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 smoking is a popular form of tobacco rate of cigarette 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 youth. 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 legal drinking age 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 laws, 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 tobacco smoking 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 death.10 According to a in the United States), 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 youth smoking 100 cigarettes, 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- nicotine 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-