Nicotine & Tobacco Research, Volume 16, Number 3 (March 2014) 373–377
Brief report
A Multiyear Assessment of Hookah Use Prevalence Among Florida High School Students Tracey E. Barnett PhD1, Jamie R. Forrest MS2, Lauren Porter PhD, MPH3, Barbara A. Curbow PhD1 1Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL; 2Bureau of Chronic Disease Prevention, Florida Department of Health, Tallahassee, FL; 3Bureau of Tobacco Free Florida, Florida Department of Health, Tallahassee, FL
Corresponding Author: Tracey E. Barnett, PhD, Department of Behavioral Science and Community Health, University of Florida, PO Box 100175, Gainesville, FL 32610-0175, USA. Telephone: 352-273-6745; Fax: 352-273-6048; E-mail: [email protected] Received June 26, 2013; accepted October 20, 2013
Introduction: The purpose of this study was to assess the prevalence of hookah use among Florida high school students over time. Alternative tobacco products, including hookah, pose a public health threat to tobacco prevention efforts, especially among adolescents. Methods: Florida Youth Tobacco Survey data, representing all public high school students in the state, were analyzed to assess the prevalence of lifetime and current hookah use and were compared by demographic groups. Multiple years of data (2007– 2012) were examined to assess changes over time. Results: During the past 6 years, there was an increase in lifetime hookah use among Florida high school students. While males remained at a higher rate overall, female adolescents increased at a faster rate. Hispanic and non-Hispanic White respondents reported increased trends as well. Current use trends did not change over 4 years, remaining at about 8%. Conclusions: Hookah is a new tobacco product in the United States that appears attractive to youth, with dramatic increases among the state population. While cigarette use among youth is declining in Florida, the increasing uptake of alternative tobacco products may lessen the overall public health gains for tobacco use. There is a need for continued monitoring of hookah use among the adolescent population, for both prevention and cessation efforts as well as policy interventions to address this emerging trend.
Introduction The prevalence of hookah (water pipe used to smoke tobacco) appears to be increasing, particularly on college campuses across the United States. Prevalence estimates of lifetime hookah use among young adults span 10% to nearly 50% (Barnett et al., 2013; Eissenberg, Ward, Smith-Simone, & Maziak, 2008; Grekin & Ayna, 2008; Primack et al., 2008; Smith-Simone, Maziak, Ward, & Eissenberg, 2008; Sutfin et al., 2011) depending on the sample characteristics. For college populations, hookah use in the past 30 days was associated with younger age (Eissenberg et al., 2008; Primack, Fertman, Rice, Adachi-Mejia, & Fine, 2010; Primack et al., 2008), being male (Grekin & Ayna, 2008; Smith-Simone et al., 2008) and being White (Eissenberg et al., 2008; Primack et al., 2008). Recent findings, however, have indicated that (a) females are closing the gap and smoking at equivalent rates to males and (b) Hispanics are smoking hookah at similar or even higher levels than non-Hispanic Whites (Barnett et al., 2013). To broaden the research to include multiple institutions, Sutfin et al. (2011) sampled college students from eight universities, finding that
40.3% of the sample reported lifetime using hookah and 17.4% of the students reported current (past 30 day) hookah tobacco use. To date, the majority of hookah research has been conducted on college students, with fewer prevalence estimates available for adolescents. Some studies have estimated the prevalence for adolescents, both in the United States and Canada. A few studies reported comparable high school students’ rates for 2010: the New Jersey lifetime rate was 20.9% (Bover Manderski, Hrywna, & Delnevo, 2012), the Canadian Youth lifetime rate was 10% (Czoli, Leatherdale, & Rynard, 2013), and the Monitoring the Future (MTF) researchers reported lifetime prevalence for 12th graders at 17.1% (Johnston, O’Malley, Bachman, & Schulenberg, 2012). Prior to that, Barnett, Curbow, Weitz, Johnson, and Smith-Simone (2009) reported a 2007 lifetime use of 11% in the state of Florida, and Primack, Walsh, Bryce, and Eissenberg (2009) reported the 2005 lifetime use of 10.3% for adolescents in Arizona. While limited in that the study included only adolescent lifetime cigarette smokers, Sterling and Mermelstein (2011) reported a lifetime prevalence of 58.5% for hookah use in this population.
doi:10.1093/ntr/ntt188 Advance Access publication December 17, 2013 © The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
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Abstract
Multiyear assessment of hookah use prevalence
Methods The Florida Youth Tobacco Survey (FYTS, 2012) is a statewide, anonymous, school-based survey administered annually to a random sample of Florida public middle and high school students. The Florida Youth Survey is a collection of multiple survey instruments. In odd-numbered years, four survey instruments are included, and the sample is drawn at the state level. In even-numbered years, only two survey instruments are included, and the sample is drawn at the county level, allowing for the creation of county-level estimates. The annual sample size for the FYTS varies because of this alternating administration. The Florida Department of Health considers this survey ongoing public health surveillance, and the University of Florida Institutional Review Board approved the deidentified data as exempt. Data were collected on students’ demographic characteristics (age, sex, grade, race/ethnicity) and tobacco use trends. The FYTS also has many other questions on the survey, and summary reports can be found in the Florida Department of Health Web site (in references under FYTS). The survey involved a two-stage cluster probability sample design. First, a random sample of public middle schools and high schools (Grades 6–12) was selected for participation in the survey. Second, within each selected school, a random sample of classrooms was selected, and students in those classrooms were invited to participate in the survey. Larger schools were sampled with greater probabilities of selection than smaller schools to ensure that every student in the state had the same probability of selection. Parental consent was
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mostly obtained through passive permission forms that parents must return to opt out their child from participation. In a few counties, however, active permission was required and was obtained. Students were provided instructions in the front of the booklet that were read aloud before beginning. The assent language indicated that participation was completely voluntary and that completing the survey was considered their assent. Please refer to the FYTS Web site for a more detailed description of the sample design. Participation rates were calculated separately for schools and students as a ratio of number participating divided by number selected. Combined participation rates were calculated by multiplying the two separate school and student participation rates by each other. The overall participation rates for the high school population for each of the 6 years were 2007 (57%), 2008 (73%), 2009 (72%), 2010 (74%), 2011 (73%), and 2012 (73%). With respect to hookah use, students were asked “Have you ever tried, even once, smoking tobacco out of a water pipe (also called a ‘hookah’)?” to determine lifetime prevalence. Current use (added in 2009) was assessed with, “During the past 30 days, have you smoked tobacco out of a water pipe (also called a ‘hookah’)?” FYTS data were statistically weighted to be representative of all Florida public middle and high school students. In the current study, we examine hookah use among high school students only using trend analyses across all years. As can be seen in the Barnett et al. (2009) study, the middle school rates were low and remain low (see FYTS Web site). The high school analysis provided a more developmental pattern of use and opportunity for prevention and intervention. Analyses were conducted with SAS v. 9.3 (SAS Institute Inc.) and accounted for the complex sampling design when prevalence rates of hookah use were estimated. Data were analyzed separately according to sex, race/ethnicity, and grade.
Results In 2012, more than one in six (16.7%) Florida high school students reported trying smoking tobacco from a hookah in their lifetime. As is evident in Table 1, hookah rates have been increasing among adolescents living in Florida. Males increased from 12.3% to 16.8% (p < .05), while females increased at a faster rate, from 9.3% to 16.5% (p < .05). NonHispanic Whites demonstrated a 6% increase over 6 years, whereas Hispanic youth nearly doubled their lifetime use (11.8%–21.9%; p < .05). In 2012, Hispanic (21.9%) and nonHispanic White (19.0%) youth both reported more hookah use than non-Hispanic Black youth (5.2%; p < .05). The other race/ethnicity group included American Indian, Alaska Native, Hawaiian, Other Pacific Islander, Asian, and “other,” which likely included adolescents of Middle Eastern descent. This group demonstrated no significant change in hookah use over time but had the highest rate at baseline (18.0% in 2007). With each passing grade level, the rates increased, and more than one fourth (26.1%) of 12th graders reported lifetime use. While 2009–2012 data did not indicate significant increases in current (past 30-day) use overall, current use among Hispanics increased significantly over the 4 years, from 7.9% to 11.2% (p < .05) (Table 2). In 2012, males reported
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While there have been a few studies of hookah use among adolescents, the research has limitations. The only national estimate in the United States is provided by MTF (Johnston et al., 2012), and the hookah items were just added in 2010. Additionally, MTF only included this question for 12th graders. Some states have collected and reported rates, as indicated above, but few have provided a multiyear analysis. A recent Canadian youth study (Czoli et al., 2013) reported a multiyear assessment (2006–2010), but the rates were substantially lower than the state level prevalence reported in the United States. The current study provides a unique look at patterns over time of hookah use for high school students, across multiple years, reporting comparisons from 2007 to 2012. Monitoring hookah rates among adolescents is important because it is not only associated with long-term effects comparable to cigarette use but also poses significant risk for even short-term use. Carbon monoxide (CO) is just one toxicant that is clearly a risk for all users (Shihadeh & Saleh, 2005), with past studies showing extremely high CO levels for users (Barnett, Curbow, Soule, Tomar, & Thombs, 2011). Case reports have even indicated CO poisonings among young adult hookah users (Ashurst, Urquhart, & Cook, 2012; Cavus, Rehber, & Ozeke, 2010; Lim, Lim, & Seow, 2010). Given the possible relationship with other tobacco products, plus the potential harm in one-time use, prevalence rates and correlates need continuous monitoring. The purpose of this study was to assess trends throughout the state of Florida for high school students. This assessment included 6 years of lifetime use prevalence among public school students across the state and a 4-year assessment of current use prevalence.
Nicotine & Tobacco Research Table 1. Prevalence of Lifetime Hookah Use for State of Florida, 2007–2012 Lifetime hookah use Percentage of Florida public high school students who ever tried smoking tobacco out of a hookah, even one or two puffs, by sex, race/ethnicity, and grade, FYTS 2007–2012 2008
2009
2010
2011
2012
N = 40,283
N = 5,673
N = 37,797
N = 6,163
N = 36,439
% (N)
% (N)
% (N)
% (N)
% (N)
% (N)
9.3 (192) 12.3 (227)
12.5 (1,979) 14.4 (2,410)
14.2 (401) 17.3 (443)
15.7 (2,552) 17.4 (2,898)
17.7 (523) 18.7 (538)
16.5 (2,365)* 16.8 (2,603)*
13.0 (228) 3.4 (22) 11.8 (114) 18.0 (54)
17.4 (2,800) 3.4 (203) 14.5 (900) 15.6 (489)
20.3 (438) 4.9 (50) 16.1 (268) 18.4 (91)
20.9 (3,396) 5.1 (313) 18 (1,168) 19.9 (560)
21.8 (509) 4.9 (62) 23.3 (389) 18.6 (101)
19.0 (2,891)* 5.2 (274) 21.9 (1,374)* 18.6 (538)
8.1 (88) 8.8 (95) 11.0 (108) 16.2 (102) 10.7 (419)
7.7 (840) 12.1 (1,053) 15.4 (1,202) 20.2 (1,272) 13.5 (4,389)
9.0 (159) 12.9 (177) 18.3 (218) 25.3 (291) 15.8 (852)
10 (972) 14.2 (1,259) 18.3 (1,436) 25.1 (1,605) 16.6 (5,490)
9.3 (153) 16.0 (251) 21.1 (297) 27.5 (338) 18.2 (1,061)
9.2 (872) 13.1 (1,136)* 19.7 (1,364)* 26.1 (1,525)* 16.7 (5,111)
Note. FYTS = Florida Youth Tobacco Survey. *p < .05; 2007–2012 increase. Table 2. Prevalence of Current Hookah Use for State of Florida, 2009–2012 Current hookah use Percentage of Florida public high school students who smoked hookah on one or more of the previous 30 days, by sex, race/ethnicity, and grade, FYTS 2007–2012
Sex Female Male Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total
2007
2008
2009
2010
2011
2012
%
%
% (N)
% (N)
% (N)
% (N)
N/A
N/A 6.4 (185) 9.1 (240)
7.1 (1,147) 9.2 (1,554)
6.7 (198) 9.3 (267)
7.0 (1,007) 8.2 (1,277)
9.6 (210) 2.7 (27) 7.9 (134) 10.1 (52)
9.7 (1,500) 3.1 (203) 9.3 (672) 11.6 (334)
7.6 (1,163) 2.8 (163) 11.2 (717)* 9.8 (297)
4.7 (80) 5.8 (83) 9.2 (113) 12.3 (145) 7.7 (427)
5.3 (516) 6.6 (568) 8.5 (684) 12.4 (771) 8.2 (2,735)
9.4 (218) 3.0 (39) 9.5 (156) 9.5 (52) 4.0 (66) 6.3 (98) 9.0 (128) 12.6 (155) 8.0 (465)
4.3 (429) 5.9 (499) 8.4 (564) 11.8 (683) 7.7 (2,359)
Note. FYTS = Florida Youth Tobacco Survey. *p < .05; 2009–2012 increase.
a significantly higher prevalence of current use (8.2%) than females (7.0%; p < .05). Hispanic (11.2%) and Other (9.8%) race/ethnicity groups reported significantly higher (p < .05) rates of current use than non-Hispanic White (7.6%) and nonHispanic Black adolescents (2.8%). Current use also increased with each grade level. By 12th grade, 11.8% (more than one in nine) were current hookah users.
Discussion Over 6 years, the prevalence of lifetime hookah use among Florida high school students increased. Our findings indicated that in 2012, 26.1% of Florida 12th graders had tried hookah in their lifetime, some of whom will potentially maintain this behavior throughout early adulthood. Compared with a lifetime
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Sex Female Male Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total
2007 N = 4,028
Multiyear assessment of hookah use prevalence
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contribute to this portrait of users and inform interventions, but the lack of increase in current use patterns is noteworthy. Hookah use, once thought to be a fad, continues to grow in the United States among adolescents and young adults. Myriad reasons for this could include beliefs about the relative lack of harm for hookah use compared with cigarettes (Eissenberg et al., 2008; Primack et al., 2008); the belief that light use poses little to no risk, as well as a social venue for this population to spend their time. Given the restrictions on cigarette smoking in public places, the mere presence of hookah cafes may reinforce the beliefs about lack of harm reported by users. Whereas a city or college town has no cafes for cigarette smoking, they might allow several hookah cafes to open. Limitations It is important to note that across all of the lifetime use prevalence, there was nearly continuous increasing from 2007 to 2011, with some slight decrease in 2012 that was reflective of 2010 numbers. More than likely, given the every other year sampling structure, the 2010 and 2012 data were most reliable, given the larger sample size (N). However, we cannot rule out the possibility that perhaps a slight decline or flattening of prevalence rates will start to occur after a solid 5-year increase. Future data will have to be examined to determine the direction of this behavior. Also, the dichotomous nature of these data does not allow for assessment of frequency or amount of use, merely lifetime use (which could already be stopped for some adolescents) and past month use. Both frequency of use and reasons for use should be explored in future studies. In conclusion, it seems that while cigarette use is declining among adolescents (CDC 2012b; Johnston et al., 2012; FYTS reports), alternative tobacco products may still result in tobacco exposure for youth. It is also possible that openness to hookah could lead to future cigarette use and a dampening of current successful efforts to reduce these rates. These high rates of hookah use among Florida adolescents are noteworthy given the increasing trends as well as patterns that match college samples. The rates remain at levels that need to be assessed continuously, and there is a need for both individual level prevention and cessation programs. Given the literature to date, including this study, demographic analyses are imperative, allowing for tailored interventions for multiple populations. Additionally, policy interventions (Morris, Fiala, & Pawlak, 2012) should be considered to reduce adolescent use.
Funding Funding for the Florida Youth Tobacco Survey is provided by the Florida Department of Health, Bureau of Tobacco Free Florida.
Declaration of Interests None declared.
References Ashurst, J. V., Urquhart, M., & Cook, M. D. (2012). Carbon monoxide poisoning secondary to hookah smoking. Journal American Osteopathic Association, 112, 686–688.
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use rate among 12th graders in 2007 of 16.2%, there was a 61% increase over just 6 years, which indicated continued and growing popularity of hookah among youth. Not only were 12th graders’ rates high, the rates increase with each grade throughout high school; in 2012, less than 1 in 10 (9.2%) of 9th graders had tried hookah, which increased to greater than one in four (26.1%) by 12th grade. These rates for the state of Florida are lower than the rates reported by the New Jersey Youth Tobacco Survey (Bover Manderski et al., 2012), which reported 2010 lifetime rates of 21%, but higher than the most recent published numbers from the Canadian Youth Tobacco Survey (Czoli et al., 2013) with only 10% reporting lifetime hookah use. The only national rate in the United States was published by the MTF (Johnston et al., 2012) and is the lifetime rate for 12th graders, at 18.5% in 2010, whereas this study showed 12th graders at 25% lifetime use in 2010. Approximately one in five of both Hispanic students (21.9%) and non-Hispanic White students (19.0%) reported lifetime use. These findings mirror a recent study that showed the rate of lifetime use for college students at the University of Florida was highest among Hispanic students, at an alarming 55.7%, and was closely followed by non-Hispanic White students at 53.5% (Barnett et al., 2013). While the New Jersey Youth Tobacco survey indicated higher lifetime rates (17.9% in 2008 and 20.9% in 2010), they also indicated increasing rates for Hispanic youth, similar to this study (Bover Manderski et al., 2012). The reasons for higher rates among Hispanics have yet to be explored and likely require some qualitative analysis to assess different reasons for use. Research on cigarette use tends to show conflicting results for Hispanic use, with some showing higher rates for Hispanic adolescents born in the United States ((SAMHSA, 2011), while other studies show Hispanic adolescent cigarette use less than Whites ((CDC, 2012a), but still higher than nonHispanic Black respondents (CDC, 2012a). Both males and females demonstrated significant increases across all 6 years, and females increased at a faster rate, virtually closing any sex differences that used to exist (male 16.8% and female 16.5%, in 2012). This, too, reflected recent studies that have shown females to have closed the gap for hookah use (Barnett et al., 2013), which used to be a more male dominant behavior (Primack et al., 2008). The overall current hookah use rate found in this study (Florida) was 7.7% in 2012, higher than the Arizona study at 5.4% in 2005 (Primack et al., 2009) but lower than the New Jersey current use rate of 9.7% in 2010 (Jordan & Delnevo, 2010). Similar to the lifetime use prevalence, current use rates were significantly higher for Hispanics at 11.2%, which also was the only racial and ethnic group to have an increasing trend in current use across the 4 years studied. Also, like lifetime use, the growing increase across grade levels was noteworthy, with only 4.3% of 9th graders reporting current use, which increased to 11.8% by 12th grade. Importantly, though, it should be noted that current use has been relatively steady across time, at around 8% over 4 years. While lifetime use showed increases across 6 years, some of the increase can be noted as a natural phenomenon where new adolescents try hookah each year, thus reflecting an increase across 4 years but perhaps not adding more frequent users. This pattern is supported in the relatively flat nature of current use. A longitudinal assessment is needed to examine if openness during adolescent years could still lead to future young adult use, or if for some adolescents there is a trial period that does not continue. Frequency of use would
Nicotine & Tobacco Research youth. Preventive Medicine, 51, 394–396. doi:10.1016/j. ypmed.2010.08.016 Lim, B. L., Lim, G. H., & Seow, E. (2010). Case of carbon monoxide poisoning after smoking shisha. International Journal of Emergency Medicine, 11, 121–122. doi:10.1007/ s12245-009-0097-8 Morris, D. S., Fiala, S. C., & Pawlak, R. (2012). Opportunities for policy interventions to reduce youth hookah smoking in the United States. Preventing Chronic Disease, 9, 120082. doi:10.5888/pcd9.120082 Primack, B. A., Fertman, C. I., Rice, K. R., Adachi-Mejia, A. M., & Fine, M. J. (2010). Waterpipe and cigarette smoking among college athletes in the United States. Journal of Adolescent Health, 46, 45–51. doi:10.1016/j. jadohealth.2009.05.004 Primack, B. A., Sidani, J., Agarwal, A. A., Shadel, W. G., Donny, E. C., & Eissenberg, T. E. (2008). Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Annals of Behavioral Medicine, 36, 81–86. doi:10.1007/s12160-008-9047-6 Primack, B. A., Walsh, M., Bryce, C., & Eissenberg, T. (2009). Water-pipe tobacco smoking among middle and high school students in Arizona. Pediatrics, 123, e282–e288. doi:10.1542/peds.2008-1663 Shihadeh, A., & Saleh, R. (2005). Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology, 43, 655–661. doi:10.1016/j. fct.2004.12.013 Smith-Simone, S., Maziak, W., Ward, K. D., & Eissenberg, T. (2008). Waterpipe tobacco smoking: Knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine & Tobacco Research, 10, 393–398. doi:10.1080/14622200701825023 Sterling, K. L., & Mermelstein, R. (2011). Examining hookah smoking among a cohort of adolescent ever smokers. Nicotine & Tobacco Research, 13, 1202–1209. doi:10.1093/ ntr/ntr146 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2011, October 4). The NSDUH report: Substance use among hispanic adolescents. Rockville, MD: Author. Retrieved from www.samhsa.gov/data/2k11/WEB_SR_007/WEB_SR_007. htm Sutfin, E. L., McCoy, T. P., Reboussin, B. A., Wagoner, K. G., Spangler, J., & Wolfson, M. (2011). Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug and Alcohol Dependence, 115, 131– 136. doi:10.1016/j.drugalcdep.2011.01.018
377
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Barnett, T. E., Curbow, B. A., Soule, E. K., Tomar, S. L., & Thombs, D. L. (2011). Carbon monoxide levels among patrons of hookah cafes. American Journal of Preventive Medicine, 40, 324–328. doi:10.1016/j.amepre.2010.11.004 Barnett, T. E., Curbow, B. A., Weitz, J. R., Johnson, T. M., & Smith-Simone, S. (2009). Water pipe tobacco smoking among middle and high school students. American Journal of Public Health, 99, 2014–2019. doi:10.2105/ AJPH.2008.151225 Barnett, T. E., Smith, T., He, Y., Soule, E. K., Curbow, B. A., Tomar, S. L., & McCarty, C. (2013). Evidence of emerging hookah use among university students: A cross-sectional comparison between hookah and cigarette use. BMC Public Health, 13, 302. doi:10.1186/1471-2458-13-302 Bover Manderski, M. T., Hrywna, M., & Delnevo, C. D. (2012). Hookah use among New Jersey youth: Associations and changes over time. American Journal of Health Behavior, 36, 693–699. doi:10.5993/AJHB.36.5.11 Cavus, U. Y., Rehber, Z. H., & Ozeke, O. (2010). Carbon monoxide poisoning associated with Narghile use. Emergency Medicine Journal, 27, 406. doi:10.1136/emj.2009.077214 Centers for Disease Control and Prevention (CDC). (2012a). Youth risk behavior surveillance—United States, 2011. Surveillance Summaries, 61, 1–162. CDC. (2012b). Current tobacco use among middle and high school students—United States, 2011. Morbidity and Mortality Weekly Report, 61, 581–585. Czoli, C. D., Leatherdale, S. T., & Rynard, V. (2013). Bidi and hookah use among Canadian youth: Findings from the 2010 Canadian Youth Smoking Survey. Preventing Chronic Disease, 10, 120290. doi:10.5888/pcd10.120290 Eissenberg, T. E., Ward, K. D., Smith-Simone, S., & Maziak, W. (2008). Waterpipe tobacco smoking on a U.S. college campus: Prevalence and correlates. Journal of Adolescent Health, 42, 526–529. doi:10.1016/j. jadohealth.2007.10.004 Florida Youth Tobacco Survey. (2012). Retrieved from www. floridahealth.gov/reports-and-data/survey-data/fl-youthtobacco-survey/reports/2012-state/index1.html Grekin, E. R., & Ayna, D. (2008). Argileh use among college students in the United States: An emerging trend. Journal of Studies on Alcohol and Drugs, 69, 472–474. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor, MI: Institute for Social Research, The University of Michigan. Jordan, H. M., & Delnevo, C. D. (2010). Emerging tobacco products: Hookah use among New Jersey
Brief report
A Multiyear Assessment of Hookah Use Prevalence Among Florida High School Students Tracey E. Barnett PhD1, Jamie R. Forrest MS2, Lauren Porter PhD, MPH3, Barbara A. Curbow PhD1 1Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, Gainesville, FL; 2Bureau of Chronic Disease Prevention, Florida Department of Health, Tallahassee, FL; 3Bureau of Tobacco Free Florida, Florida Department of Health, Tallahassee, FL
Corresponding Author: Tracey E. Barnett, PhD, Department of Behavioral Science and Community Health, University of Florida, PO Box 100175, Gainesville, FL 32610-0175, USA. Telephone: 352-273-6745; Fax: 352-273-6048; E-mail: [email protected] Received June 26, 2013; accepted October 20, 2013
Introduction: The purpose of this study was to assess the prevalence of hookah use among Florida high school students over time. Alternative tobacco products, including hookah, pose a public health threat to tobacco prevention efforts, especially among adolescents. Methods: Florida Youth Tobacco Survey data, representing all public high school students in the state, were analyzed to assess the prevalence of lifetime and current hookah use and were compared by demographic groups. Multiple years of data (2007– 2012) were examined to assess changes over time. Results: During the past 6 years, there was an increase in lifetime hookah use among Florida high school students. While males remained at a higher rate overall, female adolescents increased at a faster rate. Hispanic and non-Hispanic White respondents reported increased trends as well. Current use trends did not change over 4 years, remaining at about 8%. Conclusions: Hookah is a new tobacco product in the United States that appears attractive to youth, with dramatic increases among the state population. While cigarette use among youth is declining in Florida, the increasing uptake of alternative tobacco products may lessen the overall public health gains for tobacco use. There is a need for continued monitoring of hookah use among the adolescent population, for both prevention and cessation efforts as well as policy interventions to address this emerging trend.
Introduction The prevalence of hookah (water pipe used to smoke tobacco) appears to be increasing, particularly on college campuses across the United States. Prevalence estimates of lifetime hookah use among young adults span 10% to nearly 50% (Barnett et al., 2013; Eissenberg, Ward, Smith-Simone, & Maziak, 2008; Grekin & Ayna, 2008; Primack et al., 2008; Smith-Simone, Maziak, Ward, & Eissenberg, 2008; Sutfin et al., 2011) depending on the sample characteristics. For college populations, hookah use in the past 30 days was associated with younger age (Eissenberg et al., 2008; Primack, Fertman, Rice, Adachi-Mejia, & Fine, 2010; Primack et al., 2008), being male (Grekin & Ayna, 2008; Smith-Simone et al., 2008) and being White (Eissenberg et al., 2008; Primack et al., 2008). Recent findings, however, have indicated that (a) females are closing the gap and smoking at equivalent rates to males and (b) Hispanics are smoking hookah at similar or even higher levels than non-Hispanic Whites (Barnett et al., 2013). To broaden the research to include multiple institutions, Sutfin et al. (2011) sampled college students from eight universities, finding that
40.3% of the sample reported lifetime using hookah and 17.4% of the students reported current (past 30 day) hookah tobacco use. To date, the majority of hookah research has been conducted on college students, with fewer prevalence estimates available for adolescents. Some studies have estimated the prevalence for adolescents, both in the United States and Canada. A few studies reported comparable high school students’ rates for 2010: the New Jersey lifetime rate was 20.9% (Bover Manderski, Hrywna, & Delnevo, 2012), the Canadian Youth lifetime rate was 10% (Czoli, Leatherdale, & Rynard, 2013), and the Monitoring the Future (MTF) researchers reported lifetime prevalence for 12th graders at 17.1% (Johnston, O’Malley, Bachman, & Schulenberg, 2012). Prior to that, Barnett, Curbow, Weitz, Johnson, and Smith-Simone (2009) reported a 2007 lifetime use of 11% in the state of Florida, and Primack, Walsh, Bryce, and Eissenberg (2009) reported the 2005 lifetime use of 10.3% for adolescents in Arizona. While limited in that the study included only adolescent lifetime cigarette smokers, Sterling and Mermelstein (2011) reported a lifetime prevalence of 58.5% for hookah use in this population.
doi:10.1093/ntr/ntt188 Advance Access publication December 17, 2013 © The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
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Abstract
Multiyear assessment of hookah use prevalence
Methods The Florida Youth Tobacco Survey (FYTS, 2012) is a statewide, anonymous, school-based survey administered annually to a random sample of Florida public middle and high school students. The Florida Youth Survey is a collection of multiple survey instruments. In odd-numbered years, four survey instruments are included, and the sample is drawn at the state level. In even-numbered years, only two survey instruments are included, and the sample is drawn at the county level, allowing for the creation of county-level estimates. The annual sample size for the FYTS varies because of this alternating administration. The Florida Department of Health considers this survey ongoing public health surveillance, and the University of Florida Institutional Review Board approved the deidentified data as exempt. Data were collected on students’ demographic characteristics (age, sex, grade, race/ethnicity) and tobacco use trends. The FYTS also has many other questions on the survey, and summary reports can be found in the Florida Department of Health Web site (in references under FYTS). The survey involved a two-stage cluster probability sample design. First, a random sample of public middle schools and high schools (Grades 6–12) was selected for participation in the survey. Second, within each selected school, a random sample of classrooms was selected, and students in those classrooms were invited to participate in the survey. Larger schools were sampled with greater probabilities of selection than smaller schools to ensure that every student in the state had the same probability of selection. Parental consent was
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mostly obtained through passive permission forms that parents must return to opt out their child from participation. In a few counties, however, active permission was required and was obtained. Students were provided instructions in the front of the booklet that were read aloud before beginning. The assent language indicated that participation was completely voluntary and that completing the survey was considered their assent. Please refer to the FYTS Web site for a more detailed description of the sample design. Participation rates were calculated separately for schools and students as a ratio of number participating divided by number selected. Combined participation rates were calculated by multiplying the two separate school and student participation rates by each other. The overall participation rates for the high school population for each of the 6 years were 2007 (57%), 2008 (73%), 2009 (72%), 2010 (74%), 2011 (73%), and 2012 (73%). With respect to hookah use, students were asked “Have you ever tried, even once, smoking tobacco out of a water pipe (also called a ‘hookah’)?” to determine lifetime prevalence. Current use (added in 2009) was assessed with, “During the past 30 days, have you smoked tobacco out of a water pipe (also called a ‘hookah’)?” FYTS data were statistically weighted to be representative of all Florida public middle and high school students. In the current study, we examine hookah use among high school students only using trend analyses across all years. As can be seen in the Barnett et al. (2009) study, the middle school rates were low and remain low (see FYTS Web site). The high school analysis provided a more developmental pattern of use and opportunity for prevention and intervention. Analyses were conducted with SAS v. 9.3 (SAS Institute Inc.) and accounted for the complex sampling design when prevalence rates of hookah use were estimated. Data were analyzed separately according to sex, race/ethnicity, and grade.
Results In 2012, more than one in six (16.7%) Florida high school students reported trying smoking tobacco from a hookah in their lifetime. As is evident in Table 1, hookah rates have been increasing among adolescents living in Florida. Males increased from 12.3% to 16.8% (p < .05), while females increased at a faster rate, from 9.3% to 16.5% (p < .05). NonHispanic Whites demonstrated a 6% increase over 6 years, whereas Hispanic youth nearly doubled their lifetime use (11.8%–21.9%; p < .05). In 2012, Hispanic (21.9%) and nonHispanic White (19.0%) youth both reported more hookah use than non-Hispanic Black youth (5.2%; p < .05). The other race/ethnicity group included American Indian, Alaska Native, Hawaiian, Other Pacific Islander, Asian, and “other,” which likely included adolescents of Middle Eastern descent. This group demonstrated no significant change in hookah use over time but had the highest rate at baseline (18.0% in 2007). With each passing grade level, the rates increased, and more than one fourth (26.1%) of 12th graders reported lifetime use. While 2009–2012 data did not indicate significant increases in current (past 30-day) use overall, current use among Hispanics increased significantly over the 4 years, from 7.9% to 11.2% (p < .05) (Table 2). In 2012, males reported
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While there have been a few studies of hookah use among adolescents, the research has limitations. The only national estimate in the United States is provided by MTF (Johnston et al., 2012), and the hookah items were just added in 2010. Additionally, MTF only included this question for 12th graders. Some states have collected and reported rates, as indicated above, but few have provided a multiyear analysis. A recent Canadian youth study (Czoli et al., 2013) reported a multiyear assessment (2006–2010), but the rates were substantially lower than the state level prevalence reported in the United States. The current study provides a unique look at patterns over time of hookah use for high school students, across multiple years, reporting comparisons from 2007 to 2012. Monitoring hookah rates among adolescents is important because it is not only associated with long-term effects comparable to cigarette use but also poses significant risk for even short-term use. Carbon monoxide (CO) is just one toxicant that is clearly a risk for all users (Shihadeh & Saleh, 2005), with past studies showing extremely high CO levels for users (Barnett, Curbow, Soule, Tomar, & Thombs, 2011). Case reports have even indicated CO poisonings among young adult hookah users (Ashurst, Urquhart, & Cook, 2012; Cavus, Rehber, & Ozeke, 2010; Lim, Lim, & Seow, 2010). Given the possible relationship with other tobacco products, plus the potential harm in one-time use, prevalence rates and correlates need continuous monitoring. The purpose of this study was to assess trends throughout the state of Florida for high school students. This assessment included 6 years of lifetime use prevalence among public school students across the state and a 4-year assessment of current use prevalence.
Nicotine & Tobacco Research Table 1. Prevalence of Lifetime Hookah Use for State of Florida, 2007–2012 Lifetime hookah use Percentage of Florida public high school students who ever tried smoking tobacco out of a hookah, even one or two puffs, by sex, race/ethnicity, and grade, FYTS 2007–2012 2008
2009
2010
2011
2012
N = 40,283
N = 5,673
N = 37,797
N = 6,163
N = 36,439
% (N)
% (N)
% (N)
% (N)
% (N)
% (N)
9.3 (192) 12.3 (227)
12.5 (1,979) 14.4 (2,410)
14.2 (401) 17.3 (443)
15.7 (2,552) 17.4 (2,898)
17.7 (523) 18.7 (538)
16.5 (2,365)* 16.8 (2,603)*
13.0 (228) 3.4 (22) 11.8 (114) 18.0 (54)
17.4 (2,800) 3.4 (203) 14.5 (900) 15.6 (489)
20.3 (438) 4.9 (50) 16.1 (268) 18.4 (91)
20.9 (3,396) 5.1 (313) 18 (1,168) 19.9 (560)
21.8 (509) 4.9 (62) 23.3 (389) 18.6 (101)
19.0 (2,891)* 5.2 (274) 21.9 (1,374)* 18.6 (538)
8.1 (88) 8.8 (95) 11.0 (108) 16.2 (102) 10.7 (419)
7.7 (840) 12.1 (1,053) 15.4 (1,202) 20.2 (1,272) 13.5 (4,389)
9.0 (159) 12.9 (177) 18.3 (218) 25.3 (291) 15.8 (852)
10 (972) 14.2 (1,259) 18.3 (1,436) 25.1 (1,605) 16.6 (5,490)
9.3 (153) 16.0 (251) 21.1 (297) 27.5 (338) 18.2 (1,061)
9.2 (872) 13.1 (1,136)* 19.7 (1,364)* 26.1 (1,525)* 16.7 (5,111)
Note. FYTS = Florida Youth Tobacco Survey. *p < .05; 2007–2012 increase. Table 2. Prevalence of Current Hookah Use for State of Florida, 2009–2012 Current hookah use Percentage of Florida public high school students who smoked hookah on one or more of the previous 30 days, by sex, race/ethnicity, and grade, FYTS 2007–2012
Sex Female Male Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total
2007
2008
2009
2010
2011
2012
%
%
% (N)
% (N)
% (N)
% (N)
N/A
N/A 6.4 (185) 9.1 (240)
7.1 (1,147) 9.2 (1,554)
6.7 (198) 9.3 (267)
7.0 (1,007) 8.2 (1,277)
9.6 (210) 2.7 (27) 7.9 (134) 10.1 (52)
9.7 (1,500) 3.1 (203) 9.3 (672) 11.6 (334)
7.6 (1,163) 2.8 (163) 11.2 (717)* 9.8 (297)
4.7 (80) 5.8 (83) 9.2 (113) 12.3 (145) 7.7 (427)
5.3 (516) 6.6 (568) 8.5 (684) 12.4 (771) 8.2 (2,735)
9.4 (218) 3.0 (39) 9.5 (156) 9.5 (52) 4.0 (66) 6.3 (98) 9.0 (128) 12.6 (155) 8.0 (465)
4.3 (429) 5.9 (499) 8.4 (564) 11.8 (683) 7.7 (2,359)
Note. FYTS = Florida Youth Tobacco Survey. *p < .05; 2009–2012 increase.
a significantly higher prevalence of current use (8.2%) than females (7.0%; p < .05). Hispanic (11.2%) and Other (9.8%) race/ethnicity groups reported significantly higher (p < .05) rates of current use than non-Hispanic White (7.6%) and nonHispanic Black adolescents (2.8%). Current use also increased with each grade level. By 12th grade, 11.8% (more than one in nine) were current hookah users.
Discussion Over 6 years, the prevalence of lifetime hookah use among Florida high school students increased. Our findings indicated that in 2012, 26.1% of Florida 12th graders had tried hookah in their lifetime, some of whom will potentially maintain this behavior throughout early adulthood. Compared with a lifetime
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Sex Female Male Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total
2007 N = 4,028
Multiyear assessment of hookah use prevalence
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contribute to this portrait of users and inform interventions, but the lack of increase in current use patterns is noteworthy. Hookah use, once thought to be a fad, continues to grow in the United States among adolescents and young adults. Myriad reasons for this could include beliefs about the relative lack of harm for hookah use compared with cigarettes (Eissenberg et al., 2008; Primack et al., 2008); the belief that light use poses little to no risk, as well as a social venue for this population to spend their time. Given the restrictions on cigarette smoking in public places, the mere presence of hookah cafes may reinforce the beliefs about lack of harm reported by users. Whereas a city or college town has no cafes for cigarette smoking, they might allow several hookah cafes to open. Limitations It is important to note that across all of the lifetime use prevalence, there was nearly continuous increasing from 2007 to 2011, with some slight decrease in 2012 that was reflective of 2010 numbers. More than likely, given the every other year sampling structure, the 2010 and 2012 data were most reliable, given the larger sample size (N). However, we cannot rule out the possibility that perhaps a slight decline or flattening of prevalence rates will start to occur after a solid 5-year increase. Future data will have to be examined to determine the direction of this behavior. Also, the dichotomous nature of these data does not allow for assessment of frequency or amount of use, merely lifetime use (which could already be stopped for some adolescents) and past month use. Both frequency of use and reasons for use should be explored in future studies. In conclusion, it seems that while cigarette use is declining among adolescents (CDC 2012b; Johnston et al., 2012; FYTS reports), alternative tobacco products may still result in tobacco exposure for youth. It is also possible that openness to hookah could lead to future cigarette use and a dampening of current successful efforts to reduce these rates. These high rates of hookah use among Florida adolescents are noteworthy given the increasing trends as well as patterns that match college samples. The rates remain at levels that need to be assessed continuously, and there is a need for both individual level prevention and cessation programs. Given the literature to date, including this study, demographic analyses are imperative, allowing for tailored interventions for multiple populations. Additionally, policy interventions (Morris, Fiala, & Pawlak, 2012) should be considered to reduce adolescent use.
Funding Funding for the Florida Youth Tobacco Survey is provided by the Florida Department of Health, Bureau of Tobacco Free Florida.
Declaration of Interests None declared.
References Ashurst, J. V., Urquhart, M., & Cook, M. D. (2012). Carbon monoxide poisoning secondary to hookah smoking. Journal American Osteopathic Association, 112, 686–688.
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use rate among 12th graders in 2007 of 16.2%, there was a 61% increase over just 6 years, which indicated continued and growing popularity of hookah among youth. Not only were 12th graders’ rates high, the rates increase with each grade throughout high school; in 2012, less than 1 in 10 (9.2%) of 9th graders had tried hookah, which increased to greater than one in four (26.1%) by 12th grade. These rates for the state of Florida are lower than the rates reported by the New Jersey Youth Tobacco Survey (Bover Manderski et al., 2012), which reported 2010 lifetime rates of 21%, but higher than the most recent published numbers from the Canadian Youth Tobacco Survey (Czoli et al., 2013) with only 10% reporting lifetime hookah use. The only national rate in the United States was published by the MTF (Johnston et al., 2012) and is the lifetime rate for 12th graders, at 18.5% in 2010, whereas this study showed 12th graders at 25% lifetime use in 2010. Approximately one in five of both Hispanic students (21.9%) and non-Hispanic White students (19.0%) reported lifetime use. These findings mirror a recent study that showed the rate of lifetime use for college students at the University of Florida was highest among Hispanic students, at an alarming 55.7%, and was closely followed by non-Hispanic White students at 53.5% (Barnett et al., 2013). While the New Jersey Youth Tobacco survey indicated higher lifetime rates (17.9% in 2008 and 20.9% in 2010), they also indicated increasing rates for Hispanic youth, similar to this study (Bover Manderski et al., 2012). The reasons for higher rates among Hispanics have yet to be explored and likely require some qualitative analysis to assess different reasons for use. Research on cigarette use tends to show conflicting results for Hispanic use, with some showing higher rates for Hispanic adolescents born in the United States ((SAMHSA, 2011), while other studies show Hispanic adolescent cigarette use less than Whites ((CDC, 2012a), but still higher than nonHispanic Black respondents (CDC, 2012a). Both males and females demonstrated significant increases across all 6 years, and females increased at a faster rate, virtually closing any sex differences that used to exist (male 16.8% and female 16.5%, in 2012). This, too, reflected recent studies that have shown females to have closed the gap for hookah use (Barnett et al., 2013), which used to be a more male dominant behavior (Primack et al., 2008). The overall current hookah use rate found in this study (Florida) was 7.7% in 2012, higher than the Arizona study at 5.4% in 2005 (Primack et al., 2009) but lower than the New Jersey current use rate of 9.7% in 2010 (Jordan & Delnevo, 2010). Similar to the lifetime use prevalence, current use rates were significantly higher for Hispanics at 11.2%, which also was the only racial and ethnic group to have an increasing trend in current use across the 4 years studied. Also, like lifetime use, the growing increase across grade levels was noteworthy, with only 4.3% of 9th graders reporting current use, which increased to 11.8% by 12th grade. Importantly, though, it should be noted that current use has been relatively steady across time, at around 8% over 4 years. While lifetime use showed increases across 6 years, some of the increase can be noted as a natural phenomenon where new adolescents try hookah each year, thus reflecting an increase across 4 years but perhaps not adding more frequent users. This pattern is supported in the relatively flat nature of current use. A longitudinal assessment is needed to examine if openness during adolescent years could still lead to future young adult use, or if for some adolescents there is a trial period that does not continue. Frequency of use would
Nicotine & Tobacco Research youth. Preventive Medicine, 51, 394–396. doi:10.1016/j. ypmed.2010.08.016 Lim, B. L., Lim, G. H., & Seow, E. (2010). Case of carbon monoxide poisoning after smoking shisha. International Journal of Emergency Medicine, 11, 121–122. doi:10.1007/ s12245-009-0097-8 Morris, D. S., Fiala, S. C., & Pawlak, R. (2012). Opportunities for policy interventions to reduce youth hookah smoking in the United States. Preventing Chronic Disease, 9, 120082. doi:10.5888/pcd9.120082 Primack, B. A., Fertman, C. I., Rice, K. R., Adachi-Mejia, A. M., & Fine, M. J. (2010). Waterpipe and cigarette smoking among college athletes in the United States. Journal of Adolescent Health, 46, 45–51. doi:10.1016/j. jadohealth.2009.05.004 Primack, B. A., Sidani, J., Agarwal, A. A., Shadel, W. G., Donny, E. C., & Eissenberg, T. E. (2008). Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Annals of Behavioral Medicine, 36, 81–86. doi:10.1007/s12160-008-9047-6 Primack, B. A., Walsh, M., Bryce, C., & Eissenberg, T. (2009). Water-pipe tobacco smoking among middle and high school students in Arizona. Pediatrics, 123, e282–e288. doi:10.1542/peds.2008-1663 Shihadeh, A., & Saleh, R. (2005). Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology, 43, 655–661. doi:10.1016/j. fct.2004.12.013 Smith-Simone, S., Maziak, W., Ward, K. D., & Eissenberg, T. (2008). Waterpipe tobacco smoking: Knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine & Tobacco Research, 10, 393–398. doi:10.1080/14622200701825023 Sterling, K. L., & Mermelstein, R. (2011). Examining hookah smoking among a cohort of adolescent ever smokers. Nicotine & Tobacco Research, 13, 1202–1209. doi:10.1093/ ntr/ntr146 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2011, October 4). The NSDUH report: Substance use among hispanic adolescents. Rockville, MD: Author. Retrieved from www.samhsa.gov/data/2k11/WEB_SR_007/WEB_SR_007. htm Sutfin, E. L., McCoy, T. P., Reboussin, B. A., Wagoner, K. G., Spangler, J., & Wolfson, M. (2011). Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug and Alcohol Dependence, 115, 131– 136. doi:10.1016/j.drugalcdep.2011.01.018
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Barnett, T. E., Curbow, B. A., Soule, E. K., Tomar, S. L., & Thombs, D. L. (2011). Carbon monoxide levels among patrons of hookah cafes. American Journal of Preventive Medicine, 40, 324–328. doi:10.1016/j.amepre.2010.11.004 Barnett, T. E., Curbow, B. A., Weitz, J. R., Johnson, T. M., & Smith-Simone, S. (2009). Water pipe tobacco smoking among middle and high school students. American Journal of Public Health, 99, 2014–2019. doi:10.2105/ AJPH.2008.151225 Barnett, T. E., Smith, T., He, Y., Soule, E. K., Curbow, B. A., Tomar, S. L., & McCarty, C. (2013). Evidence of emerging hookah use among university students: A cross-sectional comparison between hookah and cigarette use. BMC Public Health, 13, 302. doi:10.1186/1471-2458-13-302 Bover Manderski, M. T., Hrywna, M., & Delnevo, C. D. (2012). Hookah use among New Jersey youth: Associations and changes over time. American Journal of Health Behavior, 36, 693–699. doi:10.5993/AJHB.36.5.11 Cavus, U. Y., Rehber, Z. H., & Ozeke, O. (2010). Carbon monoxide poisoning associated with Narghile use. Emergency Medicine Journal, 27, 406. doi:10.1136/emj.2009.077214 Centers for Disease Control and Prevention (CDC). (2012a). Youth risk behavior surveillance—United States, 2011. Surveillance Summaries, 61, 1–162. CDC. (2012b). Current tobacco use among middle and high school students—United States, 2011. Morbidity and Mortality Weekly Report, 61, 581–585. Czoli, C. D., Leatherdale, S. T., & Rynard, V. (2013). Bidi and hookah use among Canadian youth: Findings from the 2010 Canadian Youth Smoking Survey. Preventing Chronic Disease, 10, 120290. doi:10.5888/pcd10.120290 Eissenberg, T. E., Ward, K. D., Smith-Simone, S., & Maziak, W. (2008). Waterpipe tobacco smoking on a U.S. college campus: Prevalence and correlates. Journal of Adolescent Health, 42, 526–529. doi:10.1016/j. jadohealth.2007.10.004 Florida Youth Tobacco Survey. (2012). Retrieved from www. floridahealth.gov/reports-and-data/survey-data/fl-youthtobacco-survey/reports/2012-state/index1.html Grekin, E. R., & Ayna, D. (2008). Argileh use among college students in the United States: An emerging trend. Journal of Studies on Alcohol and Drugs, 69, 472–474. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor, MI: Institute for Social Research, The University of Michigan. Jordan, H. M., & Delnevo, C. D. (2010). Emerging tobacco products: Hookah use among New Jersey
