|Year : 2015 | Volume
| Issue : 3 | Page : 244-249
An emerging trend: Hookah smoking among youth smokers in Gurgaon, Haryana
Esha Bali, BR Chinmaya, Sachin Chand, Shourya Tandon, Sumanth Prasad, Deepsikha Sahu, Sahil Handa
Department of Public Health Dentistry, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
|Date of Web Publication||14-Sep-2015|
536, Subhash Nagar, Rehari, Jammu, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Introduction: Hookah is becoming the favorite form of tobacco use by youth globally. This problem has received more attention in recent years. Aim: The aim was to investigate the characteristics, behavior, and perceptions related to hookah smoking among the youth smokers in Gurgaon, Haryana. Materials and Methods: Two hundred and fifteen established hookah smokers participated in this study. Data were collected using a 28-item questionnaire, constructed using three main domains: Characteristics (sociodemographic and personal), behavior and perceptions (about harmful effects in comparison to cigarette smoking). Descriptive and Chi-square test were performed, and P < 0.05 was considered as statistically significant value. Results: The mean age of starting hookah smoking in the present study was 17.3 years. Hookah smoking on a daily basis was reported by 37.7% participants. Another 44.7% participants smoke hookah in hookah cafes with friends and the total number of participants who informed that hookah is easily available and accessible are 83.3%. The participants who were addicted to hookah smoking; light-headedness, dizziness and headache, post hookah smoking are 63.3%. About 60.9% participants had attempted to quit but restarted. Most of the participants 60-70% had misperception about the safety of hookah smoking over cigarette smoking, and 36-82% participants were unaware of health effects. Conclusions: Compared to cigarettes, there appears to be a lack of knowledge about the harmfulness of smoking hookah among users regardless of their demographic background. Education about the harmfulness of smoking hookah and policies to limit its use should be implemented to prevent the spread of this new form of tobacco use.
Keywords: Hookah, smokers, youth
|How to cite this article:|
Bali E, Chinmaya B R, Chand S, Tandon S, Prasad S, Sahu D, Handa S. An emerging trend: Hookah smoking among youth smokers in Gurgaon, Haryana. J Indian Assoc Public Health Dent 2015;13:244-9
|How to cite this URL:|
Bali E, Chinmaya B R, Chand S, Tandon S, Prasad S, Sahu D, Handa S. An emerging trend: Hookah smoking among youth smokers in Gurgaon, Haryana. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2019 Dec 15];13:244-9. Available from: http://www.jiaphd.org/text.asp?2015/13/3/244/165240
| Introduction|| |
Five to six million people worldwide die as a result of tobacco use each year.  Cigarette smoking is the most common form of tobacco use, which is widely reported. However, the use of waterpipe (hookah) is gaining popularity in the recent trends.  Evidence also suggests that hookah smoking is associated with negative health outcomes similar to those of cigarette smoking.  Over the years researchers have identified, the association between hookah smoking and lung cancer, respiratory illness, low birth-weight, blood pressure and heart rate increase, and periodontal disease. 
Hookah smoking originated nearly four centuries ago in ancient Persia and India, which involves the passage of tobacco smoke through water before inhalation.  There are 100 million daily hookah smokers worldwide.  The burning temperature of tobacco for hookah use is about 900°C, compared to 450°C for cigarettes, which could produce different type and levels of harmful chemicals and tar.  Hookah smoke also contains 36 times the amount of nicotine and a higher concentrations of heavy metals. Emerging literature suggests that smoke from hookah contains many of the toxins as cigarette smoke, including carcinogenic polycyclic aromatic hydrocarbons, volatile aldehydes, carbon monoxide, and nicotine.  Moreover, the plasma nicotine levels are reached on a single hookah use whereas it takes 10 cigarettes to reach the same level if only cigarettes are consumed.  Studies have shown that using the water as a filter in the hookah did not change the level of nicotine in the smoke as compared to that without using the water. 
Like cigarettes, hookah use is a health hazard to nonsmokers because of secondhand smoke and it can lead to the transmission of infectious diseases, since the same hookah mouthpiece can be used by many people during one smoking session.  The World Health Organization (WHO) has warned that waterpipe smoking may pose the same health risks as cigarettes, and has urged more research to better understand the link between waterpipe use and various illnesses. 
Earlier only rich classes were exposed to hookah smoking but now this trend has emerged again in which hookah has been seen along with many houses using hookah as a customary practice, in respective of their social class, and this practice is available in all strata of people.  Different epidemiological studies related to hookah smoking have been conducted, which evaluate the attitudes, perceptions, and behavior of the youth and university students. Widespread usage of Hookah is observed in Haryana. Keeping this in mind, the present study was conducted to investigate the characteristics, perceptions, and behavior of the hookah smoking among youth smokers of Gurgaon, Haryana.
| Materials and methods|| |
The study was a cross-sectional survey of university students. A self-administered, anonymous questionnaire was distributed to university students in three private institutes of Gurgaon, Haryana. Data collection were done through snowball sampling. The study was conducted for the duration of 3 months: May 20l4 to July 2014. Prior to the commencement of the main pilot study was conducted among 20 students to assess the feasibility and validity of the questionnaire.
The questionnaire was based on three main domains: Characteristics had 28 items.
Q: 1-6 related to Personal detail and Q: 7-19 represent hookah Smoking behavior among the study group, Q: 20-27 deal with perceptions that have nine items related to comparison between knowledge of hookah and cigarette Q: 28 - Harmful effects of hookah smoking.
Inclusion criteria for study is - Established hookah smoker (smoking hookah for over a year) were taken, young adults not more than 35 years among health professionals or technical streams and the participants who are willing to participate in the study are provided with written informed consent.
The questionnaires were distributed by snowball sampling method from which 35 did not respond and 30 were missing, so total sample size was 215 for this study. A previous study on hookah smoking Knishkowy et al. 2005  was referred while designing the questionnaire for the present study.
All the data collected were entered into the computer using Microsoft Excel (Windows MS Office XP professional version). All statistical analysis was performed using SPSS version 20 (IBM SPSS, SPSS Inc., Chicago IL, USA), and P < 0.05 was considered as statistically significant. Descriptive and Chi-square test was performed.
| Results|| |
Of 215 participants, the majority of participants 80.4% were males, and 19.5% were females. Participants who were from health professional such as dental and medical streams are 61.4%. The majority of participants use hookah alone (58.1%) and participants who smoked cigarettes/bidis along with hookah are 35.3%. Most of the participants (64.6%) were reported to have started the habit of hookah smoking between the ages of 10-20 years. Almost half of the participants used their pocket money to purchase hookah or other tobacco products [Table 1].
[Table 2] describes the hookah smoking behavior among the study group. Hookah was found to have a pleasurable experience in 28.8%, and it added intimacy (47.3%) socializing in and it emerged as the major reasons for hookah smoking. Many participants (42.8%) felt relaxed while 18.1% enjoyed the pleasure of hookah smoking. However, 23.3% participants agreed that it creates pollution, and 59.5% believed that hookah smoking is harmful to health. About 63.3% participants were addicted to hookah smoking, and 60.9% said that they made attempts to quit but restarted as majority of them enjoyed it to company friends, though a 67.7% of participants reported that they cannot use hookah in front of their far parents. Still they manage to smoke hookah everyday 37.7% with 25.6% reporting that they consumed hookah more than once a day. About 43.7% said that they do hookah smoking to socializing with friends with 30% at a leisure place. About 83.3% agreed that hookah is easily accessible and avoidable, and they can reach out to hookah in <10 min (63.7%).
Perception of hookah smoking in comparison with cigarette smoking: Post hookah use the majority of them experienced light headedness, dizziness, and headache but still they continued to smoke hookah with friends at leisure time (30.1%). It was also observed that the majority of the hookah smokers had the wrong perception about hookah smoking in comparison to cigarette smoking (67.6%). Participants felt that "hookah smoking releases higher concentration of smoke than cigarette smoking" (63.3%) Q: 24 and 69.3% participants knew that tobacco and other flavoring substances were used in hookah smoking [Table 3].
|Table 3: Perception of hookah smoking in comparison to cigarette smoking among study group |
Click here to view
[Table 4] shows the distribution of the participants as per the knowledge of the harmful effects of hookah smoking. Maximum participants said yes (82.8%) for oral cancer and same response for lung cancer (82.8%), which is the main effect of hookah smoking.
The majority of participants in both health professionals and technical streams were aware of the harmful effects of hookah smoking. They knew hookah smoking causes staining of teeth, oral cancer, lung cancer, and other related cancer as shown in [Table 5]. It was observed that 53.4% (n = 115) of health professionals were aware that hookah smoking causes oral cancer where as in response to same question in case of technical streams, only 29.3% (n = 63) were aware of connection between hookah smoking and oral cancer with significant value of 0.008. Similarly, the awareness among two groups regarding hookah smoking also causes other lung cancer showed almost the same results though it did not yield the significant value. Surprisingly, 25.58% (n = 55) health professionals responded, as they did not know the question in relation to hookah smoking and its effects in alterations of the chromosome. Almost 35-40% from each stream responded less awareness regarding hookah use causing an alteration to chromosomes, but this result was not significant.
| Discussion|| |
The present study was carried out among university graduates in Gurgaon, Delhi NCR region, which revealed the personal and sociodemographic detail that 61.4% of health professionals and 38.6% of technical students were habitual users of hookah. Whereas Taha et al.  reported a low prevalence of 8.6% among medical students in Saudi Arabia using invariable analysis. The prevalence of hookah use is high in Gurgaon, Haryana; where it is the most common form of tobacco use, and it is easily available.  Many families in Haryana have been using hookah from generations.  It is easily available as a common tobacco item in markets. Male gender was associated with hookah smoking in a number of studies (Eissenberg et al.,  Smith-Simone et al.,  Primack et al.,  Maziak et al.  ) who reported that the hookah smoking was more common among male students.
It is clear from the present study that hookah smokers are more likely to be habituated to cigarette smoking, which was parallel to studies done by Kakodkar and Bansal,  Aljarrah et al.  Surprisingly, 35.3% of hookah smokers also smoke cigarette along with hookah. Similar studies were also reported by Maziak et al.,  Khan et al.,  Kakodkar and Bansal;  and a study conducted in central Saudi Arabia it was revealed that among medical students who smoked both hookah 23.7% and cigarettes  This shows a lot of connection between hookah and cigarettes. Probably, the addiction is the effect of tobacco that is playing a role. 
About 25.6% of the respondents mentioned that they had tried to quit hookah habit many times. In fact, more number of health professionals has tried to quit this habit than a technical stream. This shows a strong addictive nature regarding the use of hookah. Smoking and chewing of tobacco are varied, that most of them commonly smoke on a daily basis, but, since hookah use requires an equipment, and a suitable place the users tend to use it as they reaches out to an area where the hookah is available. As many as 57.7% of the participants use it on a daily basis and weekly basis 15.3% whereas the study done in Pune by Kakodkar and Bansal  reported little different results as against the present study that is, 24.6% and 33.5%. In other studies, only 7% Syrian students reported hookah smoking on daily basis  and 25% university students from Jordan  reported hookah smoking on daily or weekly basis. It shows that in the present study that in Gurgaon, the practice of hookah is more customary and is not taken as harmful substances but more of an indulgence in a habit without any reason.
The reasons for smoking were a pleasurable experience that accounts for 28.8% and socializing with friends account for 43.7%. Among the Gurgaon, Delhi NCR region university students surveyed, positive feeling about hookah smoking was that it gives relaxation in 42.8% participants and the negative feeling about hookah smoking reported by 59.5%, participants that it is harmful to health mainly oral cancer, staining of teeth, lung cancer etc., were the reasons. Similar results were seen in the study done in Pune university students. 
In this study, it is observed that more than half of participants live with their families, that is, 62.3% and 67.0% cannot smoke in front of their parents or guardians. Surprisingly 22.8% do not mind smoking in front of their family, which is quite uncommon in a traditional Indian family though those who smoke hookah with the family is more, in whom have seen their parents or elders indulging on the habit at a young age and the hookah is left open for usage at one point of time or the other in the houses. Similarly,  in some studies of Eastern Mediterranean Region, certain forms of substance use including hookah smoking are commonly shared within a family.  Family members have been seen to smoke together at home, which probably makes this habit more acceptable and easy going.
In our present study, the majority of participants (76.3%) indicated that they believe that hookah is harmful to health than cigarette smoking. Opposite findings reported by Maziak et al.,  who reported that 89% of the participants thought that hookah is less harmful than cigarettes. There is also a perception that hookah smoking is safer than cigarette smoking because the invention of hookah smoking involves the passage of smoke through water that is presumed to filter the smoke and remove toxic agents as reported by no. of studies (Kandela,  WHO,  Dawn). 
According to reports of Ward et al.  and Smith-Simone et al.,  many hookah smokers do not see themselves as addicts, and there is a common perception among hookah users the that they can quit whenever they want and in this study 63.3% reported that they are hooked to hookah. Likewise, Primack et al.  reported that 52% of college students believed hookah are less addictive than cigarettes. However, the perception that hookah smoking is not as addictive as the smoking cigarette is proven to be wrong. This is evidenced by the studies, which revealed that approximately half of the respondents still returned to hookah smoking after trying to quit it (Maziak et al.  Jackson and Aveyard  Mohammad et al.) 
Many hookah smokers believe that because hookah tobacco smoke is filtered by the water in the base of the smoking apparatus, many of the harmful substances are removed making hookah smoking to be less detrimental to health than cigarette smoking  American Lung Association,  Ward et al.  likewise, in this study, 69.8% says that hookah smoking is less irritating and, therefore, less toxic to the respiratory tract. The WHO committee on Tobacco Product Regulation has refused these claims stating that the amount of smoke inhaled in a single hookah session often surpasses that from a single cigarette, and that hookah smoking contains the same harmful substances. 
| Limitations|| |
- The study was done by convenient sampling method; it may not cover the whole Haryana and not covering urban and rural condition of using Hookah
- Snowball sampling method is a self-assessed method
- There is nonreturn of 30 participants out of 250, and 35 were not eligible for the study.
| Recommendations|| |
- Awareness of the health threat associated with hookah use may be encouraged and that a comprehensive and coordinated research program be implemented, which may help to guide the policy makers treatment efforts that prevent a new wave of tobacco-associated addiction, disease, and death
- More efforts on the legislative aspect university regulations, harmful of tobacco use, and evidence base initiatives on tobacco control should be started in undergraduate curriculum teaching and training, policy makers and more propaganda on nonuse of tobacco related products should be emphasized in university campuses at a large scale.
| Conclusion|| |
Among established hookah smokers, the present study found 61.4% of health professionals students and 38.6% among technical streams were using hookah in Gurgaon, Haryana. This highlights the lack of awareness and the negative consequences of hookah smoking even among well-educated health professional and engineers.
Public health campaigns need to be conducted to educate, motivate, and alter lifestyles with good counseling among both genders, youths in particular, and their families through continued counseling. For this universities should be engaged in educating their students against the health risks of tobacco use to totality targeting, smokers in any form including hookah users and chewers. There is a growing recognition, with a minimal research base, that tobacco smoking using a hookah is increasingly common and potentially lethal in Gurgaon Haryana.
I want to thank all the people who helped in my study.
Financial support and sponsorship
Conflict of interest
There are no conflict of interest.
| References|| |
Khabour OF, Alzoubi KH, Eissenberg T, Mehrotra P, Azab M, Carroll MV, et al.
Waterpipe tobacco and cigarette smoking among university students in Jordan. Int J Tuberc Lung Dis 2012;16:986-92.
Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al.
The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. BMC Public Health 2011;11:244.
Ghafouri N, Hirsch JD, Heydari G, Morello CM, Kuo GM, Singh RF. Waterpipe smoking among health sciences university students in Iran: Perceptions, practices and patterns of use. BMC Res Notes 2011;4:496.
Koul PA, Hajni MR, Sheikh MA, Khan UH, Shah A, Khan Y, et al.
Hookah smoking and lung cancer in the Kashmir valley of the Indian subcontinent. Asian Pac J Cancer Prev 2011;12:519-24.
Poyrazoglu S, Sarli S, Gencer Z, Günay O. Waterpipe (narghile) smoking among medical and non-medical university students in Turkey. Ups J Med Sci 2010;115:210-6.
Shihadeh A, Azar S, Antonios C, Haddad A. Towards a topographical model of narghile water-pipe café smoking: A pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacol Biochem Behav 2004;79:75-82.
Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol 2005;43:655-61.
Alzyoud S, Weglicki LS, Kheirallah KA, Haddad L, Alhawamdeh KA. Waterpipe smoking among middle and high school Jordanian students: Patterns and predictors. Int J Environ Res Public Health 2013;10:7068-82.
Jackson D, Aveyard P. Waterpipe smoking in students: Prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health 2008;8:174.
World Health Organization. Waterpipe tobacco smoking: Health effects, Research needs and Recommended action by regulators.Geneva, Switzerland: WHO Study Group on Tobacco Product Regulation (TobReg); 2005.
Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: Predictors and characteristics among current hookah users. Tob Induc Dis 2009;5:16.
Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics 2005;116:e113-9.
Taha AZ, Sabra AA, Al-Mustafa ZZ, Al-Awami HR, Al-Khalaf MA, Al-Momen MM. Water pipe (shisha) smoking among male students of medical colleges in the eastern region of Saudi Arabia. Ann Saudi Med 2010;30:222-6.
Gupta V, Yadav K, Anand K. Patterns of tobacco use across rural, urban, and urban-slum populations in a north Indian community. Indian J Community Med 2010;35:245-51.
Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. College campus: Prevalence and correlates. J Adolesc Health 2008;42:526-9.
Smith-Simone S, Maziak W, Ward KD, Eissenberg T. Waterpipe tobacco smoking: Knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine Tob Res 2008;10:393-8.
Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med 2008;36:81-6.
Maziak W, Eissenberg T, Rastam S, Hammal F, Asfar T, Bachir ME, et al.
Beliefs and attitudes related to narghile (waterpipe) smoking among university students in Syria. Ann Epidemiol 2004;14:646-54.
Kakodkar PV, Bansal SS. Hookah smoking: Characteristics, behavior and perceptions of youth smokers in Pune, India. Asian Pac J Cancer Prev 2013;14:4319-23.
Khan N, Siddiqui MU, Padhiar AA, Hashmi SA, Fatima S, Muzaffar S. Prevalence, knowledge, attitude and practice of shisha smoking among medical and dental students of Karachi, Pakistan. J Dow Univ Health Sci 2008;2:3-10.
Al-Turki YA. Smoking habits among medical students in Central Saudi Arabia. Saudi Med J 2006;27:700-3.
Dar-Odeh NS, Bakri FG, Al-Omiri MK, Al-Mashni HM, Eimar HA, Khraisat AS, et al.
Narghile (water pipe) smoking among university students in Jordan: Prevalence, pattern and beliefs. Harm Reduct J 2010;7:10.
Kandela P. Nargile smoking keeps Arabs in wonderland. Lancet 2000;356:1175.
Ward KD, Eissenberg T, Gray JN, Srinivas V, Wilson N, Maziak W. Characteristics of U.S. Waterpipe users: A preliminary report. Nicotine Tob Res 2007;9:1339-46.
Mohammad HR, Zhang Y, Newman IM, Shell M. Cigarettes and waterpipe smoking in Kuwait. East Mediterr Health J 2010;16:1115-20.
Asfar T, Ward KD, Eissenberg T, Maziak W. Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers. BMC Public Health 2005;5:19.
American Lung Association. An Emerging Deadly Trend; Waterpipe Tobacco Use. Washington, DC: American Lung Association; 2007.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]