Prevalence and Predictors of Shisha Smoking in Ghana and Sierra Leone: Findings from the 2017 Global Youth Tobacco Surveys

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Yet in countries like Ghana and Sierra Leone, there remains a critical gap in understanding the behavioral patterns and underlying factors driving this trend. Methods We retrieved secondary data from a public sphere collected using a cross-sectional study design. Overall, 12,281 students in grades associated with 11-18 year olds were selected using stratified two-stage cluster sampling. Descriptive statistics estimated smoking prevalence by age, sex, school grade, country, and survey year. Multivariate logistic regression models were used to determine associations between socio-demographic, behavioural, tobacco policy factors and current Shisha smoking. Adjusted odds ratios and their 95% confidence intervals are reported. Results The overall prevalence of current shisha smoking was 7.2% (7.8% males and 6.6% of females). The prevalence was slightly higher in Sierra Leone (7.69%, 95% CI: 7.05-8.33) than Ghana (6.58%, 95% CI: 5.94-7.23). Adolescents who did not support banning tobacco sales to minors had higher shisha use (7.96%, 95% CI: 7.34-8.57) than their counterparts (6.01%, 95% CI: 5.34-6.67). Participants who smoked cigarettes, were more likely to smoke shisha compared to those who did not smoke (AOR = 9.86; 95% CI: 7.84–12.38; p < 0.001). Conclusion Shisha smoking among school-going adolescents in Ghana and Sierra Leone reviewed emerging patterns suggesting early initiation and strong association with cigarette use. There is a need for stronger enforcement of tobacco control policies, targeting poly-tobacco use control and factors influencing early initiation. These findings provide valuable insight to inform tobacco control. Clinical trial number: not applicable Shisha Adolescents Tobacco Control Ghana Sierra Leone Figures Figure 1 INTRODUCTION Shisha, also known as waterpipe or hookah, is gaining popularity around the world, especially among young people ( 1 , 2 ). In contrast to cigarette smoking, which has been declining in many countries due to strong tobacco control measures, shisha is often and mistakenly seen as a safer alternative ( 3 , 4 ). This misconception has contributed to widespread use ranging from cafés in Europe and the Middle East to social gatherings in Asia and the Americas ( 5 – 7 ). As a result, global health experts are increasingly worried about the long-term impact of shisha smoking on public health ( 8 ). In Africa, shisha use has been rising steadily ( 9 , 10 ). Many young people are drawn to it because of the flavored tobacco and the social atmosphere around shisha smoking ( 11 , 12 ). Unfortunately, awareness of its health risks is still low. Studies have shown that shisha exposes users to harmful levels of nicotine, carbon monoxide, and cancer-causing substances ( 13 , 14 ). Despite the growing concerns, shisha lounges remain prevalent in many African cities, where tobacco control policies are either weak or inadequately enforced ( 15 ). Countries such as Ghana and Sierra Leone are experiencing similar trends ( 16 , 17 ). Young people in these countries are increasingly experimenting with shisha at early ages, often under peer influence and exposed to environments where tobacco advertising is not strictly regulated ( 17 , 18 ). Education efforts through schools and community programs are frequently under resourced to educate youths about these dangers ( 12 ). Although, policies restricting tobacco sales to minors and banning smoking in public places exist, their enforcement is inconsistent, allowing the habit to spread ( 19 ). While studies have been conducted on shisha smoking among adolescents in Africa, we are not aware of a study that analyzed pooled data from two countries. The aim of this study is to examine the prevalence and predictors of shisha smoking among school-going adolescents in Ghana and Sierra Leone. The findings from this study will provide evidence that can guide targeted interventions, strengthen existing policies, and help reduce the rising burden of tobacco-related harm in these countries and across Africa. METHODS Data Source This study used secondary data from the Global Tobacco Youth Surveys (GTYS) collected in 2017. The analysis focused on data from two West African countries: Ghana and Sierra Leone. The GYTS is a school based survey of students, in grades 7 to 9, aged 11 to 18 years. It is designed to produce a cross sectional national representative sample. The GYTS methodology for the sampling framework, selection of schools and classes, and data processing is standardized. The survey uses a standard questionnaire with core questions on tobacco use and key tobacco control variables and allows adaption to the needs of a particular country. All participants provided informed consent with their anonymity preserved through the use of unique identifiers instead of personal information. In addition, each country obtains ethical approval from the relevant authorities, ensuring compliance with local and international ethical standards. A more detailed description of the overall objectives and methodology of the GYTS are available elsewhere (20). The sample size and the schools are determined using a standard procedure and software developed by the Center for Disease Control and Prevention (CDC) upon receiving the sampling frame from the GYTS research coordinators. The actual sample size and its computation was not available, however, a minimum sample size of 1500 students, 50% of whom are female is required for the GYTS (20). A total of 12,281 school-going adolescents from Ghana (46%) and Sierra Leone (54%) were surveyed independently in the two countries in 2017. Records with missing data on current shisha smoking status were excluded to ensure accurate analysis. Dependent variable The primary outcome variable of interest was current shisha smoking that was generated from the question, “During the past 30 days (one month), on how many days did you smoke shisha?” with response options: 0, 1 or 2, 3 to 5, 6 to 9, 10 to 19, 20 to 29, all 30 days. Participants who smoked shisha at least once (Yes) in the preceding 30 days were classified as current shisha smokers, while those who did not (No) were classified as non-current shisha smokers. Independent variables Socio-demographic factors These were: age (≥11, 12, 13, 14, 15, 16, ≤18 years), sex (male and female) and grade (seven, eight, nine, ten, eleven and twelve). Behavioral and tobacco marketing factors Participants were asked, “During the last 30 days, have you ever tried smoking cigarettes?” Students who answered “Yes” were classified as cigarette smokers otherwise they were not. Participants who responded “Yes” to the question, “During the past 30 days, did you see any advertisements or promotions for shisha on TV, the internet or social media (Facebook, Twitter, Instagram, TikTok or YouTube) or any public place?” were classified as having been exposed to tobacco marketing. Curriculum factors Students were asked, “During the past 12 months, were you taught in any of your classes at school about the dangers of smoking shisha?” Students’ answers to this question were categorized as Yes or No. Policy factors This variable had two questions to which the students responded Yes/No; 1) “Are you in favour of banning smoking in public?” 2) “Do you think the sale of shisha or other smoked tobacco products to minors (under 18) should be banned?” Statistical Analysis Descriptive statistics were used to obtain numbers and percentages of current shisha smokers and non-smokers by their socio-demographic characteristics, behavioral and policy factors (21). The Chi-square test of association was utilized to determine associations between various factors and current shisha smoking status. Additionally, univariate and multivariate logistic regression models were used to examine the associations between factors that may influence shisha smoking among school-going adolescents in Ghana and Sierra Leone (22). Variables that were found to be significantly associated (p<0.05) with current shisha smoking status in the univariate analyses were included in the multivariate models. Stepwise model selection with Akaike Information Criterion (AIC) was applied to identify the most parsimonious model while retaining age and sex in the model due to their known confounding effects. Adjusted odds ratios (aORs) with 95% confidence intervals and p-values were reported and used as measures of magnitude of associations. Age, gender, ever tried smoking cigarettes, taught in class about the dangers of smoking were controlled for in the full model. To visualize the relationship between age and the probability of current shisha smoking, predicted probabilities were computed from the final adjusted model. Using Bayesian simulations from the model’s posterior distribution (1,000 simulations), we estimated mean predicted probabilities and 95% credible intervals by age and sex. These predictions were plotted to illustrate risk patterns across adolescent age groups. All analyses were conducted using R (version 4.5.0). Ethical Considerations Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (Ref. No.7265-2025) and the National Health Research Authority of Zambia (Ref. No: NHRA-2899/14/11/2025), in compliance with national research guidelines. Access to the anonymized GYTS datasets was granted by the WHO through the NCD Microdata Repository. As the study involved no direct contact with participants and used de identified data, no additional consent was required. The data for this research were accessed between 1 st April 2025 and 31 st December 2025. The authors had no access to information that could identify individual participants during or after data collection. RESULTS Characteristics of study participants The study included 12,281 school-going adolescents from Ghana (46%) and Sierra Leone (54%), surveyed independently in the two countries in 2017. The overall sample for the two countries was nearly evenly split by sex, with 53% female and 47% male. Age distribution showed most participants were between 13 and 15 years old, representing over 70% of the sample. School grade levels ranged from 7 to 12, with the largest groups in grades 9 and 10. These demographic details provide a broad overall picture of the youth population surveyed in two West African countries (Table 1). The overall prevalence of current shisha smoking among the youth was 7.2%. The prevalence of shisha smoking was significantly higher in Sierra Leone (7.69%, 95% CI: 7.05-8.33) than Ghana (6.58%, 95% CI: 5.94-7.23) (Table 1). Current cigarette smokers had a much higher shisha smoking prevalence (41.47%, 95% CI: 36.52-46.42) compared to non-smokers (6.08%, 95% CI: 5.65-6.51), indicating a strong association between cigarette and shisha use. Age-specific prevalence showed notable high rate of shisha use among youngest group (age 11), at 20.7%. Prevalence was lower ranging from 5.0% to 7.0% among those aged 13-14, and 7.5% among those aged 15 to 17. Males reported significantly higher prevalence (7.84%, 95% CI: 7.15-8.54) compared to females (6.60%, 95% CI: 6.00-7.21). Shisha smoking prevalence varied by school grade and attitudes toward tobacco control policies. Overall grade 7 students had a high prevalence (17.33%, 95% CI: 14.10-20.57), while older grades showed lower but steady rates (5.0% - 8.0%). Youth who did not support banning tobacco sales to minors had higher prevalence of shisha use (7.96%, 95% CI: 7.34-8.57) than those who supported such bans (6.01%, 95% CI: 5.34-6.67). Similarly, those opposing bans on smoking in public had extremely high prevalence (46.75%, 95% CI: 35.61-57.9) compared to (6.93%, 6.48-7.38) among supporters. These findings show how attitudes towards tobacco policies relate closely to actual tobacco use among young people. Table 1: Socio-demographic characteristics of participants and Percentage Prevalence of Current Shisha Smoking by gender, variable and level (Pooled GYTS Ghana 2017 and Sierra Leone 2017) (N=12281) n (%) (%) (95% CI) P-Value Country 0.0191 Ghana 5652 (46.0) 6.58 (5.94-7.23) Sierra Leone 6629 (54.0) 7.69 (7.05-8.33) Age <0.00001 11 266 (2.2) 20.68 (15.81-25.54) 12 259 (2.1) 13.9 (9.69-18.11) 13 1986 (16.2) 5.94 (4.90-6.98) 14 2724 (22.2) 5.29 (4.45-6.13) 15 3866 (31.5) 7.45 (6.62-8.28) 16 1555 (12.7) 7.65 (6.33-8.97) 17 1625 (13.2) 7.51 (6.23-8.79) Sex 0.00889 Female 6556 (53.4) 6.60 (6.00-7.21) Male 5725 (46.6) 7.84 (7.15-8.54) School Grade <0.00001 7 525 (4.3) 17.33 (14.10-20.57) 8 1986 (16.2) 5.94 (4.90-6.98) 9 2947 (24.0) 5.40 (4.58-6.21) 10 3643 (29.7) 7.49 (6.64-8.35) 11 1555 (12.7) 7.65 (6.33-8.97) 12 1625 (13.2) 7.51 (6.23-8.79) Cigarette smoking <0.00001 No 11900 (96.9) 6.08 (5.65-6.51) Yes 381 (3.1) 41.47 (36.52-46.42) Saw smoking advertisement 0.000407 No 3 (0.0) 66.67 (13.31-120.01) Yes 12278 (100) 7.17 (6.71-7.62) Taught about the effects of tobacco smoking <0.00001 No 0 (0.00) Yes 12281 (100) 7.18 (6.73-7.64) Currently uses shisha No 11399 (92.8%) Yes 882 (7.2%) Supported banning of shisha smoking in minors <0.00005 No 7404 (60.3) 7.96 (7.34-8.57) Yes 4877 (39.7) 6.01 (5.34-6.67) Supported banning of smoking in public <0.00000 No 77 (0.6) 46.75 (35.61-57.9) Yes 12204 (99.4) 6.93 (6.48-7.38) The main factors associated with current shisha smoking were age, country, cigarette smoking status, and attitudes toward tobacco control policies (Table 2). After adjusting for other factors, age groups 13 to 17 had significantly lower odds of shisha smoking compared to age 11, with adjusted odds ratios (aOR) ranging from 0.30 (95% CI: 0.21–0.45, p < 0.001) for age-group 14 to 0.43 (95% CI: 0.29–0.64, p < 0.001) for age-group 16. Age-group 12 showed no significant difference after adjustment (aOR = 0.88; 95% CI: 0.53–1.46; p = 0.631). Males had slightly higher odds than females, but this was not statistically significant (aOR = 1.07; 95% CI: 0.93–1.24; p = 0.364). Living in Sierra Leone was associated with 74% higher odds of shisha smoking compared to living in Ghana (aOR = 1.74; 95% CI: 1.42–2.13; p < 0.001). The most significant factor associated with shisha use was current cigarette smoking, with smokers having nearly ten times the odds of using shisha compared to non-smokers (aOR = 9.86; 95% CI: 7.84–12.38; p < 0.001). Conversely, support for banning tobacco sales to minors was protective, reducing the odds of shisha smoking by 52.0% (aOR = 0.48; 95% CI: 0.39–0.58; p < 0.001). Support for bans on smoking in public places showed an even stronger protective effect, lowering odds by 90% (aOR = 0.10; 95% CI: 0.06–0.17; p < 0.001). Table 2: Crude and Adjusted Odds Ratios for Current Shisha Smoking – Pooled GYTS Ghana 2017 and Sierra Leone 2017 Variable Crude Adjusted Odds Ratio (95%CI) p-value Odds Ratio (95% CI) p-value Country Ghana 1.00 Sierra Leone 1.18 (1.03-1.36) 0.017 1.74 (1.42-2.13) <0.0001 Age 11 1.00 12 0.62 (0.39-0.98) 0.0410 0.88 (0.53-1.46) 0.6310 13 0.24 (0.17-0.35) <0.0001 0.33 (0.22-0.50) <0.0001 14 0.21 (0.15-0.30) <0.0001 0.30 (0.21-0.45) <0.0001 15 0.31 (0.23-0.43) <0.0001 0.42 (0.29-0.62) <0.0001 16 0.32 ( 0.22-0.45) <0.0001 0.43 (0.29-0.64) <0.0001 17 0.31 (0.22-0.44) <0.0001 0.39 (0.27-0.59) <0.0001 Sex Female 1.00 Male 1.2 (1.05-1.38) 0.008 1.07 (0.93-1.24) 0.3640 School grade 7 1.00 8 0.3 (0.23-0.40) <0.0001 9 0.27 (0.21-0.36) <0.0001 10 0.39 (0.30-0.50) <0.0001 11 0.4 (0.30-0.53) <0.0001 12 0.39 (0.29-0.52) <0.0001 Cigarette smoking No 1.00 Yes 10.94 (8.79-13.58) <0.0001 9.86 (7.84-12.38) <0.0001 Saw smoking advertisement No 1.00 Yes 0.04 (0.00-0.40) 0.008 Supported banning of tobacco smoking in minors No 1.00 Yes 0.74 (0.64-0.85) <0.0001 0.48 (0.39-0.58) 0.0000 Supported banning of tobacco smoking in public No 1.00 Yes 0.08 (0.05-0.13) <0.0001 0.1 (0.06-0.17) 0.0000 Comparing crude and adjusted models shows that adjustment slightly weakened some associations but the overall patterns remained consistent. For example, crude ORs for age groups 13 to 17 were even lower (0.21–0.32) than adjusted, suggesting confounding factors raised odds somewhat after adjustment. Crude OR for current smokers was 10.94 (95% CI: 8.79–13.58; p < 0.001), close to the adjusted estimate. Country effect was smaller but still significant in crude (OR = 1.18; 95% CI: 1.03–1.36; p = 0.017). Support for tobacco bans showed weaker protective effects in crude models (OR 0.74 for sales ban; OR 0.08 for public ban) but remained highly significant. Overall, the analysis highlights age, smoking status, country, and tobacco policy attitudes as key independent factors shaping shisha use among youth in these countries. The predicted probability of current shisha smoking among students varied across ages 11 to 17 as shown in Figure 1. The probability increased gradually from age 11 years until it peaked at 15 before slightly declining at ages 16 and 17 but it was still higher than in the younger age category. This suggests that mid-adolescence represents a crucial time for shisha initiation, with the risk increasing gradually from early to mid-adolescence and continuing into late adolescent years. These findings review the importance of targeting tobacco control activities in early adolescence to prevent an increase in shisha use as adolescents grow. DISCUSSION This study estimates the prevalence and predictors of shisha smoking among school going adolescents in Ghana and Sierra Leone in 2017. Spatially, the study’s data were derived from two distinct countries with different cultural and regulatory environments, offering important regional insights. Sierra Leone accounted for a slightly larger portion of the sample than Ghana, which may influence the patterns observed. These geographic differences, combined with demographic and behavioral data, highlight areas where tobacco control efforts could be strengthened, especially regarding youth perceptions and policy awareness across West Africa. The overall prevalence of current shisha smoking among adolescents in Ghana and Sierra Leone was 7.2%. Shisha smoking was significantly higher in Sierra Leone compared to Ghana, highlighting important regional differences. Current cigarette smokers were nearly ten times more likely to use shisha. Interestingly, adolescents aged 13 to 17 had significantly lower odds of smoking shisha compared to the younger group aged 11, suggesting early initiation may be a critical factor. Students who saw smoking advertisements were more likely to smoke as compared to those who did not. Surprisingly, adolescents who were taught in class about the effects of tobacco smoking reported a higher prevalence of smoking shisha than those who were not. Support for tobacco control policies, especially bans on smoking in public places and sales to minors, was strongly associated with reduced shisha smoking. Although males showed a slightly higher prevalence, sex was not a significant factor after accounting for other variables. These findings provide important insight into the demographic, behavioral, and policy factors influencing shisha use among youth in this region. This study found an overall shisha smoking prevalence of 7.2% among adolescents in Ghana and Sierra Leone, a figure that conforms with emerging global trends showing increasing use of alternative tobacco products among young people (23). Globally, shisha smoking has gained popularity in urban areas (13,24) and among the youth, partly due to perceptions that it is less harmful than cigarettes (25). In Africa, though data remain limited, growing shisha use is being reported in countries like South Africa (26) and Nigeria (27,28). It is therefore not surprising that our findings confirm this trend in West Africa and call for urgent attention to this rising public health challenge. Shisha smoking was significantly higher in Sierra Leone compared to Ghana. This country difference may reflect varying tobacco control enforcement (19), cultural acceptance, or availability of shisha products (29). Across Africa, disparities in tobacco control policy implementation and enforcement remain a challenge (19,30,31). Despite these differences between the two countries, they could still benefit from strengthening regulations and consistent enforcement. Current cigarette smokers were almost ten times more likely to smoke shisha in Ghana and Sierra Leone. This finding is consistent with global evidence showing poly-tobacco use is common among the youth (32,33). Poly-tobacco use complicates cessation efforts by intensifying nicotine dependence (34) and sustaining dependence despite attempts to quit smoking (35). However, it also offers an opportunity to target both behaviors simultaneously during interventions (35,36). Tobacco control programs in Ghana and Sierra Leone should therefore integrate strategies addressing multiple tobacco products, including cigarettes and shisha. Students aged 13–17 had significantly lower odds of shisha smoking compared to the youngest group (age 11). This finding is unexpected, as it contrasts with most of the existing literature, which consistently reports a higher mean age (above 13 years) of shisha initiation (37,38). The observed pattern suggests early smoking initiation, which is concerning because early tobacco use increases the risk of long-term addiction (39–41). Globally and in Africa, prevention efforts often focus on older teens, but these findings highlight the need for earlier, age-appropriate education and prevention programs starting before adolescence (42,43). In our study, students who saw a smoking advertisement reported a lower prevalence of shisha smoking than their counterparts. This finding was unexpected, as it does not conform to most of the existing literature, which reports higher smoking rates among adolescents exposed to tobacco advertising and lower smoking rates for adolescents exposed to anti-smoking messages (44). The observed pattern could be attributed to random variation, but it also highlights the need for further investigation into the underlying factors driving this pattern. Being taught in school about the effects of tobacco use emerged as protective factor against shisha smoking though marginally, with students who were taught about smoking reporting lower smoking prevalence. This is consistent with other studies done in Africa (45) Support for tobacco control policies, especially bans on smoking in public and sales of tobacco products to minors, was strongly associated with lower shisha use. This supports the evidence that policy measures are effective deterrents (45–47). Increasing public education about tobacco laws and enhancing enforcement in the two countries will be essential. There is a need for countries in Africa to accelerate the adoption and implementation of comprehensive tobacco control frameworks, including the WHO Framework Convention on Tobacco Control (FCTC) (48). Sex showed a small, non-significant effect on shisha use after adjustment. While males often have higher tobacco use rates including that of shisha (24), cultural and social norms vary widely across settings which might explain why there was no association between gender and shisha smoking in our study. Policies should be gender-sensitive but focus broadly on all youth at risk (49). While tobacco control measures must address the diverse ways it affects boys and girls, they should not overlook the broader population of vulnerable adolescents. This study has several limitations that should be considered when interpreting the findings. The cross-sectional nature of the GYTS data limits establishing causal relationships; we cannot confirm that identified predictors caused shisha use. Additionally, self-reported data may have been affected by social desirability or recall bias, potentially leading to underestimation of the true prevalence of shisha smoking. Although the multivariable model accounted for potential confounders, residual confounding, a common limitation in observational studies might have remained and influenced the interpretation of findings. The study findings have limited generalizability to the broader African context as it only included data from two countries. Future research should use longitudinal designs and expand geographic coverage to overcome these limitations. Despite these limitations, the study has important strengths. By focusing on emerging tobacco products in African countries, this study addresses a significant gap in literature and provides valuable insight to inform policy and public health intervention. Furthermore, the application of robust statistical methods, including accounting for potential confounders, strengthens the validity and reliability of the results. In conclusion, shisha smoking among school-going adolescents in Ghana and Sierra Leone is a significant public health concern. Our findings review an urgent and emerging public health crisis among adolescents. This issue stems from early tobacco initiation, poly-tobacco use and weak enforcement of tobacco control measures. Addressing the growing threat requires effective tobacco control policies, early prevention efforts, and targeted education. Policymakers and public health practitioners in Ghana, Sierra Leone, and across Africa should prioritize comprehensive tobacco control strategies that specifically include alternative tobacco products like shisha. By ensuring strong enforcement and youth engagement, countries can protect the health of future generations. Abbreviations AIC – Akaike Information Criterion AOR – Adjusted Odds Ratio CDC – Center for Disease Control and Prevention CI – Confidence Interval FCTC – Framework Convention on Tobacco Control GYTS – Global Youth Tobacco Survey TAPS – Tobacco Advertising Promotion and Sponsorship US – United States WHO – World Health Organization Declarations Author’s contributions JS performed data management, analysis and drafting the paper; WN and CZ reviewed the data management, analysis and the draft paper. All authors approved the final draft manuscript. Data availability The datasets analysed during the current study were obtained from the Global Youth Tobacco Surveys and are publicly available. Access to the raw data can be requested from the World Health Organization (WHO) through the WHO NCD Microdata Repository or by contacting the WHO NCD Surveillance Team at [email protected] , subject to approval and relevant data-sharing agreements. The analytical code used in this study is available from the author upon reasonable request. Ethics approval and consent to participate Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (Ref. No.7265-2025) and the National Health Research Authority of Zambia (Ref. No: NHRA-2899/14/11/2025), in compliance with national research guidelines. Access to the anonymized GYTS datasets was granted by the WHO through the NCD Microdata Repository. As the study involved no direct contact with participants and used de identified data, no additional consent was required. Consent for publication This manuscript does not contain any individual-level identifiable data and therefore Consent for publication is not applicable. Funding information We did not receive any funding to conduct this analysis. Competing interest We declare that there was no competing interest. The paper was prepared as part of the Doctoral Studies in Global Health at University of Zambia. References Hirpa S, Fogarty A, Addissie A, Bauld L, Frese T, Unverzagt S, et al. An Emerging Problem of Shisha Smoking among High School Students in Ethiopia. International Journal of Environmental Research and Public Health. 2021 Jan;18(13):13. doi:10.3390/ijerph18137023 Cham B, Weaver SR, Jones CK, Popova L, Jacques N. Prevalence and associated factors of shisha smoking among students in Senegal: Global Youth Tobacco Survey 2020. 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Profile and Predictors of Adolescent Tobacco use in Ghana: Evidence from the 2017 Global Youth Tobacco Survey (GYTS). Journal of Preventive Medicine and Hygiene. 2021 Oct 15;E664 Pages. doi:10.15167/2421-4248/JPMH2021.62.3.2035 Egbe CO, Magati P, Wanyonyi E, Sessou L, Owusu-Dabo E, Ayo-Yusuf OA. Landscape of tobacco control in sub-Saharan Africa. Tob Control. 2022 Mar;31(2):153–9. doi:10.1136/tobaccocontrol-2021-056540 Global Youth Tobacco Survey Collaborative Group. Global Youth Tobacco Survey (GYTS): Sample Design and Weights. [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2014 [cited 2025 Oct 10]. Report No.: Version 1.1. Available from: https://drupal.gtssacademy.org/wp-content/uploads/2025/06/4GYTS-Sample-Design-and-Weights-Manual.pdf Ng’ambi WF, Muula AS. A reproducible R workflow to preserve variable and value labels in Stata, SPSS, and SAS datasets for transparent and reproducible health research. Malawi Med J. 2025 Sep 15;37(3):13506. Available from: https://www.mmj.mw/?p=13506. Ng’ambi, W. F., Zyambo, C., & Muula, A. S. (2025, September 19). A practical guide to key considerations in logistic regression for clinical and public health research: R tutorial. Malawi Medical Journal. Retrieved from https://www.mmj.mw/?p=13527. Gilreath TD, Leventhal A, Barrington-Trimis JL, Unger JB, Cruz TB, Berhane K, et al. Patterns of Alternative Tobacco Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst Youth. Journal of Adolescent Health. 2016 Feb;58(2):181–5. doi:10.1016/j.jadohealth.2015.10.001 Agaku IT, Sulentic R, Dragicevic A, Njie G, Jones CK, Odani S, et al. Gender differences in use of cigarette and non-cigarette tobacco products among adolescents aged 13–15 years in 20 African countries. Tobacco Induced Diseases [Internet]. 2024 [cited 2025 Jul 8];22:10–18332. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10801700/ Kanmodi KK, Mohammed FA, Nwafor NJ, Fagbule OF, Adesina MA, Aliyu BM, et al. Poor Knowledge of the Harmful Effects of Shisha Among Shisha Smokers: Findings from a Preliminary Survey in Northwest Nigeria. Medical University. 2019 Jun 1;2(2):49–56. doi:10.2478/medu-2019-0009 N Naicker, J Teare, P Albers, A Mathee. Prevalence of hookah pipe smoking in high-school learners in Johannesburg, South Africa | South African Medical Journal [Internet]. 2020 [cited 2025 Jul 13]. Available from: https://journals.co.za/doi/abs/10.7196/SAMJ.2020.v110i6.14333 Mdege ND, Ekpo R, Ogolla S, Ali SJ, Camara A, Mugweni E. Reasons for shisha smoking: Findings from a mixed methods study among adult shisha smokers in Nigeria. PLOS Global Public Health. 2024 Feb 2;4(2):e0002853. doi:10.1371/journal.pgph.0002853 Otakhoigbogie U, Osagbemiro Bb, Akaji E. Knowledge and Sociodemographic Predictors of Shisha Smoking Among Students in a Nigerian University. Nigerian Journal of Clinical Practice. 2022 Jun;25(6):779–85. doi:10.4103/njcp.njcp_1424_21 Erinoso OA, Emesobum M, Perez S, Fuss C, Sebrié EM, Crosbie E. Waterpipe tobacco and public health: a content analysis of media discourse on waterpipe tobacco smoking across Africa. Tob Control. 2025 May 22;tc-2024-059247. doi:10.1136/tc-2024-059247 Singh A. Tobacco Control in Ghana: Evidence from Qualitative and Cross-sectional Studies [Internet]. Tampere University; 2023 [cited 2025 Jul 13]. Available from: https://researchportal.tuni.fi/en/publications/tobacco-control-in-ghana-evidence-from-qualitative-and-cross-sect Paracandola M, Twesten J, Cleffi K, Murphy J. The landscape of tobacco control in Africa. Tob Induc Dis. 2018 Mar 1;16(1). doi:10.18332/tid/84758 Al Oweini D, Jawad M, Akl EA. The association of waterpipe tobacco smoking with later initiation of cigarette smoking: a systematic review and meta-analysis exploring the gateway theory. Tob Control. 2019 Jul 30;tobaccocontrol-2018-054870. doi:10.1136/tobaccocontrol-2018-054870 Salloum RG, Haider MR, Barnett TE, Guo Y, Getz KR, Thrasher JF, et al. Waterpipe Tobacco Smoking and Susceptibility to Cigarette Smoking Among Young Adults in the United States, 2012–2013. Prev Chronic Dis. 2016 Feb 18;13. doi:10.5888/pcd13.150505 Huh Y, Lee CM, Cho HJ. Comparison of nicotine dependence between single and multiple tobacco product users among South Korean adults. Tobacco Induced Diseases. 2022 Feb 25;20:22. doi:10.18332/tid/145899 PubMed PMID: 35291560. Ali M, Gray TR, Martinez DJ, Curry LE, Horn KA. Risk Profiles of Youth Single, Dual, and Poly Tobacco Users. NICTOB. 2016 Jul;18(7):1614–21. doi:10.1093/ntr/ntw028 Le D, D’Souza G, Atnafou R, Moran M. Perceived Barriers to and Recommendations for Cessation among Poly-tobacco-using Young Adults. Health Behav and Policy Rev. 2021 Nov 1;488–502. doi:10.14485/hbpr.8.6.1 Yasmin I, Nawaz Y, Rasool U. Prevalence of Shisha Smoking and Factors Associated with the Initiation of Shisha Smoking among Students of University of the Punjab, Lahore. PJBMR. 2023 Jul 23;1(2). doi:10.61171/pjbmr.v1i2.11 Pérez A, Kuk AE, Bluestein MA, Harrell MB, Perry CL, Chen B. Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1–4 (2013–2017). Addictive Behaviors. 2021 Jun;117:106838. doi:10.1016/j.addbeh.2021.106838 Huggett SB, Keyes M, Iacono WG, McGue M, Corley RP, Hewitt JK, et al. Age of initiation and transition times to tobacco dependence: Early onset and rapid escalated use increase risk for dependence severity. Drug and Alcohol Dependence. 2019 Sep;202:104–10. doi:10.1016/j.drugalcdep.2019.04.027 Zyambo C, Olowski P, Mulenga D, Syapiila P, Mazaba Liwewe M, Hazemba A, et al. Prevalence and Factors Associated with Tobacco Smoking in a National Representative Sample of Zambian Adults: Data from the 2017 STEPS – NCDs Survey. Asian Pac J Cancer Prev. 2023 Jan 1;24(1):111–9. doi:10.31557/APJCP.2023.24.1.111 Chileshe B, Ng’ambi WF, Habbanti SG, Zyambo C. Policy implication of high prevalence of tobacco use and alcohol consumption among school-going adolescents in 2021: A cross-sectional study in a mining town of Kalulushi Zambia. International Journal of Noncommunicable Diseases. 2025 Jan;10(1):17–24. doi:10.4103/jncd.jncd_123_24 Sharapova S, Reyes-Guzman C, Singh T, Phillips E, Marynak KL, Agaku I. Age of tobacco use initiation and association with current use and nicotine dependence among US middle and high school students, 2014–2016. Tobacco Control. 2020 Jan 1;29(1):49–54. doi:10.1136/tobaccocontrol-2018-054593 PubMed PMID: 30498008. Syapiila P, Mulenga D, Mazaba M, Njunju E, Zyambo C, Chongwe G, et al. Factors associated with intention to smoke cigarettes among never smoker school going adolescents in Zambia. Afr H Sci. 2023 Apr 11;23(1):596–605. doi:10.4314/ahs.v23i1.63 Addo IY, Acquah E, Nyarko SH, Dickson KS, Boateng ENK, Ayebeng C. Exposure to pro-tobacco and anti-tobacco media messages and events and smoking behaviour among adolescents in Gambia. BMC Public Health. 2024 Apr 15;24(1):1041. doi:10.1186/s12889-024-18543-5 Zyambo C, Olowski P, Mulenga D, Liamba F, Syapiila P, Siziya S. School tobacco-related curriculum and behavioral factorsassociated with cigarette smoking among school-goingadolescents in Zambia: Results from the 2011 GYTS study. Tob Induc Dis. 2022 May 5;20(May):1–9. doi:10.18332/tid/146960 Levy DT, Tam J, Kuo C, Fong GT, Chaloupka F. The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard. Journal of Public Health Management and Practice. 2018 Sep;24(5):448–57. doi:10.1097/phh.0000000000000780 Luputa C, Ng’ambi WF, Zyambo C. Cigarette availability and affordability among school-going adolescent smokers in Zambia: Results from the 2011 Global Youth Tobacco Survey. International Journal of Noncommunicable Diseases. 2024 Jul;9(3):126–33. doi:10.4103/jncd.jncd_49_24 Bandara S, Phiri MM, Magati P, Drope J, Adams A, Hunt M, et al. Contextual factors impacting WHO Framework Convention on Tobacco Control implementation in Africa—a scoping review. Health Promotion International. 2024 Dec 1;39(6). doi:10.1093/heapro/daae155 Radhika AG, Preetha GS, Neogi S. Need for Gender Focused Policies Addressing Smokeless Tobacco Use among Women in India: A Review. Asian Pac J Cancer Prev. 2021 Nov 1;22(S2):7–12. doi:10.31557/apjcp.2021.22.s2.7 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Mar, 2026 Editor assigned by journal 05 Mar, 2026 Submission checks completed at journal 05 Mar, 2026 First submitted to journal 24 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8960733","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597693784,"identity":"0abfb3b1-d561-4434-8def-6ac65fa2641b","order_by":0,"name":"Jerry Sinyangwe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYBACxgYIzQMTkAMRBx6QosUYrCWBFGsTwWbg08Lc3vvsMw9DnYy5RPKzh1/bbNLnhx1+CLTFTk63AYfDeo4bz+ZhOMxjOSPN3Fi2LS134+00A6CWZGOzAzi0zEhjZuZhOMBjcCPBTFpy2+HcjbMTQFoOJG7DpWX+M5CWOqCW9G9ALf/TDWenf8CvZQYbSAszUEuOmeTHbQcS5KVzCNjSk8bMOMfgMI/BmTdl0oz/kg03SOcUHEgwwO0Xw/ZjzAxvKursDY6nb5P8ccZOXn52+uYPHyrs5HBqaWBgYOIxALIEEoDOA9IGYJUG2JWDgDzIcT9ALP4DEIZ8A27Vo2AUjIJRMDIBAHxoXYpjvOMvAAAAAElFTkSuQmCC","orcid":"","institution":"University of Zambia","correspondingAuthor":true,"prefix":"","firstName":"Jerry","middleName":"","lastName":"Sinyangwe","suffix":""},{"id":597693785,"identity":"2401ac4d-cf55-4702-89ff-ae6bd433f3a2","order_by":1,"name":"Wingston Felix Ng'ambi","email":"","orcid":"","institution":"University of Zambia","correspondingAuthor":false,"prefix":"","firstName":"Wingston","middleName":"Felix","lastName":"Ng'ambi","suffix":""},{"id":597693786,"identity":"5797b872-d990-402c-9811-95c36c51861b","order_by":2,"name":"Cosmas Zyambo","email":"","orcid":"","institution":"University of Zambia","correspondingAuthor":false,"prefix":"","firstName":"Cosmas","middleName":"","lastName":"Zyambo","suffix":""}],"badges":[],"createdAt":"2026-02-24 19:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8960733/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8960733/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104166764,"identity":"4f0eecc5-a60e-4fb1-b1af-8e36a88164d0","added_by":"auto","created_at":"2026-03-08 14:19:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38507,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePredicted probability of shisha smoking by age in Pooled GYTS Ghana (2017) and Sierra Leone (2017)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8960733/v1/22aca06e7c685a81c420dd0a.png"},{"id":104403921,"identity":"4bf7fc04-faac-47f8-843a-f7de272d8d95","added_by":"auto","created_at":"2026-03-11 12:19:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1071714,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8960733/v1/ed1e2244-0916-4206-aa08-c7076624774a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and Predictors of Shisha Smoking in Ghana and Sierra Leone: Findings from the 2017 Global Youth Tobacco Surveys","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eShisha, also known as waterpipe or hookah, is gaining popularity around the world, especially among young people (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In contrast to cigarette smoking, which has been declining in many countries due to strong tobacco control measures, shisha is often and mistakenly seen as a safer alternative (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This misconception has contributed to widespread use ranging from caf\u0026eacute;s in Europe and the Middle East to social gatherings in Asia and the Americas (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). As a result, global health experts are increasingly worried about the long-term impact of shisha smoking on public health (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Africa, shisha use has been rising steadily (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Many young people are drawn to it because of the flavored tobacco and the social atmosphere around shisha smoking (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Unfortunately, awareness of its health risks is still low. Studies have shown that shisha exposes users to harmful levels of nicotine, carbon monoxide, and cancer-causing substances (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite the growing concerns, shisha lounges remain prevalent in many African cities, where tobacco control policies are either weak or inadequately enforced (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCountries such as Ghana and Sierra Leone are experiencing similar trends (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Young people in these countries are increasingly experimenting with shisha at early ages, often under peer influence and exposed to environments where tobacco advertising is not strictly regulated (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Education efforts through schools and community programs are frequently under resourced to educate youths about these dangers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Although, policies restricting tobacco sales to minors and banning smoking in public places exist, their enforcement is inconsistent, allowing the habit to spread (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile studies have been conducted on shisha smoking among adolescents in Africa, we are not aware of a study that analyzed pooled data from two countries. The aim of this study is to examine the prevalence and predictors of shisha smoking among school-going adolescents in Ghana and Sierra Leone. The findings from this study will provide evidence that can guide targeted interventions, strengthen existing policies, and help reduce the rising burden of tobacco-related harm in these countries and across Africa.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch3\u003eData Source\u003c/h3\u003e\n\u003cp\u003eThis study used secondary data from the Global Tobacco Youth Surveys (GTYS) collected in 2017. The analysis focused on data from two West African countries: Ghana and Sierra Leone. The GYTS is a school based survey of students, in grades 7 to 9, aged 11 to 18 years. It is designed to produce a cross sectional national representative sample. The GYTS methodology for the sampling framework, selection of schools and classes, and data processing is standardized. The survey uses a standard questionnaire with core questions on tobacco use and key tobacco control variables and allows adaption to the needs of a particular country. All participants provided informed consent with their anonymity preserved through the use of unique identifiers instead of personal information. In addition, each country obtains ethical approval from the relevant authorities, ensuring compliance with local and international ethical standards. A more detailed description of the overall objectives and methodology of the GYTS are available elsewhere (20). The sample size and the schools are determined using a standard procedure and software developed by the Center for Disease Control and Prevention (CDC) upon receiving the sampling frame from the GYTS research coordinators. The actual sample size and its computation was not available, however, a minimum sample size of 1500 students, 50% of whom are female is required for the GYTS (20). A total of 12,281 school-going adolescents from Ghana (46%) and Sierra Leone (54%) were surveyed independently in the two countries in 2017. Records with missing data on current shisha smoking status were excluded to ensure accurate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDependent variable\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome variable of interest was current shisha smoking that was generated from the question, \u0026ldquo;During the past 30 days (one month), on how many days did you smoke shisha?\u0026rdquo; with response options: 0, 1 or 2, 3 to 5, 6 to 9, 10 to 19, 20 to 29, all 30 days. Participants who smoked shisha at least once (Yes) in the preceding 30 days were classified as current shisha smokers, while those who did not (No) were classified as non-current shisha smokers.\u003c/p\u003e\n\u003cp\u003eIndependent variables\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSocio-demographic factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese were: age (\u0026ge;11, 12, 13, 14, 15, 16, \u0026le;18 years), sex (male and female) and grade (seven, eight, nine, ten, eleven and twelve).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBehavioral and tobacco marketing factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were asked, \u0026ldquo;During the last 30 days, have you ever tried smoking cigarettes?\u0026rdquo; Students who answered \u0026ldquo;Yes\u0026rdquo; were classified as cigarette smokers otherwise they were not. Participants who responded \u0026ldquo;Yes\u0026rdquo; to the question, \u0026ldquo;During the past 30 days, did you see any advertisements or promotions for shisha on TV, the internet or social media (Facebook, Twitter, Instagram, TikTok or YouTube) or any public place?\u0026rdquo; were classified as having been exposed to tobacco marketing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCurriculum factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents were asked, \u0026ldquo;During the past 12 months, were you taught in any of your classes at school about the dangers of smoking shisha?\u0026rdquo; Students\u0026rsquo; answers to this question were categorized as Yes or No.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePolicy factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis variable had two questions to which the students responded Yes/No; 1) \u0026ldquo;Are you in favour of banning smoking in public?\u0026rdquo; 2) \u0026ldquo;Do you think the sale of shisha or other smoked tobacco products to minors (under 18) should be banned?\u0026rdquo; \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics were used to obtain numbers and percentages of current shisha smokers and non-smokers by their socio-demographic characteristics, behavioral and policy factors (21). The Chi-square test of association was utilized to determine associations between various factors and current shisha smoking status. Additionally, univariate and multivariate logistic regression models were used to examine the associations between factors that may influence shisha smoking among school-going adolescents in Ghana and Sierra Leone (22). Variables that were found to be significantly associated (p\u0026lt;0.05) with current shisha smoking status in the univariate analyses were included in the multivariate models. Stepwise model selection with Akaike Information Criterion (AIC) was applied to identify the most parsimonious model while retaining age and sex in the model due to their known confounding effects. Adjusted odds ratios (aORs) with 95% confidence intervals and p-values were reported and used as measures of magnitude of associations. Age, gender, ever tried smoking cigarettes, taught in class about the dangers of smoking were controlled for in the full model. To visualize the relationship between age and the probability of current shisha smoking, predicted probabilities were computed from the final adjusted model. Using Bayesian simulations from the model\u0026rsquo;s posterior distribution (1,000 simulations), we estimated mean predicted probabilities and 95% credible intervals by age and sex. These predictions were plotted to illustrate risk patterns across adolescent age groups. All analyses were conducted using R (version 4.5.0).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (Ref. No.7265-2025) and the National Health Research Authority of Zambia (Ref. No: NHRA-2899/14/11/2025), in compliance with national research guidelines. Access to the anonymized GYTS datasets was granted by the WHO through the NCD Microdata Repository. As the study involved no direct contact with participants and used de identified data, no additional consent was required. The data for this research were accessed between 1\u003csup\u003est\u003c/sup\u003e April 2025 and 31\u003csup\u003est\u003c/sup\u003e December 2025. The authors had no access to information that could identify individual participants during or after data collection.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 12,281 school-going adolescents from Ghana (46%) and Sierra Leone (54%), surveyed independently in the two countries in 2017. The overall sample for the two countries was nearly evenly split by sex, with 53% female and 47% male. Age distribution showed most participants were between 13 and 15 years old, representing over 70% of the sample. School grade levels ranged from 7 to 12, with the largest groups in grades 9 and 10. These demographic details provide a broad overall picture of the youth population surveyed in two West African countries \u003cstrong\u003e(Table 1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall prevalence of current shisha smoking among the youth was 7.2%. The prevalence of shisha smoking was significantly higher in Sierra Leone (7.69%, 95% CI: 7.05-8.33) than Ghana (6.58%, 95% CI: 5.94-7.23) \u003cstrong\u003e(Table 1).\u003c/strong\u003e Current cigarette smokers had a much higher shisha smoking prevalence (41.47%, 95% CI: 36.52-46.42) compared to non-smokers (6.08%, 95% CI: 5.65-6.51), indicating a strong association between cigarette and shisha use. Age-specific prevalence showed notable high rate of shisha use among youngest group (age 11), at 20.7%. Prevalence was lower ranging from 5.0% to 7.0% among those aged 13-14, and 7.5% among those aged 15 to 17. Males reported significantly higher prevalence (7.84%, 95% CI: 7.15-8.54) compared to females (6.60%, 95% CI: 6.00-7.21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShisha smoking prevalence varied by school grade and attitudes toward tobacco control policies. Overall grade 7 students had a high prevalence (17.33%, 95% CI: 14.10-20.57), while older grades showed lower but steady rates (5.0% - 8.0%). Youth who did not support banning tobacco sales to minors had higher prevalence of shisha use (7.96%, 95% CI: 7.34-8.57) than those who supported such bans (6.01%, 95% CI: 5.34-6.67). Similarly, those opposing bans on smoking in public had extremely high prevalence (46.75%, 95% CI: 35.61-57.9) compared to (6.93%, 6.48-7.38) among supporters. These findings show how attitudes towards tobacco policies relate closely to actual tobacco use among young people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Socio-demographic characteristics of participants and Percentage Prevalence of Current Shisha Smoking by gender, variable and level (Pooled GYTS Ghana 2017 and Sierra Leone 2017)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(N=12281) n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(%) (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u0026nbsp;\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0.0191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ghana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e5652 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e6.58 (5.94-7.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Sierra Leone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e6629 (54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.69 (7.05-8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026lt;0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e266 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e20.68 (15.81-25.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e259 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e13.9 (9.69-18.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1986 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e5.94 (4.90-6.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e2724 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e5.29 (4.45-6.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e3866 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.45 (6.62-8.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1555 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.65 (6.33-8.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1625 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.51 (6.23-8.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e0.00889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e6556 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e6.60 (6.00-7.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e5725 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.84 (7.15-8.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool Grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026lt;0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e525 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e17.33 (14.10-20.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1986 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e5.94 (4.90-6.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e2947 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e5.40 (4.58-6.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e3643 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.49 (6.64-8.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1555 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.65 (6.33-8.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e1625 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.51 (6.23-8.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCigarette smoking\u0026nbsp;\u003c/strong\u003e\u0026lt;0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e11900 (96.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e6.08 (5.65-6.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e381 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e41.47 (36.52-46.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSaw smoking advertisement\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0.000407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e3 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e66.67 (13.31-120.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e12278 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.17 (6.71-7.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTaught about the effects of tobacco smoking\u0026nbsp;\u003c/strong\u003e\u0026lt;0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e12281 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.18 (6.73-7.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrently uses shisha\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e11399 (92.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e882 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupported banning of shisha smoking in minors\u0026nbsp;\u003c/strong\u003e\u0026lt;0.00005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e7404 (60.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e7.96 (7.34-8.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e4877 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e6.01 (5.34-6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupported banning of smoking in public\u0026nbsp;\u003c/strong\u003e\u0026lt;0.00000\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e77 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e46.75 (35.61-57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8347%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.7355%;\"\u003e\n \u003cp\u003e12204 (99.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.5537%;\"\u003e\n \u003cp\u003e6.93 (6.48-7.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.876%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe main factors associated with current shisha smoking were age, country, cigarette smoking status, and attitudes toward tobacco control policies \u003cstrong\u003e(Table 2).\u003c/strong\u003e After adjusting for other factors, age groups 13 to 17 had significantly lower odds of shisha smoking compared to age 11, with adjusted odds ratios (aOR) ranging from 0.30 (95% CI: 0.21\u0026ndash;0.45, p \u0026lt; 0.001) for age-group 14 to 0.43 (95% CI: 0.29\u0026ndash;0.64, p \u0026lt; 0.001) for age-group 16. Age-group 12 showed no significant difference after adjustment (aOR = 0.88; 95% CI: 0.53\u0026ndash;1.46; p = 0.631). Males had slightly higher odds than females, but this was not statistically significant (aOR = 1.07; 95% CI: 0.93\u0026ndash;1.24; p = 0.364). Living in Sierra Leone was associated with 74% higher odds of shisha smoking compared to living in Ghana (aOR = 1.74; 95% CI: 1.42\u0026ndash;2.13; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe most significant factor associated with shisha use was current cigarette smoking, with smokers having nearly ten times the odds of using shisha compared to non-smokers (aOR = 9.86; 95% CI: 7.84\u0026ndash;12.38; p \u0026lt; 0.001). Conversely, support for banning tobacco sales to minors was protective, reducing the odds of shisha smoking by 52.0% (aOR = 0.48; 95% CI: 0.39\u0026ndash;0.58; p \u0026lt; 0.001). Support for bans on smoking in public places showed an even stronger protective effect, lowering odds by 90% (aOR = 0.10; 95% CI: 0.06\u0026ndash;0.17; p \u0026lt; 0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Crude and Adjusted Odds Ratios for Current Shisha Smoking \u0026ndash; Pooled GYTS Ghana 2017 and Sierra Leone 2017\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 486px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrude \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ghana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Sierra Leone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.18 (1.03-1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.74 (1.42-2.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.62 (0.39-0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.0410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.88 (0.53-1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.6310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.24 (0.17-0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.33 (0.22-0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.21 (0.15-0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.30 (0.21-0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.31 (0.23-0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.42 (0.29-0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.32 ( 0.22-0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.43 (0.29-0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.31 (0.22-0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.39 (0.27-0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.2 (1.05-1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.07 (0.93-1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.3640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.3 (0.23-0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.27 (0.21-0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.39 (0.30-0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.4 (0.30-0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.39 (0.29-0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCigarette smoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10.94 (8.79-13.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9.86 (7.84-12.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSaw smoking advertisement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.04 (0.00-0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupported banning of tobacco smoking in minors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.74 (0.64-0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.48 (0.39-0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupported banning of tobacco smoking in public\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.08 (0.05-0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.1 (0.06-0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.0000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eComparing crude and adjusted models shows that adjustment slightly weakened some associations but the overall patterns remained consistent. For example, crude ORs for age groups 13 to 17 were even lower (0.21\u0026ndash;0.32) than adjusted, suggesting confounding factors raised odds somewhat after adjustment. Crude OR for current smokers was 10.94 (95% CI: 8.79\u0026ndash;13.58; p \u0026lt; 0.001), close to the adjusted estimate. Country effect was smaller but still significant in crude (OR = 1.18; 95% CI: 1.03\u0026ndash;1.36; p = 0.017). Support for tobacco bans showed weaker protective effects in crude models (OR 0.74 for sales ban; OR 0.08 for public ban) but remained highly significant. Overall, the analysis highlights age, smoking status, country, and tobacco policy attitudes as key independent factors shaping shisha use among youth in these countries.\u003c/p\u003e\n\u003cp\u003eThe predicted probability of current shisha smoking among students varied across ages 11 to 17 as shown in Figure 1. The probability increased gradually from age 11 years until it peaked at 15 before slightly declining at ages 16 and 17 but it was still higher than in the younger age category. This suggests that mid-adolescence represents a crucial time for shisha initiation, with the risk increasing gradually from early to mid-adolescence and continuing into late adolescent years. These findings review the importance of targeting tobacco control activities in early adolescence to prevent an increase in shisha use as adolescents grow.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study estimates the prevalence and predictors of shisha smoking among school going adolescents in Ghana and Sierra Leone in 2017. Spatially, the study\u0026rsquo;s data were derived from two distinct countries with different cultural and regulatory environments, offering important regional insights. Sierra Leone accounted for a slightly larger portion of the sample than Ghana, which may influence the patterns observed. These geographic differences, combined with demographic and behavioral data, highlight areas where tobacco control efforts could be strengthened, especially regarding youth perceptions and policy awareness across West Africa.\u0026nbsp;The overall prevalence of current shisha smoking among adolescents in Ghana and Sierra Leone was 7.2%. Shisha smoking was significantly higher in Sierra Leone compared to Ghana, highlighting important regional differences. Current cigarette smokers were nearly ten times more likely to use shisha. Interestingly, adolescents aged 13 to 17 had significantly lower odds of smoking shisha compared to the younger group aged 11, suggesting early initiation may be a critical factor. Students who saw smoking advertisements were more likely to smoke as compared to those who did not. Surprisingly, adolescents who were taught in class about the effects of tobacco smoking reported a higher prevalence of smoking shisha than those who were not. Support for tobacco control policies, especially bans on smoking in public places and sales to minors, was strongly associated with reduced shisha smoking. Although males showed a slightly higher prevalence, sex was not a significant factor after accounting for other variables. These findings provide important insight into the demographic, behavioral, and policy factors influencing shisha use among youth in this region.\u003c/p\u003e\n\u003cp\u003eThis study found an overall shisha smoking prevalence of 7.2% among adolescents in Ghana and Sierra Leone, a figure that conforms with emerging global trends showing increasing use of alternative tobacco products among young people (23). Globally, shisha smoking has gained popularity in urban areas (13,24) and among the youth, partly due to perceptions that it is less harmful than cigarettes (25). In Africa, though data remain limited, growing shisha use is being reported in countries like South Africa (26) and Nigeria (27,28). It is therefore not surprising that our findings confirm this trend in West Africa and call for urgent attention to this rising public health challenge.\u003c/p\u003e\n\u003cp\u003eShisha smoking was significantly higher in Sierra Leone compared to Ghana. This country difference may reflect varying tobacco control enforcement (19), cultural acceptance, or availability of shisha products (29). Across Africa, disparities in tobacco control policy implementation and enforcement remain a challenge (19,30,31). Despite these differences between the two countries, they could still benefit from strengthening regulations and consistent enforcement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurrent cigarette smokers were almost ten times more likely to smoke shisha in Ghana and Sierra Leone. This finding is consistent with global evidence showing poly-tobacco use is common among the youth (32,33). Poly-tobacco use complicates cessation efforts by intensifying nicotine dependence (34) and sustaining dependence despite attempts to quit smoking (35). However, it also offers an opportunity to target both behaviors simultaneously during interventions (35,36). Tobacco control programs in Ghana and Sierra Leone should therefore integrate strategies addressing multiple tobacco products, including cigarettes and shisha.\u003c/p\u003e\n\u003cp\u003eStudents aged 13\u0026ndash;17 had significantly lower odds of shisha smoking compared to the youngest group (age 11). This finding is unexpected, as it contrasts with most of the existing literature, which consistently reports a higher mean age (above 13 years) of shisha initiation (37,38). The observed pattern suggests early smoking initiation, which is concerning because early tobacco use increases the risk of long-term addiction (39\u0026ndash;41). Globally and in Africa, prevention efforts often focus on older teens, but these findings highlight the need for earlier, age-appropriate education and prevention programs starting before adolescence (42,43).\u003c/p\u003e\n\u003cp\u003eIn our study, students who saw a smoking advertisement reported a lower prevalence of shisha smoking than their counterparts. This finding was unexpected, as it does not conform to most of the existing literature, which reports higher smoking rates among adolescents exposed to tobacco advertising and lower smoking rates for adolescents exposed to anti-smoking messages (44). The observed pattern could be attributed to random variation, but it also highlights the need for further investigation into the underlying factors driving this pattern.\u003c/p\u003e\n\u003cp\u003eBeing taught in school about the effects of tobacco use emerged as protective factor against shisha smoking though marginally, with students who were taught about smoking reporting lower smoking prevalence. This is consistent with other studies done in Africa (45)\u003c/p\u003e\n\u003cp\u003eSupport for tobacco control policies, especially bans on smoking in public and sales of tobacco products to minors, was strongly associated with lower shisha use. This supports the evidence that policy measures are effective deterrents (45\u0026ndash;47). Increasing public education about tobacco laws and enhancing enforcement in the two countries will be essential. There is a need for countries in Africa to accelerate the adoption and implementation of comprehensive tobacco control frameworks, including the WHO Framework Convention on Tobacco Control (FCTC) (48).\u003c/p\u003e\n\u003cp\u003eSex showed a small, non-significant effect on shisha use after adjustment. While males often have higher tobacco use rates including that of shisha (24), cultural and social norms vary widely across settings which might explain why there was no association between gender and shisha smoking in our study. Policies should be gender-sensitive but focus broadly on all youth at risk (49). While tobacco control measures must address the diverse ways it affects boys and girls, they should not overlook the broader population of vulnerable adolescents.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. The cross-sectional nature of the GYTS data limits establishing causal relationships; we cannot confirm that identified predictors caused shisha use. Additionally, self-reported data may have been affected by social desirability or recall bias, potentially leading to underestimation of the true prevalence of shisha smoking. Although the multivariable model accounted for potential confounders, residual confounding, a common limitation in observational studies might have remained and influenced the interpretation of findings. The study findings have limited generalizability to the broader African context as it only included data from two countries. Future research should use longitudinal designs and expand geographic coverage to overcome these limitations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite these limitations, the study has important strengths. By focusing on emerging tobacco products in African countries, this study addresses a significant gap in literature and provides valuable insight to inform policy and public health intervention. Furthermore, the application of robust statistical methods, including accounting for potential confounders, strengthens the validity and reliability of the results.\u003c/p\u003e\n\u003cp\u003eIn conclusion, shisha smoking among school-going adolescents in Ghana and Sierra Leone is a significant public health concern. Our findings review an urgent and emerging public health crisis among adolescents. This issue stems from early tobacco initiation, poly-tobacco use and weak enforcement of tobacco control measures. Addressing the growing threat requires effective tobacco control policies, early prevention efforts, and targeted education. Policymakers and public health practitioners in Ghana, Sierra Leone, and across Africa should prioritize comprehensive tobacco control strategies that specifically include alternative tobacco products like shisha. By ensuring strong enforcement and youth engagement, countries can protect the health of future generations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAIC\u003c/strong\u003e \u0026ndash; Akaike Information Criterion\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAOR\u003c/strong\u003e \u0026ndash; Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCDC\u003c/strong\u003e \u0026ndash; Center for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e \u0026ndash; Confidence Interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFCTC\u003c/strong\u003e \u0026ndash; Framework Convention on Tobacco Control\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGYTS\u003c/strong\u003e \u0026ndash; Global Youth Tobacco Survey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTAPS\u003c/strong\u003e \u0026ndash; Tobacco Advertising Promotion and Sponsorship\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUS\u003c/strong\u003e \u0026ndash; United States\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e \u0026ndash; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJS performed data management, analysis and drafting the paper; WN and CZ reviewed the data management, analysis and the draft paper. All authors approved the final draft manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study were obtained from the Global Youth Tobacco Surveys and are publicly available. Access to the raw data can be requested from the World Health Organization (WHO) through the WHO NCD Microdata Repository or by contacting the WHO NCD Surveillance Team at \u003cstrong\[email protected]\u003c/strong\u003e, subject to approval and relevant data-sharing agreements. The analytical code used in this study is available from the author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (Ref. No.7265-2025) and the National Health Research Authority of Zambia (Ref. No: NHRA-2899/14/11/2025), in compliance with national research guidelines. Access to the anonymized GYTS datasets was granted by the WHO through the NCD Microdata Repository. As the study involved no direct contact with participants and used de identified data, no additional consent was required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not contain any individual-level identifiable data and therefore Consent for publication is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe did not receive any funding to conduct this analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that there was no competing interest. The paper was prepared as part of the Doctoral Studies in Global Health at University of Zambia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHirpa S, Fogarty A, Addissie A, Bauld L, Frese T, Unverzagt S, et al. An Emerging Problem of Shisha Smoking among High School Students in Ethiopia. International Journal of Environmental Research and Public Health. 2021 Jan;18(13):13. doi:10.3390/ijerph18137023\u003c/li\u003e\n\u003cli\u003eCham B, Weaver SR, Jones CK, Popova L, Jacques N. Prevalence and associated factors of shisha smoking among students in Senegal: Global Youth Tobacco Survey 2020. Tob Induc Dis. 2024 May 14;22(May):1\u0026ndash;13. doi:10.18332/tid/186656\u003c/li\u003e\n\u003cli\u003eHusain H, Al-Fadhli F, Al-Olaimi F, Al-Duraie A, Qureshi A, Al-Kandari W, et al. Is Smoking Shisha Safer than Cigarettes: Comparison of Health Effects of Shisha and Cigarette Smoking among Young Adults in Kuwait. Med Princ Pract. 2016;25(2):117\u0026ndash;22. doi:10.1159/000442417\u003c/li\u003e\n\u003cli\u003eBadran M, Laher I. Waterpipe (shisha, hookah) smoking, oxidative stress and hidden disease potential. Redox Biology. 2020 Jul;34:101455. doi:10.1016/j.redox.2020.101455\u003c/li\u003e\n\u003cli\u003eMugyenyi AEK, Haberer JE, O\u0026rsquo;Neil I. Pleasure and practice: a qualitative study of the individual and social underpinnings of shisha use in cafes among youth in the UK. BMJ Open. 2018 Apr;8(4):e018989. doi:10.1136/bmjopen-2017-018989\u003c/li\u003e\n\u003cli\u003eFanous N. Secondhand Smoke Emission levels in Waterpipe Cafes in Doha, Qatar. In: Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1 [Internet]. Qatar National Convention Center (QNCC), Doha, Qatar,: Hamad bin Khalifa University Press (HBKU Press); 2016 [cited 2025 Jul 13]. 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Asian Pac J Cancer Prev. 2021 Nov 1;22(S2):7\u0026ndash;12. doi:10.31557/apjcp.2021.22.s2.7\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Shisha, Adolescents, Tobacco Control, Ghana, Sierra Leone","lastPublishedDoi":"10.21203/rs.3.rs-8960733/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8960733/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003cbr\u003e\nRising shisha use among young people in Africa is a growing public health challenge. Yet in countries like Ghana and Sierra Leone, there remains a critical gap in understanding the behavioral patterns and underlying factors driving this trend.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003cbr\u003e\n \u003c/strong\u003eWe retrieved secondary data from a public sphere collected using a cross-sectional study design. Overall, 12,281 students in grades associated with 11-18 year olds were selected using stratified two-stage cluster sampling. Descriptive statistics estimated smoking prevalence by age, sex, school grade, country, and survey year. Multivariate logistic regression models were used to determine associations between socio-demographic, behavioural, tobacco policy factors and current Shisha smoking. Adjusted odds ratios and their 95% confidence intervals are reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\n The overall prevalence of current shisha smoking was 7.2% (7.8% males and 6.6% of females). The prevalence was slightly higher in Sierra Leone (7.69%, 95% CI: 7.05-8.33) than Ghana (6.58%, 95% CI: 5.94-7.23). Adolescents who did not support banning tobacco sales to minors had higher shisha use (7.96%, 95% CI: 7.34-8.57) than their counterparts (6.01%, 95% CI: 5.34-6.67). Participants who smoked cigarettes, were more likely to smoke shisha compared to those who did not smoke (AOR = 9.86; 95% CI: 7.84–12.38; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\nShisha smoking among school-going adolescents in Ghana and Sierra Leone reviewed emerging patterns suggesting early initiation and strong association with cigarette use. There is a need for stronger enforcement of tobacco control policies, targeting poly-tobacco use control and factors influencing early initiation. These findings provide valuable insight to inform tobacco control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable\u003c/p\u003e","manuscriptTitle":"Prevalence and Predictors of Shisha Smoking in Ghana and Sierra Leone: Findings from the 2017 Global Youth Tobacco Surveys","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 14:19:30","doi":"10.21203/rs.3.rs-8960733/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-11T05:32:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-05T06:33:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-05T06:29:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-24T19:47:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6275b92d-076e-4ec9-8f91-cb7a0a8195b3","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T11:53:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 14:19:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8960733","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8960733","identity":"rs-8960733","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}