JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 61, NO. 6 Major Article

Knowledge and Attitudes Toward Hookah Usage Among University Students

Adam L. Holtzman, MD; Dara Babinski, MA; Lisa J. Merlo, PhD, MPE

Abstract. Objective: Hookah is a popular form of rate of use among college students.6 However, un- use on university campuses. This study documented use, attitudes, like cigarette smoking, which is a focus of much research and and knowledge of hookah smoking among college students. Par- public health initiatives,7 relatively little research exists on ticipants: The sample included 943 university students recruited between February 2009 and January 2010. Respondents (M age = understanding hookah use among college . Thus, fur- 20.02) included 376 males, 533 females, and 34 who did not report ther exploration of characteristics related to hookah smoking sex. Methods: An anonymous online questionnaire was completed was greatly needed. by respondents. Results: In this sample, 42.9% of college students The popularity of hookah smoking among college stu- had tried hookah, and 40% of those individuals had used it in the dents may result from several factors. First, hookah smoking past 30 days. Students perceived fewer negative consequences of hookah smoking compared with cigarette smoking. Age, sex, racial appears to be a social activity, with many users sharing a background, marijuana/cigarette use, and perceptions of side effects “bowl” of tobacco and passing the pipe around to others. were significantly associated with hookah use. Conclusions:Uni- Hookah cafes offer an alternative social scene for students versity students are misinformed regarding the health consequences under the who do not have access to bars,8 of hookah smoking. Programs aimed at education, prevention, and and a disproportionate number of hookah cafes have been es- intervention for hookah use are needed to address this growing public health concern. tablished near university campuses. In addition, hookah cafes are often exempt from indoor smoking , providing a le- Keywords: attitudes, health risk perceptions, hookah, tobacco gal venue for consuming tobacco products in public settings. Furthermore, hookah smoking is often marketed as “natu- ral,”8 which may be perceived by students as less potentially he popularity of hookah smoking, also referred to as harmful than cigarette smoking. waterpipe smoking, narghile, shisha, or goza,1 has in- However, emerging evidence demonstrates that hookah creased rapidly over the past 2 decades.2 Although smoking is associated with a range of negative consequences T similar to those of cigarette smoking, including cardio- hookah-based had historically been a pre- dominantly Middle Eastern practice, with roots dating back vascular disease, cancer,9 abnormal pulmonary functions, as far as the 12th century, its worldwide popularity has grown elevated heart rate and blood pressure, high carboxyhe- substantially since the production of “maasel” (or “shisha” moglobin, decreased fertility, and .10 According to a in the ), which is a fruit-flavored tobacco intro- report from the World Health Organization (WHO),11 an duced by Egyptian tobacco corporations in 1990. Hookah use hour-long hookah smoking session may be equivalent to has become particularly popular among college-aged 100 , which likely results from inhaling in the United States.2,3 A recent survey of college students smoke from both the tobacco and the coal used to heat the indicated that 6% had used hookah in the past 30 days,4 al- tobacco in the waterpipe. The hookah device essentially in- though others have shown rates as high as 17% to 20%.2,5 cludes a head, body, waterbowl, and hose. When the coal This considerable rate of hookah use is nearly equal to the placed in the head is lit, it heats the tobacco below it, which flows and diffuses into the waterbowl and is smoked through the hose. Although smoke is diffused into the waterbowl, Dr Holtzman, Ms Babinski, and Dr Merlo are with the McKnight the smoke inhaled through the hookah contains the harmful Brain Institute at University of Florida in Gainesville, Florida. contents of the tobacco smoke, as well as the carcinogens of Copyright © 2013 Taylor & Francis Group, LLC the coal heating the tobacco.

362 Hookah Usage Among University Students

Despite the known toxicants found in hookah smoke and bars/cafes, campus libraries, dormitories, and local coffee- its presumed health consequences, the popularity of hookah houses, and asked students if they would like to participate smoking in the United States is expanding,12 even at a time in a brief anonymous study on tobacco use, knowledge, and when cigarette consumption is at its lowest levels in over 5 attitudes. Interested individuals were given a flyer containing decades.13 Much research has shown that early exposure to the link to the online survey, which was hosted on survey- is associated with a higher likelihood of develop- monkey.com. ing addiction, so the increase and popularity among college The Web link first directed participants to the informed youth may be a particular long-term public health concern. consent. To protect anonymity, participants were required Furthermore, although hookah smoke composition both for to choose “Yes, I consent” in order to access the anonymous the primary and secondhand smoker is different from other online survey, rather than signing their names. The survey re- forms of tobacco, it has the potential to pose systemic health quired approximately 10 to 20 minutes to complete. With the hazards and therefore deserves further exploration. exception of students who received extra credit for study par- Relatively few studies exist on the epidemiology, percep- ticipation, participants were provided no compensation for tions, and knowledge of hookah smoking among university completing the survey. Data were collected between Febru- students, and only recently have efforts begun to identify the ary 2009 and January 2010. characteristics of hookah smokers in the United States. Given the rise of hookah smoking, these efforts are greatly needed. Measures Furthermore, without adequate knowledge of the use and at- After completing the consent, participants were presented titudes that college students have towards hookah smoking, with an online questionnaire that was adapted from an earlier researchers and policy makers will be uninformed or mis- survey on hookah use in the United States,14 plus additional informed about how best to intervene. The purpose of the questions added for this study. The measure assessed whether present study was to assess patterns, perceptions, and knowl- respondents had ever used a hookah to smoke tobacco (1 edge of university students’ hookah use, as well as to identify item) and frequency of use (1 item). It also included 3 items psychosocial factors associated with hookah use. describing hookah users’ initial use experience (ie, age, com- pany, location). Items assessing the importance of 14 factors METHODS associated with smoking and the importance of 14 reasons Participants for smoking were rated on a 5-point Likert-type scale. Three This study included 943 students (376 male, 533 female, items assessed concerns about addiction, perceived ability to 34 did not report sex) who ranged in age from 17 to 35 years quit and desire to quit. Eight additional items assessed pat- old (M = 20.02, SD = 1.74) at a university in the south- terns and characteristics of hookah use (ie, where waterpipe eastern United States. The study sample was ethnically di- is obtained, flavor of tobacco, type of charcoal used, etc). verse (ie, 16.3% Asian, 9.5% African American, 13.7% His- Furthermore, for respondents who endorsed using hookah panic or Latino, 59.4% Caucasian, 1.1% other), and was within the past 30 days, additional items assessing patterns relatively representative of the overall student population, of use (ie, length of typical smoking session, number of bowls which is 7.7% Asian, 8.0% African American, 18.1% His- smoked per session, number of sessions per day, company panic/Latino, 58.4% Caucasian, 5.0% other, and 2.7% not and location while smoking) were administered. reported, although Asian students were overrepresented in All respondents, whether they ever used a hookah pipe the sample. The sample was composed primarily of under- or not, were asked to estimate prevalence of hookah pipe graduate students (98.7%). Specifically, the sample included use, and were asked about other substance use, including 20.7% college freshmen, 24.7% sophomores, 29.0% juniors, other forms of tobacco use. Four questions asked their per- 20.3% seniors, 1.3% fifth year or higher, and 1.3% graduate ceptions of the relative risk of hookah pipe use compared or professional students. The remaining 2.7% of participants with cigarette use. Four additional questions were added to did not report student status. assess perceptions and attitudes towards passive smoke ex- posure. In all, the questionnaire contained 53 items. Demo- graphic data were also gathered from students including age, Procedures sex, racial/ethnic background, and educational status (see The University of Florida Institutional Review Board ap- Tables 1 to 3 for survey items and response options). proved all study procedures. The majority of participants were recruited through announcements in online undergrad- uate courses. The students were provided with a link to ac- Data Analytic Plan cess the survey and complete it at their convenience. Some Respondents were categorized dichotomously as hookah course professors offered extra credit to students who either users versus hookah nonusers based on their self-reported completed the survey or an alternative assignment relevant history of use. Demographics, substance use behaviors, per- to the course. The remaining participants were recruited by ceptions of hookah use, and attitudes towards secondhand research staff who visited several areas frequented by uni- smoke were compared by group using chi-square analysis, versity students, including the student union, local hookah and logistic regression was used to explore predictors of

VOL 61, AUGUST/SEPTEMBER 2013 363 Holtzman, Babinski, & Merlo

TABLE 1. Characteristics of Hookah Nonusers Versus Users

Nonusers Ever-users (n = 522) (n = 392) Characteristics % % Crude OR 95% CI Adjusted OR 95% CI

Demographics Sex (female = 0, male = 1) 1.70 1.30, 2.23 1.44 1.05, 1.98 Male 49.650.4 Female 62.637.3 Race (black/African American = 0, all other races = 1) 6.53 3.33, 12.80 5.00 2.38, 10.50 Asian 58.141.9 Black/African American 88.311.7 Caucasian 51.348.7 Hispanic/Latino 59.840.1 Other 50.050.0 Age (under 21 = 0, 21 or older = 1) 1.42 1.07, 1.89 1.19 0.85, 1.65 Under 21 60.539.5 21 or older 51.948.1 Previous substance use Previous marijuana use (no = 0, yes = 1) 4.77 3.56, 6.38 3.82 2.75, 5.31 Yes 37.662.4 No 74.225.8 Past year cigarette use (no = 0, yes = 1) 4.07 2.94, 5.63 2.22 1.52, 3.24 Yes 33.966.1 No 67.632.4 Perceptions of side effects Health effects (cigarettes more harmful = 1, all others = 0) 1.87 1.42, 2.46 0.87 0.58, 1.31 Cigarettes much more harmful 17.225.5 Cigarettes slightly more harmful 26.433.6 Same 43.028.6 Waterpipe slightly more harmful 7.66.4 Waterpipe much more harmful 5.95.9 Addictive effects (cigarettes more addictive = 1, all others = 0) 4.55 3.35, 6.19 3.26 2.08, 5.11 Cigarettes much more addictive 27.861.8 Cigarettes slightly more addictive 16.516.6 Same 48.819.9 Waterpipe slightly more addictive 4.70.8 Waterpipe much more addictive 2.20.8 Nicotine content (cigtarettes more nicotine = 1, all others = 0) 2.46 1.85, 3.26 0.95 0.60, 1.49 Cigarettes much more nicotine 23.944.7 Cigarettes slightly more nicotine 21.522.5 Same 45.826.7 Waterpipe slightly more nicotine 5.32.8 Waterpipe much more nicotine 3.53.4 Health risk switch from cigarette to waterpipe (reduction = 1, all 1.91 1.45, 2.52 1.12 0.75, 1.67 others = 0) Large increase 2.92.5 Moderate increase 10.67.6 Small increase 7.57.0 No reduction 45.333.6 Small reduction 27.131.9 Moderate reduction 6.315.4 Large reduction 0.42.0 Secondhand exposure (no = 0, yes = 1) If people are smoking cigarettes I would rather be somewhere else 0.31 0.29, 0.43 0.49 0.22, 1.10 Yes 86.569.5 No 13.530.5 If people are smoking waterpipe I would rather be somewhere else 0.11 0.08, 0.15 0.22 0.14, 0.35 Yes 61.315.4 No 38.784.6 (Continued on next page)

364 JOURNAL OF AMERICAN COLLEGE HEALTH Hookah Usage Among University Students

TABLE 1. Characteristics of Hookah Nonusers Versus Users (Continued)

Nonusers Ever-users (n = 522) (n = 392) Characteristics % % Crude OR 95% CI Adjusted OR 95% CI

If people are smoking cigarettes it does not bother me 2.00 1.42, 2.81 0.47 0.20, 1.07 Yes 14.126.6 No 85.973.4 If people are smoking waterpipe it does not bother me 4.42 3.30, 5.86 2.07 1.35, 3.16 Yes 25.465.3 No 74.634.7

Note.OR= odds ratio; CI = confidence intervals. The total sample included 943 participants. Crude ORs are presented to explore the effect of each variable on ever using hookah. Follow-up binary logistic regressions were conducted to explore the impact of the variable controlling for other related variables and the resultant adjusted ORs are also presented. Follow-up analyses of demographic and previous substance abuse variables controlled for all other demographic and substance use variables. Demographic and side effect variables were controlled for in follow-up analyses of perceptions of side effects variables. hookah use. Given that very little is known about predictors RESULTS of hookah use, separate logistic regressions were conducted for each potential predictor variable. Demographics (ie, sex, Hookah Users Versus Nonusers age, and race), substance use behaviors (ie, previous mari- Of the participants who responded (n = 914), 42.9% juana use and cigarette use within the last year), perceptions reported ever smoking hookah. As seen in Table 1, male of side effects (ie, health effects, addictive effects, nicotine students were more likely to have tried hookah smoking than 2 content, and secondhand exposure), and attitudes toward sec- female students (χ = 15.22, p < .001), and non-African ondhand smoke were first explored individually and unad- American/black students were more likely than African 2 justed odds ratios were calculated. Next, to determine the American/black students to smoke hookah (χ = 44.87, p < relation between the predictor and hookah use after con- .001). Individuals 21 years or older were more likely to have 2 trolling for other significant predictors of hookah use, lo- ever tried hookah smoking than those under 21 (χ = 5.92, gistic regressions were again conducted and adjusted odds p < .05); however, rates of hookah use in the past 30 days ratios were calculated. Given the significant correlations be- were higher for individuals under 21 (43.9%) than for those 2 tween demographic and substance use behavior variables, 21 or older (32.6%; χ = 4.47, p < .05). Individuals who 2 they were added to the first step of the follow-up logis- had ever smoked marijuana (χ = 116.81, p < .001) or had 2 tic regression. Perceptions of health effects and attitudes smoked cigarettes in the past year (χ = 76.84, p < .001) towards secondhand smoke were also intercorrelated with were significantly more likely to have tried smoking hookah each other, and thus follow-up logistic regressions for per- than those who had not. Unadjusted and adjusted odds ceptions of side effects and secondhand smoke controlled ratios (ORs) are presented in Table 1. All demographics and for these other perceptions as well as demographic variables. substance use behaviors remained significantly related to To simplify the interpretation of these analyses, binary lo- hookah use when controlling for other demographics and gistic regressions were conducted. Thus, for variables with substance use behaviors, with the exception of age. more than 2 levels, meaningful comparison groups were cre- The plurality of students reported believing that smok- ated (ie, race: African American/black compared with all ing tobacco from a waterpipe was as addictive or harmful other races; health effects: cigarettes much more harmful or as smoking cigarettes (see Table 1), but many respondents slightly more harmful compared with all other categories; ad- reported believing that cigarettes were more harmful and dictive effects: cigarettes much more addictive or cigarettes addictive than hookah. This trend was also seen regarding slightly more addictive compared with all other categories; perceived nicotine content, where a large proportion of re- nicotine content: cigarettes much more nicotine or cigarettes spondents thought that cigarettes have more nicotine than slightly more nicotine compared with all other categories; hookah smoke does. Perceptions of hookah use were related health risk switch from cigarette to waterpipe: any increase to history of ever using hookah. Individuals reporting that [ie, small, moderate, or large] compared with all other cate- cigarettes were more harmful than hookah were more likely 2 gories). Follow-up descriptive analyses were conducted only to have used hookah (χ = 20.43 p < .001) compared with for those participants who endorsed ever using hookah. De- other respondents; individuals who indicated that cigarettes scriptive analyses of recent (ie, within the last 30 days) contained more nicotine were more likely to have smoked 2 hookah users were also conducted. Data were analyzed hookah (χ = 40.50, p < .001) than other respondents; indi- using IBM SPSS Statistics 20 software (SPSS, Chicago, viduals indicating lower risk from switching from cigarettes Illinois). to hookah smoking were more likely to have smoked hookah VOL 61, AUGUST/SEPTEMBER 2013 365 Holtzman, Babinski, & Merlo

TABLE 2. Characteristics of Hookah Users

Ever users Past 30-day (n = 392) users (n = 150) Characteristics % %

Initiation of use Age at initial use Younger than 9 years old 0.8 10–12 years old 0.3 13–15 years old 5.3 16–18 years old 57.1 19–21 years old 33.9 22–24 years old 1.9 25–29 years old 0.8 Company at initial use Alone 0.8 With one friend 5.3 With more than one friend 85.4 With a family member 2.6 With more than one family member 3.7 With a new acquaintance 1.9 Other 0.3 Location of initial use In a cafe´ or restaurant 45.9 In my own home 6.8 In my dorm room 0.6 At a family member’s home 2.8 At a fraternity/sorority house 3.1 At a friend’s or acquaintance’s house 38.7 In someone else’s dorm room 2.0 Frequency of hookah use Less than once a year 33.1 At least once a year, but not monthly 41.0 At least once a month, but not weekly 18.5 At least once a week, but not daily 6.1 At least once a day, or most days each week 1.3 Method of hookah use Number of hookahs owned None 79.6 116.9 2 3.0 3 0.3 More than 3 0.6 Frequency of flavored tobacco hookah use Never 4.1 Sometimes 9.1 Always 86.8 Ever used hookah to smoke anything other than tobacco No 77.3 Yes 22.7 Addicted to hookah No 98.4 Yes 1.6 Confidence in ability to quit Not at all confident 0.3 A little confident 0.8 Moderately confident 1.6 Very confident 97.3 Plans to quit No 55.9 In the next month 21.8 In the next six months 2.5 In the next 12 months 1.1 In the future (not in the next 12 months) 18.7 (Continued on next page)

366 JOURNAL OF AMERICAN COLLEGE HEALTH Hookah Usage Among University Students

TABLE 2. Characteristics of Hookah Users (Continued)

Ever users Past 30-day (n = 392) users (n = 150) Characteristics % %

Frequency of hookah use in past 30 days None 60.0 Once 22.7 2–5 times 13.3 6–10 times 1.9 11–20 times 1.3 21–30 times 0.3 31 or more times 0.5 Frequency of hookah use each day (past 30 days) About 1 time per day 89.7 About 2 times per day 7.5 About 3 times per day 1.4 More than 3 times per day 1.4 Length of typical hookah session (past 30 days) 0–10 minutes 7.5 11–30 minutes 39.5 31–60 minutes 35.4 61–90 minutes 14.3 121 or more minutes 0.7 Number of bowls smoked per occasion (past 30 days) None 2.1 One 37.7 2–5 47.9 6–10 6.8 11–20 2.7 21–30 1.4 31 or more bowls 1.4

Note. The total sample included 943 participants. The items in this table were only presented to respondents who endorsed ever using hookah (n = 392). As indicated, additional follow-up items were presented only for individuals endorsing hookah use within the last 30 days (n = 150).

TABLE 3. Self-reported Reasons for Hookah Use

Survey item MSD

It’s a good way to socialize with friends. 3.32 1.29 It helps control my weight. 1.16 0.54 It helps control my appetite. 1.16 0.52 It helps me not smoke cigarettes. 1.19 0.62 If I don’t smoke waterpipe, I think about it a lot. 1.13 0.52 It helps me not smoke other tobacco products besides cigarettes. 1.16 0.59 It’s something to do when I get bored. 2.01 1.21 I enjoy the smell. 2.11 1.14 It helps me feel less stressed. 1.90 1.15 It helps me to feel relaxed. 2.24 1.21 If I don’t smoke a waterpipe, I experience unpleasant feelings such as 1.09 0.44 irritability and/or have trouble concentrating and/or feel sad. I enjoy the taste. 2.58 1.24 Waterpipe smoke is less harsh than cigarette smoke. 2.07 1.31 I like trying things that are new, different, or “hip.” 1.85 1.08

Note. Participants were asked to rate reasons on a 1 (not at all)to5(the most important) scale about how specific factors determine their usage. Only participants who had endorsed ever using hookah were administered these questions about reasons for use. All reasons displayed a range of 1–5, based on participant report.

VOL 61, AUGUST/SEPTEMBER 2013 367 Holtzman, Babinski, & Merlo than other respondents (χ 2 = 21.15, p < .001), and indi- Hookah Use Patterns of Current Smokers viduals reporting that cigarettes were more addictive than To further assess hookah smoking behaviors, participants hookah were more likely to have used hookah (χ 2 = 104.29, who reported smoking hookah in the 30 days prior to p < .001) than other respondents. Individuals indicating that completing the questionnaire were administered additional they would rather be elsewhere when people are smoking questions. The majority of respondents indicated smoking cigarettes (χ 2 = 55.46, p < .001) or hookah (χ 2 = 196.37, 1–5 times in the past 30 days, typically for 11–60 minutes p < .001) were less likely to use hookah compared with at a time. They generally indicated smoking 1–5 bowls of other respondents, whereas individuals indicating that they tobacco in the past 30 days combined. were not bothered by either cigarette (χ 2 = 16.35, p < .001) χ 2 = < or hookah ( 111.52, p .001) smoke were more likely Desire to Quit to use hookah than other respondents. The relations between Few respondents reported feeling addicted to hookah, and health perceptions and hookah use were no longer signifi- the majority of respondents indicated feeling very confident cant when controlling for other health perception and demo- in their ability to quit smoking hookah at any time. However, graphic variables, with the exception of addictive effects and over half of hookah users did not intend to quit. secondhand exposure related to hookah use (see Table 1). Regarding attitudes towards secondhand smoke, partici- COMMENT pants were overall less bothered by hookah smoke compared with cigarette smoke, and most respondents were subjected to The current study explored the perceptions and knowl- passive hookah smoke during the year. More respondents in- edge of university students related to hookah use, and identi- dicated preferring not to be around cigarette smoke compared fied psychosocial factors associated with hookah use in this with hookah smoke. The majority of participants (including group. For the current sample, nearly half of all respondents nonusers) said they would be willing to spend some time reported ever smoking tobacco from a hookah (waterpipe). < 1 Several risk factors, including older age, male sex, racial (ranging from 2 hour up to an hour) around other people smoking hookah, even if they were not smoking. Hookah background (ie, not African American or black), history of users were more likely to report spending time around other cigarette and/or marijuana smoking, as well as perceptions people using hookah (χ 2 = 197.93, p < .001), and reported generally indicating a lower health risk of hookah use com- being willing to spend more time around others using hookah pared with cigarette use, were related to a greater likelihood (χ 2 = 152.33, p < .001). of having ever tried hookah smoking. Overall, respondents, and particularly those who had tried hookah smoking, per- ceived hookah smoke to be less harmful and addictive, and Initiation of Use to contain less nicotine than cigarette smoke. Relatively few Most respondents reported using hookah for the first time respondents indicated a desire to quit. between the ages of 16 and 18, and the second largest pro- It is noteworthy that, in this sample, rates of hookah smok- portion of respondents reported beginning between 19 and ing in the past 30 days were higher among individuals un- 21 years old. The majority of participants reported that their der age 21 than among individuals 21 and over. In addi- first use of hookah occurred in the presence of more than 1 tion, respondents indicated socializing as the primary reason friend, typically outside of their own home in either a restau- for smoking hookah, and described engaging in this behav- rant/cafe´ or the house of a friend/acquaintance (see Table 2). ior primarily in restaurants/cafes with a group of friends. These results are consistent with previous research show- ing that hookah smoking was particularly popular among Characteristics of Hookah Use young college students, who were below the legal drinking Of the respondents who had reported hookah use, age, as smoking at a hookah cafe´ may offer an alternative the largest proportion of respondents indicated smoking social scene for younger students.15 This trend is concern- 1–11 times per year, followed by smoking less than once ing, as the social acceptance/promotion of hookah smoking a year, then 1–4 times per month, 1–6 times per week, and among underage college students may prompt even younger finally everyday or almost every day (see Table 2). As il- students (ie, high school or middle school) to view exper- lustrated in Table 3, respondents did not strongly endorse imentation with hookah smoking as “cool” and desirable. any reasons for hookah smoking. However, the most impor- Given the increased risk of developing addiction to tobacco tant reasons reported for hookah use, in descending order, when smoking is initiated by the age of 12,16 any conditions were socializing, its taste, relaxation, its smell, the fact that that encourage tobacco use in younger individuals should the smoke is less harsh than tobacco smoke, and combating be avoided. Whereas rates of cigarette smoking have sig- boredom. nificantly declined in the past 5 decades,6 hookah smoking Most self-reported hookah users indicated that they did not may provide an alternative method of tobacco use that does own a hookah, and the vast majority reported using flavored not have the negative stigma, social constraints, or perceived tobacco during hookah use. Finally, a small but significant risks of smoking cigarettes. Furthermore, there are significant number of both hookah smokers and nonsmokers reported public health concerns related to secondhand smoke exposure using a waterpipe to smoke substances other than tobacco. associated with hookah use. A recent WHO report suggested

368 JOURNAL OF AMERICAN COLLEGE HEALTH Hookah Usage Among University Students that hookah smoking may be more problematic than smoking fects. To our knowledge, no studies have yet evaluated the cigarettes.11 In addition, emerging studies show that hookah longitudinal patterns of hookah smoking for longer than a smoking is related to similar negative health outcomes as 1-year period.19 However, it may be that hookah use is some- cigarette smoking, and there may be negative side effects of what age specific, and that typically developing young adults secondhand smoke associated with hookah smoking.17 In- “age out” of their risk for hookah use as they mature, similar deed, even in states with strong smoke-free indoor air laws, to patterns of risky alcohol consumption.21 Future research hookah cafes may be exempt. This suggests that college stu- should explore this question further. dents have easier access to hookah use and greater expo- sure to secondhand hookah smoke, making it a particularly Conclusions 18 significant area of public health concern. It is important In conclusion, results of the present study demonstrated to note that individuals who endorsed using hookah at least that a large proportion of the college student sample had once also reported spending more time around others who are experimented with hookah smoking, and many students did smoking hookah, which would increase their risk associated not perceive hookah smoking to be as harmful or addictive with secondhand exposure, in addition to their increased risk as cigarette smoking. Given the mounting evidence of nega- from primary use. tive consequences of hookah smoking, as well as the growing Although in general respondents indicated that they en- popularity of hookah use, these results suggest that efforts are gaged in hookah smoking only rarely, and perceived few needed on college campuses to educate students and college benefits of doing so, the students generally did not endorse officials about risks of hookah use, and to develop hookah wanting to quit. It is noteworthy that the positive effects of smoking prevention programs. Based on the study results, hookah use endorsed most often included social benefits, particular benefit may result from targeting high-risk groups taste, stress relief, and relaxation. These effects are similar (ie, former marijuana and cigarette users, males, and individ- to positive expectancies endorsed by college students for al- uals under 21 years of age). cohol and other substance use. This may suggest increased 19 abuse potential for hookah use, despite relatively minimal ROLE OF FUNDING SOURCES DISCLOSURE concerns from the respondents in the study. No funding was used to support this research and/or the preparation of the manuscript. Limitations Although the current results are generally consistent with CONFLICT OF INTEREST DISCLOSURE other studies of hookah use among college youth,2,5 it is The authors have no conflicts of interest to report. The important to mention that our results may not generalize to authors confirm that the research presented in this article all college youth. A considerable proportion (26%) of re- met the ethical guidelines, including adherence to the legal spondents in the current sample endorsed at least monthly requirements, of the United States and received approval hookah use. The rate of monthly use in our sample is con- from the Institutional Review Board of the University of sistent with previous surveys of hookah use among college Florida. students.2,5 Sutfin and colleagues5 reported that having more hookah bars near the college campus increases the rate of NOTE current hookah smoking. Despite being located in a midsize For comments and further information, address correspon- town, at the time of the current study, there were at least 8 dence to Lisa J. Merlo, PhD, MPE, McKnight Brain Insti- to 10 restaurants, cafes, and bars that offered hookah smok- tute, University of Florida, PO Box 100183, Gainesville, FL ing in close proximity to the campus where this study was 32610-0183, USA (e-mail: lmerlo@ufl.edu). conducted. Further, this study was conducted at a large uni- versity in the southeastern United States, a region that has demonstrated higher rates of hookah smoking than other ar- 5 REFERENCES eas of the country, such as the midwestern United States. 1. Chaouachi KT. The narghile (hookah, shisha, goza) epi- We did not collect information on other potential risk factors demic and the need for clearing up confusion and solving prob- for hookah use, such as affiliations with sororities/fraternities lems related with model building of social situations. Sci World J. or emotional and behavior problems, which may predispose 2007;7:1691–1696. individuals to greater hookah use.20 All data were collected 2. Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Wa- terpipe tobacco smoking on a U.S. college campus: prevalence and using self-report, which may have introduced social desir- correlates. J Adolesc Health. 2008;42:526–529. ability bias or recall bias to the results. Finally, the study was 3. 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