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Hookah Use Among US High School Seniors Abstract ARTICLE Hookah Use Among US High School Seniors AUTHORS: Joseph J. Palamar, PhD, MPH,a Sherry Zhou, WHAT’S KNOWN ON THIS SUBJECT: Hookah use is increasing BA,b Scott Sherman, MD, MPH,a and Michael Weitzman, dramatically among US adolescents. Many consider it a safer MDb alternative to cigarettes. Existing studies often use Departments of aPopulation Health, and bPediatrics and nonrepresentative local populations to assess prevalence and Environmental Medicine, New York University Langone Medical correlates of hookah use. Center, New York, New York KEY WORDS WHAT THIS STUDY ADDS: This study used a nationally hookah, adolescents, tobacco, socioeconomic status representative sample of US high school seniors. It confirmed ABBREVIATIONS some previously found correlates and determined that AOR—adjusted odds ratio adolescents of higher socioeconomic status were at high risk for CI—confidence interval MTF—Monitoring the Future hookah use. Dr Palamar conceptualized and designed the study, conducted the statistical analyses, and drafted the initial manuscript; Drs Zhou, Sherman, and Weitzman helped draft the initial manuscript, helped interpret results, critically reviewed the manuscript, and reviewed and revised the manuscript; and all abstract authors approved the final manuscript as submitted. OBJECTIVES: fi The National Institute on Drug Abuse, Inter-university Prevalence of hookah use is increasing signi cantly among Consortium for Political and Social Research, and Monitoring adolescents. This study aimed to delineate demographic and socioeco- the Future principal investigators had no role in analysis, nomic correlates of hookah use among high school seniors in the interpretation of results, or the decision to submit the manuscript for publication. United States. We hypothesized that more impoverished adolescents and those who smoked cigarettes would be more likely to use hookahs. The content is solely the responsibility of the authors and does not necessarily represent the official views of the principal METHODS: Data were examined for 5540 high school seniors in Mon- investigators, the National Institutes of Health, or the National itoring the Future (years 2010–2012), an annual nationally represen- Institute on Drug Abuse. tative survey of high school students in the United States. Using data www.pediatrics.org/cgi/doi/10.1542/peds.2014-0538 weights provided by Monitoring the Future, we used multivariable doi:10.1542/peds.2014-0538 binary logistic regression to delineate correlates of hookah use in Accepted for publication May 16, 2014 the last 12 months. Address correspondence to Joseph J. Palamar, PhD, MPH, RESULTS: Department of Population Health, One Park Avenue, 7th Floor, New Eighteen percent of students reported hookah use in the past York, NY 10016. E-mail: [email protected] year. Compared with white students, black students were at lower odds PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). for use (adjusted odds ratio [AOR] = 0.27, P , .0001). High parent , Copyright © 2014 by the American Academy of Pediatrics education increased the odds for use (AOR = 1.58, P .001), and . , FINANCIAL DISCLOSURE: The authors have indicated they have student weekly income from a job of $50/week (AOR = 1.26, P .05) no financial relationships relevant to this article to disclose. or $11 to $50 per week from other sources (AOR = 1.35, P , .01) also FUNDING: This project was not funded. Monitoring the Future increased odds for use. Males and urban students were also at data were collected through a research grant (R01 DA-01411) higher odds for use, as were users of alcohol, marijuana, and from the National Institute on Drug Abuse, National Institutes of other illicit substances. Former cigarette smokers were at higher Health. risk, and current smokers were at highest risk for use. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. CONCLUSIONS: Adolescents of higher socioeconomic status appear to be at particularly high risk for hookah use in the United States. Pre- vention efforts must target this group as prevalence continues to in- crease. Pediatrics 2014;134:227–234 PEDIATRICS Volume 134, Number 2, August 2014 227 Downloaded from www.aappublications.org/news by guest on September 30, 2021 Although cigarette use is declining outcomes. Research has shown that are selected, then schools within areas precipitously among youth,1–4 evidence hookahs deliver tar, nicotine, and carbon are selected, and then students within indicates that American adolescents monoxide in even higher doses than schools are selected.37,38 Approximately are turning to ethnically linked alter- cigarettes.10–12 Moreover, recent meta- 15 000 seniors are assessed every year. native tobacco products, such as hookahs, analyses have linked hookah use to MTF assesses content through 6 dif- cigars, and various smokeless tobacco lung cancer, respiratory illness, peri- ferent survey forms, which are dis- products.5,6 A recent report from the odontal diseases, and low birth weights.13 tributed randomly. All forms assess Centers for Disease Control and Pre- Individual studies have linked use to demographics, socioeconomic variables, vention warns that the drop in ciga- esophageal cancer,14,15 chromosomal and use of various licit and illicit sub- rette consumption is being “offset by aberrations,16 decreased pulmonary stances; however, only survey Form 3 increases in other forms of tobacco.”7 and cardiovascular functions,17,18 assesses (last 12-month) hookah use. Although alternative tobacco use may infertility,19 dental problems,20 and Therefore, hookah use was assessed in have originated among immigrants infectious diseases.21 Surveys of univer- only about one-sixth of the sample. MTF from South Asia and the Middle East, sity students in multiple countries, in- began assessing hookah use in 2010, so use of hookah has clearly moved into cluding the United States, suggest that this analysis focuses on aggregated (and – the mainstream US population.8 people are unaware of these dangers22 35 weighted) Form 3 data collected from the and believe that hookah is less harmful 3 most recent cohorts with available Hookah, an ancient form of smoking in and less addictive than cigarettes.22,23,25–35 data (2010–2012). MTF protocols were which shisha (an herbal material that reviewed and approved by the University can be tobacco- or non–tobacco-based) A number of studies have examined the of Michigan Institutional Review Board. smoke is passed through water before prevalence and correlates of hookah inhalation, is 1 such alternative to- use among local and national pop- Measures bacco product. Hookah smoking is ulations,9,36 including US adolescents. Students were asked to indicate their rapidly gaining popularity among ado- The current study complements and gender, age (,18, $18 years), and lescents in the United States and expands on previous findings by in- race or ethnicity (ie, black, white, His- worldwide. Existing data based on the vestigating a number of previously panic). MTF classified population 2011 US National Youth Tobacco Survey unexplored but potentially important density of students’ residences as in indicated that ∼8% of adolescents predictors of adolescent hookah use in terms of metropolitan statistical areas reported ever trying hookah, and 3% a nationally representative sample of (MSAs). Small MSAs are defined as reported using hookah within the past high school students in the United fi counties or groups of counties with $1 month.9 The most recent data pub- States. This study delineates speci c city of $50 000 inhabitants, and the 24 lished in the Morbidity and Mortality demographic, socioeconomic, and sub- largest MSAs are defined as large Weekly Review showed an increase of stance use factors related to hookah use MSAs.37 Non-MSAs are the remaining hookah use from from 4.1% in 2011 to among US high school seniors. It was hypothesized that more impoverished areas. To assess family composition, 5.4% in 2012 among high school stu- students were asked which parents 1 adolescents with more poorly educated dents, and recent work by our group they lived with. Answers were coded as found that nearly 1 in 5 adolescents in parents would be more likely to use hookahs, as is true of adolescent ciga- 0 parents, 1 parent, or 2 parents. Level the United States reported having tried rette use. Similarly, it was hypothesized of religiosity was determined by 2 or- hookah before high school gradua- that hookah use would be independently dinal items that asked about level of tion.9 The most alarming statistic was associated with use of cigarettes, alco- religious attendance and importance. recently reported from the Monitoring hol, and illicit drugs. These items were computed into a the Future (MTF) study, which found composite (range 1–4) and divided into that 12-month hookah use significantly METHODS tertiles indicating low (1.0–2.0), mod- increased among US high school erate (2.5–3.0), and high (3.5–4.0) re- Procedure seniors from 18.3% in 2012 to 21.4% in ligiosity. Parent level of educational 2013.3 MTF is an annual cross-sectional survey attainment (ie, grade school, some Although the literatureon health effects of high school seniors in ∼130 public high school, high school graduate, of hookah smoking and exposure to and private schools throughout 48 some college, college graduate, or secondhand smoke from hookahs is states in the United States. Schools are graduate school) was assessed for limited,existingdataareconsistentand selected through a multistage random each parent, and a mean score for both suggest significant adverse health sampling procedure: geographic areas parents (or raw score if only 1 parent) 228 PALAMAR et al Downloaded from www.aappublications.org/news by guest on September 30, 2021 ARTICLE was coded into 3 groups: low (1.0–3.0), Statistical Analyses descriptive statistics of the sample and medium (3.5–4.0), and high (4.5–6.0) Analyses focused on students with com- the comparisons of demographic, so- education.
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