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 Table of Contents  
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 30-35

Rising popularity of “tobacco-free” hookah among youth: A burgeoning public health challenge for India!

Program Officer, Jhpiego, India

Date of Web Publication18-Jul-2017

Correspondence Address:
Pavan Pandey
E-33 Surya Apartments, Model Town, Nehru Nagar (E), Bhilai - 490 020, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jncd.jncd_14_17

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The world is experiencing a second tobacco consumption pandemic in the form of increasing hookah use among youths. Post-1990s, there has been an unprecedented increase in the number of hookah smokers across the world. Despite having a well-formulated tobacco control policy, India has one of the highest numbers of tobacco users in the world. The increase in the proportion of hookah smokers to the levels currently seen in Middle Eastern countries would prove disastrous for India's demographic dividend. However, compared to rest of the world, India is witnessing a slightly different problem in the form of an increase in the number of “tobacco-free” hookah users. This article reviews global hookah smoking trend and how India is ill prepared to counter the increasing hookah use among youths and suggests what government needs to do to prevent global hookah smoking pandemic to spread in India.

Keywords: Hookah, India, smoking, tobacco free, youth

How to cite this article:
Pandey P. Rising popularity of “tobacco-free” hookah among youth: A burgeoning public health challenge for India!. Int J Non-Commun Dis 2017;2:30-5

How to cite this URL:
Pandey P. Rising popularity of “tobacco-free” hookah among youth: A burgeoning public health challenge for India!. Int J Non-Commun Dis [serial online] 2017 [cited 2023 Mar 31];2:30-5. Available from: https://www.ijncd.org/text.asp?2017/2/2/30/211073

  Introduction Top

India is currently at the midriff of an epidemiological transition. While the deaths due to communicable diseases are declining, those due to noncommunicable diseases are on the rise.[1] Currently, cardiovascular diseases, cerebrovascular diseases, and chronic obstructive pulmonary disease are the most common causes of death among adults in India.[1] Tobacco use is an important causative factor for both the development as well as death due to numerous noncommunicable diseases.[2],[3] A series of surveys conducted in the recent years have concluded that there is an upward trend for tobacco smoking among Indian youth.[4],[5],[6] This means that morbidity and mortality due to tobacco-related diseases will further increase in India in the coming future. Evidence from Western countries suggests that any significant reduction in the proportion of deaths due to noncommunicable diseases would not be possible without reducing the number of tobacco consumers in the country. This article reviews the trends in hookah use throughout the world, its implications for India, and suggests measures to shield India from adverse effects of global hookah pandemic.

  Hookah Smoking “ the Second Global Tobacco Pandemic Top

Review of global trends has made epidemiologists believe that ever-increasing use of hookah among youth represent “the second global tobacco pandemic” since the introduction of cigarettes.[7] Hookah smoking was initially limited to Eastern Mediterranean and Southeast Asian countries.[8] Middle Eastern countries of the early 1990s are believed to be the epicenter of current global hookah pandemic.[9] Before the 1990s, crude unprocessed tobacco was used as the key ingredients by most hookah users in Middle Eastern countries.[9] Then came the “Maassel,” also known as “flavored hookah,” and everything changed for worse.[9]

Epidemiologists on the basis of anecdotal evidence(s) believe that a temporal link exists between mass production of Maassel and the surge in the number of young hookah smokers in the world.[9] Data from the world over prove that Maassel is the preferred tobacco used with hookah by the majority of today's smokers, especially youth.[9]Maassel is a variety of tobacco used in hookah for smoking; it is manufactured by mixing tobacco with molasses, flowers, glycerine, and fruits at the time of fermentation, thus resulting in a moist pliable mixture with a sweet eccentric aroma.[10] Traditional hookah emitted strong and harsh smoke, unlike the smooth aromatic smoke of Maassel.[10] In addition to providing young users with varieties of flavors with pleasant aroma for smoking, Maassel had simplified the process of hookah preparation. Many tourists who visited Middle Eastern countries during the 1990s were seduced by Maassel's smooth soothing aroma; they carried Maassel with them on way back home, thus paving way for the initial spread of Maassel to Western countries and later to other parts of the world.[9] However, the recent surge in popularity of hookah among youth is attributed to the marketing agency's pioneering use of internet and social networking websites to woo young population.[11]

Ever since the introduction of Maassel, hookah use is increasing globally, particularly among schoolchildren and university students.[12],[13],[14] The Global Youth Tobacco Survey reported that the prevalence of hookah use among children aged 13–15 years varied from 6% to 34% in the surveyed countries.[14] The rise in tobacco use among children in about 34 surveyed countries was specifically attributed to increases in the number of hookah smokers rather than cigarette smokers. Thus, it would be safe to conclude that what Maassel did for hookah is equivalent to what Bonsack machine did for cigarettes.[9]

The Eastern Mediterranean Region has the highest prevalence of hookah smoking in the world, especially among young people. In some countries of this region, the prevalence of hookah smoking among children aged 13–17 years was higher than cigarette smoking.[14] A national level study conducted in the USA reported that the prevalence of current hookah smokers among university student was 8.4%.[15] Of all current hookah smokers, 51.4% reported no current cigarette use.[15] Of the total 104,434 respondents of survey, 31,749 (30.4%) reported to have used hookah in the past for some time; of these 31,749 participants, 29.7% reported of never using cigarettes.[15] In a survey conducted across 28 countries of the European Union, 16% of respondent reported that they had tried a hookah at least once.[16] In South Asian region, the prevalence of hookah use among men was highest in Bangladesh (1.3%), followed by India (1.1%), Indonesia (0.3%), and Thailand (0.03%); the prevalence of hookah use among women was highest in India (0.6%), followed by Bangladesh (0.2%) and Thailand (0.01%).[6],[14]

  Hookah Smoking in India “ Making of a Tragedy Top

India is believed to be one of the places where hookah was first used ever.[8] Traditionally, in India, hookah smoking was limited to middle-aged to elderly male residing in the rural areas of the country. In India, the prevalence of hookah smoking was significantly higher in people aged >50 years than in those aged <30 years (2.0% vs. 0.3%), in those living in rural rather than urban areas (1.1% vs. 0.0%), and among those with lower rather than higher educational attainment (1.4% vs. 0.0%).[6] Lately, anecdotal evidence from newspapers, online resources, and social networking sites hint that global hookah pandemic has started affecting India's youth; today most pubs, discotheques, restaurants, and bars are offering so-called “tobacco-free” “flavored” hookah to youth without any regulation.[17],[18] Moreover, a number of so-called hookah lounge/bar/ café have grown up like mushrooms in almost all major Indian cities; these lounges are strategically located at places frequented by youngsters such as near college campuses, schools, malls, and coaching classes.[17],[18] This sudden increase in a number of hookah cafés in Indian cities is very similar to the trends first seen in Western countries. In the UK, London alone has more than 400 exclusive hookah cafés. In the USA, the number of hookah cafés has increased dramatically in the past decade, and most such cafés are often situated around university campuses.[19] In a study conducted on students of eight US universities, hookah smoking was associated with the presence of a hookah café/restaurant within a 10-mile radius of the university campus.[20] Increasing availability of hookah at multiple locations in different Indian cities proves that hookah smoking is swiftly gaining popularity among urban Indian youth (students and young professionals) of both genders.[21],[22],[23]

Perhaps, the most disturbing fact about this trend is the profound use of the prefix “tobacco free” with the “flavored hookah” offered at these places, which misleads the users in believing that smoking such hookah will not cause any harm or addiction. Such nomenclature prompts youth including minors to initiate and continue smoking such “tobacco-free” hookahs without knowing what kind of health hazards can be caused by smoking these hookahs. Experimental studies have proven that the concentration of many harmful substances (carbon monoxide, polyaromatic hydrocarbons, and volatile aldehydes) in the smoke emitted from “tobacco-free” hookah was equal to or greater than those from a tobacco-based hookah.[24],[25] Thus, except for nicotine, smoke from tobacco-free hookah has the similar toxicological profile (content and biological activity) as that of tobacco-containing hookah.[24],[25]

Several longitudinal studies have shown that smoking hookah increases the odds of initiating cigarette smoking by nonsmokers.[26],[27] This is perhaps the most menacing public health threat that India will transpire if the rising popularity of hookah among youth remains unchecked. Even among exclusive hookah smokers, it increases the chance of dual (both cigarette and hookah) addiction. At present, India has a significant chunk of global tobacco users, and the projections indicate that the number of tobacco smokers is continuously increasing every year.[28] This agonizing situation will be further worsened by any increase in the number of “tobacco-free” hookah smokers because the current evidence(s) tell us that some proportion of these hookah smokers will ultimately become addicted to cigarette smoking.[26],[27] Even those who do not start smoking cigarette will suffer from health hazards of “tobacco-free” hookah.[24],[25] Probably, the worst health outcome would be seen among those who continued to smoke both hookahs as well as cigarettes.

Over the due course of time, this increase in the number of smokers (both hookah and cigarette) will result in higher incidence of morbidity and mortality due to smoking-related noncommunicable diseases. Thereafter, the physical burden of morbidity will transform into economic burden due to health related out of pocket expenditure and reduced productivity.

  Hookah Smoking “ a Threat for India's Demographic Dividend Top

Surveys conducted in Western countries revealed that young population (survey respondents) believe that hookah smoking has fewer side effects as compared to cigarette smoking and respondent believed that they were not addicted to hookah and can quit hookah smoking anytime they feel.[29],[30] In a sharp contrast to their beliefs, evidence suggests that smoking hookah can cause several independent health hazards in addition to all adverse health outcome associated with cigarette smoking.[25],[31],[32] This is because hookah smoke contains many similar chemicals as cigarette smoke, including those responsible for the cardiovascular disease (carbon monoxide), lung disease (volatile aldehydes), cancer (polycyclic aromatic hydrocarbons), and addiction (nicotine).[25],[31],[32]

The following facts suggest that hookah smoking might actually be more dangerous than cigarette smoking;first, a single hookah is often shared by several individuals (friends) during any hookah smoking session, thus exposing many people at a time.[31] Second, smoke from hookah feels less irritating as compared to cigarette smoke; the smoke is filtered through water before inhalation, smoke from flavored hookah has a sweet eccentric aroma, and it contains additives which mask the irritating effects of smoke on the upper respiratory system.[29],[30] Smooth inhalation of smoke makes users inhale a larger amount of smoke deeper into their lungs, thus increasing the amount of toxicant absorbed in users blood.[32] Such smooth and deeper inhalation makes users believe that hookah smoking is less harmful and makes cigarette smokers believe that switching to hookahs would reduce their health risks.[31] Third, each session of hookah smoking lasts much longer than the duration of a single cigarette (½–1 h vs. 5 min), thus increasing the amount of smoke inhaled by users. A pooled study concluded that smoking hookah on daily basis is equivalent to smoking ten cigarettes a day.[33] Finally, sharing the mouthpiece of hookah can help spread infectious diseases such as tuberculosis, herpes, and influenza among its users.[7] Second-hand smoke generated from longer sessions of hookah contains a higher amount of toxicants as compared to cigarette's smoke, thus posting a higher danger to the passive smoker.[34]

Despite the availability of evidence (s) about health hazards of hookah smoking, the Government of India to date has no reliable estimate of the number of “tobacco-free” hookah smokers and the number of hookah lounges functioning in India. At present, we do not have any idea about how many “tobacco-free” hookah smokers ultimately become addicted to cigarette smoking or to hookah smoking itself. Till now, only a handful of studies has focused on the use of hookah by Indian youngsters.[21],[22],[23],[35]

  What Government of India Needs to Do? Top

The government needs to frame an overarching policy to close all the existing loopholes in the present system so as to prevent the harm caused due to unregulated sale and consumption of hookah by youth, especially by minors. For decades, tobacco industry questioned the validity of evidence(s) linking tobacco use with adverse health outcome(s) among smokers and labeled the evidence(s) as “flawed,” “biased,” and “inconsistent.” Such tactics misled policy-makers in delaying the implementation of an effective tobacco control measures in India. There is little doubt that the same story would be repeated with “tobacco-free” hookah if the government does not act now. This seems to be an apt time for formulating a clear-cut policy for “tobacco-free” hookah because the problem is not large enough, and hookah industry is not yet powerful (financially) enough as cigarette industry to interfere in policy formulation. To be effective any hookah, control policy must be formulated on the basis of sound scientific research and should follow the process of documentation, analysis, and prescription in that order.[36]

  Filling the Data Gap Top

Before formulating a policy, we need to know with absolute precision as why, where, when, and people of which age group are using the so-called “tobacco-free” hookah and at what frequency. We need to be sure about user's attitude and extent of knowledge about “tobacco-free” hookah. This information will form the basis of our actions, recommendations, regulations, and policy. Thus, the very first thing the Government of India needs to do is to commission a large-scale survey to assess the exact magnitude of “tobacco-free” hookah smoking among youth. There is need to conduct an exclusive survey for “tobacco-free” hookah smoking because the routinely conducted survey focuses on the use of tobacco either in smokeless or smoked form. Moreover, the pattern and behavioral determinants of “tobacco-free” hookah use cannot be fully captured by the questionnaire/tools developed for cigarettes.[37],[38],[39] Data from such survey would help us in designing appropriate interventions (health education message, warning labels, formulating marketing restrictions, and minimizing minor's access) for reducing the hookah use among youth. To get even a more detailed picture of the extent of the problem, governmental agencies which deal with youth such as educational institute should include questions related to hookah smoking in their routine surveys. The inclusion of such questions will help in gathering time bound data at regular interval for making accurate predictions about incidence, prevalence, and trends for hookah smoking, thus helping policy-makers and public health professionals to make better decisions.

  Filling the Research Gap Top

The government needs to set up a committee to look into the existing evidence (s) about the health hazards of hookah smoking and review the interventions and policy framework developed by other countries to counter the menace of hookah smoking.[24] Laboratory-based research is also needed to determine the exact biochemical (heavy metal, toxic, neurostimulant, and carcinogenic) content of the smoke emitted from “tobacco-free” hookah used in India.[40],[41] Scientists need to develop biomarker(s) to assess the concentration of biochemical compound(s) inhaled through smoke to determine the addiction and withdrawal pattern among hookah smokers.[40],[41] Finally, the government also needs to commission large-scale analytical studies in India to verify the adverse health outcome from smoking of “tobacco-free” hookah.

  Filling the Policy Gap Top

Right now, perhaps, the most important thing government needs to do is to clearly define the term “tobacco-free” hookah in the context of India's current tobacco control policies. Does the term “tobacco free” means that its use will not cause any health hazard and hence it does not require any kind of “statutory warning” similar to cigarettes and such “tobacco-free” hookah can be served to a person of any age group including minors? Moreover, since it is “tobacco-free” hookah, so the current rules which apply to sale and distribution of tobacco-containing products do not apply to it, and thus, “tobacco-free” hookah can be served in canteens of schools and colleges. Currently, hookah instrument and smoking powder are sold at shops and online to anyone including minors without any restriction. Increasing popularity of “tobacco-free” hookah among youth (especially minors) can also be attributed to the fact that these so-called “hookah lounges” have become a popular destination for gathering, socializing, and partying among youth.[17],[18] Long sessions of hookah in the privacy of personal cabin at hookah lounge provide an ideal conducive environment for social interactions among youth.[42] Since even a single hookah can be simultaneously used by many friends, makes it an ideal companion to for daily/weekly discussion.[43] The prefix “tobacco free” added to these hookahs probably prevents children from having any regret of acquiring a bad habit. Closed environment of hookah lounges is toxic both to hookah smokers as well as nonsmokers because experiments have proven that at places where hookah is smoked exclusively tend to have higher concentrations of respirable particulate matter than places in where cigarettes are smoked exclusively.[34]

In the absence of any specific policy against “tobacco-free” hookah, the functioning of such hookah lounges remains largely unregulated; they do not restrict entry of minors, do not cross-check the age of customers, and do not follow the guidelines for an indoor smoke.[17],[18] Thus, it is urgent for the government to regulate the opening and functioning of hookah lounge/bar because, in addition to “tobacco-free” hookah, youth can be exposed to other forms of addictions including drugs at these places.[17],[18] Newspapers have reported that many hookah lounges in India were selling banned drugs to youth in addition to offering hookah.[17],[18] Thus, it becomes essential to restrict entry of minors at these places to prevent the youngster from picking harmful habits at an early age. The current antismoking mass media campaign is directed against conventional forms of tobacco smoking (cigarette and bidi) only and does not include hookah. The government needs to create a health education campaign directed at youth and their parents to increase their awareness about the adverse effect of hookah smoking.

Only on the basis of a sound policy, the government can regulate the production, contents, marketing, and sale of such “tobacco-free” flavored hookah. Existing loopholes are exploited by product managers and lounge owners to sell hookah without any regulation. Any such policy must at least cover following minimum points:[44]

  1. Ban on the sale of “tobacco-free” hookah to minors and hefty penalty for offenders
  2. Monitoring the opening and functioning of so-called hookah lounges
  3. Fixing the minimum distance between establishment of hookah lounge and an educational institute similar on the lines of tobacco products
  4. Prohibiting the entry of minors to all places (restaurant and lounges) which serves hookah
  5. Prohibiting the online sale of hookah
  6. Smoke from “tobacco-free” hookah must be included in the clean indoor policies similar to cigarette smoke
  7. Minimize the toxicant content of hookah by regulating production
  8. Compulsory warning labels on every hookah instrument
  9. Mandatory disclosure by manufacturers of the contents and emissions of hookah smoke
  10. Tax on the “tobacco-free” hookah on the lines of tobacco products.

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Conflicts of interest

There are no conflicts of interest.

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