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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.100 n.5 Pretoria May. 2010




High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg



A CombrinkI; N IrwinI; G LaudinI; K NaidooI; S PlagersonII; A MatheeIII

IMB ChB. Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
IIPhD. Environment and Health Research Unit, South African Medical Research Council, Johannesburg
IIIPhD. Environment and Health Research Unit, South African Medical Research Council, Johannesburg, and Faculty of Health Sciences, University of Johannesburg



To the Editor: Smoking of hookahs (also known as water-pipes) represents an emerging trend in tobacco use.1 Hookah smokers are at risk for the same diseases caused by cigarette smoking - cancer, respiratory and heart diseases, and pregnancy-related complications. Globally, the highest rates occur in the North African and East Mediterranean regions and among young people in the USA and European countries.2 There has been little research on hookah smoking in southern Africa.


The Health, Environment and Development study,3 conducted by the South African Medical Research Council in five deprived areas of Johannesburg, observed surprisingly high rates of smoking in a community near the centre of Johannesburg. Anecdotal reports and direct observations pointed to a high frequency of hookah smoking as a possible explanation. Subsequently, undergraduate medical students of the University of the Witwatersrand were invited to conduct a health education workshop on the effects of hookah smoking in the secondary school serving this community. To inform the workshop, a baseline survey was conducted among the student population. All Grade 10 students were invited to participate. Approval to conduct the study was obtained from the school principal, and verbal consent was obtained from the individual students, following an explanation that the study was voluntary and anonymous and that the results would be used for research purposes only. The ages of participants (N=202) in the four classes were from 14 - 20 years (mean 16.3 years). Three students elected not to participate.


The survey findings are summarised in Table I; 72% of respondents reported having used a tobacco product, including over 60% who said they had used or were using hookahs at the time of the study. A third of hookah users and a fifth of the entire sample reported daily use. Most respondents started smoking hookahs between the ages of 13 and 15, while 21% had started when <12 years old. The most common setting for smoking was social occasions (such as parties), with many also reporting home use. While the norm was to use tobacco in the hookah, significant numbers also reported using marijuana and/or alcohol-based products in combination with tobacco. Almost 10% of the total sample reported using marijuana in hookahs. The most common reason for smoking a hookah was the absence of alternative recreation ('nothing better to do'); other reasons were peer pressure, relaxation and addiction.

Among non-users, the vast majority said they would not consider smoking a hookah in the future; however, 39% had been subjected to pressure from peers to do so. Hookahs were perceived to be safer than cigarettes by most users, but as equally unsafe by the majority of non-users.



The survey highlighted an alarmingly high rate of hookah use among the schoolchildren surveyed. Sixty per cent of study participants reported use of a hookah, including 20% who reported daily use, which is comparable with the rates observed among youths in settings where the use of hookahs is traditional.4 Our survey further highlighted the commencement of hookah use at a young age and the widespread use of tobacco in combination with substances such as alcohol and marijuana. In line with studies conducted elsewhere, the survey points to a widely held belief among users that hookah smoking is less harmful than other forms of smoking.5 Nevertheless, levels of awareness of the equally damaging effects to health of cigarettes and hookahs were higher among non-users.

Though conducted on a small scale, our study plays an important role in bringing to light the disturbingly high prevalence of hookah smoking in one community, and points to an urgent need to conduct research on a nation-wide basis to determine the extent of hookah smoking in South Africa and the factors associated with its use. The reasons given by participants for commencing hookah smoking (e.g. boredom and a lack of recreational opportunities) imply a probable need for social and public health interventions that provide safer recreational alternatives to urban youth in Johannesburg and very likely elsewhere in South Africa.



1. Maziak W, Ward D, Afifi S, Soweid R, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13(4): 327-333.         [ Links ]

2. WHO. Waterpipe Tobacco Smoking: Health EffectsResearch Needs and Recommended Actions by Regulators. Geneva: World Health Organization, 2005.         [ Links ]

3. Mathee A. Indicators of Health, Environment and Development: A Longitudinal Study in Johannesburg 2006-2008. Johannesburg: World Health Organization Collaborating Centre for Urban Health, 2009.         [ Links ]

4. Afifi R, Yeretzian J, Rouhana A, Nehlawi M, Mack A. Neighbourhood influences on narghile smoking among youth in Beirut. Eur J Publ Health 2009; 2 Nov [epub ahead of print]         [ Links ].

5. Roskin J, Aveyard P. Canadian and English students' beliefs about waterpipe smoking: a qualitative study. BMC Publ Health 2009; 10(9): 10.         [ Links ]



Accepted 24 December 2009.



Corresponding author: S Plagerson (

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