JRHS 2014; 14(4): 268-271

Copyright© Journal of Research in Health Sciences

Prevalence of Hookah Smoking in Relation to Religiosity and Familial Support in College Students of Tabriz, Northwest of Iran

Asghar Mohammadpoorasl (PhD)a, Abbas Abbasi-Ghahramanloo (MSc)b, Hamid Allahverdipour (PhD)c*, Jabiz Modaresi Esfeh (PhD)d

a Department of Public Health, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran

b Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Science, Tehran, Iran

c Clinical Psychiatry Research Centre & Department of Health Education and Promotion, School of Health & Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran

d Department of Nutrition, School of Public Health, Alborz University of Medical Sciences, Karaj, Iran

* Correspondence: Hamid Allahverdipour (PhD), E-mail: allahverdipourh@tbzmed.ac.ir

Received: 30 June 2014, Revised: 30 September 2014, Accepted: 25 October 2014, Available online: 02 November 2014


Background: Hookah smoking has increased worldwide especially among youth and young adults and has been identified as an emerging threat to public health. The aim of the present study was to determine the prevalence of hookah use and related factors in a sample of Iranian college students.

Methods: This study took place in Tabriz (northwest of Iran) in April and May 2011. The randomly selected sample consisted of 1837 college students. Data was collected in a survey. A self-administered questionnaire was used to measure religious belief, parental support and risk taking behaviors including hookah smoking. Logistic regression model was performed in data analysis.

Results: The prevalence of hookah smoking was 8.5% (CI95%: 7.3-9.9). After adjustment, being male (OR= 2.01), living in single house in comparison with living with parents (OR= 2.22), smoking (OR= 5.96) and ever drug abuse (OR= 3.02) were factors associated with students hookah use.

Conclusions: Our results showed a low prevalence of hookah smoking in Iranian college female students and revealed some of its associated factors. We demonstrated the co-occurrence of risky behaviors which emphasizes the importance of interventions aimed at reducing or preventing different high risk behaviors simultaneously.

Keywords: Water-Pipe, Substance Abuse, Familial Support, Religiosity, Risk-Taking Behaviors, College Students


Hookah smoking has increased worldwide especially among youth and young adults and has been identified as an emerging threat to public health1. Compared to smoking a single cigarette, a single hookah tobacco session exposes users to a higher nicotine dose, greater carbon monoxide, and more than 40 times the smoke volume2.

Lifetime prevalence of hookah use increased from 29% at college entry to 45% at one-year follow-up at a large private university in upstate New York 3. Primack et al. 4 found that the prevalence of hookah smoking among United States college students in lifetime, over the past year and over the past 30 days were 40.5%, 30.6% and 9.5%, respectively.

The results of two national health and disease evaluations in 1991 and 1999 showed that hookah smoking is increasing among 15-24 years old males and females in Iran5. Overall the rate of hookah smoking across the country is 5.3% and in the southern cities is 8.2% 6,7. The results of Ghoreshi and Shajari study in Zanjan showed that 13% and 4.2% of university students were occasionally and regular hookah user, respectively8.

Unfortunately, there is little information about hookah smoking among college students in Iran. The aim of the present study was to estimate the prevalence of hookah smoking among a representative sample of college students in Tabriz City, and to evaluate the associated factors.


A sample of 1837 college students was selected by random proportional cluster sampling by considering student's study fields from nine universities in Tabriz, northwest of Iran. During April and May 2011, a self-administrated questionnaire was distributed to the students. The questions were aimed at obtaining information on hookah use, drug abuse, alcohol consumption, smoking, unsafe sex, parental support, religious beliefs, as well as demographic information.

The Ethics Committee of Tabriz University of Medical Sciences approved the study and its questionnaire. To enhance the validity of students self-reports, they were assured about strict confidentiality of their responses and were informed that they could not be recognized by their answers. They were also informed about the voluntary nature of their participation in the study and their right to refuse or skip any questions.

The survey questionnaire was pilot tested on 97 college students similar to study participants. The purpose of the pilot test was to 1) examine the utility of the questionnaire and 2) collect data to examine its reliability. The pilot test input was used to modify the instrument.

Students who used hookah at least once per month were considered as hookah users. Students who had smoked 100 cigarettes or more in their lifetime were considered cigarette smokers irrespective of their current smoking status. Having unsafe sex was defined as using drugs or alcohol before the last sexual relationship, having sexual intercourse with different partners, or having sex without using condom. Alcohol use was defined as consuming alcohol in the past 30 days. Ever use of any illicit drugs such as ritalin, methamphetamine, ecstasy, cannabis, opium and heroin were regarded as drug abuse.

Religious beliefs were evaluated by a 28-items questionnaire with potential score range of 28 to 140, in which higher scores indicated stronger religious beliefs. Parental support was measured by a 13-items questionnaire with potential score range of 13 to 65, in which higher scores indicated more parental support. More detail about items, validity and reliability of these questionnaires has been presented elsewhere9.

Logistic regression model, Chi- Square test and t-test were used for statistical analysis, performed, by SPSS-16 (Chicago, IL, USA) and Stata-10. Final logistic regression model was selected by using likelihood ratio test.


The mean age of the subjects was 22.1±2.27 (min. 18, max. 34). The majority of the sample was females (59.90%). Only 7.9 % of the sample was married. Among 1843 students, 157(8.5%, CI95%: 7.3-9.9) had a history of smoking hookah. Table 1 shows the frequency distribution of the hookah smoking by gender. As it can be seen in this table, hookah smoking is more prevalent among the males as compared with females.

Table 2 presents the demographic and key characteristics of the sample, as well as the conditional distribution of hookah smoking at each level of the variables. As seen in this table, marital status and residency status had no significantly relationship with hookah smoking status. Age, gender, living in status, having job along with education, smoking status, having unsafe sex, alcohol consumption, a history of drug abuse, religious beliefs and familial support had a significant relationship with hookah smoking status.

A logistic model was used to evaluate the relationship of all variables listed in Table 2 except marital status with hookah smoking. The results of these analyses (Table 3) indicated that, being male increases the risk of hookah smoking as two folds (OR= 2.01); living in single house in comparison to living with parents increases the risk of hookah smoking more than two times (OR= 2.22); cigarette smoking increases the risk of hookah smoking about six folds (OR= 5.96) and a history of drug abuse increases the risk of hookah smoking about three times (OR= 3.02).

Table1: Prevalence of hookah smoking by gender

Table 2: Demographic characteristics of the students by “hookah use"

Table 3: Logistic regression analysis of the relationship between hookah smoking and risk variables in a sample of Iranian students in Tabriz (2011)


The prevalence of hookah smoking (at least once per month) in this study was 8.5%. We also realized that 39.4% of the samples had at least tried hookah smoking in some occasions. These results in comparison with studies undertaken in southern parts of Iran and in other countries are relatively low. The results of a study in a random sample of university students at two major universities in South Iran showed that respondents lifetime and in the last 30 days hookah smoking was 42.5% and 18.7%, respectively10. In a random sample of college students in United States, the lifetime and past 30 day prevalence rates were 40.5% and 9.5%, respectively4. Results of a study in Midwestern University students with average age of 23.1 yr old revealed that approximately 15.4% of the samples had previously smoked hookah, while 6% had smoked hookah within the past 30 days11. Fielder et al.3 showed that lifetime prevalence of hookah use among first-year female college students increased from 29% at college entry to 45% at one-year follow-up. Current (past 30 days) hookah use ranged from 5% to 13% during the year after college entry. In addition, the prevalence of hookah smoking was 40% for male college student in Saudi Arabia12. In Poland 38% of high school and college students had smoked water pipeat least once in their life, and 22% had smoked hookah during the last 30 days13.

Findings show that hookah smoking prevalence is much higher in males than in females. (15.5% vs. 3.8%). The logistic regression models demonstrated that being male increases the risk of hookah smoking by 2.01. These results are similar to previous studies results performed in Iran which has shown that substance use including cigarette smoking and hookah smoking is more prevalent among   men5-7.

We identified that youth who are current smokers were more likely to use or have used hookah compared with nonsmokers (OR=5.96), and those who had tried illicit drugs were more likely to use or have used hookah (OR=3.02). These findings are consistent with existing research 14,15. We also identified that students who had used alcohol in the past 30 days and those who had unsafe sex (OR=1.64) were also more likely to use hookah, however in logistic regression alcohol use did not remain in the model. Numerous studies have emphasized the co-occurrence of risky behaviors 14,16-22. Considering co-occurrence, co-changing is one of the most effective approaches in prevention of high risk behaviors. Co-occurrence of risky behaviors in the present study further highlights the importance of implementing co-morbid substance use prevention programs in students.

Several studies have demonstrated the role of religious beliefs and parental support in the prevention of high risk behaviors 23-28. However the mean score of religious beliefs and parental support of hookah users were significantly lower than other students, but the results of logistic regression model showed that these variables has no significant association with hookah smoking status.


Our results show low prevalence of hookah smoking in Iranian college female students. We also identified some factors associated with hookah smoking. Our study represents the co-occurrence of risky behaviors which endorses the importance of interventions aimed at reducing or preventing different high risk behaviors simultaneously.


Funding for this study was provided by Tabriz University of Medical Sciences. The authors would like to acknowledge all participants of the study.

Conflict of interest statement

The authors declare that there are no conflict of interests.


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