Correlates of Hookah Use and Predictors of Hookah Trial in U.S. Young Adults Andrea C. Villanti, PhD, MPH, Caroline O. Cobb, PhD, Amy M. Cohn, PhD, Valerie F. Williams, MA, MS, Jessica M. Rath, PhD, MPH Introduction: Hookah, or waterpipe, tobacco smoking has increased among young adults (YAs) in the U.S., but few prospective studies have examined predictors of hookah use. The current study examined correlates of hookah use and predictors of hookah initiation at a 6-month follow-up in a nationally representative, prospective sample of U.S. YAs. Methods: Data were drawn from a subset of participants aged 18–24 years at study entry from two waves of the Legacy Young Adult Cohort Study. Wave 5 was completed in July 2013 by 1,555 participants and 74% (n¼1,150) completed follow-up 6 months later in January 2014. Weighted bivariate and multivariable analyses were conducted in June 2014 to estimate the prevalence and correlates of ever and past 30–day hookah use and to examine associations between baseline covariates and hookah initiation 6 months later. Results: At baseline (Wave 5), almost 25% of the sample had ever used hookah and 4% reported past 30–day use. Alcohol, marijuana, and cigarette use were more prevalent among ever and past 30– day hookah users than among never users. Eight percent of never users at baseline reported trying hookah at the 6-month follow-up. Significant predictors of hookah trial in a multivariable model included college enrollment; alcohol, marijuana, and cigarette use; and perceptions that hookah is less harmful than cigarettes. Conclusions: Results highlight rapid transitions in hookah use and several risk factors for initiation. Future studies should examine how these factors could be used as intervention targets to reduce tobacco use in this vulnerable age group. (Am J Prev Med 2015;](]):]]]–]]]) & 2015 American Journal of Preventive Medicine
Introduction
H
ookah, or waterpipe, tobacco smoking recently experienced a surge in prevalence in the U.S., particularly among adolescents and young adults (YAs).1–3 Studies demonstrate high rates of hookah initiation, ranging from 13% over a 7-month period in undergraduate and graduate students4 to 23% over the course of the first year of college among female students.5 These rates of initiation and use are concerning, as a single hookah session exposes users to the From the Schroeder Institute for Tobacco Research and Policy Studies (Villanti, Cobb, Cohn), Department of Research and Evaluation (Williams, Rath), Legacy, Washington, District of Columbia; and the Department of Health, Behavior and Society (Villanti, Rath), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Address correspondence to: Andrea C. Villanti, PhD, MPH, Associate Director for Regulatory Science and Policy, The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, 1724 Massachusetts Ave. NW, Washington DC 20036. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.01.010
& 2015 American Journal of Preventive Medicine
equivalent of at least one to as many as 50 cigarettes, depending on the measured toxicant,6 and may place users at risk for nicotine dependence7,8 and many of the same diseases as cigarette smokers.9–12 Several risk factors and correlates of hookah use may be contributing to its rising popularity in YAs. First is the perception among YAs that hookah is less harmful13–19 and less addictive14,15,18,19 than cigarettes. Second, a number of studies have documented that other health risk behaviors highly prevalent in YAs, such as alcohol and marijuana use, are correlated with hookah use.5,20–23 Finally, dual use of cigarettes and hookah is especially common in YAs.23–25 Thus, the profiles of hookah-using YAs may portend negative health consequences, propensity for nicotine dependence, and tobacco-related morbidity and mortality. To date, few studies have examined predictors of hookah initiation using a prospective design; most have focused on hookah initiation in college-attending samples,5,21 which may exclude a significant portion of
Published by Elsevier Inc.
Am J Prev Med 2015;](]):]]]–]]] 1
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
2
Table 1. Correlates of Hookah Use in U.S. Young Adults Aged 18–24 at Baseline (Weighted n¼1,697)
Variable Overall
Never use (%, weighted n¼1,310; ref)
Ever use (%, weighted n¼314)
Past 30-day use (%, weighted n¼73)
77
19
4
Male
51
47
49
Female
49
53
51
White, non-Hispanic
53
68
43
Black, non-Hispanic
15
9
Gender
Race/ethnicity
22 *
Other, non-Hispanic
11
6
Hispanic
21
17
25
Less than high school
16
6
8
High school
39
26
47
Some college or greater
44
68**
46
Currently enrolled in college
45
45
57
10
Education
**
83**
Alcohol use (every day or some days)
49
89
Marijuana use (every day or some days)
10
23**
32**
Other drug use (every day or some days)
2
5
6
13
31**
28**
Little cigars/cigarillos (LCCs)
2
6*
14*
E-cigarettes
2
10**
19**
4
8
26*
A little less harmful
18
42**
29*
About the same
52
37**
34**
A little more harmful
10
11
A lot more harmful
16
Current use (past 30 days) Cigarettes
Harm perceptions of hookah compared to cigarettes A lot less harmful
2**
4* 7**
Note: Boldface indicates statistical significance. Missing observations: alcohol use (22), marijuana use (28), other drug use (26), hookah harm perceptions (69). n po0.05; nnpo0.01
YAs.26 This study sought to extend previous work and fill an important research gap by examining correlates of hookah use and predictors of hookah initiation in a nationally representative, prospective sample of U.S YAs.
Methods Study Sample This study used data from the Legacy Young Adult Cohort Study, a national sample of YAs aged 18–34 years drawn from an existing address-based probability sample. Online consent was collected from participants before questionnaire self-administration, and the cumulative response rate was 5.7% for Wave 5. This study was approved by the Chesapeake IRB, Inc. Details of study recruitment and methods have been published elsewhere.27 The present analysis focused on a subset of 1,555 participants aged 18–24 from whom data were collected in July 2013 (Wave 5), 74% of whom (n¼1,150) completed follow-up 6 months later in January 2014 (Wave 6). Analyses were conducted in June 2014, and data were weighted to offset nonresponse bias and produce nationally representative estimates.
Measures Participants were asked about ever use and past 30–day use of cigarettes; little cigars/cigarillos (LCCs); electronic cigarettes (e-cigarettes); and hookah at both waves. Never use, ever use, and past 30–day use of hookah were developed as mutually exclusive categories. Standard demographic data were collected by GfK at Wave 5, with additional items on current enrollment in college; current alcohol, marijuana, or other drug use (every day or some days versus not at all); and harm perceptions of hookah compared to traditional cigarettes on a 5-point scale from a lot less harmful to a lot more harmful. Hookah trial was defined as ever use of hookah at follow-up among those who reported never use of hookah at Wave 5.
Statistical Analysis
Bivariate analyses were used to estimate ever and current hookah use (versus never use) at Wave 5 and to examine associations among baseline demographics, other tobacco use, alcohol and substance use, hookah harm perceptions, and hookah trial at follow-up. Multivariable logistic regression was used to identify predictors of hookah trial, controlling for all covariates associated with hookah trial at po0.10 in bivariate analyses. Significant predictors of hookah trial www.ajpmonline.org
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
3
30–day users reported an average of 2.6 days of hookah use (SD¼3.4) in the Tried hookah in past month. Among those Variable past 6 months (%) AOR (95% CI) with at least some college Overall 8 education, ever use of hooa kah was significantly highGender er than never use or past Male 27 ref 30–day use. Current alcoFemale 73 2.50 (1.00, 6.23) hol, marijuana, and cigarette use were significantly Race/ethnicity higher in ever and past 30– White, non-Hispanic 45 day hookah users relative to Black, non-Hispanic 17 never users. Past 30–day hookah users also reported Other, non-Hispanic 11 greater use of LCCs and eHispanic 27 cigarettes compared to hooEducation kah ever and never users. Approximately half (52%) Less than high school 10 of those who had never High school 42 used hookah at Wave 5 Some college or greater 48 reported that hookah was Currently enrolled in collegea 65 3.45 (1.44, 8.27)* about as harmful as cigarettes; only 22% reported it a * Alcohol use (every day or some days) 84 3.81 (1.56, 9.31) as less harmful than cigaMarijuana use (every day or some days)a 22 1.19 (0.43, 3.32) rettes. Significantly more Other drug use (every day or some days) 8 2.48 (0.37, 16.71) ever hookah users (50%) and past 30–day users Current use (past 30 days) (55%) reported hookah as 33 4.05 (1.70, 9.63)* Cigarettesa a lot or a little less harmful Little cigars/cigarillos (LCCs) 1 than cigarettes relative to never users. E-cigarettes 4 At 6-month follow-up, Harm perceptions of hookah compared to a 8% of baseline never users cigarettes tried hookah (Table 2) and A lot less harmful 19 ref initiates used hookah on A little less harmful 14 0.17 (0.03, 0.92)* an average of 1.8 (SD¼1.7) days in the past month. About the same 46 0.13 (0.03, 0.52)* Hookah trial was signifiA little more harmful 7 0.10 (0.02, 0.68)* cantly higher among women A lot more harmful 15 0.14 (0.03, 0.75)* (73%); college attendees ** (65%); and current alcohol Constant 0.02 (0.002, 0.10) (84%), marijuana (22%), Note: Boldface indicates statistical significance. Design-based F(10, 2702) ¼ 3.26, p¼0.0003. a and cigarette users (33%). Indicates variable associated with hookah trial in bivariate analyses that were included in the full multivariable model. Past 30–day e-cigarette use n po0.05; nnpo0.01. was not associated with hookah trial. A third (33%) of hookah initiates at follow-up were identified using p-values from the t statistic. All analyses were endorsed hookah as less harmful than cigarettes. In the performed in Stata/IC, version 13.0. multivariable model, college enrollment, alcohol and cigarette use, and perceptions of hookah as a lot less Results harmful compared to cigarettes (all measured at Wave 5) remained significant predictors of hookah trial at In the weighted sample, 23% had ever used hookah and follow-up. 4% had used hookah in the past 30 days (Table 1). Past Table 2. Predictors of Hookah Trial at Six Months Among Baseline Never Users (Weighted n¼887)
] 2015
4
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
Discussion
References
This is the first study to examine correlates of hookah use and predictors of hookah trial using a prospective design in a national sample of YAs. Among those aged 18–24 years, almost a quarter of the sample had ever used hookah at baseline and 8% of never users reported trying hookah by 6-month follow-up. Predictors of hookah trial included college enrollment; alcohol, marijuana, and cigarette use; and perceptions that hookah is less harmful than cigarettes. These findings are consistent with other studies of hookah use23 and initiation in college students,4,5,21 though the prevalence of past 30–day hookah use in this general population sample is lower than a recent study conducted in a national college sample (i.e., 4% vs 10%, respectively).23 The current study extends findings on perceptions of relative harm of hookah compared to cigarettes from cross-sectional studies in college and university students22,28,29 by revealing the impact of lower hookah harm perceptions on subsequent hookah trial. They are consistent with previous work documenting the correlation between college hookah use and the presence of commercial waterpipe venues near campus.22 Of note, there was no association between e-cigarette use and subsequent hookah trial.
1. CDC. Tobacco product use among middle and high school students— United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep. 2013; 62(45):893–897. 2. Amrock SM, Gordon T, Zelikoff JT, Weitzman M. Hookah use among adolescents in the United States: results of a national survey. Nicotine Tob Res. 2014;16(2):231–237. http://dx.doi.org/10.1093/ntr/ntt160. 3. Primack BA, Shensa A, Kim KH, et al. Waterpipe smoking among U.S. university students. Nicotine Tob Res. 2013;15(1): 29–35. http://dx.doi.org/10.1093/ntr/nts076. 4. Sidani JE, Shensa A, Barnett TE, Cook RL, Primack BA. Knowledge, attitudes, and normative beliefs as predictors of hookah smoking initiation: a longitudinal study of university students. Nicotine Tob Res. 2014;16(6):647–654. http://dx.doi.org/10.1093/ntr/ntt201. 5. Fielder RL, Carey KB, Carey MP. Predictors of initiation of hookah tobacco smoking: a one-year prospective study of first-year college women. Psychol Addict Behav. 2012;26(4):963–968. http://dx.doi.org/ 10.1037/a0028344. 6. Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav. 2010;34(3):275–285. http://dx.doi.org/10.5993/AJHB. 34.3.3. 7. Auf RA, Radwan GN, Loffredo CA, El Setouhy M, Israel E, Mohamed MK. Assessment of tobacco dependence in waterpipe smokers in Egypt. Int J Tuberc Lung Dis. 2012;16(1):132–137. http://dx.doi.org/ 10.5588/ijtld.11.0457. 8. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;9(10):987–994. http://dx.doi.org/10.1080/14622200701591591. 9. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;39(3):834–857. http://dx.doi.org/10.1093/ije/dyq002. 10. Khabour OF, Alzoubi KH, Bani-Ahmad M, Dodin A, Eissenberg T, Shihadeh A. Acute exposure to waterpipe tobacco smoke induces changes in the oxidative and inflammatory markers in mouse lung. Inhal Toxicol. 2012;24(10):667–675. http://dx.doi.org/10.3109/08958378.2012.710918. 11. Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M. In vitro cytotoxicity and mutagenicity of mainstream waterpipe smoke and its functional consequences on alveolar type II derived cells. Toxicol Lett. 2012;211(3):220–231. http://dx.doi.org/10.1016/j.toxlet.2012.04.003. 12. Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M. In vitro effects of waterpipe smoke condensate on endothelial cell function: a potential risk factor for vascular disease. Toxicol Lett. 2013;219(2):133– 142. http://dx.doi.org/10.1016/j.toxlet.2013.02.015. 13. Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009;5(1):16. http://dx.doi.org/10. 1186/1617-9625-5-16. 14. Ward KD, Eissenberg T, Gray JN, Srinivas V, Wilson N, Maziak W. Characteristics of U.S. waterpipe users: a preliminary report. Nicotine Tob Res. 2007;9(12):1339–1346. http://dx.doi.org/10.1080/1462220070170 5019. 15. Smith-Simone SY, Curbow BA, Stillman FA. Differing psychosocial risk profiles of college freshmen waterpipe, cigar, and cigarette smokers. Addict Behav. 2008;33(12):1619–1624. http://dx.doi.org/10. 1016/j.addbeh.2008.07.017. 16. Smith SY, Curbow B, Stillman FA. Harm perception of nicotine products in college freshmen. Nicotine Tob Res. 2007;9(9):977– 982. http://dx.doi.org/10.1080/14622200701540796. 17. Grekin ER, Ayna D. Waterpipe smoking among college students in the United States: a review of the literature. J Am Coll Health. 2012;60(3): 244–249. http://dx.doi.org/10.1080/07448481.2011.589419. 18. Noonan D, Patrick ME. Factors associated with perceptions of hookah addictiveness and harmfulness among young adults. Subst Abus. 2013;34(1):83–85. http://dx.doi.org/10.1080/08897077.2012.718251.
Limitations This study has several limitations, including the use of self-report; limited examination of potential moderators of the association between relevant predictors (hookah harm perceptions, alcohol, marijuana, or cigarette use) and subsequent hookah trial; and use of a web-based panel. The address-based sampling frame and methods improve generalizability of the sample through the inclusion of non-Internet households.
Conclusions The current study documents rapid transitions in hookah use in U.S. YAs over a 6-month time period and examines concurrent risk factors (i.e., alcohol, marijuana, and other tobacco use) that influence hookah trial. It also highlights lower harm perceptions of hookah relative to cigarettes as a likely antecedent of hookah use. Future studies should examine the specific ways in which these factors could be used as intervention targets to reduce tobacco use in this vulnerable age group. This study was funded by Legacy. No financial disclosures were reported by the authors of this paper.
www.ajpmonline.org
Villanti et al / Am J Prev Med 2015;](]):]]]–]]] 19. Griffiths MA, Harmon TR, Gilly MC. Hubble bubble trouble: the need for education about and regulation of Hookah smoking. Journal of Public Policy & Marketing. 2011;30(1):119–132. http://dx.doi.org/10.1509/jppm.30.1.119. 20. Berg CJ, Schauer GL, Asfour OA, Thomas AN, Ahluwalia JS. Psychosocial factors and health-risk behaviors associated with hookah use among college students. J Addict Res Ther. 2011; Suppl2. 21. Fielder RL, Carey KB, Carey MP. Hookah, cigarette, and marijuana use: a prospective study of smoking behaviors among first-year college women. Addict Behav. 2013;38(11):2729–2735. http://dx.doi.org/10. 1016/j.addbeh.2013.07.006. 22. Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend. 2011;115 (1–2):131–136. http://dx.doi.org/10.1016/j.drugalcdep.2011.01.018. 23. Jarrett T, Blosnich J, Tworek C, Horn K. Hookah use among U.S. college students: results from the National College Health Assessment II. Nicotine Tob Res. 2012;14(10):1145–1153. http://dx.doi.org/10.1093/ntr/nts003. 24. Barnett TE, Smith T, He Y, et al. Evidence of emerging hookah use among university students: a cross-sectional comparison between hookah and cigarette use. BMC Public Health. 2013;13: 302. http://dx.doi.org/10.1186/1471-2458-13-302.
] 2015
5
25. Lee YO, Bahreinifar S, Ling PM. Understanding tobacco-related attitudes among college and noncollege young adult hookah and cigarette users. J Am Coll Health. 2014;62(1):10–18. http://dx.doi.org/ 10.1080/07448481.2013.842171. 26. U.S. Department of Education, National Center for Education Statistics,. Fast Facts: Enrollment. Digest of Education Statistics, 2012 (NCES 2014-015), Chapter 3. 2013. www.nces.ed.gov/fastfacts/display. asp?id=98. 27. Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation. J Environ Public Health. 2012;2012: 679134. http://dx.doi.org/10.1155/2012/679134. 28. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med. 2008;36(1):81– 86. http://dx.doi.org/10.1007/s12160-008-9047-6. 29. Heinz AJ, Giedgowd GE, Crane NA, et al. A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav. 2013;38(11): 2751–2760. http://dx.doi.org/10.1016/j.addbeh.2013.07.009.
Introduction
H
ookah, or waterpipe, tobacco smoking recently experienced a surge in prevalence in the U.S., particularly among adolescents and young adults (YAs).1–3 Studies demonstrate high rates of hookah initiation, ranging from 13% over a 7-month period in undergraduate and graduate students4 to 23% over the course of the first year of college among female students.5 These rates of initiation and use are concerning, as a single hookah session exposes users to the From the Schroeder Institute for Tobacco Research and Policy Studies (Villanti, Cobb, Cohn), Department of Research and Evaluation (Williams, Rath), Legacy, Washington, District of Columbia; and the Department of Health, Behavior and Society (Villanti, Rath), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Address correspondence to: Andrea C. Villanti, PhD, MPH, Associate Director for Regulatory Science and Policy, The Schroeder Institute for Tobacco Research and Policy Studies, Legacy, 1724 Massachusetts Ave. NW, Washington DC 20036. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.01.010
& 2015 American Journal of Preventive Medicine
equivalent of at least one to as many as 50 cigarettes, depending on the measured toxicant,6 and may place users at risk for nicotine dependence7,8 and many of the same diseases as cigarette smokers.9–12 Several risk factors and correlates of hookah use may be contributing to its rising popularity in YAs. First is the perception among YAs that hookah is less harmful13–19 and less addictive14,15,18,19 than cigarettes. Second, a number of studies have documented that other health risk behaviors highly prevalent in YAs, such as alcohol and marijuana use, are correlated with hookah use.5,20–23 Finally, dual use of cigarettes and hookah is especially common in YAs.23–25 Thus, the profiles of hookah-using YAs may portend negative health consequences, propensity for nicotine dependence, and tobacco-related morbidity and mortality. To date, few studies have examined predictors of hookah initiation using a prospective design; most have focused on hookah initiation in college-attending samples,5,21 which may exclude a significant portion of
Published by Elsevier Inc.
Am J Prev Med 2015;](]):]]]–]]] 1
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
2
Table 1. Correlates of Hookah Use in U.S. Young Adults Aged 18–24 at Baseline (Weighted n¼1,697)
Variable Overall
Never use (%, weighted n¼1,310; ref)
Ever use (%, weighted n¼314)
Past 30-day use (%, weighted n¼73)
77
19
4
Male
51
47
49
Female
49
53
51
White, non-Hispanic
53
68
43
Black, non-Hispanic
15
9
Gender
Race/ethnicity
22 *
Other, non-Hispanic
11
6
Hispanic
21
17
25
Less than high school
16
6
8
High school
39
26
47
Some college or greater
44
68**
46
Currently enrolled in college
45
45
57
10
Education
**
83**
Alcohol use (every day or some days)
49
89
Marijuana use (every day or some days)
10
23**
32**
Other drug use (every day or some days)
2
5
6
13
31**
28**
Little cigars/cigarillos (LCCs)
2
6*
14*
E-cigarettes
2
10**
19**
4
8
26*
A little less harmful
18
42**
29*
About the same
52
37**
34**
A little more harmful
10
11
A lot more harmful
16
Current use (past 30 days) Cigarettes
Harm perceptions of hookah compared to cigarettes A lot less harmful
2**
4* 7**
Note: Boldface indicates statistical significance. Missing observations: alcohol use (22), marijuana use (28), other drug use (26), hookah harm perceptions (69). n po0.05; nnpo0.01
YAs.26 This study sought to extend previous work and fill an important research gap by examining correlates of hookah use and predictors of hookah initiation in a nationally representative, prospective sample of U.S YAs.
Methods Study Sample This study used data from the Legacy Young Adult Cohort Study, a national sample of YAs aged 18–34 years drawn from an existing address-based probability sample. Online consent was collected from participants before questionnaire self-administration, and the cumulative response rate was 5.7% for Wave 5. This study was approved by the Chesapeake IRB, Inc. Details of study recruitment and methods have been published elsewhere.27 The present analysis focused on a subset of 1,555 participants aged 18–24 from whom data were collected in July 2013 (Wave 5), 74% of whom (n¼1,150) completed follow-up 6 months later in January 2014 (Wave 6). Analyses were conducted in June 2014, and data were weighted to offset nonresponse bias and produce nationally representative estimates.
Measures Participants were asked about ever use and past 30–day use of cigarettes; little cigars/cigarillos (LCCs); electronic cigarettes (e-cigarettes); and hookah at both waves. Never use, ever use, and past 30–day use of hookah were developed as mutually exclusive categories. Standard demographic data were collected by GfK at Wave 5, with additional items on current enrollment in college; current alcohol, marijuana, or other drug use (every day or some days versus not at all); and harm perceptions of hookah compared to traditional cigarettes on a 5-point scale from a lot less harmful to a lot more harmful. Hookah trial was defined as ever use of hookah at follow-up among those who reported never use of hookah at Wave 5.
Statistical Analysis
Bivariate analyses were used to estimate ever and current hookah use (versus never use) at Wave 5 and to examine associations among baseline demographics, other tobacco use, alcohol and substance use, hookah harm perceptions, and hookah trial at follow-up. Multivariable logistic regression was used to identify predictors of hookah trial, controlling for all covariates associated with hookah trial at po0.10 in bivariate analyses. Significant predictors of hookah trial www.ajpmonline.org
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
3
30–day users reported an average of 2.6 days of hookah use (SD¼3.4) in the Tried hookah in past month. Among those Variable past 6 months (%) AOR (95% CI) with at least some college Overall 8 education, ever use of hooa kah was significantly highGender er than never use or past Male 27 ref 30–day use. Current alcoFemale 73 2.50 (1.00, 6.23) hol, marijuana, and cigarette use were significantly Race/ethnicity higher in ever and past 30– White, non-Hispanic 45 day hookah users relative to Black, non-Hispanic 17 never users. Past 30–day hookah users also reported Other, non-Hispanic 11 greater use of LCCs and eHispanic 27 cigarettes compared to hooEducation kah ever and never users. Approximately half (52%) Less than high school 10 of those who had never High school 42 used hookah at Wave 5 Some college or greater 48 reported that hookah was Currently enrolled in collegea 65 3.45 (1.44, 8.27)* about as harmful as cigarettes; only 22% reported it a * Alcohol use (every day or some days) 84 3.81 (1.56, 9.31) as less harmful than cigaMarijuana use (every day or some days)a 22 1.19 (0.43, 3.32) rettes. Significantly more Other drug use (every day or some days) 8 2.48 (0.37, 16.71) ever hookah users (50%) and past 30–day users Current use (past 30 days) (55%) reported hookah as 33 4.05 (1.70, 9.63)* Cigarettesa a lot or a little less harmful Little cigars/cigarillos (LCCs) 1 than cigarettes relative to never users. E-cigarettes 4 At 6-month follow-up, Harm perceptions of hookah compared to a 8% of baseline never users cigarettes tried hookah (Table 2) and A lot less harmful 19 ref initiates used hookah on A little less harmful 14 0.17 (0.03, 0.92)* an average of 1.8 (SD¼1.7) days in the past month. About the same 46 0.13 (0.03, 0.52)* Hookah trial was signifiA little more harmful 7 0.10 (0.02, 0.68)* cantly higher among women A lot more harmful 15 0.14 (0.03, 0.75)* (73%); college attendees ** (65%); and current alcohol Constant 0.02 (0.002, 0.10) (84%), marijuana (22%), Note: Boldface indicates statistical significance. Design-based F(10, 2702) ¼ 3.26, p¼0.0003. a and cigarette users (33%). Indicates variable associated with hookah trial in bivariate analyses that were included in the full multivariable model. Past 30–day e-cigarette use n po0.05; nnpo0.01. was not associated with hookah trial. A third (33%) of hookah initiates at follow-up were identified using p-values from the t statistic. All analyses were endorsed hookah as less harmful than cigarettes. In the performed in Stata/IC, version 13.0. multivariable model, college enrollment, alcohol and cigarette use, and perceptions of hookah as a lot less Results harmful compared to cigarettes (all measured at Wave 5) remained significant predictors of hookah trial at In the weighted sample, 23% had ever used hookah and follow-up. 4% had used hookah in the past 30 days (Table 1). Past Table 2. Predictors of Hookah Trial at Six Months Among Baseline Never Users (Weighted n¼887)
] 2015
4
Villanti et al / Am J Prev Med 2015;](]):]]]–]]]
Discussion
References
This is the first study to examine correlates of hookah use and predictors of hookah trial using a prospective design in a national sample of YAs. Among those aged 18–24 years, almost a quarter of the sample had ever used hookah at baseline and 8% of never users reported trying hookah by 6-month follow-up. Predictors of hookah trial included college enrollment; alcohol, marijuana, and cigarette use; and perceptions that hookah is less harmful than cigarettes. These findings are consistent with other studies of hookah use23 and initiation in college students,4,5,21 though the prevalence of past 30–day hookah use in this general population sample is lower than a recent study conducted in a national college sample (i.e., 4% vs 10%, respectively).23 The current study extends findings on perceptions of relative harm of hookah compared to cigarettes from cross-sectional studies in college and university students22,28,29 by revealing the impact of lower hookah harm perceptions on subsequent hookah trial. They are consistent with previous work documenting the correlation between college hookah use and the presence of commercial waterpipe venues near campus.22 Of note, there was no association between e-cigarette use and subsequent hookah trial.
1. CDC. Tobacco product use among middle and high school students— United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep. 2013; 62(45):893–897. 2. Amrock SM, Gordon T, Zelikoff JT, Weitzman M. Hookah use among adolescents in the United States: results of a national survey. Nicotine Tob Res. 2014;16(2):231–237. http://dx.doi.org/10.1093/ntr/ntt160. 3. Primack BA, Shensa A, Kim KH, et al. Waterpipe smoking among U.S. university students. Nicotine Tob Res. 2013;15(1): 29–35. http://dx.doi.org/10.1093/ntr/nts076. 4. Sidani JE, Shensa A, Barnett TE, Cook RL, Primack BA. Knowledge, attitudes, and normative beliefs as predictors of hookah smoking initiation: a longitudinal study of university students. Nicotine Tob Res. 2014;16(6):647–654. http://dx.doi.org/10.1093/ntr/ntt201. 5. Fielder RL, Carey KB, Carey MP. Predictors of initiation of hookah tobacco smoking: a one-year prospective study of first-year college women. Psychol Addict Behav. 2012;26(4):963–968. http://dx.doi.org/ 10.1037/a0028344. 6. Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav. 2010;34(3):275–285. http://dx.doi.org/10.5993/AJHB. 34.3.3. 7. Auf RA, Radwan GN, Loffredo CA, El Setouhy M, Israel E, Mohamed MK. Assessment of tobacco dependence in waterpipe smokers in Egypt. Int J Tuberc Lung Dis. 2012;16(1):132–137. http://dx.doi.org/ 10.5588/ijtld.11.0457. 8. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;9(10):987–994. http://dx.doi.org/10.1080/14622200701591591. 9. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;39(3):834–857. http://dx.doi.org/10.1093/ije/dyq002. 10. Khabour OF, Alzoubi KH, Bani-Ahmad M, Dodin A, Eissenberg T, Shihadeh A. Acute exposure to waterpipe tobacco smoke induces changes in the oxidative and inflammatory markers in mouse lung. Inhal Toxicol. 2012;24(10):667–675. http://dx.doi.org/10.3109/08958378.2012.710918. 11. Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M. In vitro cytotoxicity and mutagenicity of mainstream waterpipe smoke and its functional consequences on alveolar type II derived cells. Toxicol Lett. 2012;211(3):220–231. http://dx.doi.org/10.1016/j.toxlet.2012.04.003. 12. Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M. In vitro effects of waterpipe smoke condensate on endothelial cell function: a potential risk factor for vascular disease. Toxicol Lett. 2013;219(2):133– 142. http://dx.doi.org/10.1016/j.toxlet.2013.02.015. 13. Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009;5(1):16. http://dx.doi.org/10. 1186/1617-9625-5-16. 14. Ward KD, Eissenberg T, Gray JN, Srinivas V, Wilson N, Maziak W. Characteristics of U.S. waterpipe users: a preliminary report. Nicotine Tob Res. 2007;9(12):1339–1346. http://dx.doi.org/10.1080/1462220070170 5019. 15. Smith-Simone SY, Curbow BA, Stillman FA. Differing psychosocial risk profiles of college freshmen waterpipe, cigar, and cigarette smokers. Addict Behav. 2008;33(12):1619–1624. http://dx.doi.org/10. 1016/j.addbeh.2008.07.017. 16. Smith SY, Curbow B, Stillman FA. Harm perception of nicotine products in college freshmen. Nicotine Tob Res. 2007;9(9):977– 982. http://dx.doi.org/10.1080/14622200701540796. 17. Grekin ER, Ayna D. Waterpipe smoking among college students in the United States: a review of the literature. J Am Coll Health. 2012;60(3): 244–249. http://dx.doi.org/10.1080/07448481.2011.589419. 18. Noonan D, Patrick ME. Factors associated with perceptions of hookah addictiveness and harmfulness among young adults. Subst Abus. 2013;34(1):83–85. http://dx.doi.org/10.1080/08897077.2012.718251.
Limitations This study has several limitations, including the use of self-report; limited examination of potential moderators of the association between relevant predictors (hookah harm perceptions, alcohol, marijuana, or cigarette use) and subsequent hookah trial; and use of a web-based panel. The address-based sampling frame and methods improve generalizability of the sample through the inclusion of non-Internet households.
Conclusions The current study documents rapid transitions in hookah use in U.S. YAs over a 6-month time period and examines concurrent risk factors (i.e., alcohol, marijuana, and other tobacco use) that influence hookah trial. It also highlights lower harm perceptions of hookah relative to cigarettes as a likely antecedent of hookah use. Future studies should examine the specific ways in which these factors could be used as intervention targets to reduce tobacco use in this vulnerable age group. This study was funded by Legacy. No financial disclosures were reported by the authors of this paper.
www.ajpmonline.org
Villanti et al / Am J Prev Med 2015;](]):]]]–]]] 19. Griffiths MA, Harmon TR, Gilly MC. Hubble bubble trouble: the need for education about and regulation of Hookah smoking. Journal of Public Policy & Marketing. 2011;30(1):119–132. http://dx.doi.org/10.1509/jppm.30.1.119. 20. Berg CJ, Schauer GL, Asfour OA, Thomas AN, Ahluwalia JS. Psychosocial factors and health-risk behaviors associated with hookah use among college students. J Addict Res Ther. 2011; Suppl2. 21. Fielder RL, Carey KB, Carey MP. Hookah, cigarette, and marijuana use: a prospective study of smoking behaviors among first-year college women. Addict Behav. 2013;38(11):2729–2735. http://dx.doi.org/10. 1016/j.addbeh.2013.07.006. 22. Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend. 2011;115 (1–2):131–136. http://dx.doi.org/10.1016/j.drugalcdep.2011.01.018. 23. Jarrett T, Blosnich J, Tworek C, Horn K. Hookah use among U.S. college students: results from the National College Health Assessment II. Nicotine Tob Res. 2012;14(10):1145–1153. http://dx.doi.org/10.1093/ntr/nts003. 24. Barnett TE, Smith T, He Y, et al. Evidence of emerging hookah use among university students: a cross-sectional comparison between hookah and cigarette use. BMC Public Health. 2013;13: 302. http://dx.doi.org/10.1186/1471-2458-13-302.
] 2015
5
25. Lee YO, Bahreinifar S, Ling PM. Understanding tobacco-related attitudes among college and noncollege young adult hookah and cigarette users. J Am Coll Health. 2014;62(1):10–18. http://dx.doi.org/ 10.1080/07448481.2013.842171. 26. U.S. Department of Education, National Center for Education Statistics,. Fast Facts: Enrollment. Digest of Education Statistics, 2012 (NCES 2014-015), Chapter 3. 2013. www.nces.ed.gov/fastfacts/display. asp?id=98. 27. Rath JM, Villanti AC, Abrams DB, Vallone DM. Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation. J Environ Public Health. 2012;2012: 679134. http://dx.doi.org/10.1155/2012/679134. 28. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med. 2008;36(1):81– 86. http://dx.doi.org/10.1007/s12160-008-9047-6. 29. Heinz AJ, Giedgowd GE, Crane NA, et al. A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav. 2013;38(11): 2751–2760. http://dx.doi.org/10.1016/j.addbeh.2013.07.009.
