The attitudes toward hookah smoking in the MENA region scale (ATHS-MENA): factor analysis and validation

Hookah smoking poses a global health challenge, especially in the MENA region where it holds deep cultural significance. Existing smoking scales often lack the cultural nuances needed for accurate assessment. This study aimed to develop and validate a culturally relevant instrument, the Attitudes Toward Hookah Smoking Scale in the MENA region (ATHS-MENA).

The ATHS-MENA was developed through a systematic process including item generation, expert review, cognitive interviewing, and pilot testing. The scale was administered to participants in the UAE. Exploratory factor analysis (EFA) identified the factor structure, followed by confirmatory factor analysis (CFA) to assess model fit. Convergent validity was tested against an existing smoking attitude scale. Known-groups validity was examined based on gender, nationality, Emirati status, and smoking behavior.

EFA revealed four factors: Hookah Engagement/Dependency, Social/Cultural Acceptance, Avoidance/Health Awareness, and Risk Minimization. The scale demonstrated high internal reliability (α = 0.94). Inter-factor correlations ranged from -0.41 to 0.57, with the four-factor solution explaining 68.4% of total variance. CFA indicated acceptable model fit following post-hoc modifications (RMSEA = 0.079, CFI = 0.912, TLI = 0.901). Convergent validity was established with the Smoking Attitudes Scale (r = 0.81, p < 0.001). Known-groups validity was supported by gender differences and associations with smoking behavior.

The ATHS-MENA demonstrates strong psychometric properties for assessing hookah smoking attitudes in the MENA region. Its culturally sensitive design enhances its relevance and utility for research and public health interventions aimed at addressing tobacco use in this population. Future research should address sampling limitations by recruiting more balanced samples and confirm the factor structure across diverse demographic groups.