Year : 2013 | Volume
: 31 | Issue : 3 | Page : 180--183
Hookah use among high school children in an Indian city
Nayak Prathibha Anand1, Khandelwal Vishal2, Nayak Ullal Anand3, Khandelwal Sushma4, Ninawe Nupur5,
1 Department of Periodontics, Mahatma Gandhi Dental College and Hospital, Jaipur, India
2 Modern Dental College and Research Centre, Indore, India
3 Department of Pedodontics, Mahatma Gandhi Dental College and Hospital, Jaipur, India
4 Department of Rasa Shatra, Sri Dhanvantari Ayurvedic College, Mathura, India
5 Department of Pedodontics, VSPM Dental College and Research Centre, Nagpur, India
Department of Pediatric and Preventive Dentistry, Modern Dental College and Research Centre, Gandhinagar, Airport Road, Indore, Madhya Pradesh - 453 112
Context: Use of hookah is on the rise among youngsters. A growing body of evidence suggests that these children are experimenting with this form of tobacco. Aims: The study was carried out to know prevalence estimates of hookah use and factors associated with it among high school students.Settings and Design: This study adds to the current literature by providing prevalence estimates and factors associated with hookah use among high school students of Indore - a city in central India.Materials and Methods: A cross-sectional survey of 1000 students from high schools was conducted to find hookah users and factors associated with its use. Results: Hookah users in this study population were 7.6%. Most of them first learned about hookah from friends (63.2%). They usually smoked in hookah lounges (85.5%). These children believed that hookah was safer and more socially acceptable than cigarettes.Conclusions: Misperceptions of safety and popularity of hookah among the younger generation are cause for concern. Presence of hookah lounges should be a target for further regulation. Prevention activities are necessary to prevent this rising public health concern.
|How to cite this article:|
Anand NP, Vishal K, Anand NU, Sushma K, Nupur N. Hookah use among high school children in an Indian city.J Indian Soc Pedod Prev Dent 2013;31:180-183
|How to cite this URL:|
Anand NP, Vishal K, Anand NU, Sushma K, Nupur N. Hookah use among high school children in an Indian city. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2020 Apr 9 ];31:180-183
Available from: http://www.jisppd.com/text.asp?2013/31/3/180/117980
An alternative form of tobacco use- 'the hookah or water pipe' appears to be on the rise among youth in India who smokes tobacco available in a variety of flavors (apple, mint, cherry, chocolate, coconut, liquorice, cappuccino, watermelon, etc). Hookah smoking is typically practiced in groups. In recent years, there has been a resurgence of hookah use around the world; most notably among young adults and young professionals.  A growing number of young people who do not smoke cigarettes are beginning to use tobacco by smoking the hookah.
Similar to cigarettes, hookah is also related to various preventable diseases including coronary heart disease,  adverse pulmonary effects,  and cancers of the lung,  mouth,  and bladder.  Additionally, hookah smoke contains many of the same carcinogens and heavy metals as cigarette smoke.  Longer hookah smoking sessions combined with increased smoke volume makes it potentially more dangerous than cigarettes.  However, many hookah users believe it to be safer. A typical 1-hour-long hookah smoking session involves inhaling 100-200 times the volume of smoke inhaled from a single cigarette.  Due to the mode of smoking-including frequency of puffing, depth of inhalation, and length of the smoking session-hookah smokers may absorb higher concentrations of the toxins found in cigarette smoke.  Hookah smokers are at risk for the same kinds of diseases as are caused by cigarette smoking, including cancers of the mouth, lung, stomach and esophagus, reduced lung function, and decreased fertility.  Second-hand smoke from hookahs poses a serious risk for non-smokers, particularly as it contains smoke not only from the tobacco but also from the heat source (e.g. charcoal) used in the hookah. , Using a hookah to smoke tobacco poses a serious potential health hazard to smokers and others exposed to the smoke emitted.  Sharing a hookah may increase the risk of transmission of tuberculosis, viruses such as herpes or hepatitis, and other illnesses.  The risk is greater among hookah smokers than among pipe or cigar smokers because hookah smoking is typically practiced (with or without inhalation) more often and for longer periods of time.  Hence, hookah smoking is NOT a safe alternative to smoking cigarettes. 
The Indian government prohibits the use of tobacco in public places and places of employment. There is an increase in the number of 'hookah lounges,' which are commercial establishments where individuals may gather to socialize and smoke hookah, usually in the proximity to colleges and universities.  Since lifetime tobacco use is frequently established by age 18,  it is significant to evaluate hookah use among those aged 18 years and younger in more detail.
The current study investigates the use of hookah by high school students by examining prevalence estimates and factors associated with it.
Materials and Methods
Data were collected from a survey of high school students from four public schools in Indore. A cross-sectional survey of 1000 students from high schools was conducted to find hookah users and factors associated with its use. The participating schools have similar high household incomes, and all the schools had indoor smoke-free policies.
A questionnaire was designed to assess the use of hookah. Specific questions were asked to evaluate a hookah use profile, including initiation/cessation factors, patterns of current hookah use and to determine its relevance to perceptions and behaviors about hookah.
All subjects were directly asked about the presence of hookah lounges near their schools and residence allowing for direct measurement of hookah lounge awareness among students. The questionnaire also inquired about the relative harm perception of hookah use.
Seventy-six potential participants who used the hookah were screened from the total population examined. They were asked to answer the 16-question written survey questionnaire. Participants were personally interviewed and were assured of confidentiality.
Of the 1000 subjects surveyed, 76 were potential subjects. Mean age of the sample was 15.3 years. In the total population, 18.42% were users of both hookah and cigarettes. Most students first learned about hookah from friends (63.2%). Gender-wise, male users of hookah were two times more in number than female users.
It was found that 10.6% of hookah users were from 9 th grade, 13.2% from 10 th grade, 48.6% from 11 th grade, and 27.6% were from 12 th grade. The mean age at initiation of smoking the hookah was 15.7 years.
Some of the children had smoked hookah only once (38.2%), some a few times (47.4%), and others once in a month (14.4%).
The hookah users reported that they first learned of hookah use from friends (63.2%) followed by siblings (22.4%) and relatives (14.5%). More than 96.1% knew about the hookah lounges in their locality, and most of them smoked at these lounges (85.5%).
All the hookah users shared the common water pipe. Sixty-three (82.9%) of them shared the pipe most of the time, 6 shared it all the time, and 7 sometimes. They reported smoking sessions that averaged 30 min. Among them, 94.8% thought it the use of hookah was socially unacceptable. Some of them (14.5%) no longer used the hookah as they did not like it.
The study reported that 85.5% did not know about the tobacco content of hookah. Twelve (15.85.3%) believed that the hookah was significantly safer than the cigarette, 4 (5.3%) that the cigarette was safer, and majority of them were unaware of its harmful effects.
Almost one-fifth (18.5%) of users reported smoking cigarettes also. Four of them (5.2%) also chewed tobacco.
Hookahs originated in ancient Persia and India and have been used extensively for approximately 400 years.  The hookah/ water pipe is used to smoke specially made tobacco by indirectly heating the tobacco, usually with burning embers or charcoal. The smoke is filtered through a bowl of water (sometimes mixed with other liquids such as wine) and then drawn through a rubber hose to a mouthpiece. The hookah is known as, Narghile, Argileh, Shisha, Hubble-bubble, and Goza. 
The discovery and popularity of hookahs and establishments that rent hookah pipes have increased greatly in the past ten years in India. An estimated 40-50 hookah lounges (liquide fumee) are being run in Indore city, and the numbers continue to grow. The target audiences to these lounges are college students and young professionals in the age 18-30 years. A growing number of young people who do not smoke cigarettes are beginning to use tobacco by smoking the hookah.
Hookah smoking is commonly viewed as a social activity and is often done in groups who share one pipe and try different flavors. Hookah smoking is seen as a relatively inexpensive way to "get together" and have fun. The expansion of the hookah bar and café industry, especially in inner cities and near universities and colleges where youth and young adults gather, illustrates the growth potential for hookah marketing and use.
Current marketing for hookah pipes and their specialized tobacco packs is fairly limited to specialized shops and online stores. The cafés and bars, on the other hand, are expanding rapidly to reach wider audiences. The data from our study of high school students indicate that use in this population is relatively common.
Primack et al.  in a study reported use of hookah (40.5%) among college students, which was quiet higher than that observed in this study (7.6%). As there is early onset among school children in our study, it will be reasonable to expect an increase in hookah use in college-age adults in the future.
Almost one-fifth (18.5%) of users in this study also reported use of cigarettes, which is higher than that reported among young adults in a study from San Diego.  Further research on the dual use of hookah and cigarettes and the chronological order of tobacco product initiation is warranted.
The belief that hookah is safer or less addictive than cigarettes has not been previously reported in high school-aged subjects. Previous studies of young adults have indicated that subjects believed hookah to be safer than cigarettes because they felt that the water in the hookah pipe filters out harmful substances.  Only 5.2% of our subjects believed hookah was safer because of water filtration.
Studies have shown that hookah and cigarette smoking deliver similar amounts of nicotine;  But, three-fourths of subjects in our study who believed hookah to be safer or less addictive than cigarettes thought that the hookah did not contained nicotine.
There was a difference in the use of hookah by gender. Males users were two times more in number than females. Similarly, previous studies , found a strong gender association with males using hookah at higher rates. The association with female use may reflect the increasing popularity of the hookah among females. This is consistent with international studies, which show that hookah smoking among women was more socially acceptable than any other tobacco product , and was tolerated by family members more than hookah smoking by men.  Similar to other studies, , we also found that hookah users were more likely to have smoked a cigarette than non-users.
Most of the samples were initiated to use the hookah mainly by friends followed by siblings and relatives. By simply increasing access to the behavior, the awareness of hookah lounge locations may increase its use. This requires further investigation using a prospective study design to determine whether hookah lounges are leading to higher hookah use in high school students.
Majority of sample reported having smoked hookah only a few times, and a large majority reported sharing the same mouthpiece at least sometimes.
Our study also found the use of hookah among minors (under 18 years of age). Sixty-five minors (85.5%) reported that they had been to a hookah lounge, suggesting fairly widespread illegal tobacco use and illegal visitation to hookah lounges by underage adolescents. Therefore, the legality of hookah lounges in India should be considered, and future studies of hookah use should incorporate this variable in their questionnaires. To our knowledge, this is the first survey of high school students for hookah use prevalence, risk perception, and other risk behavior factors. Furthermore, this is the first study to address patterns of initiation, use and cessation in a population of hookah users in India and Asia. Since the populations targeted in this study were from public schools from the city, findings from this study cannot be generalized to all high school students.
Hookah use is increasing among adolescents and young adults who are unaware of the tobacco content of hookah and its harmful effects. This study shows that the hookah is attracting adolescents at a very early age and that they were first introduced to its use because of the presence of hookah lounges in their locality. Cigarettes have traditionally been the focus of media campaigns. The lack of such promotions on the dangers of hookah smoking may also be contributing to the increase in hookah use. The legality of hookah lounges in India should investigate. Therefore, anti-tobacco campaign community and tobacco research community should re-assess priorities for this age group and address the growing hookah epidemic through continued research and media messaging. Prevention activities like restricting/banning hookah lounges are necessary to prevent this rising public health concern.
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