Intentions to Use Hookah Among Israeli-Arab Youth: From Socioeconomic-Status to Planned Behavior and Beyond

Background: Narghile (hookah) smoking is spreading throughout the world. But tobacco, a major component of hookah smoking, has many health effects that can even result in death. According to the World Health Organization every 6.5 seconds a person dies worldwide from tobacco damage. Hookah smoking is a new behavior among young people in general, and young people in Israeli society in particular. The accepted perception among teenagers for hookah smoking is that the activity is of low risk and great pleasure. This is despite the objective damage that smoking may cause.

Goal: The present study examined factors influencing the decision of youth from the Arab society in Israel to smoke hookahs. In particular the study compared factors drawn from social deprivation theory compared to factors drawn from planned behavior theory in predicting hookah smoking. It was hypothesized that high socioeconomic-status (SES) would lower intention to smoke hookah, that personal attitudes, and social norms supporting hookah smoking would be associated with higher intention to smoke, and that higher self-esteem would lower the effect of social norms, while increasing the effect of personal attitudes.

Method: Young male Israeli-Arabs (n=221), ages 18-22 were surveyed by means of purposive convenience sample. Response rate was 80.4% (out of 275 that were approached). The survey questionnaire included socio-demographic background variables (including parental education, perceived relative SES family status, housing density, and geographic housing locality), as well as Rosenberg's self-esteem questionnaire, and a questionnaire measuring the factors of Planned Behavior Theory, including Attitudes, Social Norms, Perceived Control, and Intention to smoke hookah. All Variables were examined for validity and reliability in previous studies, and had high reliability scores in the current study. Analysis was conducted using stepwise regression, in three steps. First step included SES and demographic variables and, second step added Planned Behavior variables and self-esteem, third step added interaction terms of self-esteem and attitudes and self-esteem and social-norms.

Results: The first step has indicated that higher SES and higher mother's education were positively associated with intention to smoke hookah, however, those effects were rendered insignificant with the introduction of self-esteem and theory of reasoned action variables. Attitudes, social norms, self-control, and self-esteem were all found to be positively associated with intention to use hookah. The interaction of attitudes and self-esteem was negative and overall decreased the slope of the regression curve, indicating that higher self-esteem has complex relationships with intention to smoke.

Conclusions and implications: One of the major goals of social work is to decrease health hindering behaviors among youth. Understanding role variables such as socio-economic status, self-esteem, and attitudes, social-norms, and self-control on intention to use hookah, would enhance the ability of social workers to develop interventions directed at reducing health-risk behaviors. The study has implications for intervention as well as for further research, including expanding the model to other health-risk behaviors. Those implications will be discussed extensively in the presentation.