Waterpipe smoking among college students in the United States: a review of the literature

An Exploration of Online Behaviors and Social Media Use Among Hookah and Electronic-Cigarette Users

Introduction

The purpose of this study was to explore the relationship between social norms and attitudes towards ENDS and hookah and use of these products.

Methods

We conducted surveys with hookah and ENDS users who regularly used the Internet and social media and analyzed the primary social media account (e.g. Facebook) of each participant, coding all references to nicotine or tobacco products. The survey included domains on perceived favorability, perceived vulnerability and subjective norms.

Results

We surveyed 21 ENDS users and 20 hookah users. Both groups used the Internet to look up information about their respective tobacco product (95% for hookah vs. 90% for ENDS). Seventy percent of hookah users had references to hookah on their social media profiles while 43% of ENDS users had references to ENDS on their page. The majority of both groups were exposed to content posted by friends in their social media network about their respective products online. Those who posted on social media about hookah and those who read about ENDS online had lower perceived vulnerability to the health risks associated with tobacco products.

Conclusions

Hookah and ENDS users actively use the Internet and social media to obtain and share information about nicotine/tobacco products. Study participants who use hookah were more likely to share photos and discuss hookah related activities via social media than those who use ENDS. Social networks also represent valuable and untapped potential resources for communicating with this group about risks and harm reduction related to emerging nicotine/tobacco products.

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We surveyed hookah & ENDS users exploring Internet use, attitudes and social norms.

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Internet & social media are used to obtain and share information on these products.

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Online-behavior related to tobacco was associated with low perceived vulnerability.

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Photos on social media enforce social acceptability and peer pressure to use hookah.

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Social media may be a good medium for interventions on alternative tobacco products.

Sustained Waterpipe Tobacco Smoking and Trends Over Time

INTRODUCTION

Use of waterpipe tobacco smoking (WTS) is now prevalent among U.S. adolescents. However, the more clinically relevant questions are whether users exhibit sustained patterns of use and whether use is increasing over time relative to other tobacco products. We aimed to examine factors associated with sustained WTS among U.S. adolescents and to compare prevalence trends between WTS and other tobacco products.

METHODS

The Monitoring the Future project began assessing WTS among 12th-grade students in 2010. In 2014, we conducted multivariable regression analyses to examine correlates of sustained WTS, which we defined as use at least six times in the past 12 months. We used trend analysis to compare use of WTS and other types of tobacco.

RESULTS

Of the 8,737 participants queried from 2010 to 2013, 18.8% (1,639) reported past-year WTS, whereas 7.2% (627) reported sustained use. Sustained WTS was inversely associated with female sex (versus male, OR=0.78, 95% CI=0.63, 0.96); African American race (versus Caucasian, OR=0.26, 95% CI=0.14, 0.48); and increased number of parents in the home (p<0.001). Sustained WTS was positively associated with increased school-level parental education (p=0.002); lower grades (p=0.005); truancy (p<0.001); lower religiosity (p<0.001); more evenings out per week (p<0.001); and dating (p=0.03). Visual inspection and non-overlapping CIs suggest that both past-year and sustained WTS are significantly increasing relative to cigarette use but not small cigar use.

CONCLUSIONS

Given the prevalence of sustained WTS and indications of its increase over time, it should be included in efforts related to tobacco surveillance and intervention.

Tracking Hookah Bars in New York: Utilizing Yelp as a Powerful Public Health Tool

BACKGROUND

While cigarette use has seen a steady decline in recent years, hookah (water pipe) use has rapidly increased in popularity. While anecdotal reports have noted a rise in hookah bars, methodological difficulties have prevented researchers from drawing definitive conclusions about the number of hookah bars in any given location. There is no publicly available database that has been shown to reliably provide this information. It is now possible to analyze Internet trends as a measure of population behavior and health-related phenomena.

OBJECTIVE

The objective of the study was to investigate whether Yelp can be used to accurately identify the number of hookah bars in New York State, assess the distribution and characteristics of hookah bars, and monitor temporal trends in their presence.

METHODS

Data were obtained from Yelp that captures a variety of parameters for every business listed in their database as of October 28, 2014, that was tagged as a "hookah bar" and operating in New York State. Two algebraic models were created: one estimated the date of opening of a hookah bar based on the first Yelp review received and the other estimated whether the bar was open or closed based on the date of the most recent Yelp review. These findings were then compared with empirical data obtained by Internet searches.

RESULTS

From 2014 onward, the date of the first Yelp review predicts the opening date of new hookah bars to within 1 month. Yelp data allow the estimate of such venues and demonstrate that new bars are not randomly distributed, but instead are clustered near colleges and in specific racial/ethnic neighborhoods. New York has seen substantially more new hookah bars in 2012-2014 compared with the number that existed prior to 2009.

CONCLUSIONS

Yelp is a powerful public health tool that allows for the investigation of various trends and characteristics of hookah bars. New York is experiencing tremendous growth in hookah bars, a worrying phenomenon that necessitates further investigation.

Hookah Smoking and Facilitators/Barriers to Lounge Use among Students at a US University

OBJECTIVE

To examine hookah tobacco use, hookah lounge attendance, and facilitators and barriers to hookah lounge attendance.

METHODS

A cross-sectional Web-based survey of a random sample of 1332 undergraduate students (Mean Age = 21.2 years) attending a United States university.

RESULTS

The majority of respondents (72.8%) had ever smoked hookah tobacco, and 28% of those had ever smoked during adolescence. The majority of ever hookah smokers (81.5%) and a portion of never hookah smokers (20%) had ever been to a hookah lounge. The adjusted odds of ever visiting a hookah lounge were 2.1 times higher among participants who reported that the closest hookah lounge to the university was < 5 miles away than those who reported that the closest hookah lounge was ≥ 5 miles away. Facilitators of visiting hookah lounges included friends and close proximity of hookah lounges to campus; barriers included cost of smoking hookah, crowded lounges, and having to be 18 years old.

CONCLUSION

Youth are vulnerable to experimenting with hookah tobacco smoking. Hookah lounges provide patrons the opportunity to smoke hookah tobacco with smoker and non-smoker friends in entertaining settings. Our findings suggest that zoning laws and anti-hookah smoking legislation may help curb hookah uptake by prohibiting hookah lounges from opening in close proximity to universities, reducing the density of hookah lounges in cities, and raising the admission age for hookah lounges to 21 years.

Pilot Study of Waterpipe Tobacco Smoking Among US Muslim College Students

Waterpipe smoking is common among the young in Muslim-majority countries despite recent Islamic rulings on tobacco. US Muslim college students, especially immigrants, may be at high risk for smoking, but information is lacking. In this pilot study, respondent-driven sampling was used to sample 156 Muslim college students. Waterpipe smoking was common (44.3%). Leading motivations to smoke were social and perceived low tobacco harm. Independent risk factors among the Muslim students were perception that friends and other students smoked, and ever drank alcohol. Personal belief that waterpipe smoking is prohibited in Islam was not significant. This pilot suggests that Muslim students are at high risk for waterpipe smoking and more definitive studies are needed.

Assessing and Predicting Susceptibility to Waterpipe Tobacco Use Among College Students

INTRODUCTION

College youth susceptible to waterpipe tobacco smoking (WTS) represent an important target to intervene upon in order to prevent their uptake of this product. This study examined the performance of a 4-item susceptibility measure to WTS to predict future waterpipe use and correlates of susceptibility.

METHODS

A cohort of college students from 11 university campuses in North Carolina and Virginia completed an online survey in 2012 and again in 2013 that assessed WTS susceptibility and subsequent waterpipe use. Tobacco use, marijuana use, binge drinking, and sensation seeking were also assessed.

RESULTS

Overall, 964 students who reported having never used waterpipe tobacco in 2012 completed the online surveys both years. Overall, about 27% of college youth were susceptible to WTS each year. Participants susceptible in 2012 were 2.5 times more likely to report having used waterpipe tobacco the subsequent year than non-susceptible participants after controlling for significant correlates of waterpipe use. Correlates of susceptibility were: being male, past 30 day cigarette smoking, use of other tobacco products, binge drinking and marijuana use, as well as higher sensation seeking.

CONCLUSIONS

A 4-item WTS susceptibility measure predicts future WTS. This measure can be used to identify and intervene upon susceptible college youth to curb further exploration of WTS. Indeed, a nontrivial proportion of college students found susceptible go on to use waterpipe tobacco within a year.

Hookah Tobacco Smoking During the Transition to College: Prevalence of Other Substance Use and Predictors of Initiation

INTRODUCTION

The prevalence of hookah tobacco smoking is increasing, and the transition to college is a vulnerable time for initiation. Hookah use is associated with other forms of substance use, but most research has been cross-sectional, thus limiting our understanding of temporal patterns of use. The goals of this longitudinal study were to assess the prevalence of hookah use and initiation, as well as other forms of substance use among hookah users, and identify which forms of substance use predicted hookah initiation during the first 30 days of college.

METHODS

Incoming students (N = 936, 50% female) reported on past 30-day substance use prior to the start of the Fall 2011 semester and again 30 days later (n = 817). Substances included hookah, cigarettes, other forms of tobacco, alcohol, marijuana, and other illegal drugs.

RESULTS

Current prevalence of hookah use increased from 9.0% before college to 13.1% during the first month of college. At baseline and follow-up, current hookah users were more likely than nonusers to report current use of cigarettes, cigars/little cigars/clove cigarettes, smokeless tobacco, marijuana, and alcohol. Among pre-college hookah never users, 13.8% initiated hookah use in the first month of college. Alcohol (adjusted odds ratio [AOR] 1.11, 95% confidence interval [CI] 1.05, 1.17) and marijuana (AOR 1.30, 95% CI 1.03, 1.65) were the only substances predictive of hookah initiation.

CONCLUSIONS

Findings indicate that hookah prevention and intervention is needed during the transition to college, and interventions may need to address comorbid alcohol, marijuana, and hookah use.

IMPLICATIONS

To our knowledge this is the first longitudinal study examining predictors of hookah initiation among male and female incoming first-year college students. While hookah users were more likely than nonusers to use all other substances before and during the first month of college, pre-college marijuana and alcohol use were the only two predictors of hookah initiation during the first 30 days of college. Collectively, these findings provide additional support for the need for efficacious hookah prevention and intervention programs. The transition to college appears to be an ideal time to deliver prevention programs given the increased prevalence of hookah use during the first 30 days of college. In addition to prevention, former users may benefit from targeted relapse prevention as one-fifth of former hookah smokers resumed use during the first 30 days of college.

Factors associated with smoking frequency among current waterpipe smokers in the United States: Findings from the National College Health Assessment II

BACKGROUND

Some waterpipe smokers exhibit nicotine dependent behaviors such as increased use over time and inability to quit, placing them at high risk of adverse health outcomes. This study examines the determinants of dependence by measuring frequency of use among current waterpipe smokers using a large national U.S.

METHODS

Data were drawn from four waves (Spring/Fall 2009 and Spring/Fall 2010) of the American College Health Association-National College Health Assessment datasets. The sample was restricted to students who smoked a waterpipe at least once in the past 30 days (N=19,323). Ordered logistic regression modeled the factors associated with higher frequency of waterpipe smoking.

RESULTS

Among current waterpipe smokers, 6% used a waterpipe daily or almost daily (20-29 days). Daily cigarette smokers were at higher odds of smoking a waterpipe at higher frequencies compared with non-smokers of cigarettes (OR=1.81; 95% CI=1.61-2.04). There was a strong association between daily cigar smoking and higher frequency of waterpipe smoking (OR=7.77; 95% CI=5.49-11.02). Similarly, students who used marijuana had higher odds of smoking a waterpipe at higher frequencies (OR=1.57; 95% CI=1.37-1.81).

CONCLUSIONS

Daily consumers of other addictive substances are at a higher risk of intensive waterpipe smoking and thus higher risk of waterpipe dependence. Intervention programs must incorporate methods to reduce waterpipe dependence and subsequently prevent its deleterious health effects.

Prevalence and predictors of hookah use in US Air Force military recruits

INTRODUCTION

Hookah use has gained recent popularity among U.S. youth. The current study describes the characteristics and correlates associated with hookah use in late adolescent and young adult US Air Force (USAF) recruits.

METHODS

Data were obtained from a cross-sectional questionnaire of USAF personnel in Technical Training School at Joint Base San Antonio (N=10,997). Response rate was 78%. Logistic regression was used to analyze the associations between hookah use, demographic variables, other tobacco and nicotine containing product (TNCP) use, and the social environment.

RESULTS

The prevalence of ever hookah use was 28%; at least monthly hookah use was 10%. Increased hookah use was positively associated with Hispanic ethnicity (OR [odds ratio] 1.52; 95% CI: 1.25, 1.85), cigarette smoking (OR 4.05; CI: 3.41, 4.82) and smokeless tobacco use (OR 1.35; 95% CI: 1.07, 1.71). Hookah use was negatively associated with age (OR 0.84; 95% 0.71 to 1.00), living as married (OR 0.54; 95% CI: 0.40-0.72), African American (OR 0.53; 95% CI: 0.40, 0.69) and ≥4-year degree (OR 0.54; 95% CI: 0.35, 0.82). Hookah use was highest among recruits who "many or almost all" of their friends smoked cigarettes (OR 2.43; 95% CI: 1.80, 3.30) and for those who reported willingness to try a tobacco product that claims to be safer than cigarettes (OR 3.16; 95% CI: 2.64, 3.77).

CONCLUSIONS

Hookah use among military recruits is similar to the civilian population. A willingness to try TNCPs claiming to be safer than cigarettes may influence hookah use. Public health campaigns disseminating accurate information about hookah health risks may be needed to reduce hookah use among youth.

Review of hookah tobacco smoking among college students: policy implications and research recommendations

BACKGROUND

About 30% of college students have smoked hookah tobacco. Although most students perceive this product to be innocuous and non-addictive, hookah tobacco increases the risk for disease and nicotine dependence. Currently, the US Food and Drug Administration (FDA) does not regulate the manufacture, distribution, or sale of hookah tobacco.

OBJECTIVE

Empirical literature pertaining to hookah tobacco smoking is reviewed with a focus on the implications for regulatory policy.

METHODS

PubMed, PsycINFO, and Scopus databases were searched to locate articles published in English. The literature search combined several key words including "hookahs", "college", "advertising", "health effects", and "health policy".

RESULTS

Smoking hookah tobacco may play a role in the initiation of smoking among tobacco-naïve college students and may portend persistent smoking among those who have smoked cigarettes. College students are typically nondaily, social smokers. They do not perceive that their heightened risk for tobacco diseases and nicotine dependence relates to their smoking behavior. However, few public health messages target college-age adults to counter media messages that endorse hookah tobacco smoking.

CONCLUSION

Given that the FDA is not authorized to ban specific tobacco products, policy actions should focus on the development of effective risk communication strategies that target college-age adults and on limiting the accessibility of hookah tobacco products to these adults. Accordingly, a research agenda that would inform these policy actions is proposed.

A review of the health effects of smoking shisha

There is emerging evidence, although at early stages, of various detrimental health effects after smoking shisha. With regard to the cardiovascular system, there is a significant acute rise in cardiovascular markers, such as heart rate and blood pressure. The long-term effects on the cardiovascular system are yet to be established. Shisha smoking has also been significantly associated with lung cancer. Various other forms of cancer have also been documented, but have not reached statistical significance and require further research. Finally, shisha smoking increases the risk of infection and has been associated with outbreaks in the Middle East. Therefore, with the increasing consumption of shisha in Europe, especially in the UK, more research is required to tackle this potential public health threat.

Correlates of hookah use and predictors of hookah trial in U.S. young adults

INTRODUCTION

Hookah, or waterpipe, tobacco smoking has increased among young adults (YAs) in the U.S., but few prospective studies have examined predictors of hookah use. The current study examined correlates of hookah use and predictors of hookah initiation at a 6-month follow-up in a nationally representative, prospective sample of U.S. YAs.

METHODS

Data were drawn from a subset of participants aged 18-24 years at study entry from two waves of the Legacy Young Adult Cohort Study. Wave 5 was completed in July 2013 by 1,555 participants and 74% (n=1,150) completed follow-up 6 months later in January 2014. Weighted bivariate and multivariable analyses were conducted in June 2014 to estimate the prevalence and correlates of ever and past 30-day hookah use and to examine associations between baseline covariates and hookah initiation 6 months later.

RESULTS

At baseline (Wave 5), almost 25% of the sample had ever used hookah and 4% reported past 30-day use. Alcohol, marijuana, and cigarette use were more prevalent among ever and past 30-day hookah users than among never users. Eight percent of never users at baseline reported trying hookah at the 6-month follow-up. Significant predictors of hookah trial in a multivariable model included college enrollment; alcohol, marijuana, and cigarette use; and perceptions that hookah is less harmful than cigarettes.

CONCLUSIONS

Results highlight rapid transitions in hookah use and several risk factors for initiation. Future studies should examine how these factors could be used as intervention targets to reduce tobacco use in this vulnerable age group.

Waterpipe use among high school students in Ontario: Demographic and substance use correlates

OBJECTIVE

To examine waterpipe use and its association with demographic factors, tobacco cigarette smoking, ever use of electronic cigarettes (e-cigarettes) and alcohol use among high school students.

METHODS

Data were derived from the 2013 Ontario Student Drug Use and Health Survey, a school-based survey of 7th to 12th grade students. This province-wide survey was based on a stratified two-stage cluster design. Analyses were based on a subsample of 2,873 high school students and included adjustments for the complex sample design.

RESULTS

Overall, 12.5% of high school students (grades 9-12) had used a waterpipe in the previous year. Awareness of waterpipes was high - 68.4% of students reported that they were aware of waterpipes but had not used one in the past year; 19.1% had never heard of waterpipes or hookah. The percentage of high school students reporting waterpipe use in the past year was similar to reports of tobacco cigarette use (12.5% and 11% respectively). Waterpipe use was highly associated with past-year tobacco cigarette and regular alcohol use as well as ever use of e-cigarettes. In multivariate analyses, males and females had similar odds of waterpipe use, and non-White students and those in higher grades had greater odds of use after controlling for other substance use.

CONCLUSION

These findings suggest that waterpipe use among high school students should be of some concern and suggest the need for policy measures to address potential risks associated with use.

Patterns of combustible tobacco use in U.S. young adults and potential response to graphic cigarette health warning labels

In the evolving landscape of tobacco use, it remains unclear how tobacco control efforts should be designed and promoted for maximum impact. The current study links the identification of latent classes of young adult combustible tobacco users with anticipated responses to graphic health warning labels (HWLs). Data were collected in January 2012 using an online address-based panel as part of the Legacy Young Adult Cohort Study, and analyses were conducted in 2013. Latent class analyses identified five groups of tobacco users in a national sample of 4,236 young adults aged 18-34years: (1) little cigar/cigarillo/bidi (LCC) and hookah users (4%); (2) nonusers, open to smoking (3%); (3) daily smokers who self-identify as "smokers" (11%); (4) nondaily, light smokers who self-identify as "social or occasional smokers" (9%); and (5) nonusers closed to smoking (73%). Of the nonusers closed to smoking, 23% may be better characterized as at risk for tobacco initiation. Results indicate differences in the potential effectiveness of HWLs across classes. Compared to the daily "smokers," LCC and hookah users (RRR=2.35) and nonusers closed to smoking (RRR=2.33) were more than twice as likely to report that new graphic HWLs would make them think about not smoking. This study supports the potential of graphic HWLs to prevent young nonusers from using tobacco products. It suggests that the extension of prominent HWLs to other tobacco products, including LCCs and hookah tobacco, may also serve a prevention function.

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally

Objective

The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review.

Data sources

The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms.

Study selection

Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10–29 years.

Data extraction

Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results.

Data synthesis

The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels.

Conclusions

The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

Which nicotine products are gateways to regular use? First-tried tobacco and current use in college students

BACKGROUND

The potential for emerging tobacco products (ETPs) to be gateway products for further tobacco use among youth is of significant concern.

PURPOSE

To examine use of various nicotine-containing products on a tobacco-free college campus and whether the first product tried predicts subsequent tobacco use.

METHODS

Undergraduate students (N=1,304) at a large university completed an online survey of past/current use of cigarettes; smokeless tobacco (SLT); hookah; ETPs (dissolvables, snus, and electronic cigarettes); and nicotine replacement therapy (NRT). Data were collected from September 2012 to May 2013 and analyses were conducted from June to September 2013. Students were classified as single, dual, or poly tobacco users.

RESULTS

The sample consisted of 79.5% non-users, 13.8% single, 4.4% dual, and 1.5% poly users. Overall, 49.4% of participants reported trying a tobacco product. Hookah was the most tried product (38%), but cigarettes were most often the first product ever tried (51%). First product tried did not predict current tobacco use and non-use, but individuals who first tried SLT or cigarettes (rather than hookah or ETPs) were more likely to be poly tobacco users. Current tobacco users who first tried ETPs or hookah were largely non-daily users of hookah; current tobacco users who first tried cigarettes or SLT were largely non-daily or daily users of cigarettes/SLT.

CONCLUSIONS

Hookah and ETPs are increasingly becoming the first tobacco product ever tried by youth; however, uptake of ETPs is poor, unlike cigarettes and SLT, and does not appear to lead to significant daily/non-daily use of cigarettes and SLT.

Non-cigarette tobacco and the lung

Cigarette smoking is known to cause a wide range of damaging health outcomes; however, the effects of non-cigarette tobacco products are either unknown or perceived as less harmful than cigarettes. Smokeless tobacco, cigar smoking, and waterpipe smoking have increased in usage over the past few decades. Some experts believe that their use is reaching epidemic proportions. Factors such as a perception of harm reduction, targeted advertising, and unrecognized addiction may drive the increased consumption of non-cigarette tobacco products. In particular, the need for social acceptance, enjoyment of communal smoking activities, and exotic nature of waterpipe smoking fuels, in part, its popularity. The public is looking for "safer" alternatives to smoking cigarettes, and some groups advertise products such as smokeless tobacco and electronic cigarettes as the alternatives they seek. Though it is clear that cigar and waterpipe tobacco smoking are probably as dangerous to health as cigarette smoking, there is an opinion among users that the health risks are less compared to cigarette smoking. This is particularly true in younger age groups. In the cases of smokeless tobacco and electronic cigarettes, the risks to health are less clear and there may be evidence of a harm reduction compared to cigarettes. In this article, we discuss commonly used forms of non-cigarette tobacco products, their impacts on lung health, and relevant controversies surrounding their use.

The growing epidemic of water pipe smoking: health effects and future needs

Water pipe smoking (WPS), an old method of tobacco smoking, is re-gaining widespread popularity all over the world and among various populations. Smoking machine studies have shown that the water pipe (WP) mainstream smoke (MSS) contains a wide array of chemical substances, many of which are highly toxic and carcinogenic for humans. The concentrations of some substances exceed those present in MSS of cigarettes. Despite being of low grade, current evidence indicates that WPS is associated with different adverse health effects, not only on the respiratory system but also on the cardiovascular, hematological, and reproductive systems, including pregnancy outcomes. In addition, association between WPS and malignancies, such as lung, oral and nasopharyngeal cancer, has been suggested in different studies and systematic reviews. Despite its long standing history, WPS research still harbors a lot of deficiencies. The magnitude of toxicants and carcinogen exposures, effects on human health, as well as the addiction and dependence potentials associated with WPS need to be studied in well-designed prospective trials. Unfortunately, many of the tobacco control and clean indoor policies have exempted water pipes. World wide awareness among the public, smokers, and policymakers about the potential health effects of WPS is urgently required. Furthermore, stringent policies and laws that control and ban WPS in public places, similar to those applied on cigarettes smoking need to be implemented.

Waterpipes and electronic cigarettes: increasing prevalence and expanding science

The prevalence of noncigarette tobacco product use is on the rise across the globe, especially for waterpipes (also known as hookah, narghile, and shisha) and electronic cigarettes (e-cigarettes). The scientific literature reveals that waterpipe tobacco smoking is associated with exposure to a variety of toxicants that can cause short- and long-term adverse health events. In contrast, there is far less evidence of health harms related to e-cigarette use, although the variety of products in this category makes it difficult to generalize. We searched the PubMed database for all publications on waterpipes and e-cigarettes from January 2000 to March 2014. The number of publications on waterpipes rose in a slow, linear pattern during this time, while the number of publications on e-cigarettes showed exponential growth. The different trends suggest there may be more interest in studying a novel nicotine product (the e-cigarette) over a traditional tobacco product (the waterpipe). We posit that, although the specific research needs for these products are different, public health would be served best by a more equitable research approach. Scientists should continue to devote attention to understanding the unknown long-term health effects of e-cigarettes and their potential to serve as harm reduction or smoking cessation tools while simultaneously investigating how to reduce waterpipe smoking given that it exposes users to toxicants known to cause harm to health. Recent regulatory action in the United States, which proposes to include waterpipes and e-cigarettes under some of the same regulations as tobacco cigarettes, makes such research particularly timely.

Hookah use among U.S. high school seniors

OBJECTIVES

Prevalence of hookah use is increasing significantly among adolescents. This study aimed to delineate demographic and socioeconomic correlates of hookah use among high school seniors in the United States. We hypothesized that more impoverished adolescents and those who smoked cigarettes would be more likely to use hookahs.

METHODS

Data were examined for 5540 high school seniors in Monitoring the Future (years 2010-2012), an annual nationally representative survey of high school students in the United States. Using data weights provided by Monitoring the Future, we used multivariable binary logistic regression to delineate correlates of hookah use in the last 12 months.

RESULTS

Eighteen percent of students reported hookah use in the past year. Compared with white students, black students were at lower odds for use (adjusted odds ratio [AOR] = 0.27, P < .0001). High parent education increased the odds for use (AOR = 1.58, P < .001), and student weekly income from a job of >$50/week (AOR = 1.26, P < .05) or $11 to $50 per week from other sources (AOR = 1.35, P < .01) also increased odds for use. Males and urban students were also at higher odds for use, as were users of alcohol, marijuana, and other illicit substances. Former cigarette smokers were at higher risk, and current smokers were at highest risk for use.

CONCLUSIONS

Adolescents of higher socioeconomic status appear to be at particularly high risk for hookah use in the United States. Prevention efforts must target this group as prevalence continues to increase.

Hookah use among college students: prevalence, drug use, and mental health

BACKGROUND

There is consistent evidence that hookah use is as, if not more, harmful than cigarette use. Yet, hookah users underestimate the potential deleterious effects of hookah use. This study examined the rates of hookah use and associated demographic characteristics in a sample of undergraduates at a small Northeastern university. This study also examined the relationships between hookah use and other substance use, mental health problems, and perceived levels of stress.

METHODS

Data were drawn from the Spring 2009 American Health Association-National College Health Assessment (ACHA-NCHA) at one small, Northeastern university (N=1799). The relationships between hookah use and other substance use, mental health problems, and perceived stress levels were examined using logistic regression analyses.

RESULTS

Hookah use (in the past month) was reported among 14.1% (253/1799) of this sample of undergraduates. Hookah users were more likely to use other substances, including cigarettes, cannabis, alcohol, cocaine, and amphetamines. The strongest associations emerged between hookah use and alcohol and cigarette use. There were no significant associations found between hookah use and any mental health problems or perceived stress levels.

CONCLUSIONS

Hookah users are significantly more likely to use other substances, including alcohol, cigarettes, cannabis, cocaine, and amphetamines compared with non-hookah users. In contrast to cigarette smoking, hookah use does not appear to be associated with mental health problems or perceived stress levels in this sample of undergraduates. Further investigation into the prevalence and correlates of hookah use is needed in representative population samples.

Reigniting tobacco ritual: waterpipe tobacco smoking establishment culture in the United States

INTRODUCTION

Waterpipe tobacco smoking (WTS) is an increasingly prevalent form of tobacco use in the United States. Its appeal may stem from its social, ritualistic, and aesthetic nature. Our aim in this study was to understand WTS as a social ritual with the goal of informing prevention efforts.

METHODS

We conducted a covert observational study consisting of 38 observation sessions in 11 WTS establishments in 3 U.S. cities. Data collection was based on an established conceptual framework describing ritualistic elements of tobacco use. Iterative codebook development and qualitative thematic synthesis were used to analyze data.

RESULTS

Atmospheres ranged from quiet coffee shop to boisterous bar party environments. While some children and older adults were present, the majority of clientele were young adults. Men and women were evenly represented. However, there were 19 occurrences of a male smoking by himself, but no women smoked alone. The vast majority (94%) of the clientele were actively smoking waterpipes. All 83 observed groups manifested at least 1 of the ritual elements of our conceptual framework, while 41 of the 83 observed groups (49%) demonstrated all 4 ritual elements.

CONCLUSIONS

Despite its heterogeneity, WTS is often characterized by 1 or more established elements of a tobacco-related social ritual. It may be valuable for clinical and public health interventions to acknowledge and address the ritualistic elements and social function of WTS.

Latent classes of young adults based on use of multiple types of tobacco and nicotine products

INTRODUCTION

New tobacco and nicotine products such as snus, hookah, and electronic cigarettes have risen in popularity in recent years. Use of these products among young adults is of particular interest given that experimentation with new products is common in young adulthood.

METHODS

We conducted latent class analysis among a population-based sample of young adults to identify separate classes based on use of 6 types of tobacco or nicotine products: snus, hookah, electronic cigarettes, cigarillos, snuff, and cigarettes. We then examined how identified classes differed on demographic characteristics and marijuana and alcohol use.

RESULTS

We identified 5 classes: the largest group (60%) was characterized as reporting no or limited use of any of the products, while the smallest group (7%) was characterized by use of many types of products (poly-users). Of the 3 middle classes, 2 were the same size (10%) and were characterized by primarily using 2 of the products: one class used snus and snuff, and the other used cigarillos and hookah; the third class (13%) was characterized by primarily cigarette smoking. Numerous differences were seen across classes, including the poly-users being less likely to be college students/graduates and more likely to be male and use marijuana and alcohol.

CONCLUSIONS

We found that young adults can be grouped into 5 subgroups based on types of tobacco/nicotine products they do and do not use. A poly-use group that uses all types of tobacco products is concerning, particularly given high levels of marijuana and alcohol use reported in this group.

Associations between race, ethnicity, religion, and waterpipe tobacco smoking

We surveyed a random sample of 852 students at a large university in 2010-2011 to clarify associations between waterpipe tobacco smoking (WTS), ethnicity, and religion. Current (past 30 day) WTS was reported by 116 (14%) students, and 331 (39%) reported ever WTS. Middle Eastern ethnicity was associated with current WTS (odds ratio [OR] = 2.37; 95% confidence interval [CI] = 1.06, 5.34) and ever WTS (OR = 2.59; 95% CI = 1.22, 5.47). South Asian ethnicity was associated with lower odds for ever WTS (OR = 0.42; 95% CI = 0.21, 0.86), but there was no significant association between South Asian ethnicity and current WTS. Being an atheist and having lower religiosity were associated with both WTS outcomes.

Knowledge, attitudes, and normative beliefs as predictors of hookah smoking initiation: a longitudinal study of university students

INTRODUCTION

While cross-sectional studies have shown that hookah tobacco smoking (HTS) is an increasingly popular behavior among university students, little is known about factors associated with initiation. This study sought to determine associations between knowledge, attitudes, and normative beliefs and initiation of HTS among university students.

METHODS

Data were from a prospective longitudinal cohort study of 569 randomly selected first- and second-year university students. Online questionnaires that were developed in accordance with our composite theoretical model were completed in September 2010 and April 2011.

RESULTS

About one-seventh (13%) of participants initiated HTS by follow-up. Positive attitudes and favorable normative beliefs were associated with increased adjusted odds of initiation (AOR = 4.12, 95% CI = 2.56, 6.59; and AOR = 2.01, 95% CI = 1.35, 2.99, respectively), while negative attitudes were associated with decreased adjusted odds (AOR = 0.62, 95% CI = 0.48, 0.80). Correct knowledge regarding toxicants associated with HTS was not significantly associated with initiation.

CONCLUSIONS

While positive attitudes and favorable normative beliefs are associated with initiation of HTS in a cohort of never-users, increased knowledge about toxins is not associated with lower initiation. It may be particularly valuable for educational interventions to attempt to alter positive attitudes and normative beliefs related to HTS.

Hookah, cigarette, and marijuana use: a prospective study of smoking behaviors among first-year college women

Better understanding of the temporal sequence of hookah, cigarette, and marijuana use will help to inform smoking prevention efforts. To address this gap in the literature, we assessed all three of these smoking behaviors in a sample of 424 first-year college women. Using a longitudinal design, we investigated whether hookah use predicts initiating/resuming cigarette and/or initiating marijuana use, and whether cigarette and/or marijuana use predicts initiating hookah use. Participants (67% White, M age = 18.1 years) completed nine monthly surveys. The initial (i.e., baseline) survey assessed demographics, sensation-seeking, impulsivity, and pre-college substance use. Follow-up surveys assessed past-month substance use; outcomes were initiating/resuming cigarette use, initiating marijuana use, and initiating hookah use during the first year of college. We controlled for sensation-seeking, impulsivity, binge drinking, and other smoking behaviors in our multivariate logistic regression models. The results showed that (a) pre-college hookah use predicted initiating/resuming cigarette use; (b) pre-college marijuana use predicted initiation of hookah tobacco smoking; and (c) pre-college cigarette use predicted neither hookah nor marijuana initiation. The findings highlight the co-occurrence of smoking behaviors as well as the need for bundling preventive interventions so that they address hookah, cigarette, and marijuana use.

A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use

The practice of waterpipe smoking (hookah) has rapidly increased in popularity among young adults yet burgeoning research suggests that its use is associated with nicotine dependence and other negative smoking-related health consequences. Moreover, descriptive studies indicate that consumers may hold the belief that hookah smoking is safer than smoking cigarettes. The current study extended previous work by conducting a comprehensive assessment of patterns and contexts of hookah use, psychological correlates of use, co-occurring substance use as well as social norms and health perceptions surrounding the practice. Participants were 143 ethnically diverse undergraduate students at a large urban US university. Approximately half of the sample (48%) reported life-time use of hookah and 22% reported use within the past 30days. Relative to cigarette smoking, hookah smoking was associated with less perceived harm and addiction potential and higher social approval. Participants who reported life-time hookah use, as compared to those who did not, perceived less associated harm, had a greater number of friends who had tried and approved of hookah, were more likely to use cigarettes, marijuana, and alcohol and in higher frequencies and quantities and were at higher risk for problem tobacco and alcohol use. Among participants who were not current smokers, those with hookah experience were more likely to endorse intent to try a cigarette soon. Hookah users did not differ from non-users on measures of trait anxiety, depression and impulsivity though they were more likely to drink alcohol for coping, social and enhancement purposes than non-users. Implications are discussed for public health initiatives to educate young adults about the potential consequences of hookah smoking.

Waterpipe smoking: analysis of the aroma profile of flavored waterpipe tobaccos

In the last years the habit of smoking waterpipes has spread worldwide, especially among young people and emerged as global health issue. Although research is now under way for no less than 40 years in the field of waterpipe smoking, in comparison to cigarette smoking there is still insufficient knowledge on the real composition and the toxicity of the smoke inhaled and the resulting levels of exposure against particular hazardous ingredients. In most cases for waterpipe smoking a highly flavored tobacco called "moassel" is used. However, the number, quantity and toxicity of the added flavorings are widely unknown. In this study the static headspace gas chromatography-mass spectrometry (SHS-GC-MS) was used to identify 79 volatile flavor compounds present in waterpipe tobacco. Among these eleven compounds were analyzed quantitatively. The results show that waterpipe tobacco contains high amounts of the fragrance benzyl alcohol as well as considerable levels of limonene, linalool and eugenol, all of which are known as being allergenic in human skin. The proposed SHS-GC-MS method has been validated and found to be accurate, simple and characterized by low limits of detection (LOD) in the range of 0.016 to 4.3 µg/g tobacco for benzaldehyde and benzyl alcohol, respectively. The identification and characterization of waterpipe tobacco ingredients indeed reveals crucial for the assessment of potential health risks that may be posed by these additives in smokers.

Using twitter to examine smoking behavior and perceptions of emerging tobacco products

BACKGROUND

Social media platforms such as Twitter are rapidly becoming key resources for public health surveillance applications, yet little is known about Twitter users' levels of informedness and sentiment toward tobacco, especially with regard to the emerging tobacco control challenges posed by hookah and electronic cigarettes.

OBJECTIVE

To develop a content and sentiment analysis of tobacco-related Twitter posts and build machine learning classifiers to detect tobacco-relevant posts and sentiment towards tobacco, with a particular focus on new and emerging products like hookah and electronic cigarettes.

METHODS

We collected 7362 tobacco-related Twitter posts at 15-day intervals from December 2011 to July 2012. Each tweet was manually classified using a triaxial scheme, capturing genre, theme, and sentiment. Using the collected data, machine-learning classifiers were trained to detect tobacco-related vs irrelevant tweets as well as positive vs negative sentiment, using Naïve Bayes, k-nearest neighbors, and Support Vector Machine (SVM) algorithms. Finally, phi contingency coefficients were computed between each of the categories to discover emergent patterns.

RESULTS

The most prevalent genres were first- and second-hand experience and opinion, and the most frequent themes were hookah, cessation, and pleasure. Sentiment toward tobacco was overall more positive (1939/4215, 46% of tweets) than negative (1349/4215, 32%) or neutral among tweets mentioning it, even excluding the 9% of tweets categorized as marketing. Three separate metrics converged to support an emergent distinction between, on one hand, hookah and electronic cigarettes corresponding to positive sentiment, and on the other hand, traditional tobacco products and more general references corresponding to negative sentiment. These metrics included correlations between categories in the annotation scheme (phihookah-positive=0.39; phi(e-cigs)-positive=0.19); correlations between search keywords and sentiment (χ²₄=414.50, P<.001, Cramer's V=0.36), and the most discriminating unigram features for positive and negative sentiment ranked by log odds ratio in the machine learning component of the study. In the automated classification tasks, SVMs using a relatively small number of unigram features (500) achieved best performance in discriminating tobacco-related from unrelated tweets (F score=0.85).

CONCLUSIONS

Novel insights available through Twitter for tobacco surveillance are attested through the high prevalence of positive sentiment. This positive sentiment is correlated in complex ways with social image, personal experience, and recently popular products such as hookah and electronic cigarettes. Several apparent perceptual disconnects between these products and their health effects suggest opportunities for tobacco control education. Finally, machine classification of tobacco-related posts shows a promising edge over strictly keyword-based approaches, yielding an improved signal-to-noise ratio in Twitter data and paving the way for automated tobacco surveillance applications.

Smoking water-pipe, chewing nass and prevalence of heart disease: a cross-sectional analysis of baseline data from the Golestan Cohort Study, Iran

OBJECTIVE

Water-pipe and smokeless tobacco use have been associated with several adverse health outcomes. However, little information is available on the association between water-pipe use and heart disease (HD). Therefore, we investigated the association of smoking water-pipe and chewing nass (a mixture of tobacco, lime and ash) with prevalent HD.

DESIGN

Cross-sectional study.

SETTING

Baseline data (collected in 2004-2008) from a prospective population-based study in Golestan Province, Iran.

PARTICIPANTS

50 045 residents of Golestan (40-75 years old; 42.4% men).

MAIN OUTCOME MEASURES

ORs and 95% CIs from multivariate logistic regression models for the association of water-pipe and nass use with HD prevalence.

RESULTS

A total of 3051 (6.1%) participants reported a history of HD, and 525 (1.1%) and 3726 (7.5%) reported ever water-pipe or nass use, respectively. Heavy water-pipe smoking was significantly associated with HD prevalence (highest level of cumulative use vs never use, OR=3.75; 95% CI 1.52 to 9.22; p for trend=0.04). This association persisted when using different cut-off points, when restricting HD to those taking nitrate compound medications, and among never cigarette smokers. There was no significant association between nass use and HD prevalence (highest category of use vs never use, OR=0.91; 95% CI 0.69 to 1.20).

CONCLUSIONS

Our study suggests a significant association between HD and heavy water-pipe smoking. Although the existing evidence suggesting similar biological consequences of water-pipe and cigarette smoking make this association plausible, results of our study were based on a modest number of water-pipe users and need to be replicated in further studies.

Differential relationships between religiosity, cigarette smoking, and waterpipe use: implications for college student health

OBJECTIVE

Using a framework informed by problem behavior theory, the authors examined differential relationships between religiosity and the frequency of cigarette and waterpipe tobacco smoking.

PARTICIPANTS

Six hundred fourteen individuals beginning their freshman year at a large, public, midwestern university.

METHODS

Paper-and-pencil surveys were administered to students who attended freshman orientation. Electronic surveys were sent to students who did not attend orientation.

RESULTS

Although a latent, generalized religiosity factor was negatively associated with frequency of cigarette smoking, there was no such relationship for frequency of waterpipe use.

CONCLUSIONS

Conceptualizing waterpipe tobacco smoking in terms of problem behavior theory may be inappropriate, given its lack of association with religiosity. These results may reflect the perception that waterpipe use is a more socially acceptable form of tobacco use that is less harmful to health than cigarette smoking, despite medical evidence to the contrary. Implications for prevention and intervention are discussed.

Hookah's new popularity among US college students: a pilot study of the characteristics of hookah smokers and their Facebook displays

OBJECTIVES

(1) To confirm the prevalence of hookah use among US college students. (2) To identify substances commonly smoked in hookahs and other substance use characteristics of hookah smokers. (3) Given the powerful influence of Facebook and its potential role in promoting behaviours, to assess the prevalence of hookah references on Facebook profiles.

DESIGN

Cross-sectional study.

SETTING

Two large US universities; www.Facebook.com.

PARTICIPANTS

307 Facebook profiles were coded and 216 of these profile owners completed an online survey. On average, participants were 18.8 years old (SD=0.7), women (54%), Caucasian (70.4%) and approximately half were from each university.

OUTCOME MEASURES

Lifetime and frequency of hookah use, substance smoked in hookah, cigarette and marijuana use, hookah references displayed on Facebook.

RESULTS

27.8% of participants endorsed hookah use; there were no significant differences between age, gender, race or university for hookah use. Hookah users reported smoking tobacco (78%), hash (12%) and both tobacco and marijuana/hash (10%) in their hookah. Compared with non-hookah smokers, hookah smokers were more likely to report using cigarettes (OR=3.41, 95%CI=1.2 to 9.64) and marijuana (OR=15.01, 95%CI=6.5 to 34.65). Hookah references were present on 5% of Facebook profiles.

CONCLUSIONS

More than one quarter of college students smoke hookah. Most smoke tobacco in their hookah, and hookah smoking is associated with polysubstance use. Hookah may present new risks for nicotine addiction in this population.

Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative

Tobacco smoking using a waterpipe (narghile, hookah, shisha) has become a global epidemic. Unlike cigarette smoking, little is known about the health effects of waterpipe use. One acute effect of cigarette smoke inhalation is dysfunction in autonomic regulation of the cardiac cycle, as indicated by reduction in heart rate variability (HRV). Reduced HRV is implicated in adverse cardiovascular health outcomes, and is associated with inhalation exposure-induced oxidative stress. Using a 32 participant cross-over study design, we investigated toxicant exposure and effects of waterpipe smoking on heart rate variability when, under controlled conditions, participants smoked a tobacco-based and a tobacco-free waterpipe product promoted as an alternative for "health-conscious" users. Outcome measures included HRV, exhaled breath carbon monoxide (CO), plasma nicotine, and puff topography, which were measured at times prior to, during, and after smoking. We found that waterpipe use acutely decreased HRV (p<0.01 for all measures), independent of product smoked. Plasma nicotine, blood pressure, and heart rate increased only with the tobacco-based product (p<0.01), while CO increased with both products (p<0.01). More smoke was inhaled during tobacco-free product use, potentially reflecting attempted regulation of nicotine intake. The data thus indicate that waterpipe smoking acutely compromises cardiac autonomic function, and does so through exposure to smoke constituents other than nicotine.

Should college campuses become tobacco free without an enforcement plan?

Tobacco-free campuses are a great public health initiative. Healthy People 2020 and Healthy Campus 2020 address tobacco use and young adults including college students. Sources indicate that of the more than 6,000 colleges and universities in the United States, less than 800 are either smoke free or tobacco free. An increasing number of college campus policy makers in the United States are implementing smoke-free or tobacco-free policies, including procedures for violators of these policies. However, without a clearly defined and actionable enforcement component, these policies serve little purpose. This has become a policy enforcement issue that campus leaders should address. Should colleges and universities become tobacco free, if enforcement is not implemented? College and university administrators should demonstrate leadership by having violators of tobacco-free campus policies held to the same standard as those who violate other policies.