

3.8 : Study Period

study period is of 6th month.

3.9. Data Collection Technique

Self-administered questionnaire will be used to collect data from participants.

3.10. Data Collection Tools

Quantitative data will be collected by using semi-structured questionnaire by
using" global youth tobacco survey Questionaaire"(30).

3.11. Data processing and Analysis

Data Processing
After data collection the data will be checked for completeness, compiled and coded daily
after the completion of field activities. After this, all data was entered in the EPI-DATA
3.1. Then data was refined to find out any errors such as coding errors and entry errors.
Data Analysis
The refined data was then exported to SPSS for further analysis. As the data collected and
entered are quantitative, it was analyzed using descriptive statistics frequencies,
percentage, and mean. Finally, the result of quantitative data was analyzed and presented
separately in the section with appropriate tables, bars and diagrams.
3.11. Quality control and Quality Assurance
Validity and reliability is the major issue of concern in research which was focused in
each steps of study from title selection to the submission of final report. Tools were
developed through extensive literature review, supervisor guidance and findings of pre-
testing.
3.12. Pretesting of the Tool
Pretesting was done in Bir Nursing college Kathmandu. Tools wiil be edited further after
pretesting as per requirements. The pretesting will be done to validate the questionnaire
and also detect any likely problems before commencing the study.

3.13. Ethical Consideration

 Ethical permission to conduct the research study was taken from Department of
Public Health of LA GRANDEE International College and nursing colleges
Pokhara Metropolitan City.
 Written or verbal consent will taken from each participant and provided freedom
to give answer and withdraw at any time.
 Information will kept confidential and will used for study purpose only.
 references

1. Sharma P, Pahari S, Acharya SR, Moon DH, Shin YC. Tobacco Consumption and its
Associated Factors among Nepalese Students. Open Public Health J. 2021 Oct
15;14(1):446–54.
2. Thapa N, Ghimire B, Upadhyay HP. Original Research Article Knowledge, Attitude and
Practice Regarding Hookah Smoking Among Nursing Students in Chitwan, Nepal: A Cross-
Sectional Study. [cited 2024 May 2]; Available from: https://doi.org/10.3126/
3. WHO global report on trends in prevalence of tobacco use 2000-2025 third edition WHO
global report on trends in prevalence of tobacco use 2000-2025, third edition. 2019
[cited 2024 May 2]; Available from: http://apps.who.int/bookorders.
4. Shrestha N, Shrestha N, Bhusal S, Neupane A, Pandey R, Lohala N, et al. Prevalence of
Smoking among Medical Students in a Tertiary Care Teaching Hospital. JNMA J Nepal
Med Assoc [Internet]. 2020 [cited 2024 May 2];58(226):366. Available from:
/pmc/articles/PMC7580352/
5. Raj Baral Y, Jyakhwo S, Bist A, Jyakhwo S, Duwal N. Prevalence of Hookah Smoking and its
Associated Factors among Undergraduate Engineering Students of Khwopa College of
Engineering, Nepal. J Fam Med [Internet]. 2023 [cited 2024 May 2];10(2). Available from:
www.austinpublishinggroup.com
6. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of
waterpipe tobacco smoking among the general and specific populations: A systematic
review. BMC Public Health [Internet]. 2011 Apr 19 [cited 2024 May 2];11(1):1–12.
Available from: https://link.springer.com/articles/10.1186/1471-2458-11-244
7. Ramôa CP, Shihadeh A, Salman R, Eissenberg T. Group Waterpipe Tobacco Smoking
Increases Smoke Toxicant Concentration. Nicotine Tob Res [Internet]. 2016 May 1 [cited
2024 May 2];18(5):770–6. Available from: https://dx.doi.org/10.1093/ntr/ntv271
8. Naicker N, Teare J, Albers P, Mathee A. Prevalence of hookah pipe smoking in high-school
learners in Johannesburg, South Africa. South African Med J [Internet]. 2020 [cited 2024
May 2];110(6):546–51. Available from: https://doi.org/10.7196/SAMJ.2020.v110i6.14333
9. Merwe N van der, Banoobhai T, Gqweta A, Gwala A, Masiea T, Misra M, et al. Hookah
pipe smoking among health sciences students. South African Med J [Internet]. 2013 Oct
25 [cited 2024 May 2];103(11):847–749. Available from:
https://www.ajol.info/index.php/samj/article/view/95790
10. Kuk AE, Bluestein MA, Chen B, Harrell M, Spells CE, Atem F, et al. The Effect of
Perceptions of Hookah Harmfulness and Addictiveness on the Age of Initiation of Hookah
 Use among Population Assessment of Tobacco and Health (PATH) Youth. Int J Environ Res
Public Heal 2022, Vol 19, Page 5034 [Internet]. 2022 Apr 21 [cited 2024 May
2];19(9):5034. Available from: https://www.mdpi.com/1660-4601/19/9/5034/htm
11. Pérez A, Kuk AE, Bluestein MA, Chen B, Sterling KL, Harrell MB. Age of initiation of
hookah use among young adults: Findings from the Population Assessment of Tobacco
and Health (PATH) study, 2013–2017. PLoS One [Internet]. 2021 Oct 1 [cited 2024 May
2];16(10):e0258422. Available from: https://journals.plos.org/plosone/article?
id=10.1371/journal.pone.0258422
12. Hamadeh RR, Ahmed J, Jassim GA, Alqallaf SM, Al-Roomi K. Knowledge of health
professional students on waterpipe tobacco smoking: Curricula implications. BMC Med
Educ [Internet]. 2018 Dec 7 [cited 2024 May 2];18(1):1–8. Available from:
https://link.springer.com/articles/10.1186/s12909-018-1406-9
13. Zielińska-Danch W. The prevalence of waterpipe tobacco smoking among Polish youths.
Arch Med Sci [Internet]. 2021 [cited 2024 May 2];17(3):731. Available from:
/pmc/articles/PMC8130471/
14. Jaffri SB, Yousuf A, Qidwai W. WATER PIPE SMOKING AMONGST THE UNIVERSITY AND
COLLEGE STUDENTS OF KARACHI, PAKISTAN. Pakistan J Chest Med [Internet]. 2012 [cited
2024 May 2];18(2):13–9. Available from:
https://www.pjcm.net/index.php/pjcm/article/view/94
15. Kaveh MH, Momenabadi V, Hossein M, Phd K, Yaser S, Msc H, et al. Factors Affecting
Hookah Smoking Trend in the Society: A Review Article. Addict Heal [Internet]. 2016 Apr
[cited 2024 May 2];8(2):123. Available from: /pmc/articles/PMC5115646/
16. Jawaid A, Zafar AM, Rehman TU, Nazir MR, Ghafoor ZA, Afzal O, et al. Knowledge,
attitudes and practice of university students regarding waterpipe smoking in Pakistan.
17. Martinasek MP, Haddad LG, Wheldon CW, Barnett TE. Beliefs and Attitudes Associated
With Hookah Smoking Among a United States College Population. Respir Care [Internet].
2017 Mar 1 [cited 2024 May 2];62(3):370–9. Available from:
https://rc.rcjournal.com/content/62/3/370
18. Nuzzo E, Shensa A, Kim KH, Fine MJ, Barnett TE, Cook R, et al. Associations between
hookah tobacco smoking knowledge and hookah smoking behavior among US college
students. Health Educ Res [Internet]. 2013 Feb 1 [cited 2024 May 2];28(1):92–100.
Available from: https://dx.doi.org/10.1093/her/cys095
19. Al Ghobain M, Ahmed A, Abdrabalnabi Z, Mutairi W, Al Khathaami A. Prevalence of and
attitudes to waterpipe smoking among Saudi Arabian physicians. East Mediterr Heal J.
2018 Mar 1;24(3):277–82.
20. Khanal GN, Khatri RB. Burden, prevention and control of tobacco consumption in Nepal:
a narrative review of existing evidence. Int Health [Internet]. 2021 Feb 24 [cited 2024
May 2];13(2):110–21. Available from: https://dx.doi.org/10.1093/inthealth/ihaa055
21. Tobacco control for sustainable development. 2017 [cited 2024 May 4]; Available from:
http://apps.who.int/bookorders.
22. Rahman S, Chang L, Hadgu S, Salinas-Miranda AA, Corvin J. Peer Reviewed: Prevalence,
Knowledge, and Practices of Hookah Smoking Among University Students, Florida, 2012.
Prev Chronic Dis [Internet]. 2014 [cited 2024 May 4];11(12):140099. Available from:
/pmc/articles/PMC4264467/
23. Jawad M, Wilson A, Lee JT, Jawad S, Hamilton FL, Millett C. Prevalence and Predictors of
Water Pipe and Cigarette Smoking Among Secondary School Students in London.
 Nicotine Tob Res [Internet]. 2013 Dec 1 [cited 2024 May 4];15(12):2069–75. Available
from: https://dx.doi.org/10.1093/ntr/ntt103
24. Daniels KE, Roman N V. A descriptive study of the perceptions and behaviors of
waterpipe use by university students in the Western Cape, South Africa. Tob Induc Dis
[Internet]. 2013 Feb 8 [cited 2024 May 4];11(1):1–5. Available from:
https://link.springer.com/articles/10.1186/1617-9625-11-4
25. Kruger L, Van Walbeek C, Vellios N. Waterpipe and Cigarette Smoking among University
Students in the Western Cape, South Africa. Am J Health Behav. 2016 Jul 1;40(4):416–26.
26. Hamadeh RR, Lee J, Abu-Rmeileh NME, Darawad M, Mostafa A, Kheirallah KA, et al.
Gender differences in waterpipe tobacco smoking among university students in four
Eastern Mediterranean countries. Tob Induc Dis [Internet]. 2020 [cited 2024 May 4];18.
Available from: /pmc/articles/PMC7720794/
27. Nasser AMA, Geng Y, Al-Wesabi SA. The Prevalence of Smoking (Cigarette and
Waterpipe) among University Students in Some Arab Countries: A Systematic Review.
Asian Pac J Cancer Prev [Internet]. 2020 Mar 1 [cited 2024 May 4];21(3):583. Available
from: /pmc/articles/PMC7437327/
28. Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA. The prevalence and trends of
waterpipe tobacco smoking: A systematic review. PLoS One [Internet]. 2018 Feb 1 [cited
2024 May 4];13(2):e0192191. Available from: https://journals.plos.org/plosone/article?
id=10.1371/journal.pone.0192191
29. Goyal R. reseaerch methodology. 2013. 305 p.
30. Global Youth Tobacco Survey (GYTS) Core Questionnaire with Optional Questions GYTS
Core Questionnaire with Optional Questions GYTS Sample Design and Weights GYTS
Implementation Instructions GYTS Analysis and Reporting Package GYTS Data
Dissemination Guidance GYTS Data Release Policy Acknowledgments GYTS Collaborating
Organizations.