Rising Public Interest of Hookah and E-cigarettes after Tobacco Cessation Law in India: A Google Trend Analysis

Introduction

Tobacco consumption is an epidemic and a public health concern worldwide. Globally, more than 7 million people are killed every year because of tobacco. Around 80% of the 1.1 billion smokers worldwide live in low and middle income countries, where the burden of tobacco related illness and death is enormous.[1] As per the Global Tobacco Survey Adults (GATS) 2016-17 estimates for India, 28.6% adults were tobacco users, with 10.6% smokers and 21.4% smokeless tobacco users. Khaini and beedi were most commonly used tobacco products. The ‘Cigarette and Other tobacco Prevention Act’ (COTPA), was launched in 2003. After the implementation of the law, a decrease in prevalence of tobacco usage by 6% was observed.[2] Any tobacco use by men observed an increase from 46.5% in NFHS-2 to 57% in NFHS-3. However, it reportedly decreased to 44.5% in NFHS-4. Any tobacco use by women reported consistent reduction in all the three NFHS surveys: 13.8% in NFHS-2, 10.8% in NFHS-3, and 6.8% in NFHS-4. The percentage reduction in tobacco use from NFHS-3 to NFHS-4, was higher in rural areas than in urban areas, both among men (urban: 50% to 39%; rural: 61% to 48%) and women (urban: 7% to 4%; rural: 13% to 8%). Except for the four states of Meghalaya, Andhra Pradesh, Manipur and Telangana; all other Indian states reported a reduction of any form of tobacco use from NFHS-3 to NFHS-4.[3] Since the COTPA, there have been many amendments in the law pertaining to tobacco(Table 1).[4]

Google is the most commonly used search engine. Google trends was started in 2004, it provides trends of the Google searches. In India, internet usage has increased tremendously and continues to grow. As the role of information technology in health care is on an increase, Google trends can be utilized for the purpose of searching the public interest in tobacco products. Data regarding public interest in tobacco products is limited even after implementation of the COTPA. Hence, this study aims to assess the trends of public interest in tobacco products after the implementation of COTPA in India, using Google trends.

Methodology

Google Trends (http://google.com/trends), a societal prospective record of search activity, calculates the relative search volume (RSV) for specific search terms. It is an open access format of data available on internet. It measures the fraction of searches that include a specific search term in a specific, user-chosen location (in this case, India) at a specific time (in this case, from January 2004 to December 2018; total of 168 months). For the purpose of analysis, the data was divided into two parts i) 2004 to 2011 ii) 2011 to 2018. The data was collected in terms of RSV i.e. relative to the total number of searches conducted at that time, normalized to a 0–100 scale (100 being highest proportion of all searches; 50 being 50% of the highest proportion). Monthly aggregated search trends originating in India were analysed. The search trends for various tobacco products like “cigarette”, “beedi”, “E cigarette”, “gutka” and “hookah” were collected. With the help of ‘related search’ the key words in Google trends were refined. Searches on these terms were screened for “India” and other synonymous terms for “water pipe” (e.g. “hookah” in Hindi language) were used. Care was taken to refine key words using the punctuations, plus and minus sign in the Google trend. Furthermore, the synonyms for the tobacco products were also corroborated with the key-words used in the Global Adults Tobacco Survey.[2]

The key words for search were “Cigarette”, “Bidi + Beedi”, “E Cigarette + Electronic Cigarette”, “Gutaka + Quid + Khaini + pan masala + betel” and “Hookah- bar + waterpipe + hukah sheesha + shisha”.

To observe the impact of tobacco-related events on public interest in tobacco products over time, on web search, projections of RSV were interpreted as the higher impact point. Thus, high spikes were detected by visual inspection, and RSVs ranging from 0 to 100 were evaluated as continuous values. Using those values with spikes, we evaluated possible relationships between the RSV and tobacco control measures in India. In addition to the non-statistical method of visual inspection f, to forecast the trends for next 5 years (60 months) the data was analysed in Excel with help of a forecasting tool.

Results

Trend analysis shows that there has been an increasing search trend towards hookah and e- cigarettes as compared to search for cigarettes after COTPA implementation.

In 2011, a major change was brought in the law for graphic health warnings on the tobacco product. For the purpose of analysis the time trend was therefore split in two phases from 2004 to 2011 and 2011 to 2018.

After implementation of COTPA (2003), the time trend from 2004 to 2011 showed a steep rise of public interest in cigarettes with a peak in November 2005 but stabilized in the year 2006, and remained the same till the 2011(Figure Ia). The trend for rest of the tobacco products remained insignificant but in Febuary 2005 a peak can be seen for hookah, and in October 2006 a peak was observed for beedi.

In 2016, the law observed that 85% the packaging of the tobacco products should show ill effects of the tobacco consumption. After 2011, especially in 2016, the internet query saw a steep rise in the hookah and electronic cigarette. (Figure Ib)

On sub-region analysis, from 2004 to 2011 the top internet queries for cigarettes were found in Tripura (100), Puducherry (70), Uttarakhand (63), and Chhattisgarh (60). Hookah was searched in Uttarakhand (32), Odisha (29), Maharashtra (26), Chandigarh (26), Assam (26). Electronic cigarettes were searched in Jammu & Kashmir (47), Puducherry (30), Andhra Pradesh (15), Kerala (15), and Tamil Nadu (14). Beedi was searched in Bihar (32), Chhattisgarh (13), Karnataka (10), Gujarat (9), and Assam (8). Gutka was searched in Bihar (32), Madhya Pradesh (14), Punjab (14), Uttar Pradesh (14), and Gujarat (12). (Figure IIa).

A major change was seen in the internet query on sub-region analysis from 2011 to 2018. The top internet queries for cigarettes were found in Puducherry (73), Tripura (73), Kerala (51), Andhra Pradesh (49), and Meghalaya (47). Hookah was searched in Goa (39), Maharashtra (37), Telangana (36) Rajasthan (35), and Uttarakhand (33). Electronic cigarette was searched in Andaman and Nicobar Island (100), Meghalaya (27), Puducherry (27), Tripura (27), and Goa (22). Beedi was searched in Bihar (17), Himachal Pradesh (11), West Bengal (11), Madhya Pradesh (11), and Kerala (8). Gutka was searched in Punjab (22), Chandigarh (20), Assam (14), Uttar Pradesh (14), and Bihar (13). (Figure IIb)

Forecast analysis shows a nearly stationary trend for cigarette with 55 RSV at December 2018 and 56 (95% CI 94-18) in next 5 years. (Figure IIIa)

Forecast analysis shows an increasing trend for cigarette with 30 RSV at December 2018 and 39 (95% CI 95-12) in next 5 years. (Figure IIIb)

Forecast analysis shows an increasing trend for cigarette with 42 RSV at December 2018 and 58 (95% CI 96- 19) in next 5 years. (Figure IIIc)

Forecast analysis shows an increasing trend for cigarette with 13 RSV at December 2018 and 17 (95% CI 31-2) in next 5 years. (Figure IIId)

Forecast analysis shows a stationary trend for cigarette in the next five years with a 10 RSV (95% CI 44 - -26). (Figure IIIe)

Discussion

Interpretations

The study shows an increasing trend of popularity of hookah which is in line with global scenario, wherein hookah has become a public health problem. Developing surveillance, interventions and regulatory/policy frameworks specific to the waterpipe has become a public health priority.[5]

In India, a study of Haryana where hookah smoking on a daily basis was reported among 37.7% participants and 44.7% amongst them smoked hookah in hookah cafés, shows similar conclusions to the present study.[6] Studies also show a connection between smoking cigarette and hookah among health professionals.[7,8] The possible increase in the Hookah popularity could be due to the notion that as the smoke passes through water it becomes less irritant and toxic but the World Health Organization (WHO) committee on Tobacco Product Regulation has refuted these claims stating that the amount of smoke inhaled in a single hookah session often surpasses that from a single cigarette, and that hookah smoking contains the same harmful substances.[9]

Earlier studies with participants from Egypt, Israel and Syria, reported ignorance of health hazards among users, as hookah smoking was considered less harmful than cigarette smoking.[10,11,12]According to reports by Ward et al. and Smith-Simone et al., many hookah smokers do not see themselves as addicts, and there is a common perception among hookah users that they can quit whenever they want and in this study 63.3% reported that they are hooked to hookah.[13] Another study documented that most of people learned about hookah from friends (63.2%), usually smoked hookah in hookah lounges (85.5%) and there was a belief that hookah was safer and more socially acceptable than cigarettes.[14]

In India, as per the COTPA, any form of tobacco smoking in public places including restaurants, hotels recreational centres, etc., is banned. Currently, there is a ban on hookah parlours in in several cities of India. However, tobacco vendors sell easy to assemble hookah water pipes to be assembled at home for convenient use, encouraging hookah smoking.[14]

E cigarettes have been shown to be popular in the western countries. In India however, only big metropolitan cities share such interest. This may be due to ‘cool image’, perceived less harmful effect, better affordability of the people in metro cities.[15]

The use of Google trends shows the public interest of the country as a whole, something which has not been done before. The use of this technology for the purpose is an innovation in itself. However, data gathered is restricted and trends can be gathered only from people having access to internet, those who have utilized Google search engine. As in India, the access to internet and Google, in lower socioeconomic status is limited; the popularity of beedi seems to have been underestimated. This can be considered as a limitation of the study.

Conclusions

The trends show an increasing popularity of the hookah and E cigarette as compared to other tobacco related products. This trend generates a hypothesis that public interest may lead an increase in usage as well. However, further research is required to validate the hypothesis. Nevertheless, the strengthening of educational programs against all forms of tobacco including hookah and E cigarettes, with emphasis to catch them young by focussing on in schools and colleges, may show long-term benefits. Immediate prioritization to sensitize young adults through evidence based policy, strict and vigilant enforcement of the COTPA will further facilitate a healthier, tobacco-free lifestyle in young adults.

Conflict of Interest

None

Acknowledgement

None

References

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