The Age-old tradition of Hookah smoking and its association with Geriatric Anaemia in rural women of north India

 

Sayani Das¹, Shivani Chandel²

¹PhD Research Scholar, Biological Anthropology Unit, Indian Statistical Institute, Kolkata, India

²Assistant Professor, Department of Anthropology, University of Delhi, India

 

ABSTRACT:

Hookah smoking is an age-old tradition prevalent among the rural population of India. It is quite risky in terms of causing addiction to nicotine as well as several illnesses. This study offers to find out the association of hookah smoking with geriatric anaemia. Cross-sectional survey was conducted to collect data on 206 elderly women of the Palwal district of Haryana, North India. Prevalence of hookah smoker was 36.4% and it is projected to rise with the increasing age. The prevalence of anaemia (69.4%) was also high among this geriatric population. Present study found that hookah smoking is significantly correlated with geriatric anaemia (r=0.472, p <0.01). Result reveals that hookah smoker are about 11 times more likely to develop anaemia (OR:11.2, 95% CI: 5.33-23.53). This study highlighted the need for more effective tobacco control policies and awareness programme in rural villages of India to prevent the health hazards related to smoking.

 

 

 

INTRODUCTION:

The changing age composition of the population over time is noticeable. Worldwide, the number of elderly is projected to increase 1500 million in 2050 from an estimated 524 million in 2010.¹ Many developing countries are expecting very rapid transition in their age structure, which will affect there demographic, socio-economic and health consequences. The United Nation defines a country as ‘Ageing’ or ‘Greying Nation’ when the proportion of people over 60 years reaches 7% of the total population.² By 2011 India has already exceeded that proportion (8.6%) and is expected to reach 20% in 2050.³ The Census of India 2001 for the first time pointed out the fact of the ‘feminisation’ of the elderly population of the country, and till now the number of elderly females in India is more than the number of elderly males.

 

The Census of India 2011 illustrates that there are nearly 104 million elderly persons in India consisting of 53 million females and 51 million males.⁴ For women, being female has been associated with a lifetime of discrimination at home and elsewhere, which continues even in old age. MOSPI 2016 also explained that in India, approximately 66% of elderly women are fully dependent on others and 32% do not have any assets of their own, which impacts in their health seeking behaviour. Sengupata & Agree (2002) confirmed that Indian older women are vulnerable with disabilities, and that is also high for north Indian older population.⁵ In a largely patriarchal society, dependence, especially physical and financial on family member impacts to their health negatively, resulting in the delayed or denied health care.⁴

 

The high prevalence of anaemia in older adults (Geriatric Anaemia), especially among elderly women in India is prominent. WHO (2005) reveals that India has the highest number of cases of anaemia among the South Asian countries.⁶ Prevalence of anaemia in South Asian countries is also highest among the world.⁷ But as anaemia remains to be a major cause of maternal mortality and low birth weight in India,⁸ most of the studies remain to constrain to this particular group. Other than pregnant women and lactating mothers, scenario is also not good for older women. Rather more attention is needed for geriatric anaemia because the typical features of anaemia are not specific in elderly adults due to the attributes of age-related changes. Geriatric anaemia in most of the cases remains unnoticed fact as the older persons always avoid going to the physicians until too late. Even if it is noticed then also they do not get proper medical attention for the ‘Unexplained Anaemia’ in Elderly (UAE). In elderly, the diagnosis of UAE is a great challenge. Another aspect of geriatric anaemia is that; it may masquerade as dementia. The people suffering from geriatric anaemia find it difficult to think clearly as they are suffering from anaemia rather than experiencing the early symptoms of dementia. This major reason makes ‘geriatric anaemia’ as a unique entity.⁹

 

 

Figure 1. Older women of rural Haryana holding the ‘hookah’ (smoking flavored tobacco)

 

The geriatric anaemia is a double burden for rural women. MOSPI 2016 pointed out that, in considering the rural and urban area, more than 71% elderly individuals in India are living in rural areas while only 29% live in urban areas.⁴ The rural aged people differs from the urban in education, occupation, income of the household as well as personal economic status. Anaemia, in general, is a major problem for aged women but it is higher for rural.¹⁰ In the rural areas, neither facilities nor financial support is available.¹¹ The rural aged women have always been ignored, so there is a huge need for special attention from the scholars, researchers, policymakers, and executive of interventions programme of geriatric anaemia in rural women.

 

What does anaemia indicates?

Anaemia is an indicator of both poor nutrition and health as well. According to the World Health Organization, anaemia is defined as haemoglobin (Hb) levels <13.0 g/dL in men, <12.0 g/dL in non-pregnant women, and less than <11.0 g/dL in pregnant women (WHO, 1992). It is an abnormal physiological and hematological condition concerned with reduction in oxygen carrying capacity of the blood due to decline in red blood cell (RBC) count, packed cell volume (PCV) and haemoglobin (Hb) concentrations than normal ranges.¹² Geriatric anaemia is the result of a wide variety of causes that can be isolated, but more often coexist. In general, it is caused because of the nutritional deficiency like vitamin B12 and folic acid deficiency, iron deficiency or the presence of chronic diseases like bone marrow failure, peptic ulcer and renal insufficiency etc. Infectious disorders and surgical complication in old age also can lead to the anaemia.¹³ There are also several socioeconomic and lifestyle factors which exaggerate the chance of anaemia in healthy elderly adults, those are preventable and can be reversed. For the early diagnosis and subsequent prevention, there is an urgent need to examine all these consequences and pathways leading to geriatric anaemia.

 

How does hookah (tobacco) smoking habit lead to anaemia?

One of the major lifestyle factor which effects anaemia is smoking. Smoking causes an increase in haemoglobin (Hb) concentration by the exposure to carbon monoxide (CO). Carbon monoxide (CO) binds to Hb, to form carboxy-haemoglobin (HbCO), an inactive form of haemoglobin having no oxygen carrying capacity. HbCO causes a shift of oxygen dissociation curve, resulting in a reduction in the ability of Hb to deliver oxygen to the tissue. To compensate the decreased oxygen delivering capacity, smokers need to maintain a higher haemoglobin level than non-smokers, which leads to anaemia.¹⁴ Global Adult Tobacco Survey India 2009-10 indicates tobacco use is higher in the country’s rural areas (38.4%) as compared to urban areas.

 

 

Figure 2. Map indicating the location of study area (Palwal district) in Haryana state, North India

 

It indicates higher prevalence among the less educated and poorer population. In India, smoking by age is the highest for age group 65+years and not only that it is also higher among rural women (52%).¹⁵

 

‘Hookah’ is a popular form of tobacco smoking (see Figure 1) in North India. It is a water pipe that is used to smoke flavoured and sweetened tobacco. Hookah smokers are known to be exposed to toxic compounds such as nicotine, polycyclic hydrocarbons, carbon monoxide, and nitrosamines. Each puff from the hookah has been reported delivering 12 times as much smoke as a cigarette smoking.¹⁶ Longitudinal Aging Study in India 2010 also explained that smoking has a deterrent effect on well-being of older population.¹⁷ Thus the present study aimed to find out the association of Hookah smoking with geriatric anaemia in rural older women of North India.

 

MATERIAL AND METHODS:

The present study was conducted in the Aurangabaad, Gopalgargh and Mitrol villages of Palwal district of Haryana state (see figure 2), North India. These villages are purposively selected, as they are adjacent, moderate in size and representative of the villages are mostly from the same caste group (‘Jat’ caste). Primary data was collected through a cross-sectional survey among the older ‘Jat’ women aged 60 years and more. ‘Jat’ had been chosen due to numerical dominance in this state and to eliminate genetic differences among the study group.

 

Sample:

The electoral rolls were used as the selection frame for the individual. All the eligible people (aged 60 years and more) of these villages are listed in its electoral roll were approached and surveyed. The inclusion criteria for the participants included: (i) willing older women population, (ii) ability to answer the questionnaire and (iii) living in the selected villages for more than 1 year. The subjects were excluded if they did use any other tobacco or smoking product (cigarette, bidis, chewed tobacco).

 

Ethical approval:

Ethical approval for this study was taken from the Ethical committee of the Department of Anthropology, University of Delhi, India. Participants were explained before the start of the data collection about the objectives of the study and were asked to sign a consent form only when they had fully understood the purpose of the study and the procedures to be undertaken for the study.

 

Sociodemographic characteristics:

Sociodemographic data was collected on age, educational status, religion, marital status, family structure, major occupation and economic status. To assess the age, subjects were asked about their date of birth and age, which was then cross-checked with their valid ID proof (voter ID card). Education status was categorized as ‘literate but no education’, ‘primary school’ (≤5), ‘secondary school’ (≤10), ‘higher secondary school’ (≤12) and ‘graduate or higher’ (≥12). Income is a sensitive issue for the families and they may not be comfortable in discussing. So, we used Aggarwal’s SES Scale, which has 22 separate questions to assess socioeconomic status of family.¹⁸

Determination of hookah smoking status:

Two questions were asked to measure the hookah smoking status among the elderly women. e.g. Q1. Current tobacco smoking status, Q2. Past tobacco smoking status (for current non-smoker). And then classified as smoker, ex-smoker and non-smoker.

 

Determination of hemoglobin concentration and anaemia:

The haemoglobin (Hb) levels of the elderly women were measured with a finger prick sample of capillary blood and analyzed immediately using a digital haemoglobinometer (Mission HB Haemoglobin Testing System, ACON Laboratories, Inc., US). Haemoglobin levels among the elderly women were classified on the basis of World Health Organization standards (1992) as normal (≥ 12.0 g/dL), mild anaemia (10.0 to 11.9 g/dL), moderate anaemia (7.0 to 9.9 g/dL), and severe anaemia (< 7.0 g/dL).¹⁹

 

Table 1. Baseline characteristics of elderly women

Characteristics	Number [n]	Percent [%]
Age group [years]
60-64	83	40.3
65-69	45	21.8
70-74	29	14.1
75-79	14	6.8
80-84	15	7.3
85-89	11	5.3
90+	9	4.4
Educational status*
Literate but no education	184	89.3
Primary	21	10.2
Secondary	1	0.5
Marital status
Married	119	57.8
Widow	87	42.2
Living arrangement
Living alone	6	2.9
Nuclear family	12	5.8
Joint family	188	91.3
Occupation
House wife	24	11.7
Ex worker	113	54.9
Presently working	69	33.5
Socioeconomic status**
Upper middle class	29	14.1
Lower middle class	144	69.9
Poor	33	16.0

Note:

^*No one belongs to higher than secondary educational status.

^**Socioeconomic status was classified according to Aggarwal’s socioeconomic scale 2005   and no one belongs to upper class, high class & very poor category.

 

Data analysis:

All the data was analysed by using the SPSS version 22. The parameters taken were analysed through descriptive statistics to find out frequency, mean and standard deviation. Bivariate correlation was used to find out the nature and direction of the association between sociodemographic factors and anaemia level. Chi-square test was used to find the variation of sociodemographic factors and anaemia level among the elderly groups. Binary logistic regression was used to establish cause effect relationship between anaemia and smoking status. All test of significance was two tailed and level of significance was taken at p<0.01 and p<0.05.

 

RESULTS:

Sociodemographic characteristics:

The normative framework provides that majority (40.3%) of the aged women were between 60-64 years age group and only a small proportion (4.4%) represented the highest age group of 90 years and above. Regarding marital status, almost all the aged women were married (57.8%) followed by the widowhood (42.2%). Educational status was very low as the 89.3% women were literate but not educated. They never attended school but can recognize few letters and can give their signatures. The present study found that 91.3% elderly women were living in a joint family. Occupation is one of the social determinants of one’s economic status. An occupational analysis of the respondents revealed that more than half of the aged women (54.9%) were not working at present but earlier they were engaged in agricultural activities (ex-worker). On the other hand, 33.5% aged women were still engaged in agricultural activities and denoted as worker. In addition to occupation, another factor which is particularly important for the aged is the economic status of the family. An attempt to assess the economic status of the family revealed that majority (69.9%) of the respondents were in lower middle class family. About 16% were poor and 14.1% were in upper middle class family (see Table 1).

 

Hookah smoking habits:

Respondents were asked about their smoking habits and it was found that 36.4% were current smoker followed by the 24.8% as the ex-smoker. While compared to both groups, only 38.8% were non-smoker (see Table 2 and Figure 3). Table 2 reveals that current smoker was lowest for 60-64 years age group but it was increasing with the age. In 90 years and above all are current smoker or ex-smoker. Chi-square test shows that the variation of smoking status between the age group is not statistically significant (X² = 20.304, p-value >0.05). But the Pearson Correlation with the smoking status and age group shows significantly positive correlation (r = 0.248, p-value <0.01).

 

 

Table 2:  Age group specific smoking status in elderly women

Note:

x² denotes Chi-Square value, r denotes Pearson Correlation value

^**. Significant at the 0.01 level.

A dash (—) in a cell indicates zero

 

Figure 3. Anaemia and smoking status of elderly women

 

Table 3:  Age group specific hemoglobin level and prevalence of anaemia in elderly women

Age group [years]	Hemoglobin [mean ± SD]		Prevalence, [n (%)]
		Normal	Mild	Moderate	Sever	x²	r
60-64	11.4 ± 1.2	37 (44.6)	37(44.6)	9 (10.8)	-	39.725**	0.258**
65-69	10.9 ± 1.2	11(24.4)	22 (48.9)	12 (26.7)	-
70-74	11.0 ± 1.3	7 (24.1)	14 (48.3)	8 (27.6)	-
75-79	10.7 ± 1.2	3 (21.4)	8 (57.1)	3 (21.4)	-
80-84	10.8 ± 1.3	3 (20.0)	9 (60.0)	3 (20.0)	-
85-89	10.6 ± 1.4	1 (9.1)	7 (63.6)	3 (27.3)	-
90+	09.7 ± 2.1	1 (11.1)	4 (44.4)	3 (33.3)	1 (11.1)
Total	11.1 ± 1.3	63 (30.6)	101(49.0)	41 (19.1)	1 (0.5)

Note:

x² denotes Chi-Square value, r denotes Pearson Correlation value

**. Significant at the 0.01 level.

A dash (—) in a cell indicates zero

 

Prevalence of anaemia and haemoglobin level:

Table 3 demonstrates that 49% aged women have mild anaemia followed by the 19.1% moderate and 0.5% severe anaemia (see figure 3). Most of the elderly women (44.6%) of the 60-64 years age group were normal in anaemic level, but the haemoglobin concentration was decreasing with advancing age. In 90 years and above only 11.1% have normal Hb level. The chi square test shows that the variation of prevalence of anaemia with different age group is statistically significant (X²=39.725, p-value <0.01). Pearson correlation is also statistically significant between anaemia and age group (r = 0.258, p-value <0.01). The mean value of haemoglobin level is 11.1 g/dL, which was below the normal level.

 

Sociodemographic factors and anaemia:

The education status shows that it was negatively correlated with anaemia as the literate aged women with no education had more chance to become severe anaemic than those who are more educated (r = -0.139, p-value <0.05). Marital status had significantly positive correlation with anaemic level.

 

 

Table 4: Distribution of hemoglobin levels and prevalence of anaemia according to different socio-demographic factors

Variables	Hemoglobin mean ± SD]	Anaemic condition, [n (%)]
		Normal	Mild	Moderate	Sever	x²	r
Educational status***
Literate but no education	11.0 ± 1.3	52 (28.3)	92 (50.0)	39 (21.4)	1 (0.5)	6.580	-0.139*
Primary	11.5 ± 1.0	11 (52.4)	8 (38.1)	2 (9.5)	-
Secondary	10.3 ± 0	-	1 (100.0)	-	-
Marital Status
Married	11.2 ± 1.3	44 (37.0)	56 (47.1)	18 (15.1)	1 (0.8)	7.949*	0.170*
Widow	10.8 ± 1.3	19 (21.8)	45 (51.7)	23 (26.4)	-
Living arrangement
Living alone	11.5 ± 1.1	2 (33.3)	4 (66.7)	-	-	2.205	0.045
Nuclear family	11.0 ± 1.1	3 (25.0)	7 (58.3)	2 (16.7)	-
Joint family	11.0 ± 1.3	58 (30.9)	90 (47.9)	39 (20.7)	1 (0.5)
Occupation
House wife	10.9 ± 1.4	6 (25.0)	11 (45.8)	7 (29.2)	-	6.888	-0.156*
Ex worker	11.0 ± 1.4	29 (25.7)	59 (52.2)	24 (21.2)	1 (0.9)
Presently working	11.3 ± 1.2	28 (40.6)	31 (44.9)	10 (14.9)	-
Socioeconomic status****
Upper middle class	11.4 ± 1.5	17 (58.6)	9 (31.0)	3 (10.3)	-	20.196**	0.252**
Lower middle class	11.1 ± 1.2	40 (27.8)	76 (52.8)	28 (19.4)	-
Poor	10.6 ± 1.5	6 (18.2)	16 (48.5)	10 (30.3)	1 (03.0)
Smoking status
Non smoker	11.8 ± 1.2	48 (60.0)	26 (32.5)	6 (7.5)	-	61.272**	0.472**
Ex-smoker	10.8 ± 1.2	9(17.6)	31 (60.8)	10(19.6)	1(2.0)
Current smoker	10.4 ± 1.1	6(8.0)	44 (58.7)	25(33.3)	-

Note:

^***No one belongs to more than secondary educational status.

^****Socioeconomic status was classified according to Aggarwal’s socioeconomic scale 2005 and no one belongs to upper class, high class & very poor category.

A dash (—) in a cell indicates zero              x² denotes Chi-Square value, r denotes Pearson Correlation value

**. Significant at the 0.01 level.

*. Significant at the 0.05 level.

 

Table 5. Crude and adjusted odds ratio according to anaemic condition

Variables	Group	Crude OR (95% CI)	p value	Adjusted OR (95% CI)	p value
Smoking status
	Non smoker	a
	Smoker (Ex and current)	11.0 (5.51-22.37)	<0.01**	11.20 (5.33-23.53)	<0.01**
Age [years]: [Median (range)]
	<65	a
	>65	3.00 (1.63-5.54)	<0.01**	2.39 (1.07-5.32)	0.034*
Marital status
	Married	a
	Widow	2.10 (1.12-3.94)	0.021*	1.32 (0.60-2.93)	0.499
Occupation
	Presently working	a
	Presently not working	2.00 (1.08-3.70)	0.028*	1.36 (0.63-2.9)	0.435
Education
	Primary and above	a
	Literate but no education	2.54 (1.04-6.21)	0.041*	1.37 (0.47-4.0)	0.561
Socioeconomic status
	Above poor category	a
	Poor category	2.21 (0.86-5.66)	0.098	3.21 (1.04-9.93)	0.043*

Note:

CI, Confidence Interval; OR, Odds ratio; p value, significance value

For Anaemic condition, reference value is normal category (Hemoglobin >12 g/dl)

^a denotes as reference value       

**. Significant at the 0.01 level.

*. Significant at the 0.05 level.

 

As result reveals, widow aged women were more vulnerable to anaemia (r = 0.170, p-value <0.01). The mean haemoglobin level is 10.8 g/dL for widow women, while for married women it is 11.2 g/dL. Living arrangement did not show any significant association with anaemic conditions. Occupational status depicts a higher chance of severe anaemia for housewives than presently working aged women (r = -0.156, p-value <0.05). Economic status and smoking status both have highly positive significant relation to anaemia levels (p-value <0.01) (see Table 4).

 

Effects of Hookah smoking on geriatric anaemia:

Table 5 reveals that, after adjusting sociodemographic factors like age, educational status, marital status, occupational status and economic status; the smoker (combination of exsmoker and current smoker) have 11.20 times higher chance of becoming anaemic than nonsmoker. Crude result shows that aged women have 3 times (95% CI: 1.63-5.54) higher chance of becoming anaemic than younger old. Widow aged women (2.10 times), presently not working (2 times) and literate but not educated women (2.54 times) were also have significantly increased chance of being anaemic.

 

DISCUSSION:

Present study shows that the prevalence of hookah smoking is alarmingly high for the rural older population of Haryana. There is evidence for the decline in non-smoker with increasing age. Gupta et al. (2010) also reported a higher prevalence of hookah smokers in the rural areas of North India. They explained that the habit of hookah smoking has been associated with Indian villages for several centuries and it is very much ingrained in the rural villages of north India.²⁰ WHO (2005) explains that according to historical account the hookah was invented in India during the reign of Emperor Akbar (who ruled from 1556 to 1605), as a purportedly less harmful method of tobacco use. Thus, the widespread belief held by many waterpipe (hookah) users today—that the practice is relatively safe.⁶ Later, Ray, C.S. (2009) highlighted the need of exposure to the fact that the more than 400-yr-old hopeful idea that the waterpipe could make tobacco smoking safe is incorrect, rather it is quite risky in terms of causing addiction to nicotine as well as several illnesses.²¹

 

The study reveals that the prevalence of anaemia is high for aged women of rural Haryana, and it was higher for the hookah smokers. Kaur and Kochar (2009) in their study among the ‘Jat’ women in rural Haryana found a very higher prevalence (97%) of anaemia. The particular study also showed that mean haemoglobin level was declining with advancing age as similar to the current result.²² Another study conducted by Malhotra et al. (2016) at the elderly population of Telangana also explained that the prevalence of anaemia was associated with age and it was more common among the elderly women than men.²³ A few clinical mechanisms can explain the association between prevalence of anaemia with advanced age.  But, several lifestyle factors and socidemographic parameters can also work as the influencing factors for anaemia. Our study shows that the hookah smoking poses a serious threat for geriatric anaemia. In this study after adjusting the confounding variables (age, educational status, marital status, occupational status and economic status), smoking also shows a higher influencing factors for anaemia. There are very few studies which tried to find out the effect of hookah smoking on geriatric anaemia, but the effect of other tobacco smoking on anaemia is well explained.^14,24-26. The study indicates a huge necessity to safeguard the aged rural women from anaemia by stopping the tobacco smoking habits. The Government of India has enacted the national tobacco-control legislation namely, ‘The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003’ in May, 2003 (Govt. of India 2003). Further, the act was modified in the year of 2007-08 to facilitate the effective implementation of the Tobacco Control Law, to bring about greater awareness about the harmful effects of tobacco. This included 21 States/Union Territories of the country including Haryana.²⁷ Thus, the present study highlights the need of social campaigns and a greater awareness programme to draw societies attention to avoid hookah smoking.

 

CONCLUDING THOUGHTS:

The hookah smoking is an age-old tradition prevalent among the rural elderly population of north India. The study found that smoking increases the chance of geriatric anaemia in rural older women, which highlighted the need of more effective tobacco control policies including increase in tobacco tax and awareness programme. The significance of the present study lies in the fact that it will help to create a database for the policymakers and facilitate planning and intervention policies for the aged elderly women in general and rural India in particular. There is lack of community based studies on the association of hookah/tobacco smoking status and geriatric anaemia. Thus, the large scale population based survey is needed to monitor the evolution of smoking and its consequences on rural population of India.

 

ACKNOWLEDGEMENTS:

We are thankful to all the participants who contributed to the study for their cooperation and

help during fieldwork. The work was supported by a grant to Dr. Shivani Chandel from the Research and Development Grant 2015-16 by Research Council, University of Delhi, India (Grant number RC/2015/9677).

 

CONFLICT OF INTEREST:

The authors declared no potential conflicts of interest with respect to the research, authorship,

and/or publication of this article.

 

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Received on 31.01.2019         Modified on 16.02.2019

Accepted on 02.03.2019      ©AandV Publications All right reserved