Socialisation Agents

The second hypothesis (H₂), socialisation agents affect attitudes towards WTS, included two sub hypotheses: (H1a) Peer influence and (H2a) Parental influence.

The findings of this study suggested that: peer influence has a positive, significant impact on the attitude towards WTS. Thus, the more favourable the attitude that peers holds towards WTS and its use, the more favourable the youths and young adults’ attitudes are towards WTS (and vice versa). On the other hand, parental influence (mother or father) did not significantly impact youths and young adults’ attitude towards WTS. These findings are in line with prior research that stresses the vital role that peers and close friends have on young individuals (Scalici and Schulz, 2014). Furthermore, it supports prior research that claimed that the older (and more independent) individuals get, the more diminishing the influence of their parents are on their behaviour. The findings of this study put more emphasis and importance on peer influence, giving them a more central role in influencing their decision-making process towards WTS. This study believed that parent’s socialisation effects are more effective during early stages of adolescents. The findings of each sub hypothesis are discussed in detail in the next section. The outcomes of this study contradict prior research that claimed that parental and peer influence affected individuals almost equally (De Vries et al., 2003).

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The results of this research supported prior studies, claiming that smoking behaviour of friends (best friendships, social networks, etc.) plays a significant role in influencing attitudes and leading to water-pipe smoking uptake (Maziak, Eissenberg, Rastam et al., 2004; Akl et al., 2015;

Singh et al., 2017). Recent research and studies support the notion that peer group identification is important for youth and young adults who put high emphasis on their peer associations. These individuals are more inclined to engage in the same behaviour as their friends (smoking) to gain their group’s approval (Nieh et al., 2018). For example, studies conducted in Lebanon and Jordan found that approval and encouragement from friends influenced WTS (Afifi et al., 2009;

Obeidat et al., 2014); while the disapproval of friends of WTS was related to less use (Salameh et al., 2014).

Nevertheless, it is recognised that friends may cause unintended peer pressure when mingling.

Socialisations among friends operate independently. Socialisations usually lead to reciprocal effects. Accordingly, friends grow more similar together. When individuals spend long hours together with their friends, they may unconsciously mimic their friends’ typical routine behaviour and patterns, such as: routines, way of dressing, leisure activities, and smoking behaviour (Ali and Jawad, 2017).

In this current research, results implied that friends enjoy outings that serve shishas. They seek places that offer WTS, especially at weekends, making shisha smoking an essential part of their group gathering. Prior studies indicated that smoking with friends has some psychological associations in the EMR, especially within male groups who hang out daily at local cafes (ahwa).

Prior studies indicated that males engage in water-pipe smoking as a sign of manhood and liberation (Akl et al., 2015). Thus, for cafe businesses, it has become a necessary product/service to offer customers. According to reports, cafes and restaurants realise the high net margin associated with shisha smoking. They serve the product everywhere in their stores, ignoring the indoor smoking ban that is initiated by policymakers (Maziak, Ward Soweid and Eissenberg, 2004; Shafey, 2007). The findings of this study also implied that friends who have a negative attitude towards WTS could influence their acquaintances to stop smoking. Among groups with a negative prevailing attitude to smoking, peer influence may discourage uptake of smoking. For example, a group of friends who are influenced, through well executed interventions, to quit

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WTS can influence the rest of the group to do so, expressing how unfavourable it may be to the rest of them. Thus, socialising that facilitates smoking can also discourage use.

6.2.4 Parental Influence

In this current study, parental influence was measured in terms of the quality of the parent-youth communication. Based on the outcomes of the pilot tests, the majority of respondents suggested that the “scale of quality of the parent-youth communication” was used separately to measure the effect of youth communication among fathers and among mothers. Most participants admitted that their mothers knew of their smoking habits, but not their fathers. The participants feared their fathers’ reactions to such behaviour. Accordingly, the research assessed each parent influence separately. The scale was divided into “Parental Influence-Father” and “Parental Influence-Mother.” This separation of parental communication influence was also done in Harakeh et al.’s (2004) study. During the data collection, almost 50 questionnaires were removed from analysis because the father section was left empty. This notion from the respondents of this study is not surprising. A prior study among university students in Jordan illustrated that about 30% of water-pipe smokers (more men than women) affirmed that their parents would discipline them for smoking water-pipes (Obeidat et al., 2014).

When conducting the SEM analysis, the variable “Parental Influence – Mother” was dropped from the analysis. Subsequently, the “Parental Influence – Father” was insignificant when tested.

These conclusions highlighted a problematic parent-youth communication issue. These outcomes implied that parental influence is insignificant due to the parenting style. Perhaps if parents kept a more open and safe communication about WTS, youth and young adults may be more inclined to listen to their parents’ opinions. Studies on anti-smoking socialisation, such as Engels and Willemsen (2004) and Harakeh et al. (2005), claimed that youth think that their parents will react in a negative manner if they find out about their offspring’s smoking behaviour. However, the parents think they would be able to react to such knowledge in a positive and helpful manner.

Accordingly, this current research observes the findings as an indication that nowadays youth are not spending much time with their parents to allow behavioural effects to occur. This outcome suggests that parents are spending long hours at work, which is due to the requirements of their jobs, the cultures of their workplaces, or the need for money for survival. Thus, life demands

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have impacted family time and influence. Harakeh et al. (2005) explained that stay-at-home mothers are more positive about their antismoking socialisation practices. Stay-at-home mothers spend more time with their children. Thus, they may have better insights into family matters than the fathers.

The communication process between parents and youth maybe more effective at younger ages, but their influence wears out, as children get older. Findings of this research are in line with past research (Chassin et al., 2005; Ennett, Bauman, Foshee, Pemberton and Hicks, 2001; Harakeh, Engels, Den Exter Blokland, Scholte and Vermulst., 2009) that argued that smoking-specific communication has no effect on adolescent smoking. According to these studies, smoking-specific parental communication was only effective at younger ages. This offers some clarity to why parental influence did not affect Egyptian youth and young adult’s attitudes towards WTS in this study. However, it contradicts other studies in tobacco smoking that suggested that parents influence smoking behaviour (Akl et al., 2015; Harakeh et al., 2005; Islam and Johnson, 2005).

For instance, Harakeh and colleagues (2005) found that it is useful for parents to discuss smoking-related issues with their offspring in a useful and respectful manner. They explained that the communication process prevents young people from taking up smoking.

6.2.5 Religiosity

The third hypothesis (H3), religiosity affects attitudes towards WTS, was tested next. In this study, it was found that: there is an inverse relationship between religiosity and attitudes towards WTS. This finding suggested that as a person’s level of religiosity increases, the less favourable is their attitude towards WTS. This outcome implied that religion and religious institutes are both relevant and important drivers for quitting smoking. These factors create a guarding effect against engaging in WTS. This finding is in line with other prior studies. Past studies suggested that religion and religiosity affect water-pipe smoking (Jawad, Nakkash et al., 2015; Korn and Magnezi, 2008; Nabipour et al., 2016; Singh et al., 2012). However, there are some prior studies that contradict the findings of this study. Some studies found that religiosity had no impact on water-pipe smoker behaviour (Klassen, Smith and Grekin, 2013; Arfeken et al., 2015; MohammadPoorasl, Abbasi-Ghahramanloo and Allahverdipourm 2014). These contradictions mainly stemmed from the belief that WTS is less harmful than cigarette smoking, hence less makruh or scorned by religious views.

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In this current study, it is important to note that the components of religiosity were related to intrinsic religiosity, which relates to the private, sincere, and emotional practice of religion for the sake of God. The extrinsic religiosity statements that related to being religious for gaining social status and for social appearance were dropped out of the SEM model when tested. This suggests that Egyptian youth and young adults use religion to a certain extent to guide their day-to-day behaviour. Religion is a culturally relevant vehicle. According to the findings of this study, religion can control (discourage) tobacco usage. Egypt is an Islamic country. In Islam, there is a religious declaration (fatwa) by Dar al-Ifta al-Misriyyah (an Egyptian educational institute and government body that represents Islam) that discourages the use of tobacco due to health concerns: “Don't throw yourself into danger by your own hands...” (el-Bakara 2/195).

Likewise, devoted Egyptian Christians also believe, through the teachings of the Bible and religious entities, that smoking is harmful to one’s self and is discouraged (Marcus, 2008).

6.2.6 Attitude towards WTS

The fourth hypothesis (H4), attitude towards WTS affects intentions to smoke was tested.

Results revealed that: attitudes towards WTS significantly influence intentions to smoke.

Attitudes towards WTS also happen to be the strongest predictor of intentions, a finding that is in line with prior studies of the TPB (Ajzen, 1991; Armitage and Conner, 2001).

In this current study, results suggested: a partial mediation role of attitudes towards WTS between each of conservation and peer influence and intentions to smoke. This conclusion supported that there is a significant impact of conservation and peer influence. This means that they remain to have a significant impact on intention to smoke in the presence of attitude towards WTS. The findings of this research indicated that conservation values negatively impact attitudes towards WTS, but positively impact intentions to smoke. This conclusion suggests that although Egyptian youth may create unfavourable impressions of WTS due to conservation values, these values may impact their intentions to smoke, linking WTS to cultural heritage, traditions, and in-group bonding activity. Akl and colleagues (2013) supported this finding. They indicated that peer influence positively influences both attitudes and intentions to smoke, which is evident in water-pipe smoking research and supported earlier in the discussion (in Section 6.2.3).