Indian Journal of Cancer
Home  ICS  Feedback Subscribe Top cited articles Login 
Users Online :958
Small font sizeDefault font sizeIncrease font size
Navigate here
Resource links
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
 »  Article in PDF (261 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free)  

  In this article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 » Acknowledgment
 »  References
 »  Article Tables

 Article Access Statistics
    PDF Downloaded231    
    Comments [Add]    
    Cited by others 3    

Recommend this journal


  Table of Contents  
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 694-697

Perception of young adults toward hookah use in Mumbai

1 Department of Research Studies, Cancer Patients Aid Association, King George Memorial, Mahalaxmi, India
2 Department of Research Studies, Cancer Patients Aid Association, King George Memorial, Mahalaxmi; School of Science, NMIMS (Deemed-to-be) University, Vile Parle (W), Mumbai, Maharashtra, India

Date of Web Publication10-Mar-2016

Correspondence Address:
D Saranath
Department of Research Studies, Cancer Patients Aid Association, King George Memorial, Mahalaxmi; School of Science, NMIMS (Deemed-to-be) University, Vile Parle (W), Mumbai, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.178384

Rights and Permissions

 » Abstract 

BACKGROUND: The use of tobacco has been on the rise globally including in India, posing a grave public health problem. Recently, tobacco use through hookah smoking has increased among young adults in India, Middle East, Southwest Asia, Africa, Europe and North America. Hookah prevalence of 0.4-15% has been reported in India. AIM: The aim of the study was to understand perception of hookah use among young adults in Mumbai. MATERIALS AND METHODS: A total of 500 college students, with/without hookah habit, were given a self-administered questionnaire to indicate their perception of hookah use, using yes/no responses. The responses were analyzed in the users/non-users and considered significantly different at P < 0.05. RESULTS: Responses were received from 122 hookah users and 325 non-users. The perception of hookah use between users and non-users and males and females, showed significant differences (P < 0.05), with respect to hookah being injurious to health, causes cancer, is addictive, influence of a close friend, flavors, curiosity toward hookah use and willingness to prepare hookah at home. Whereas, differences in the groups perception of hookah as safer than cigarettes, harmful air quality, ambience, cool look and means of socializing, was not observed. CONCLUSION: The perception of young adults in Mumbai, toward hookah use, indicates an increased trend to use hookah. We recommend deterrents for hookah use by display of health warnings on hookah assembly and the tobacco products, implementation of government policies on hookah and tobacco use and punitive measures for offenders.

Keywords: Hookah use, India, Mumbai, perception, young adults

How to cite this article:
Dani K K, Oswal K, Maudgal S, Saranath D. Perception of young adults toward hookah use in Mumbai. Indian J Cancer 2015;52:694-7

How to cite this URL:
Dani K K, Oswal K, Maudgal S, Saranath D. Perception of young adults toward hookah use in Mumbai. Indian J Cancer [serial online] 2015 [cited 2021 Aug 1];52:694-7. Available from: https://www.indianjcancer.com/text.asp?2015/52/4/694/178384

 » Introduction Top

Tobacco use is a major cause of morbidity and mortality, responsible for more than 5 million deaths world-wide each year.[1] It is estimated that by 2030, 10 million people will die annually from tobacco use and 70% of the deaths will be in developing countries.[2] In India, 275 million people use tobacco, 35% of them being older than 15 years.[3] Tobacco is primarily smoked as bidi and cigarette in India and chewed perse or as a mixture with added lime, catechu and areca nut or tobacco with additional spiced ingredients available as a sachet. Tobacco is also applied on gums as powdered tobacco called masheri. In India, prevalence of smoking in school and college students estimated as 0-2.3% girls and 6.9-22.5% boys.[4],[5] Whereas, several reports from schools in US, indicated 12.6-79% school students were using tobacco.[6],[7]

The prevalence of hookah smoking is increasing among young adults world-wide with a dramatic rise in Middle East countries, India, Southwest Asia, Africa, Europe, Canada and United States.[8],[9],[10],[11] In the US, 15-41% of undergraduate college students are reported to be addicted to the habit.[12] It is estimated that greater than 100 million people world-wide smoke tobacco through hookah pipes daily. Further, documented estimates of hookah users are 11-32% in Syria, 33% in a British University [13] and 40.5% in US.[14]

In India, hookah prevalence of 5-14% has been reported, being 2.6% in rural and 0.4% in urban groups.[15],[16] Hookah may be used singly or with multiple hoses to enable simultaneous smoking by several users or the same mouthpiece passed from person-to-person.[17] The tobacco smoked in a hookah is sweetened with syrup and usually flavored. Hookah smoking is harmful as smokers inhale a volume of smoke equivalent to 100 cigarettes during a typical 45-60 min hookah session.[18] Furthermore, high concentrations of carbon monoxide, tar and heavy metals are present in hookah smoke.[19],[20],[21],[22]

Several factors promote hookah smoking among young adults. Use of the hookah is often considered innocuous due to the passage of the smoke through water before inhalation as emphasized in the Indian group of users in the valley of Kashmir.[17] There is considerable awareness about the harmful effects of tobacco even in children. Of 1004 children surveyed in the Indian states of Maharashtra and Assam, 75% were aware that tobacco use was dangerous and harmful to health.[23] It is a paradox that a majority of hookah smokers in India are aware of the health hazards of hookah smoking. A report from a study conducted in US, it was noted that the Asian group was much less likely than other ethnic groups in the belief that hookah was less harmful than cigarettes.[24]

On the Indian scenario, there is a dearth of information on perception of hookah use, among young adults, primarily in the 16-26 age groups. It is commonly noted that the young adult group is a vulnerable group prone to hookah use due to their tendency to experiment.[25],[26] Understanding perception of these young adults toward hookah use may give clues to planned programs for discouraging the use as also increase awareness of the health hazards of hookah to the individuals. Tobacco use is initiated in India as early as 9-12 years of age and 12-18 years in Nepal.[26],[27] In general, the habit escalates to using hookah due to their tendency to experiment.[8],[12],[24],[26] Addition of hookah smoking to other forms of tobacco habits and vice versa has been reported earlier.[28] Hence, the current project was undertaken to assess perception among young adults in a college environment towards using hookah for smoking tobacco.

 » Materials and Methods Top

The study was initiated at Cancer Patients Aid Association, a non-government organization, whose mission is total management of cancer for socio-economically disadvantaged individuals and approved by the Institution Ethics Committee. The study was carried out in Mumbai, from October to December 2011. Data was collected from a convenience sample of 500 students, aged 16-26 years, from a college in South Mumbai. The participants comprised 167 males and 280 females (M:F = 1.68) [Table 1]. A self-administered questionnaire primarily pertaining to hookah use as addictive, unsafe and injurious to health, causes cancer, safer than cigarettes and harmful to the enclosed air quality, was given to the participants. Further, influence of close friends, means of socializing, creating a cool effect, ambience of the parlor, flavors and fruits in hookah and willingness to prepare and use hookah at home, were also queried. The queries were assigned as variables with responses as either yes/no. The responses by users and non-users were analyzed and considered significantly different at P < 0.05 using Statistical Package for Social Sciences IBM SPSS (version 16.0) software.
Table 1: Demographic data of the participants

Click here to view

 » Results Top

Participant details

A total of 500 college students were given the questionnaire and completed responses were obtained from 447 (89.4%) participants. A majority of the participants (62.6%) were females, with 73% non-users of hookah. About 27% were hookah users comprising 50% males and 50% females. However, daily users were a small group of 5% and a majority 80% of smoked hookah less than once a month [Table 1].

Perception of hookah use

Perception of hookah use amongst hookah users (n = 122) and non-users (n = 325) was analyzed [Table 2]. We noted a significant difference in the perception of hookah use among the users and non-users with respect to hookah being addictive, injurious to health and causes cancer, influence of a close friend using hookah, willingness to prepare hookah at home, use of flavors in hookah and use due to curiosity [Table 2]. A significant difference was observed in the perception of hookah being addictive in hookah users versus non-users (P < 0.001). Furthermore, the users perceived hookah to be injurious to health (P = 0.001) and that it causes cancer (P < 0.05). However, an equivalent percent of both users and non-users perceived hookah to be safer than cigarettes [Table 2]. This may be due to the infrequent use of hookah in a majority of our participants. Thus, it should be noted that educational messages need to be tailored to account for infrequent use. We noted that hookah users were more likely to have a close friend who smokes hookah (P < 0.001). Thus, educational messages demoralizing hookah use may not be effective in smokers, with hookah smoking in their peer groups. On the other hand, significant difference in the perception that hookah is safer than cigarettes, presence of fruits in hookah, air quality of hookah parlor is harmful, ambience of the parlor, looking cool and enabling socializing, was not observed in the users and non-users of hookah as well as in males and females [Table 2]. Besides, a significant difference was also not observed in the male users and non-users, with respect to certain parameters, i.e., injurious to health, causes cancer, influenced by flavors and curiosity [Table 2]. Further, a comparison between female and male hookah users indicated that 66.6% of females perceived hookah as addictive while only 47.5% of males considered as addictive (P < 0.05). Both male (56.7%) and female (58.3%) users perceived hookah use as safer than cigarette smoking. The perception with reference to air quality of hookah parlors being safer was equivalent in male and female users. Whilst among the non-users, both males and females indicated hookah and cigarettes as equally harmful to the environment and the deteriorating air quality as not safe [Table 2].
Table 2: Response of hookah users and non-users

Click here to view

 » Discussion Top

In our study, we noted that a majority of the hookah users were aware of the health hazards, carcinogenic property, addictive nature and harmful air quality. Despite this awareness, the young adults used hookah. Besides, the participants indicated perception of hookah smoking as a safer option than cigarettes. Whereas, earlier studies with participants from Egypt, Israel and Syria, reported ignorance of health hazards by users and hookah smoking was considered less harmful than cigarette smoking.[10],[29],[30],[31] The influence of close friends seemed an important contributory factor for hookah users. In addition, hookah was considered a means of socializing and projecting a “cool image.” The hookah users were also influenced by the ambience of the parlors.

Earlier studies evaluating the air quality of enclosed hookah parlors, have reported it to range from “unhealthy” to “hazardous” according to Environmental Protection Agency standards, posing a potential health risk for patrons and employees.[32] Cobb et al. further reiterate that the air quality of hookah cafes is worse than restaurant rooms in which cigarette smoking was permitted and may expose patrons and employees to particulate matter concentrations above national and international air quality standards.[33] In accordance, the hookah users and non-users in our study, perceived the air quality of hookah parlor as being harmful. Hence, total implementation of the health directive to prohibit hookah cafes, will effectively reduce health risks of hookah use.

In several countries, hookah use is promoted by media, hookah retailers and hookah bars/cafes, as an enjoyable and safe social activity for college students and conveys hookah smoking as a cheaper and safer alternative to use of addictive drugs or barhopping. In India, as per the cigarette and other tobacco product act,[34] any form of tobacco smoking in public places including restaurants, hotels recreational centers, etc., is banned. Currently, there is a ban on hookah parlors in Mumbai. However, sale of the hookah is on the rise in several parts of the country.[15] Further, tobacco vendors sell easy to assemble hookah water pipes to be assembled at home for convenient use, encouraging hookah smoking. Thus, the young hookah users are amenable to preparing the assembly and using hookah at home as indicated in one-third (29%) of the users in our study.

 » Conclusion Top

Hookah use is increasing in popularity among young adults in the country, despite the short-term and long-term ill-effects. The perception of the young adults toward hookah use indicates an increased trend to use hookah despite the known health hazards. Prominent health warnings on hookah and tobacco products may educate consumers that hookah is not a safe alternative to cigarettes. Implementation of government policies, although difficult in our densely populated, heterogeneous population, spread over the country, is critical for tobacco control in the country. Thus, a strict implementation of the policies with punitive measures for offenders is recommended. The strengthening of educational programs against all forms of tobacco including hookah, with emphasis in schools and colleges, to catch them young, may show long-term benefits. School/college based interventions including counseling to promote tobacco cessation and enforcement of legislation to decrease availability, accessibility and affordability of tobacco products, are recommended. The immediate prioritization to sensitize young adults with evidence based policy and strict and vigilant enforcement of banning of hookah by the enforcement agencies will facilitate health in the young adults.

Limitations of the study

The study exclusively examined the perception of tobacco use in hookah and did not query use of tobacco in cigarette smoking, smokeless tobacco and other forms, with or without hookah use. Besides, the monothematic nature of the study and the closed questions may have limited the answers given by the participants resulting in a certain amount of inaccuracy. Furthermore, the sample was a convenience sample, which thereby limits generalization of the results. The study was limited in being focused on perception of hookah use, resulting in masking the perception of dangers of passive smoking hazards due to the hookah use.

 » Acknowledgment Top

The authors acknowledge Cancer Patients Aid Association for the help and support in facilitating the study.

 » References Top

WHO. WHO report on the global tobacco epidemic, 2009: Imple menting smoke-free environments. Geneva, Switzerland: World Health Organization; 2009. p. 1-568.  Back to cited text no. 1
Jha P. Avoidable deaths from smoking: A global perspective. Public Health Rev 2012;33:569-600.  Back to cited text no. 2
Ministry of Health and Family Welfare, Government of India. (2011) Global Adult Tobacco Survey (GATS). Fact sheet India: 2009-2010. India: Ministry of Health and Family Welfare, Government of India; 2011.  Back to cited text no. 3
Jayant K, Notani PN, Gulati SS, Gadre VV. Tobacco usage in school children in Bombay, India. A study of knowledge, attitude and practise. Indian J Cancer 1991;28:139-47.  Back to cited text no. 4
Kapoor SK, Anand K, Kumar G. Prevalence of tobacco use among school and college going adolescents of Haryana. Indian J Pediatr 1995;62:461-6.  Back to cited text no. 5
Rode P, Oswald J. Teens and tobacco in Minnesota. New findings from the Minnesota youth tobacco survey. Minn Med 2001;84:42-6.  Back to cited text no. 6
Moberg DP, Rettammel RJ. Tobacco use trends and correlates among students in the Madison Metropolitan School District. WMJ 2001;100:43-8.  Back to cited text no. 7
Dar NA, Bhat GA, Shah IA, Iqbal B, Makhdoomi MA, Nisar I, et al. Hookah smoking, nass chewing, and oesophageal squamous cell carcinoma in Kashmir, India. Br J Cancer 2012;107:1618-23.  Back to cited text no. 8
Maziak W, Fouad FM, Asfar T, Hammal F, Bachir EM, Rastam S, et al. Prevalence and characteristics of narghile smoking among university students in Syria. Int J Tuberc Lung Dis 2004;8:882-9.  Back to cited text no. 9
Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: A re-emerging strain in a global epidemic. Tob Control 2004;13:327-33.  Back to cited text no. 10
Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics 2005;116:e113-9.  Back to cited text no. 11
Brockman LN, Pumper MA, Christakis DA, Moreno MA. Hookah's new popularity among US college students: A pilot study of the characteristics of hookah smokers and their facebook displays. BMJ Open 2012;2:E001709.  Back to cited text no. 12
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.  Back to cited text no. 13
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.  Back to cited text no. 14
Ray CS. The hookah-The Indian waterpipe. Curr Sci 2009;9:19-23.  Back to cited text no. 15
John RM. Household's tobacco consumption decisions: Evidence from India. J South Asian Dev 2006;1:119-47.  Back to cited text no. 16
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.  Back to cited text no. 17
WHO. WHO Study Group on Tobacco Product Regulation (TobReg). Waterpipe tobacco smoking: Health effects, research needs and recommended actions by regulators. Advisory Note. Geneva, Switzerland 2005. p. 1-11.  Back to cited text no. 18
Kiter G, Uçan ES, Ceylan E, Kilinç O. Water-pipe smoking and pulmonary functions. Respir Med 2000;94:891-4.  Back to cited text no. 19
Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: Levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther 2002;40:249-55.  Back to cited text no. 20
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.  Back to cited text no. 21
Shihadeh A. Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 2003;41:143-52.  Back to cited text no. 22
Raval S, Maudgal S, More N. Study on tobacco use and awareness among marginalized children. Indian J Cancer 2010;47 Suppl 1:14-8.  Back to cited text no. 23
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.  Back to cited text no. 24
Chadda R, Sengupta S. Tobacco use by Indian adolescents. Tob Induc Dis 2002;1:111-9.  Back to cited text no. 25
Sreeramareddy CT, Kishore P, Paudel J, Menezes RG. Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey. BMC Public Health 2008;8:97.  Back to cited text no. 26
Notani P. Epidemiology and prevention of head and neck cancer: A global view. In: Saranath D, editor. Contemporary Issues in Oral Cancer. New Delhi: Oxford University Press; 2000. p. 1-29.  Back to cited text no. 27
Primack BA, Aronson JD, Agarwal AA. An old custom, a new threat to tobacco control. Am J Public Health 2006;96:1339.  Back to cited text no. 28
Varsano S, Ganz I, Eldor N, Garenkin M. Water-pipe tobacco smoking among school children in Israel: Frequencies, habits, and attitudes. Harefuah 2003;142:736-41, 807.  Back to cited text no. 29
Israel E, Loffredo C, El-Setouhy M, Mohamed MK. Egyptian Smoking Prevention Research Institue (ESPRI). J Egypt Soc Parasitol 2003;33:1009-17.  Back to cited text no. 30
Ward KD, Eissenberg T, Rastam S, Asfar T, Mzayek F, Fouad MF, et al. The tobacco epidemic in Syria. Tob Control 2006;15 Suppl 1:i24-9.  Back to cited text no. 31
Fiala SC, Morris DS, Pawlak RL. Measuring indoor air quality of hookah lounges. Am J Public Health 2012;102:2043-5.  Back to cited text no. 32
Cobb CO, Vansickel AR, Blank MD, Jentink K, Travers MJ, Eissenberg T. Indoor air quality in Virginia waterpipe cafes. Tob Control 2012; 2011-050350.  Back to cited text no. 33
Ministry of Health and Family Welfare, Government of India. (2003) Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce Production, Supply and Distribution) Act, 2003 and Related Rules and Regulations.  Back to cited text no. 34


  [Table 1], [Table 2]

This article has been cited by
1 Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review
Adam Arshad,Jaideep Matharoo,Ebrahim Arshad,Simardeep Singh Sadhra,Rosemary Norton-Wangford,Mohammed Jawad
BMC Public Health. 2019; 19(1)
[Pubmed] | [DOI]
2 Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review
Li-Ling Huang,Hannah M Baker,Clare Meernik,Leah M Ranney,Amanda Richardson,Adam O Goldstein
Tobacco Control. 2017; 26(6): 709
[Pubmed] | [DOI]
3 Hookah addiction among adolescents of five major cities in Central India
Vishal Khandelwal,Ullal Anand Nayak,Prathibha Anand Nayak,Sudeep S. Iyer,Yash Bafna
International Journal of Adolescent Medicine and Health. 2017; 29(6)
[Pubmed] | [DOI]


Print this article  Email this article


  Site Map | What's new | Copyright and Disclaimer
  Online since 1st April '07
  © 2007 - Indian Journal of Cancer | Published by Wolters Kluwer - Medknow