Theoretical Perspectives on Hookah Smoking Behavior: A Scoping Review of Studies Among Young Adults in Low- and Middle-Income Countries.

Hookah smoking among young adults is a growing public health concern, especially in low- and middle-income countries (LMICs). Despite its prevalence, comprehensive reviews evaluating theoretical frameworks used to study this behavior are lacking. This scoping review synthesized studies examining hookah smoking behaviors among young adults in LMICs. A systematic search was conducted in PubMed, Embase, Google Scholar, and CINAHL using keywords such as "Hookah OR Waterpipe OR Shisha," "Adverse effects OR Harmful Effects," "Young adults OR Adolescents," "Theory," and "Low-middle-income countries." Articles meeting predefined inclusion and exclusion criteria were screened using Covidence, and data on prevalence, predictors, and theoretical frameworks were extracted. The review included 28 studies involving 13,150 young adults with an average age of 19.2 years. Hookah use prevalence ranged from 2.6 to 89.4%, with a pooled prevalence of 26.4%. Frequently applied theoretical frameworks included the Theory of Planned Behavior (TPB) and Social Cognitive Theory (SCT), along with the Protection Motivation Theory and PRECEDE-PROCEED. Facilitators of hookah use included subjective norms, favorable attitudes, perceived low risk, environmental influences, and limited awareness of health risks. Protective factors included self-efficacy, perceived risks, awareness of harmful effects, and anti-smoking attitudes. Interventions based on TPB and SCT showed positive outcomes, though some failed, highlighting the need for culturally sensitive approaches. The findings emphasize the importance of education and policy measures targeting both individual and environmental factors to reduce hookah smoking prevalence and its associated risks in LMICs.