Assessing awareness, knowledge, and perceptions of hubbly bubbly smoking health risks among South African university students

Aniekie Motloutsi
a:1:{s:5:"en_US";s:26:"University of johannesburg";}
Elizabeth Lubinga
University of johannesburg


Globally, the smoking of hubbly bubbly tobacco pipes is a growing trend among young people. However, the promotion of health awareness about hubbly bubbly (HB) smoking risks does not appear to be common, especially in South Africa. This study intended to assess awareness of the HB smoking health risks among students; to determine the students’ knowledge levels about its risks; to examine the students’ perceptions of HB smoking and to determine whether their knowledge and perceptions on smoking health risks would influence their HB smoking behaviour intentions. The Extended Parallel Process Model was applied. A quantitative approach was applied with a sample of 350 students participating in the study: n = 175 HB users and n = 175 non-users. A 2×2 experimental design between and within participants was followed. Results indicate that most participants (75%) had not heard or seen any health communication awareness campaigns about HB risks and that knowledge about HB smoking health risks was inadequate. Most participants in the study, including both HB users 74% (129) and non-users 80% (140), were able to identify lung cancer as one of the health risks of HB smoking. This study is important to health promotion organisations including government departments to enable them to construct effective health communication messages.


  1. Akl, E., Jawad, M., Lam, W., Co, C., Obeid, R., and Irani, J. 2013. Motives, beliefs, and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduction, 10(12):1-5. DOI: 10.1186/1477-7517-10-12.
  2. Allahverdipour, H., MacIntyre, R., Hidarnia, A., Shafii, F., Kzamnegad, A., Ghaleiha, A. and Emami, A. 2007. Assessing protective factors against drug abuse among high school students: Self-control and the extended parallel process model. Journal of Addictions Nursing, 18(2):65-73.
  3. Al-Naggar, R., A., and Saghir, F., S. 2011. Waterpipe (shisha) smoking and associated factors among Malaysia university students. Asian Pacific Journal of Cancer Prevention, 12(11): 3041-3047.
  4. Al-Nomay, N., S., and Ahmed, A., E. 2015. Waterpipe use and awareness of its effects on oral health in Riyadh, Saudi Arabia. Journal of Oral Hygiene and Health, 3(6):1-5.
  5. AlQahtani, J., M. 2017. Knowledge, Attitude and Practice of Tobacco Smoking among Health Colleges’ students at Njran University, Saudi Arabia: A cross-sectional descriptive study. Journal of Health Specialities, 5(1): 35-41.
  6. Alvur, M., T., Cinar, N., Akduran, F., and Dede, C. 2014. Fallacies about water pipe use in Turkish university students-what might be the consequences. Asian Pacific Journal of Cancer Prevention, 15:1977-1980.
  7. American Lung Association. 2020. Facts About Hookah. Available at (Accessed: 07 December 2021).
  8. Anjum, Q., Ahmed, F., and Ashfaq, T. 2008. Knowledge, attitude, and perception of waterpipe smoking (shisha) among adolescents aged 14-19 years. Journal of Pakistan Medical Association, 58(6): 312-317.
  9. Aslam, H., M., Saleem, S., German, S., and Qureshi, W., A. 2014. Harmful effects of shisha: a literature review. International archives of medicine, 7(1): 1-9.
  10. Awan, K., H., Alrshedan, A., Al Kahtani, M., and Patil, S. 2016. Waterpipe smoking among health sciences university students: Knowledge, attitude, and patterns of use. The Saudi dental journal, 28(4):189-193.
  11. Cancer Association of South Africa. 2015. CANSA on the Move for the Youth: Hubbly Bubbly or Hookah smoking increases cancer risks. Available at: Cancer Association of South Africa (Accessed: 07 December 2021).
  12. Combrink, A., Irwin, N., Laudin, G., Naidoo, K., Plagerson, S., and Mathee, A. 2010. High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg. South African Medical Journal, 100(5):297-299.
  13. Daniels, K., E., and Roman, N. 2013. A descriptive study of the perceptions and behaviours of waterpipe use by university students in the Western Cape, South Africa. Tobacco Induced Diseases, 11(1): 1-5.
  14. Daniels, K., E. 2012. Hookah pipe use: comparing male and female university students’ knowledge, risk perceptions and behaviours. A mini thesis submitted in partial fulfilment of the requirements for the Degree of Magister Artium in Child and Family Studies. Available at (Accessed:22 August 2022).
  15. Department of Health. 2018. Draft Control of Tobacco Products and Electronic Delivery Systems Draft Bill. Government Gazette (Vol. 635, No. 41617). Available at (Accessed: 07 December 2021).
  16. du Plooy-Cilliers, F., Davis, C., and Bezuidenhout R. 2014. Research Matters. 2nd ed. Cape Town. Juta.
  17. Essa-Hadad, J., Linn, S., and Rafaeli, S. 2015. A web-based program to increase knowledge and reduce cigarette and nargila smoking among Arab university students in Israel: a mixed-methods study to test acceptability. Journal of medical Internet research, 17(2).
  18. European Institute for Gender Equality. 2017. Awareness-raising: a study on the collection of methods, tools, and good practices in the field of domestic violence (area D of Beijing platform for action). Available at: (Accessed: 07 December 2021).
  19. Gore, T., D., and Bracken, C., C. 2005. Testing the theoretical design of a health risk message: Reexamining the major tenets of the extended parallel process model. Health Education & Behavior, 32(1):27-41.
  20. Hammad, A. 2020. ‘The Adverse Consequences of Shisha on Human Health -By Roqeebat Busari’, Opinio Nigeria, 04 July. Available at (Accessed: 07 December 2021).
  21. Health Communication Capacity Collaborative. 2014. The Extended Parallel Processing Model. Available at: (Accessed: 07 December 2021).
  22. Jawad, M., Nakkash, R., T., Hawkins, B., and Akl, E., A. 2015. Waterpipe industry products and marketing strategies: analysis of an industry trade exhibition. Tobacco control, 24(e4): e275-e279.
  23. Kakodkar, P., V., and Bansal, S., S. 2013. Hookah Smoking: Characteristics, Behaviour, and Perceptions of Youth Smokers in Pune, India. Asian Pacific Journal of Cancer Prevention, 14(7): 4319-4323.
  24. Kassem, N.O., Kassem, N.O., Liles, S., Jackson, S.R., Posis, A.I.B., Chatfield, D.A. and Hovell, M.F. 2018. Levels of urine cotinine from hookah smoking and exposure to hookah tobacco secondhand smoke in hookah lounges and homes. International journal of high-risk behaviors & addiction, 7(1).
  25. Kruger, L., M. 2014. Waterpipe tobacco smoking among university students in the Western Cape Province of South Africa: Differences and similarities to cigarette smoking. Dissertation for a Master of Commerce in the Applied Economics University of Cape Town. Available at University of Cape Town (Accessed: 07 December 2021).
  26. Lipkus, I., M., Eissenberg, Schwartz-Bloom, R., D., Prokhorov, A., V., and Levy, J. 2014. Relationships among factual and perceived knowledge of harm of waterpipe tobacco, perceived risk, and desire to quit among college users. Journal of Health Psychology, 19(12): 1525-1535.
  27. Mugyenyi, A., E., K., Haberer, J., E and O’Neil, I. 2018. Pleasure and practice: a qualitative study of the individual and social underpinnings of shisha use in cafes among youth in the UK. BMJ Open, 8(4): e018989.
  28. Naicker, N., Teare, J., Albers, P. and Mathee, A. 2020. Prevalence of hookah pipe smoking in high-school learners in Johannesburg, South Africa. South African Medical Journal, 110(6): 546-551.
  29. Nyatsanza, S. 2020. ‘There’s nothing harmless about e-cigarettes, hookah pipes’, Independent Online News South Africa, 14 July. Available at (Accessed: 07 December 2021).
  30. Obeidat, S., R., Khabour, O., F., Alzoubi, K., H., Mahasneh, A., M., Bibars, A., R., M., Khader, Y., S., and Alsa’di, A. 2014. Prevalence, social acceptance, and awareness of waterpipe smoking among dental university students: a cross-sectional survey conducted in Jordan. BMC Research Notes, 7(832): 1-8.
  31. Omole, O., B., Ogunbanjo, G., A., and Ayo-Yusuf, O., A. 2011. Review of alternative practices to cigarette smoking and nicotine replacement therapy: how safe are they? South African Family Practice, 53(2):154-160.
  32. Pepper, J., K. 2014. Waterpipes and Electronic Cigarettes: Increasing Prevalence and Expanding Science. Chemical Research in Toxicology, 27(8): 1336–1343.
  33. Phan, L., Villanti, A.C., Leshner, G., Wagener, T.L., Stevens, E.M., Johnson, A.C. and Mays, D. 2020. Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults. International Journal of Environmental Research and Public Health, 17(23): 8752.
  34. Pickens, J. 2005. Attitudes and perceptions. Available at: (Accessed: 07 December 2021).
  35. Qasim, H., Alarabi, A.B., Alzoubi, K.H., Karim, Z.A., Alshbool, F.Z. and Khasawneh, F.T. 2019. The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environmental health and preventive medicine, 24(1): 1-17.
  36. Repace, J., Kawachi, I. and Glantz, S., 1999, February. Fact sheet on secondhand smoke. In The 2nd European Conference on Tobacco or Health, the 1st Iberoamerican Conference on Tobacco or Health (:23-27). Available at (Accessed: 07 December 2021).
  37. Roskin, J., and Aveyard, P. 2009. Canadian and English students' beliefs about waterpipe smoking: a qualitative study. BMC public health, 9(1):10.
  38. Senkubuge, F., Ayo-Yusuf, O., A., Louwagie, G., M., C., and Okuyemi, K., S. 2012. Water Pipe and Smokeless tobacco use among medical students in South Africa. Nicotine and Tobacco Research, 14(6):755-760.
  39. Shearston, J., Lee, L., Eazor, J., Meherally, S., Park, S.H., Vilcassim, M.R., Weitzman, M. and Gordon, T., 2019. Effects of exposure to direct and secondhand hookah and e-cigarette aerosols on ambient air quality and cardiopulmonary health in adults and children: protocol for a panel study. BMJ open, 9(6): e029490.
  40. Shihadeh, A., and Saleh, R. 2005. Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and Nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology, 43(5):655-661.
  41. Singh, S., K., Enzhong, L., Reidpath, D., D., and Allotey, P. 2017. Shisha (waterpipe) smoking initiation among youth in Malaysia and global perspective: a scoping review (2006–2015). Public health, 144: 78-85.
  42. Thabit, M., F., Mohsin, A., A., B., and Niazy, S., M. 2015. Waterpipe (shisha) smoking among a sample of Iraqi male college students: Knowledge and attitudes. Journal of Nursing and Health Science, 4(6): 50-54.
  43. Urkin, J., Ochaion, R., and Peleg, A. 2006. Hubble Bubble Equals Trouble: The Hazards of Water Pipe Smoking. The Science World Journal, 6: 1990-1997.
  44. Van der Merwe, N., Banoobhai, T., Gqweta, A., Gwala, A., Masiea, T., Misra, M., Zweigenthal, V. 2013. Hookah pipe smoking among health sciences students. South African Medical Journal, 103(11): 847-849.
  45. Vega-Encabo, J. 2016. The concept of knowledge: what is it for? BIBLIB [0873-626X (2016) 43: 187-202]. Available at: The-concept-of-knowledge.pdf (Accessed: 07 December 2021).
  46. Witte, K. 1992. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59(4), 329-349. Available at: (Accessed: 07 December 2021)
  47. Witte, K. 1996. Predicting risk behaviors: Development and validation of a diagnostic scale. Journal of Health Communication, 1(4):317-342.
  48. Wright, D., Burrow, H., and Hurst, D. 2016. Should dental teams be doing more to make adolescents aware of the health risks of water pipe tobacco smoking (shisha)? British dental journal, 221(11):697.
  49. Zang, C., and Fan, J. 2013. A study of the perception of health risks among college students in China. International Journal of Environmental Research and Public Health, 10: 2133-2149. DOI:10.3390/ijerph10062133.
How to Cite
Motloutsi, A., & Lubinga, E. (2023). Assessing awareness, knowledge, and perceptions of hubbly bubbly smoking health risks among South African university students. Communicare: Journal for Communication Studies in Africa, 42(1), 97–112.

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