Assessing and Predicting Susceptibility to Waterpipe Tobacco Use Among College Students

Correlates of susceptibility to waterpipe tobacco smoking in young adults

INTRODUCTION

Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults.

METHODS

Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility.

RESULTS

Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (β = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (β = -0.09, p = 0.04), and greater perceived social acceptability of WTS (β = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (β = 0.53, p<0.01), used cannabis (β = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (β = 0.18, p = 0.03) also had higher WTS susceptibility.

CONCLUSIONS

Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits.

Identifying the Determinants of Hookah Smoking Among the Youth; A Mixed-Methods Study

Hookahs have been rising in popularity in the United States (U.S.) especially among the youth yet not much research has been carried out to understand the various predictors of hookah use among youth. We have thus conducted a cross-sectional study with a mixed-methods triangulation design to identify the hookah use determinants at different levels of the Social Ecological Model among youth. Participants between the ages of 18-24 years were sampled purposively, between April to November 2023, following a snowballing technique from various communities in Virginia and California, United States. Data were collected via a survey, one-on-one interviews, and focus groups. The study had a total sample size of 20. We found that participants smoked for a median of 5 times in the past 30 days. The main determinants of hookah smoking included the limited knowledge of health effects and addiction, positive attitude, family and peer influence, use as a means to socially connect with others, culture, social acceptability, lack of education at school and work place, access to hookah bars and smoke shops, and lack of strict enforcement of laws to ban smoking of youth. Educational interventions should be implemented by public health authorities to target the youth, their social and communities to provide education on hookah harm and addictiveness and to restrict access to- and the production, distribution, marketing and sales of hookahs.

Longitudinal Transition Patterns of Tobacco Use Among Youth and Young Adults Never Tobacco Product Users: Findings From the Population Assessment of Tobacco and Health Study, 2014-2019

Aims

To identify, visualize, and describe the prevalence of within-product patterns of tobacco use behaviors for e-cigarettes, cigarettes, and hookah (TP) by 3 age groups (ie, 12-14-year-old, 15-17-year-old, and 18-20-year-old) with U.S. nationally representative data.

Methods

In 2014-2015, never users of each (TP) and age group were followed-up longitudinally between 2015-2019 using five transition states: non-susceptible to (TP) use, susceptible to (TP) use, ever (TP) use, past 30-day (TP) use, and discontinued past 30-day (TP) use. Sankey diagrams were used to graphically visualize patterns in tobacco use behaviors across time.

Results

Among 12-14-year-old who were never users and susceptible to each TP from 2014-2017, 7% initiated ever e-cigarette use and 9.4% first reported past 30-day use by 2018-2019; 5.8% initiated ever cigarette use and 3% first reported past 30-day cigarette use by 2018-2019; and, 4.5% initiated ever hookah use and 1.0% first reported past 30-day hookah use by 2018-2019. Among 15-17-year-old who were never users and susceptible to each TP from 2014-2017, 4.2% initiated ever e-cigarette use and 9.0% first reported past 30-day use by 2018-2019; 4.5% initiated ever cigarette use and 3% first reported past 30-day cigarette use by 2018-2019; and, 4.5% initiated ever hookah use and 2.4% first reported past 30-day hookah use by 2018-2019. Among 18-20-year-old who were never users and susceptible to each TP from 2014-2017, 3.2% initiated ever e-cigarette use and 3.6% first reported past 30-day e-cigarette use by 2018-2019; 3.0% initiated ever cigarette use and 2.3% first reported past 30-day cigarette use; and, 2.8% initiated ever hookah use and 1.0% first reported past 30-day hookah use by 2018-2019.

Conclusions

From 2014 to 2019, onset and progression of e-cigarette, cigarette, and hookah use occurred more frequently in 12-14 and 15-17-year-old than in young adults 18-20-year-old.

Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods

Items measuring tobacco use intentions are used to predict future use. Researchers combine items using different methods; however, no research has compared these methods’ predictive validity. Here, we compare how well six methods of analyzing four intention items predict initiation of cigarettes, e-cigarettes, snus pouches, and other smokeless tobacco one year later. We analyzed youth and young adult never users from the US Population Assessment of Tobacco and Health Study. We compared six methods of analyzing Wave 3 intention items in predicting Wave 4 use: susceptibility scoring (susceptible is not answering “definitely no” to all items); dichotomizing the four-item average using two cut-points on the 1–4 response scale; and dichotomizing one item (next year use intention) with three cut-points. Analyses (1) tested whether each single-item predicted initiation; and (2) compared each method’s (a) true positive rate (rate of correctly identifying future initiators), (b) true negative rate (rate of correctly identifying future non-initiators), and (c) model fit. Results were similar across products and age groups. Averaging items best predicted initiation in regression. Susceptibility scoring had the highest true positive rate but lowest true negative rate. False positives (incorrectly identifying someone as a future initiator) were best minimized by averaging items with a cutoff of 3, or using the single item with a 3 or 4 cutoff. Findings suggest researchers predicting tobacco use initiation using regression should average the four items; and researchers seeking to identify likely initiators should use different analytic methods depending on if they seek to maximize true positives or minimize false positives.

Effects of mental simulation of future waterpipe tobacco smoking on attitudes, perceived harms and intended use among young adults

The desire to engage in waterpipe tobacco smoking (WTS) may occur when smokers and nonsmokers conjure positive mental simulations of WTS. However, effects of these simulations on desire to smoke waterpipe tobacco and potential mediators are unexplored. This research addressed these effects among young adult waterpipe tobacco smokers and nonsmokers. Two online studies were conducted with adults ages 18-30. In Study 1, 200 smokers, 190 susceptible nonsmokers, and 182 nonsusceptible nonsmokers were randomized to mentally simulate or not WTS in the future. In Study 2, 234 smokers and 241 susceptible nonsmokers were randomized to four arms: no simulation or simulations that varied valence of experience (positive, negative or no valence provided). Main outcomes were immediate desire to smoke waterpipe tobacco, cognitive and affective attitudes, and perceived harms. In Study 1, mental simulations increased the desire to smoke waterpipe tobacco among smokers. In Study 2, asking participants to simulate WTS positively or with no valence instruction increased desire to smoke relative to negative valence instruction or no simulation. Negative simulations reduced perceived probability of smoking within a month compared to positive simulations. Effects on desire to engage in WTS were mediated by cognitive and affective attitudes among susceptible nonsmokers and by cognitive attitudes among smokers. These findings suggest that exploring when and how often mental simulations about WTS are evoked and their potency for promoting prevention and cessation of WTS merit further attention.

Psychophysiological responses to hookah tobacco public education messages among young adults

OBJECTIVE

Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting.

METHOD

One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure.

RESULTS

The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks.

DISCUSSION

Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Pilot Study Assessing Reactions to Educational Videos on Harm of Waterpipe among Young Adults Susceptible to Waterpipe Tobacco Smoking

Young adults who never engaged in waterpipe tobacco smoking (WTS) yet are open to trying it, that is, are susceptible, is a high-risk group for initiation WTS. Very few interventions dissuade this group from WTS. Thus, we explored how four short videos that varied themes of WTS harms influenced susceptible young adults' risk perceptions, risk beliefs, and susceptibility to future WTS. As part of online cross-sectional study, 208 participants aged 18-34 were randomized to watch or not a short video; each video focused on different themes of WTS risks: physical harms, myths about WTS, addiction, and harms to others. The main outcomes were perceived personal risks, risk beliefs, perceived harm of WTS compared to cigarettes, and susceptibility to future WTS. Watching any video increased beliefs of harm of WTS and lowered susceptibility to future WTS compared to not watching a video. The theme of physical harms was most effective at increasing risk beliefs and lowering susceptibility to future WTS. All four videos were rated as credible, engaging, personally relevant, producing negative affect toward WTS, and effective at dissuading WTS. These promising findings suggest further testing is needed to determine if effects persist and prevent WTS among adults susceptible to WTS.

Initial development of the Hookah Smoker Scale: Assessing young adults' mental schemas about hookah "smokers"

Many young adult hookah tobacco users do not consider themselves hookah "smokers," but data on this topic are limited. There are no existing measures of young adults' mental schemas of hookah "smokers." We examined the factor structure and reliability of the Hookah Smoker Scale and examined associations with perceived harm and addictiveness and attitudes toward hookah. Two hundred and forty-six young adult (ages 18-30) hookah smokers participated in a cross-sectional online study. Participants completed items assessing schemas characterizing hookah smokers and valid measures of perceived harm and addictiveness of hookah smoking, risk appraisals, and attitudes toward hookah. Exploratory factor analysis using principal axis factoring with oblique rotation extracted a 12-item scale with three dimensions (Regular Use, Social-Enabled Use, and Self-Enabled Use). The scale explained 69.7% of the variance (eigenvalue = 9.2). Cronbach's α for the scale was .89, with Cronbach's α ≥ .80 for four-item subscales. Higher subscale scores indicate stronger beliefs that the dimension characterizes a hookah smoker. Higher Regular Use scores (score variance = 46.9%; eigenvalue = 5.6) were associated with greater perceived harm and addictiveness (β = 0.21, p = .01), greater risk appraisals (β = 0.20, p = .02), and more negative attitudes toward hookah (β = -0.18, p = .03). The Hookah Smoker Scale is a promising measure that can be used to identify targets for preventing and reducing young adults' hookah tobacco use. Findings also suggest young adults associate health risks of hookah with daily smoking, but not with intermittent social smoking patterns.

Transitions in frequency of hookah smoking among youth and adults: findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study, 2013-15

BACKGROUND AND AIMS

The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers.

DESIGN

Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at wave 1 (2013-14); frequency of hookah smoking and past-year cessation were ascertained at wave 2 (2014-15). Weighted multivariable logistic and ordinal logistic regression models were fitted to predict hookah smoking cessation and frequency of hookah smoking at wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking and frequency of hookah smoking at wave 1.

SETTING

United States.

PARTICIPANTS

A total of 693 youth and 4400 adult past-year hookah smokers.

MEASUREMENTS

Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI).

FINDINGS

At wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Among all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, the availability of appealing flavors and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors [adjusted odds ratio (aOR) = 0.40; 95% confidence interval (CI) = 0.26-0.62] compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly or more frequent hookah smoking at wave 2, compared with cessation or less than monthly smoking, were higher for adults who liked hookah flavors [adjusted proportional odds ratio (aPOR) = 2.10; 95% CI = 1.48-2.99 and enjoyed socializing while smoking hookah (aPOR = 1.82; 95% CI =1.13-2.94) compared with adults who did not like hookah flavors or socializing.

CONCLUSION

The availability of appealing flavors, affordability and socialization while smoking hookah in the United States are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Prevalence and predictors of susceptibility and future intention to smoke cigarettes among school-going adolescents in Ibadan, Nigeria

Introduction

the tobacco control interventions targeted at preventing the initiation of tobacco habits are crucial to effective control of tobacco use among adolescents. An understanding of the predictors of smoking susceptibility and future intention to smoke is important in developing effective intervention programmes. This study, therefore, assessed the prevalence and predictors of susceptibility and future intention to smoke cigarettes among school-going adolescents in Ibadan, Nigeria.

Methods

a cross-sectional study among 830 school-going, non-smoking adolescents, who were randomly selected from 18 secondary schools in Ibadan, Nigeria. Using a self-administered, structured questionnaire, information on socio-demography, tobacco attitudes and habits were collected and analyzed using SPSS version 25.

Results

the prevalence of susceptibility and future intention to smoke cigarette were 25.9% and 6.3%, respectively. Predictors of susceptibility were low social-class (aOR:1.68; 95%CI:1.01-2.80); cigarette sale near schools (aOR:2.04; 95%CI:1.16-3.61); poor attitude (aOR:1.93; 95%CI:1.29-2.89); no harm-perception to smoking (aOR:3.55; 95%CI:2.13-5.92), exposure to secondhand smoke (SHS) (aOR:2.31; 95%CI:1.52-3.50) and perceived safety of short-term smoking (aOR:1.59; 95%CI:1.02-2.44). Predictors of future intention to smoke were: ever-tobacco smoking (aOR:2.05; 95%CI:1.003-4.170); cigarette sale near schools (aOR:1.79; 95%CI:1.09-2.94); poor attitude (aOR:1.95; 95%CI:1.31-2.88), no harm perception to smoking (aOR:3.87; 95%CI:2.38-6.31), exposure to SHS (aOR:2.45; 95%CI:1.64-3.67) and perceived safety of short-term smoking (aOR:1.59; 95%CI:1.05-2.44).

Conclusion

a significant proportion of the population had high susceptibility to smoke as well as high future intention to smoke. Sales of cigarettes near schools, poor attitude and poor perception about the harm from smoking and exposure to SHS were important predictors of both susceptibility and future intention to smoke among respondents.

Using Latent Class Analysis to Examine Susceptibility to Various Tobacco Products Among Adolescents

INTRODUCTION

Most tobacco use is initiated during adolescence and susceptibility is an important predictor of initiation. Research is needed to understand susceptibility across tobacco products among youth to inform prevention efforts.

AIMS AND METHODS

We surveyed 2945 students from four Southeastern Connecticut high schools in 2017. We assessed susceptibility to future use of seven different tobacco products (ie, cigarettes, e-cigarettes, hookah, cigars, cigarillos, blunts, and smokeless tobacco) among youth who had never used a tobacco product. Susceptibility was coded as any response other than "definitely not" to three items assessing (1) curiosity, (2) willingness to experiment with the product in the future, and (3) willingness to try if offered by a friend. Latent class analysis was used to identify patterns of susceptibility across multiple tobacco products and sociodemographic predictors of these classes.

RESULTS

Among n = 1246 youth who had never tried a tobacco product, 51.2% (n = 638) were susceptible to at least one product and 29.1% (n = 363) were susceptible to two or more products (average among susceptible youth: M = 2.4 products, SD = 1.7, range 1-7). Latent class analysis identified three classes: youth who were: (1) susceptible to all products (5.6%), (2) susceptible to e-cigarettes, hookah, and blunts (23.6%), and (3) mostly non-susceptible to all products (70.8%). In a multivariable model, demographic variables and peer tobacco use predicted class membership.

CONCLUSIONS

We observed high rates of susceptibility to non-traditional tobacco products among youth, and many youth were susceptible to more than one product. Targeting susceptibility across multiple tobacco products may be important for reducing youth tobacco use.

IMPLICATIONS

Patterns of polytobacco use susceptibility were identified among youth who had never previously used tobacco products. Many youth were susceptible to more than one product and we observed three distinct classes of susceptibility among youth: those who were mostly non-susceptible, those who were susceptible to alternative or non-traditional tobacco products (e-cigarettes, hookah, and blunts), and those who were susceptible to all tobacco products. These findings suggest the importance of addressing susceptibility across multiple tobacco products.

Hookah use patterns, social influence and associated other substance use among a sample of New York City public university students

Background

Most hookah use studies have not included racial and ethnic minorities which limits our understanding of its use among these growing populations. This study aimed to investigate the individual characteristics of hookah use patterns and associated risk behaviors among an ethnically diverse sample of college students.

Methods

A cross-sectional survey of 2460 students (aged 18–25) was conducted in 2015, and data was analyzed in 2017. Descriptive statistics were used to present the sociodemographic characteristics, hookah use-related behavior, and binge drinking and marijuana use according to the current hookah use group, including never, exclusive, dual/poly hookah use. Multivariate logistic regression was conducted to examine how hookah related behavior and other risk behaviors varied by sociodemographics and hookah use patterns.

Results

Among current hookah users (n = 312), 70% were exclusive hookah users and 30% were dual/poly hookah users. There were no statistically significant differences in sociodemographic characteristics except for race/ethnicity (p < 0.05). Almost half (44%) of the exclusive hookah users reported having at least five friends who also used hookah, compared to 30% in the dual/poly use group. Exclusive users were less likely to report past year binge drinking (17%) and past year marijuana use (25%) compared to those in the dual/poly use group (44 and 48% respectively); p < 0.001.

Conclusions

The socialization aspects of hookah smoking seem to be associated with its use patterns. Our study calls for multicomponent interventions designed to target poly tobacco use as well as other substance use that appears to be relatively common among hookah users.

Waterpipe Tobacco Smoking and Associated Risk Factors among Bangladeshi University Students: An Exploratory Pilot Study

Over the past two decades, there has been a global rise in the prevalence of waterpipe tobacco smoking. Waterpipe tobacco smoking involves the inhalation of heated tobacco smoke after passing through water, and it has been associated with an identified dependence effect similar to that found with cigarette smoking. Despite the popularity of waterpipe tobacco among youth (and in particular, university students) in many countries, detailed data of its usage are lacking in Bangladesh. Therefore, the present study was conducted to explore waterpipe tobacco smoking behavior and normative beliefs among university students in Bangladesh and to assess the factors associated with waterpipe tobacco use. A quantitative cross-sectional survey was carried out among 340 Bangladeshi university students (64.4% male; mean age 21.6 years). Among participants, 13.5% reported they had ever smoked tobacco from a waterpipe and 9.4% had it in past 30 days. Among past 30-day users, 72% were categorized as having waterpipe smoking dependence (n = 23). No females in the sample had ever smoked using a waterpipe. Maternal occupation, monthly expenditure, and regular smoking status were major predominant factors associated with waterpipe smoking behavior of the students. The study is of existential value given that there are no prior studies ever carried out in Bangladesh previously. Recommendations are provided based on the study’s findings, particularly in relation to what action is needed from universities in Bangladesh.

One-item susceptibility measure predicts waterpipe and little cigar/cigarillo uptake in a national sample of adolescents and young adults in the United States

INTRODUCTION

Adolescents and young adults in the United States (US) are increasingly using non-cigarette tobacco products such as waterpipe (WP) and little cigars/cigarillos (LCC). One way to predict which non-user adolescents and young adults are most likely to use these products is through measuring their susceptibility or openness to using the products.

METHODS

We conducted a national phone survey (baseline) and an internet survey (follow-up) of adolescents and young adults (ages 13–25 years), who, at baseline, had never used WP (N=1002) or LCC (N=990). At baseline, we measured susceptibility using a single item, asking participants whether they would try WP or LCC if their best friend offered it to them, and subsequently measured uptake at follow-up. We conducted multivariate regression analyses to determine whether product-specific susceptibility was a significant predictor of uptake at follow-up.

RESULTS

Participants who were susceptible and participants who had ever used another tobacco product had higher odds of using WP (AOR=3.5, AOR=4.2) and LCC (AOR=3.2, AOR=5.3) at follow-up than those who were not susceptible to those products, and had not ever used tobacco products respectively, controlling for sociodemographic factors. The one-item measure had adequate sensitivity (WP=51.4%, LCC=40.2%) and specificity (WP=84.9%, LCC=87.9%).

CONCLUSIONS

Our national study of US adolescents and young adults shows that a one-item susceptibility measure at baseline was a significant predictor of WP and LCC uptake at follow-up, even after controlling for other predictors. Future research should assess the predictive validity of the one-item compared to the multi-item scale.

Hookah Susceptibility and Transitions Over the First Year of College

OBJECTIVE

There has been a growth in popularity of hookah (or waterpipes) among American college students, despite the health risks. This study investigated factors that predict hookah susceptibility and whether hookah susceptibility predicts hookah initiation and continued use.

METHOD

The study established a cohort of 529 incoming college freshmen (51.6% female) who completed an online survey approximately 1 week before their arrival to a large U.S. university. Students were sent four follow-up surveys throughout the 2016-2017 academic year; 90.5% completed at least one follow-up survey.

RESULTS

A total of 13.2% of the sample had used hookah at baseline and 9.9% initiated hookah use over the course of their freshman year. Among the nonusers who had no hookah susceptibility at baseline, 30.0% came to indicate some susceptibility. Multivariable logistic regression indicated that the personality construct conscientiousness was protective against becoming susceptible, whereas coming from a rural part of the state was a risk factor. Susceptibility predicted both continued use among the baseline ever-users and initiation among the baseline never-users.

CONCLUSIONS

These findings highlight the role of susceptibility in the trajectory of hookah use among U.S. college students.

Susceptibility to smoking and determinants among medical students: A representative nationwide study in China

INTRODUCTION

The rationale behind why the majority of medical students are non-smokers, but some initiate smoking after becoming physicians is not fully understood in China. Exploring factors that may increase susceptibility to smoking initiation among medical students is an essential first step in assessing preventative actions.

METHODS

Participants were 11954 students, who were identified through a multistage survey sampling process that included 50 universities in China. Subsequent analysis focused on 8916 non-smokers among medical students. Both unadjusted and adjusted logistic methods were considered in the data analyses.

RESULTS

The prevalence of susceptibility to smoking was 23.0%. Multivariate logistic regression analyses found that exposure to secondhand smoke (SHS) in domestic places (OR= 1.63) and in public places (OR=1.78), cigarette advertising (OR=1.91) and promotional activities on campus (OR=1.90) were positively associated with susceptibility to smoking. In contrast, positive attitudes toward tobacco control on the part of health professionals, HPs, (OR=0.52) were negatively associated with susceptibility to smoking. Those who received information about the dangers of smoking (OR=0.75) and did not agree that light cigarettes are less harmful to health (OR=0.79) were less susceptible to smoke. Caring about exposure to secondhand smoke (OR=0.68 care, and OR=0.33 very) and advising family members to stop smoking (OR=0.81) were negatively associated with susceptibility to smoking.

CONCLUSIONS

These findings underscore the importance of tobacco control training and establishing smoke-free campuses for reducing susceptibility to smoking among medical students.

Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review

BACKGROUND

Despite evidence for the harms of waterpipe tobacco smoking (WTS), its use is increasing amongst college and university students worldwide. This systematic review aims to assess the knowledge of, attitudes towards and perceptions of WTS among college or university students.

METHODS

We electronically searched MEDLINE, EMBASE, CINAHL, PSYCHINFO and ISI the Web of Science in October 2018, restricting our search to studies published since January 1990. We included studies among university or college students that used qualitative or quantitative methods, and addressed either knowledge, attitudes, or perceptions towards WTS. We excluded studies where WTS could not be distinguished from other forms of tobacco use and studies reported as abstracts where the full text could not be identified. Data were synthesised qualitatively and analysed data by region (global north/ south), and by reasons for use, knowledge of health hazards, how knowledge influences use, perceptions towards dependence, and policy knowledge.

RESULTS

Eighty-six studies were included; 45 from the global north and 41 from the global south. Socio-cultural and peer influences were major contributing factors that encouraged students to initiate WTS. Furthermore, WTS dependence had two components: psychological and social. This was compounded by the general perception that WTS is a less harmful, less addictive and more sociable alternative to cigarette smoking. Knowledge of WTS harms failed to correlate with a reduced risk of WTS use, and some students reported symptoms of WTS addiction. A large proportion of students believed that quitting WTS was easy, yet few were able to do so successfully. Finally, students believed current public health campaigns to educate on WTS harms were inadequate and, particularly in the global north, were not required.

CONCLUSION

Reasons for WTS amongst university students are multi-faceted. Overall, interventions at both the individual and community level, but also policy measures to portray a message of increased harm amongst students, are required. Additional studies are necessitated to understand temporal changes in students' beliefs, thus allowing for better targeted interventions.

Curiosity About and Susceptibility Toward Hookah Smoking Among Middle and High School Students

INTRODUCTION

Hookah smoking has increased among young people. Curiosity and susceptibility may be associated with experimentation or established use. Because tobacco use behaviors are established primarily during adolescence, our objective was to examine factors that may increase the risk of future tobacco product use among youth.

METHODS

We analyzed data from the 2016 National Youth Tobacco Survey, a nationally representative survey of US students. Analyses were restricted to youth who had never smoked a hookah and stratified by their ever having used other tobacco products. The prevalence of hookah curiosity and susceptibility was assessed by sociodemographic characteristics, perceptions of harmfulness and addictiveness of hookahs, and peer use of hookahs. Associations between covariates and curiosity and susceptibility were assessed by using multivariable-adjusted regression.

RESULTS

Overall, 29.1% of students reported any hookah curiosity or susceptibility. Curiosity was reported by 14.6% of those who never used tobacco products and by 45.9% of those who ever used tobacco products. Hookah susceptibility was reported by 15.6% of never-users and 52.5% of ever-users. Regardless of ever having used other tobacco products, odds of curiosity and susceptibility were higher among students with perceptions of reduced hookah harmfulness and addictiveness and among those who perceived high levels of hookah use among peers.

CONCLUSION

Nearly 3 in 10 youth who never smoked a hookah (6.9 million) reported hookah curiosity or susceptibility, and prevalence was highest among those who had ever used other tobacco products. These findings reinforce the importance of educating youth about the dangers of all tobacco products and dispel misperceptions about the harmfulness and addictiveness of hookah smoking. Continued surveillance of youth curiosity, susceptibility, and use of hookahs can inform public health policy and practice.

Adolescent Tobacco Uptake and Other Substance Use: A Latent Class Analysis

Objective: The purpose of this study was to identify patterns of tobacco uptake and other substance use, from early to late adolescence. Methods: We used weighted latent class analysis, conducted separately for 7^th, 9^th, and 11^th graders, to assess patterns of susceptibility, ever and current use of combustible tobacco and e-cigarettes, and other substance use (ie, current alcohol, binge drinking, and marijuana). Data were from Wave 3 of the Texas Adolescent Tobacco and Marketing Surveillance System (n = 2733; N = 461,069), collected in fall 2015. Multinomial regression was used to examine differences in class membership by demographic factors. Results: Two latent classes were identified in 7^th grade, 3 classes in 9^th grade, and 4 classes in 11^th grade models. In each grade, classes included both a "no risk" and a "tobacco susceptible" class. For 9^th grade, there was an additional "tobacco ever use" class, and 11^th grade had the same additional class as well as an "all products use" class. Conclusion: Distinct patterns of polysubstance use emerged as grade level increased, supporting a stage-sequential model of onset and progression across developmental age groups. Future research can examine other factors affecting transitions across these stages.

Measurement and predictive value of susceptibility to cigarettes, e-cigarettes, cigars, and hookah among Texas adolescents

Susceptibility to cigarette smoking, defined as the lack of a firm commitment not to smoke in the future, begins in childhood and is a phase in the transition from never to ever use of cigarettes. While a consistent and validated predictor of cigarette use, little research has assessed whether the susceptibility construct applies equally well across other tobacco products. Baseline data were collected in 2014–2015 from a representative sample of (n = 2844) middle and high school students in five counties surrounding the four largest cities in Texas, (49% female and mean age 13.13 years, with subsequent waves at 6, 12, and 18 months. Confirmatory factor analysis examined the appropriateness of a three-item susceptibility measure (product-specific curiosity, intention to use, and peer influence) across product types and ethnic groups (Hispanic versus non-Hispanic). Logistic regression examined whether product specific susceptibility at baseline predicted future product initiation. At baseline, 11.5%, 17.0%, 17.4% and 29.4%, of adolescent never users were susceptible to cigars, cigarettes, hookah and e-cigarettes, respectively; significantly more Hispanic than non-Hispanic adolescents were susceptible to e-cigarettes (32.4% versus 26%, p < 0.01) and cigarettes (19.9% versus 13.9%, p < 0.05). Product-specific items were significantly and consistently associated with the respective underlying susceptibility product construct and across ethnic groups (p < 0.001 for all). Susceptibility to e-cigarettes (AOR = 2.28–6.64) or any combustible product (cigarettes, hookah, cigars; AOR = 3.38–5.20) significantly predicted subsequent ever use. This study confirms the appropriateness of the susceptibility construct across four tobacco product types and ethnic groups, and the utility of susceptibility in predicting future product use among adolescents.

•

Susceptibility to e-cigarettes and combustible tobacco products is robustly measured by the same three product-specific items

•

Product-specific susceptibility constructs predicted use of respective tobacco products at 6, 12, and 18 months post-baseline

•

Susceptibility to e-cigarettes and combustible tobacco products can be measured reliably in Hispanic and non-Hispanic youth

Social and substance use correlates of adult hookah use, 2016

Introduction

Hookah prevalence has been increasing in U.S. adults. This study examines correlates and frequency of hookah use in a national sample of U.S. adults (18–44 years).

Methods

Data were drawn from Wave 10 (October 2016) respondents aged 18–44 years from the Truth Initiative Young Adult Cohort Study (n=4,085). Weighted bivariate analyses were used to estimate correlates and frequency of hookah use, and differences between past 30-day and noncurrent hookah users on social and substance use (alcohol, marijuana, and other drugs) correlates.

Results

Twenty percent of the sample ever used hookah, and 2% used hookah in the past 30 days. Compared to never users and non-current users, a significantly greater proportion of ever and past 30-day hookah users reported past 30-day e-cigarette, tobacco, and substance use (p’s<0.01). Eighty-one percent of past 30-day hookah users had at least one close friend who also used hookah, and 35% self-identified as social/occasional smokers. The majority (68%) of past 30-day users reported hookah use on fewer than five of the past 30 days, and 58% engaged in two or more hookah sessions on those days.

Conclusions

Ever and past 30-day hookah use are associated with concurrent tobacco, e-cigarette, and substance use. They are also correlated with peer hookah use and self-identification as a social/occasional smoker. Even infrequent hookah sessions can expose users to health risks. Research identifying contexts in which hookah is used and how it is used with other substances is needed to inform interventions to reduce hookah use.

Comparing harm beliefs and risk perceptions among young adult waterpipe tobacco smokers and nonsmokers: Implications for cessation and prevention

Introduction

Very little is known about how waterpipe tobacco smokers and nonsmokers compare on harm beliefs about waterpipe tobacco smoking (WTS) and how these beliefs are related to risk appraisals and intentions to engage in WTS. We investigated these issues among young adult waterpipe tobacco smokers, susceptible nonsmokers, and non-susceptible nonsmokers.

Methods

Young adults ages 18 to 30 who smoked waterpipe tobacco during the last 30 days or never used waterpipe tobacco were recruited online through Turkprime. Nonsmokers were grouped as susceptible or not. Participants completed measures of harm beliefs, risk appraisals (i.e., perceived risks and worry), and desire to quit among smokers or willingness/curiosity to try waterpipe among nonsmokers.

Results

Analyses were based on 247 smokers and 418 nonsmokers. Smokers endorsed most strongly harm beliefs that portrayed WTS as safe, followed by susceptible and then non-susceptible nonsmokers. Most harm beliefs were significantly related to risk appraisals, yet weakly associated with desire to quit or willingness/curiosity to try waterpipe tobacco, except among susceptible nonsmokers.

Conclusions

Greater efforts are needed to correct maladaptive beliefs about WTS harms, especially among smokers. Among susceptible nonsmokers, harm beliefs may be more influential in predicting willingness to try WTS than risk appraisals.

•

Waterpipe tobacco smokers view waterpipe tobacco smoking as safer than nonsmokers.

•

Perceived risk correlates with many harm beliefs about waterpipe tobacco smoking.

•

Among smokers, desire to quit is related more with perceived risk than harm beliefs.

•

Among susceptible nonsmokers, intent to try waterpipe relates to many harm beliefs.

Characterizing Young Adults' Susceptibility to Waterpipe Tobacco Use and Their Reactions to Messages About Product Harms and Addictiveness

Introduction

There is very little insight into the psychosocial characteristics of young adults susceptible to waterpipe tobacco use and their reactions to messages about harms of waterpipe tobacco smoking (WTS). We investigated how young adults who were or were not susceptible to WTS differed on various characteristics and their reactions to messages about WTS harms.

Methods

Young adults ages 18 to 30 who had never used waterpipe tobacco were recruited through an online crowdsourcing site. Participants were stratified on susceptibility status (susceptible or not) and randomized to receive messages about harms and addictiveness of WTS or a control condition that received no messages. Participants' perceptions of risk and worry, their attitudes toward, and willingness/curiosity to try WTS were assessed.

Results

Compared to nonsusceptible participants, susceptible participants perceived themselves to be at lower risk and worried less about harms and addictiveness of WTS, had more positive attitudes toward use, and expressed a greater willingness and curiosity to try it. Among susceptible participants, messages decreased willingness/curiosity to try WTS; messages had no effect on nonsusceptible participants. The message effects among susceptible participants were explained by more negative attitudes and less ambivalence toward WTS.

Conclusions

Susceptible young adults' psychosocial characteristics place them at high risk for future uptake of WTS. Brief public health messages about harm and addiction may deter susceptible young adults' willingness to try WTS and prevent WTS initiation and progression.

Implications

Findings suggest that in order to curb the initiation of WTS among susceptible young adults, interventions should target risk appraisals and attitudes toward WTS.

University students' perceived risk of and intention to use waterpipe tobacco

Emerging tobacco product use is increasing. We evaluated factors associated with perceived risk of and intention to use waterpipe tobacco by surveying students at a large university in the southeastern U.S. (N = 667). Proportional odds modeling assessed whether demographic characteristics and social acceptability are associated with perceived risk of waterpipe tobacco use; and if these factors and perceived risk are related to intention to use waterpipe tobacco. Participants who perceived waterpipe tobacco to be more socially acceptable had lower odds of perceiving it as risky (95% confidence interval [CI] 0.50-0.68). Compared with never users, former tobacco users and current users had lower odds of perceiving waterpipe tobacco use as risky (95% CI 0.38-0.80 and 0.28-0.63, respectively). Similarly, students with greater perceived social acceptability scores had higher odds of intending to use waterpipe tobacco (95% CI 1.41-2.63), while those who perceived greater risk had lower odds of intending to use it (95% CI 0.34-0.64). Compared with never users, former users had higher odds of intending to use waterpipe tobacco (95% CI 1.42-7.21). Among those who had ever used waterpipe tobacco, 90% reported 'to socialize' as the most frequent reason for deciding to do so. Findings underscore the need for future prevention efforts.

Engagement With Online Tobacco Marketing and Associations With Tobacco Product Use Among U.S. Youth

PURPOSE

Youth who engage with online tobacco marketing may be more susceptible to tobacco use than unengaged youth. This study examines online engagement with tobacco marketing and its association with tobacco use patterns.

METHODS

Cross-sectional analysis of youths aged 12-17 years who participated in wave 1 of the Population Assessment of Tobacco and Health Study (N = 13,651). Engagement with tobacco marketing was based on 10 survey items including signing up for email alerts about tobacco products in the past 6 months. Logistic regression was used to examine the association of online engagement with tobacco marketing and susceptibility to use any tobacco product among never-tobacco users, ever having tried tobacco, and past 30-day tobacco use.

RESULTS

An estimated 2.94 million U.S. youth (12%) engaged with ≥ one forms of online tobacco marketing. Compared with no engagement, the odds of susceptibility to the use of any tobacco product among never-tobacco users was independently associated with the level of online engagement: adjusted odds ratio (AOR) = 1.48 (95% confidence interval [CI], 1.24-1.76) for one form of engagement and AOR = 2.37 (95% CI, 1.53-3.68) for ≥ two forms of engagement. The odds of ever having tried tobacco were also independently associated with the level of online engagement: AOR = 1.33 (95% CI: 1.11-1.60) for one form of engagement and AOR = 1.54 (95% CI, 1.16-2.03) for ≥ two forms of engagement. The level of online engagement was not independently associated with past 30-day tobacco use.

CONCLUSIONS

Online engagement with tobacco marketing may represent an important risk factor for the onset of tobacco use in youth.

Hookah tobacco smoking in a large urban sample of adult cigarette smokers: Links with alcohol and poly-tobacco use

Hookah tobacco smoking (HTS) has been increasing, particularly among young adults and has similar health effects compared to cigarette smoking. The link between HTS and poly-tobacco use is well documented, but fewer show an association between HTS and alcohol use. It is essential to identify factors that increase the risk for or addictiveness and consequences of HTS, given its growing prevalence. This study examined whether the association between HTS and poly-tobacco use differed as a function of age and alcohol consumption within in a sample of 1223 adult cigarette smokers. Approximately 20% of participants reported HTS. Compared to non-users, hookah users were more likely to be male, highly educated, and to report drug and alcohol use, binge drinking, and poly-tobacco use but were less likely to be heavy smokers (≥10 cigarettes per day). Regression analyses predicting number of tobacco products used (excluding cigarettes and HTS) indicated a three-way interaction of HTS, frequency of alcohol use, and age such that the association between HTS and number of tobacco products used was strongest for younger respondents who consumed alcohol more frequently. As observed in previous studies, alcohol is an important risk factor in the relationship between HTS and poly-tobacco use, particularly among younger cigarette smokers. The links between alcohol, HTS, and poly-tobacco use should be considered when developing HTS education and prevention materials directed toward younger cigarette smokers. Findings provide information relevant to FDA's interest in the addiction potential of HTS and its link to poly-tobacco use.

Initiation, Progression, and Sustained Waterpipe Use: A Nationally Representative Longitudinal Study of U.S. Young Adults

Background: Waterpipe tobacco smoking (WTS) is increasing in popularity despite evidence of harm and potential for dependence. Intervention development has been hampered by a lack of longitudinal, nationally representative data on usage patterns and factors independently associated with WTS initiation. Therefore, we aimed to characterize key transitions between WTS states in a nationally representative group of young adults, with particular attention to factors independently associated with initiation.Methods: Participants were randomly selected from a national probability-based panel representing 97% of the United States. A total of 1,785 adults ages 18 to 30 at baseline completed two Web-based surveys 18 months apart in 2013 and 2014. Assessments included knowledge of waterpipe tobacco smoke composition, positive and negative attitudes toward WTS, normative beliefs, intention to use waterpipe, and WTS behavior. We used multivariable logistic regression to assess the association between predictive factors and subsequent WTS initiation.Results: In fully adjusted models, overall knowledge about toxicants associated with WTS was not associated with subsequent WTS initiation. Similarly, negative attitudes and normative beliefs were not associated with WTS uptake. However, baseline positive attitudes were strongly and significantly associated with WTS initiation [adjusted OR (AOR) = 1.7; 95% confidence interval (CI), 1.2-2.3]. Similarly, baseline intention to use WTS was strongly associated with subsequent initiation (AOR = 7.0; 95% CI, 3.5-13.7).Conclusions: Prevention efforts may be most successful if they target individuals with clear intentions to use WTS and challenge positive attitudes surrounding WTS.Impact: Surveillance of WTS trajectories will help inform health care and policy surrounding this emerging risk behavior among U.S. young adults. Cancer Epidemiol Biomarkers Prev; 26(5); 748-55. ©2017 AACR.

Adolescents' and Young Adults' Knowledge and Beliefs About Constituents in Novel Tobacco Products

INTRODUCTION

Novel tobacco products, such as little cigars, cigarillos, hookah, and e-cigarettes, and their smoke or aerosol contain chemicals which the FDA has determined to be Harmful or Potentially Harmful Constituents. We explored adolescents' and young adults' knowledge and beliefs about constituents in novel tobacco products and their smoke or aerosol, in order to inform risk communication messages.

METHODS

Seventy-seven adolescents and young adults (ages 13-25) participated in 10 focus groups, including 47 novel tobacco product users and 30 susceptible nonusers. Participants were asked to discuss 10 pre-selected constituents found in novel tobacco products and their smoke or aerosol. The first author analyzed the discussion for emergent themes.

RESULTS

Participants were generally familiar with arsenic, carbon monoxide, formaldehyde, and nicotine, but unfamiliar with acetaldehyde, acrolein, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanon (NNK), and N-nitrosonornicotine (NNN). All participants had negative beliefs about most constituents, although users had positive beliefs about nicotine. "Unfamiliar" constituents were associated with similarly-sounding words (eg, acetaldehyde sounds like acetaminophen), and some participants recognized words in the chemical names of NNK/NNN (eg, "nitro"). "Familiar" constituents were associated with negative health effects and other common products the constituents are found in. All participants wanted more information about the constituents' health effects, toxicity, and other common products. Most participants were unaware the constituents discussed are in novel tobacco products and their smoke or aerosol.

CONCLUSIONS

Risk communication messages could capitalize on negative associations with familiar constituents, or attempt to educate about unfamiliar constituents, to discourage novel tobacco product use among adolescents and young adults.

IMPLICATIONS

The results of this study have implications for how the FDA and other agencies can communicate about the risks of novel tobacco products to the general public, which will be particularly important once the Deeming Rule is finalized. Our findings suggest it may be effective to capitalize on the public's negative beliefs about and associations with familiar constituents, or to educate about unfamiliar constituents and their health effects, their concentration and toxicity in novel tobacco products and their smoke or aerosol, and other products they are found in.

Waterpipe tobacco smoking: A new smoking epidemic among the young?

Waterpipe (hookah, narghile) tobacco smoking (WTS) is becoming prevalent worldwide and is one of the most popular forms of tobacco use among youth. WTS prevalence has increased dramatically among youth in the United States within the past decade. Misperceived as less harmful than cigarette smoking, WTS is associated with many of the same chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, bronchitis, and asthma. Much of this risk is due to the fact that a single WTS session exposes users to large volumes of smoke that contain toxic chemicals such as carbon monoxide, cancer-causing polycyclic aromatic hydrocarbons, and volatile aldehydes. Unlike cigarette smoking, WTS poses unique risks of acute negative health outcomes including carbon monoxide poisoning and the spread of communicable diseases such as herpes and tuberculosis. Because waterpipe tobacco smoke contains the addictive chemical nicotine, youth who smoke tobacco from a waterpipe may be at risk for dependence. As a result, many youth may initiate WTS and continue to use despite negative health effects. Considering many of the potential negative health effects associated with WTS affect the pulmonary system, pulmonologists and primary care providers may treat patients who are waterpipe tobacco smokers and should be aware of the risk associated with WTS. The purpose of this review is to describe a waterpipe, the prevalence and correlates of WTS, the toxicants found in waterpipe tobacco smoke, the health effects of WTS, and implications for pulmonologists and other clinicians.