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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 352-355

Association of shisha smoking with acute otitis media in men: A case-control study

1 Department of Pathology, College of Medicine, King Saud University; King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
2 College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission27-Dec-2020
Date of Acceptance04-Jul-2021
Date of Web Publication06-Oct-2021

Correspondence Address:
Khalifa Binkhamis
Department of Pathology, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_173_20

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Objectives: The objective of this study is to determine the possible associations between acute otitis media (AOM) and shisha smoking, cigarette smoking, and vaping in adults. Materials and Methods: The study was carried out from August 2019 to April 2020 using a case-control design. The sample consisted of 144 male participants from King Saud University Medical City aged 18–55 years, of whom 72 were cases, i. e., diagnosed by a physician with AOM, and 72 were controls, i.e. diagnosed with a physical injury with no history of AOM. The participants were interviewed over the phone based on a validated questionnaire by the WHO and were evaluated for shisha smoking, cigarettes smoking, and vaping status. Results: Of the 144 patients originally contacted, 136 (67 cases and 69 controls) were included in the analysis. The total number of participants who smoked any type of tobacco was 51 (37.5%). Among the 51 general smokers, 54.9% had a history of AOM with odds ratio of 1.436 (confidence interval [CI] 0.715–2.884, P = 0.308). Among shisha smokers, 70% developed AOM with odds ratio of 2.774 (CI 0.996–7.721, P = 0.045). Among cigarette smokers, 53.6% had a history of AOM with odds ratio of 1.287 (CI 0.617–2.681, P = 0.501). The number of vape users was too low to produce any significant results. Conclusion: The study found a significant association between shisha smoking and AOM among adult men in Riyadh. This finding correlates with what previous studies found about the dangers of tobacco consumption.

Keywords: Acute otitis media, adults, shisha

How to cite this article:
Binkhamis K, Alsaeed AH, Alfehaid SN, Almetary RJ, Alshahrani AS, Alduhayyim AH, Alanazi WS. Association of shisha smoking with acute otitis media in men: A case-control study. J Nat Sci Med 2021;4:352-5

How to cite this URL:
Binkhamis K, Alsaeed AH, Alfehaid SN, Almetary RJ, Alshahrani AS, Alduhayyim AH, Alanazi WS. Association of shisha smoking with acute otitis media in men: A case-control study. J Nat Sci Med [serial online] 2021 [cited 2022 Jan 19];4:352-5. Available from: https://www.jnsmonline.org/text.asp?2021/4/4/352/327595

  Introduction Top

Acute otitis media (AOM) is defined as an infection of the middle ear fluid.[1] The most common signs and symptoms of AOM in adults are bulging or cloudy tympanic membrane, earache (otalgia), fever, ear effusions, and hearing loss.[2],[3] The global incidence of AOM is 10.9%, which accounts for 709 million cases each year, with 51% of the cases in children under 5 years of age.[4] There are no dedicated reports about the burden of AOM in adults, especially in the Middle East. However, a study published in 2017 about the burden of AOM among children up to 5 years old revealed that the incidence of AOM in Saudi Arabia per 1000 children per year is 207 patients, with an average cost of $67.1 USD for each episode.[5]

Cigarette smoking is theorized to be a risk factor for AOM in children,[6],[7] adults,[8] and the elderly.[9] The majority of studies explore the risk of AOM from cigarette smoking involves children. For example, a meta-analysis demonstrated a significant increase in the risk (66%) of children developing recurrent acute otitis media (RAOM) and chronic otitis media (OME) with effusion in the presence of parental smoking.[6] Another study conducted in Istanbul, Turkey found that passive smoking was a significant risk factor for RAOM and OME.[7] Conversely, studies about the effect of tobacco consumption on AOM in adults are very limited in number. There is one published study about the subject, which reported that those who consumed tobacco were 1.16 times more likely to have AOM than those who did not.[8] However, they did not study a specific type of tobacco consumption.

Since passive cigarette smoking has been identified as a risk factor for AOM-at least in children-[6],[7] and tobacco consumption, in general, correlates with an increase in the occurrence of AOM in adults,[8] more studies should be done regarding the association between AOM and active tobacco consumption in adults, especially since it is prevalent in Saudi Arabia. According to the Saudi Health Interview Survey Results from 2013, 21.5% of male Saudis aged 15 or older smoke tobacco daily, and 20.9% use shisha daily.[10] And yet, there is a gap in the literature about AOM in adults, as well as the specific relationship between shisha smoking and AOM and how it compares to other forms of tobacco consumption. This study aimed to fill this gap and increase our understanding of how smoking affects AOM, as well as increase public awareness and inform health policies worldwide regarding shisha smoking. Furthermore, this study briefly investigated and compared the relationship of AOM with other related activities: cigarette smoking and vaping.

  Materials And Methods Top

Study design

The study was carried out as a case-control study from August 2019 to April 2020. Data were collected from patients who visited King Saud University Medical City, specifically King Khalid University Hospital (KKUH) and King Abdul-Aziz University Hospital (KAUH) in Riyadh, Saudi Arabia.

Case and control definitions

The participants of the study were randomly selected using simple random sampling from a population of male patients aged from 18 to 55 years who visited KKUH or KAUH during 2015–2019. The cases definition is those who have been diagnosed by a physician in KKUH or KAUH with AOM during 2015–2019. All controls were randomly selected from those who visited KKUH or KAUH for physical injury during 2015–2019, with no past medical history of AOM diagnosis. Physical trauma was chosen as the controls' definition to avoid conditions related to AOM or shisha smoking.

The participants of the study were included based on the following criteria:

  • Male (as the prevalence of shisha smoking in Saudi Arabia among females is low (1.4%) compared to males (20.9%) according to the Saudi Health Interview Survey results)[10]
  • 18–55
  • Visited KKUH or KAUH during 2015–2019, for either AOM (cases) or physical trauma (controls). There were no exclusion criteria for the cases, but for the controls, anyone who has been diagnosed with AOM in the past was excluded from this analysis.

Statistical analysis and sample size

The total sample size was 144 and a 1:1 ratio of cases to controls was used (72 cases and 72 controls) with a power of 90% and a confidence level of 95%.

Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 24 (IBM SPSS, Armonk, NY, USA). The independent variables were the following: Age, shisha smoking status, cigarettes smoking status, and vaping status. The dependent variable was disease status AOM. Bivariate statistical analysis was carried out using a Chi-square test for all the values except for vaping, which had a frequency of <5 in two cells. Instead, Fisher's exact test was used to report the P value. A P value of 0.05 > and 95% confidence interval (CI) were used to report the statistical significance and precision of results.

Data collection

The cases and controls were identified and selected from KKUH and KAUH medical records. They were then contacted using their phone number and informed consent was obtained. Those who gave consent were interviewed over the phone to measure the independent variables using questions validated and published by the WHO.[11]

Ethical considerations

This study was approved by the King Saud University Institutional Review Board (Research ID: E-19–4424). This study was approved by the King Saud University Institutional Review Board (Research ID: E-19–4424). The date of approval was 08/DEC/2019.

  Results Top

The initial sample size was 144 patients (72 cases and 72 controls); however, after contacting the patients, eight of them did not wish to participate in the study for personal reasons. Therefore, the final number of participants included in the study was 136 (67 cases and 69 controls, response rate 94%). All the participants answered every question, so there was no missing data. Among all the precipitants in the study, 51 (37.5%) were found to be smokers with the following distribution: cigarette (41/51 [80%] of smokers), shisha smoking (20/51 [39.2%] of smokers), and vaping (1/51 [1.96%] of smokers).

It was found that among the 51 smokers, 28 (54.9%) had a history of AOM in the past (odds ratio of 1.436 (CI 0.715–2.884); however, this was not statistically significant (P = 0.308) [Table 1].
Table 1: The distribution of smokers among cases of otitis media and the control

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Among the 20 shisha smokers, 70% had a history of AOM(odds ratio of 2.774 (CI 0.996–7.721)), and P = 0.045 which is statistically significant. As for cigarette smokers, 53.6% had a history AOM (odds ratio of 1.287 (CI 0.617–2.681)) with P = 0.501.

There was only one vape smoker, thus, we were unable to calculate a significant odds ratio or P value [Table 2].
Table 2: The distribution of different types of smoking among cases of otitis media and control

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  Discussion Top

AOM is a distressing disease with some serious complications including tympanic membrane perforation and hearing loss. While it is more common in children, it can still occur in adults where it causes significant discomfort and negatively affects the quality of life and function of the patient.

This study found a significant association between shisha smoking among males aged 18–55 and the development of AOM. It also found that the odds of developing AOM were increased in cigarette smokers when compared to those who do not smoke.

Gaur et al.[8] performed a retrospective cohort study on the risk of developing ear diseases (is it infection) among tobacco consumers. Four thousand and forty-three men were evaluated for tobacco use (in any form) to study the association with ear diseases. The study found that in tobacco users, the age-adjusted odds ratio for the development of AOM compared to nonusers was 1.16 (CI 0.82–1.64), suggesting an association between tobacco use and middle ear diseases. Our study found a higher odds ratio for developing AOM among shisha smokers (2.77, CI 0.996–7.721). This variation in the odds ratio of AOM between our study and the study by Gaur et al.[8] maybe due to the higher toxic impact of shisha smoking compared to other forms of tobacco use.[12] This explanation goes along with another study reporting that shisha contains a higher number of toxicants (up to 50 times higher) compared to cigarette smoking.[12] However, one of the main limitations of this study was the fact that they investigated the effects of tobacco consumption in all its forms (smoking, chewable, etc.,) without differentiating between consumption types. Therefore, it was not possible to look at the effect of each type and compare it to the effect of others to know which one was more dangerous.

As for cigarette smoking, the present study shows a slightly higher odds ratio of 1.287 (CI 0.617–2.681) compared to the study by Gaur et al.[8] Although the odds ratios are close to each other, the present study's higher odds ratio could be attributed to the fact that the present study looked at the effect of cigarette smoking separately, while Gaur K et al. looked at the combined effect of smoked and nonsmoked (chewing, snuff, etc.,) tobacco consumption. This may have led to a lower odds ratio in their study. Regarding vaping, no significant association between vaping and AOM was found since only one participant in this study vaped.

Strengths of this study include uniqueness, as it is the only study in the Middle East to evaluate the association between different types of smoking and AOM in adults, and specificity, as it investigated the effect of each type of smoking separately. Furthermore, in an effort to ensure high accuracy of data collection, each participant was interviewed individually, instead of taking the information from the patient files, which could be improperly filled. Moreover, the controls and cases were chosen from the same community (KKUH and KAUH in Riyadh city), which helped increase the similarity between the two groups.

Due to the retrospective nature of the study, cause and effect cannot be proven. Another limitation of this study is that the sample size was limited due to the limited time and resources available for data collection. The results may be generalized to include those with characteristics similar to the study's sample; however, it may not be as accurate to apply it to females, children, or people outside Saudi Arabia. Further studies are needed to cover these areas.

  Conclusion Top

This study showed an association between shisha smoking and AOM, which correlates with previous studies about the dangers of tobacco consumption. In light of this association and the increasing popularity of shisha use,[10] urgent measures must be taken to reduce the number of shisha smokers, as a continuation of the status quo may lead to costly diseases, significant disabilities, and premature deaths in the working adult population.

Ethical approval

This study was approved by the King Saud University Institutional Review Board (Research ID: E-19–4424).


The authors thank the Deanship of Scientific Research and Researchers Support and Services Unit at King Saud University for their technical support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Danishyar A, Ashurst JV. Acute Otitis Media. In: StatPearls.Treasure Island (FL): StatPearls Publishing; 2020. Available from: http://www.ncbi.nlm.nih. gov/pubmed/29262176. [Last accessed on 2020 Jul 30].  Back to cited text no. 1
Acute Otitis Media (AOM) – Clinical Guidelines. Medecins Sans Frontieres. Available from: https://medicalguidelines.msf.org/viewport/CG/english/acute-otitis-media-aom-16689234.html. [Last accessed on 2019 Aug 28].  Back to cited text no. 2
Ramakrishnan K, Sparks RA, Berryhill WE. Diagnosis and treatment of otitis media. Am Fam Physician 2007;76:1650-8.  Back to cited text no. 3
Monasta L, Ronfani L, Marchetti F, Montico M, Vecchi Brumatti L, Bavcar A, et al. Burden of disease caused by otitis media: Systematic review and global estimates. PLoS One 2012;7:e36226.  Back to cited text no. 4
Mustafa G, Al Aidaroos AY, Al Abaidani IS, Meszaros K, Gopala K, Ceyhan M, et al. Incidence and economic burden of acute otitis media in children aged up to 5 years in three Middle Eastern countries and Pakistan: A multinational, retrospective, observational study. Epidemiol Glob Health 2017;7:123-30.  Back to cited text no. 5
Kong K, Coates HL. Natural history, definitions, risk factors and burden of otitis media. Med J Aust 2009;191:S39.  Back to cited text no. 6
Ilicali OC, Keleş N, Değer K, Savaş I. Relationship of passive cigarette smoking to otitis media. Arch Otolaryngol Head Neck Surg 1999;125:758-62.  Back to cited text no. 7
Gaur K, Kasliwal N, Gupta R. Association of smoking or tobacco use with ear diseases among men: A retrospective study. Tob Induc Dis 2012;10:4.  Back to cited text no. 8
Al-Sadeeq H, Algarni Z, Alobaid A, Aloyaid A, Alotaibi M, Al-Qwizani A, et al. Otitis media among elderly: Incidence, complication and prevention. Int J Community Med Public Heal 2018;5:839.  Back to cited text no. 9
Saudi Health Interview Survey Results. Saudi Arabia Ministry of Health. Available from: http://www.healthdata.org/sites/default/files/files/Projects/KSA/Saudi-Health-Interview-Survey-Results.pdf. [Last accessed on 2019 Aug 28].  Back to cited text no. 10
Global Youth Tobacco Survey (GYTS). WHO/PAHO. Available from: https://www.paho.org/hq/index.php?option=com_content and view=article and id=13432:gyts and Itemid=42359 andlang=en. [Last accessed on 2019 Oct 29].  Back to cited text no. 11
Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: An emerging health crisis in the United States. Am J Health Behav 2010;34:275-85.  Back to cited text no. 12


  [Table 1], [Table 2]


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