Abstract
Background: About 30% of college students have smoked hookah tobacco. Although most students perceive this product to be innocuous and non-addictive, hookah tobacco increases the risk for disease and nicotine dependence. Currently, the US Food and Drug Administration (FDA) does not regulate the manufacture, distribution, or sale of hookah tobacco. Objective: Empirical literature pertaining to hookah tobacco smoking is reviewed with a focus on the implications for regulatory policy. Methods: PubMed, PsycINFO, and Scopus databases were searched to locate articles published in English. The literature search combined several key words including “hookahs”, “college”, “advertising”, “health effects”, and “health policy”. Results: Smoking hookah tobacco may play a role in the initiation of smoking among tobacco-naïve college students and may portend persistent smoking among those who have smoked cigarettes. College students are typically nondaily, social smokers. They do not perceive that their heightened risk for tobacco diseases and nicotine dependence relates to their smoking behavior. However, few public health messages target college-age adults to counter media messages that endorse hookah tobacco smoking. Conclusion: Given that the FDA is not authorized to ban specific tobacco products, policy actions should focus on the development of effective risk communication strategies that target college-age adults and on limiting the accessibility of hookah tobacco products to these adults. Accordingly, a research agenda that would inform these policy actions is proposed.
Introduction
Although much progress has made in reducing the prevalence of heavy cigarette smoking among US adults under age 25 (Citation1,Citation2), light smoking and nondaily smoking has dramatically risen among these young adults (Citation3). This increase can be partly explained by the advent of flavored products in the US, particularly hookah tobacco (Citation4,Citation5). Considering that half the population of tobacco smokers dies from smoking tobacco-related diseases (Citation6), prevention of hookah tobacco smoking merits high priority for effective regulatory policy.
A survey conducted by the American College Health Association (ACHA) in 2012 reveals that 30% of college students have smoked hookah tobacco at least once (Citation7). A 2004 report by Smokeshop, a tobacco trade journal, indicates that up to 300 hookah venues have been opened in the US since 1999 (Citation8–11). A report by Smokeshop published in 2009 documented that hookah tobacco imports rose from 20 000–100 000 pounds during 2002–2003; these imports further increased to two million pounds by 2007, and there was an 85% increase in the population of US consumers during 2002–2009 (Citation12).
The consumption of hookah tobacco has been greatest among college-educated adults (Citation5,Citation13). While hookah tobacco is available in more than 50 flavors, cigarettes are only available in one flavor (menthol) (Citation14). The flavors in hookah tobacco mask respiratory irritation that is typically associated with tobacco smoking (Citation15). The experience of hookah tobacco smoking is usually convivial, and this experience is associated with relaxation (Citation16). Previous research shows that the first experience with a tobacco product portends future use and nicotine dependence (Citation17). The social context of hookah tobacco use and the pleasurable sensory experience increases the likelihood of habitual hookah tobacco use and nicotine dependence (Citation18).
Hookah tobacco poses a serious health threat because of the commonly held belief by college students that this tobacco product is innocuous and non-addictive. Between 61 and 67% of students deem hookah tobacco to be less harmful than cigarettes and 76–79% perceive it to be less addictive than cigarettes (Citation11). Students who endorse hookah tobacco consumption are more likely to espouse these beliefs than nonusers (Citation9,Citation19). The misperception that hookah tobacco is a safe non-cigarette product is perpetuated by the inaccurate labeling in which tar and nicotine levels are listed as negligible (Citation20). In addition, hookah tobacco packages are devoid of health warning labels (Citation21). Indeed, the full complement of hookah tobacco ingredients are unknown (Citation22).
Research on warning labels on hookah tobacco products and the uptake of hookah tobacco smoking is lacking. However, the research on cigarette warning labels shows that labels are effective in deterring cigarette smoking among college students (Citation23–25). This research has also shown that the type of cigarette warning labels used (graphic images of disease, images of suffering with testimonials, or emotional tone) affects students differently depending on their smoking status (Citation25).
Similar to other tobacco products, hookah tobacco confers an increased risk for impairment of pulmonary function (Citation26,Citation27), lung diseases (Citation28,Citation29), periodontal disease (Citation28,Citation30), and cardiovascular disease (Citation8). However, hookah tobacco produces higher levels of toxicants than cigarettes (Citation31). A meta-analysis of four studies concluded that one bowl of hookah tobacco is equivalent to smoking 10 cigarettes (Citation32). While hookah tobacco smokers often believe that the water used in the hookah filters the smoke produced from the coal and tobacco (Citation33), the empirical evidence do not support this belief (Citation32).
Prior reviews of the hookah smoking literature on college students have focused on epidemiology, specific sub-populations – particularly youths and college students (Citation34), global health impact (Citation35), health risks (Citation8,Citation28), and policy (Citation36,Citation37). This literature review examines hookah tobacco smoking within the context of the current mandate of the U.S. Food and Drug Administration (FDA) to regulate tobacco consumption.
Family smoking prevention and Tobacco Control Act of 2009
The Family Smoking Prevention and Tobacco Control Act of 2009 (also referred to as the Tobacco Control Act) authorized the FDA to regulate the manufacture, distribution, and marketing of tobacco products (Public Law 111-31). This law does not empower the FDA to ban specific tobacco products such as hookah tobacco. Circumscribed primarily to cigarettes and smokeless tobacco, the Tobacco Control Act mandates that the FDA regulate tobacco consumption in the following ways:
Verify that the customer is at least 18 years old at the point of purchase;
Prohibit advertising and marketing campaigns directed at youth, including (a) distributing free product samples and (b) sponsoring entertainment and sporting events;
Establish manufacturing and labeling standards; and
Prohibit flavors except menthol in cigarettes.
The Tobacco Control Act provided the impetus to establish the Center for Tobacco Products (CTP) to support tobacco research. Within this framework, there is the opportunity to conduct research on hookah tobacco smoking to assist policy formulation and analysis. Toward this objective, the ensuing discussion focuses on two components of hookah tobacco smoking related to policy informed by research: (i) characteristics of individuals prone to consumption, and (ii) environments that promote consumption in college.
Methods
Literature sources and searches
The literature searches were conducted using PubMed (which includes MEDLINE 1946–2014), Ovid PsycINFO (1967–2014), and Scopus (Elsevier) databases to locate English language articles. A clinical medical librarian (MKF) developed the search strategies. Details of these strategies are provided in the Appendix. Two searches were run in PubMed and PsycINFO each. The first search in PubMed focused on the hookah tobacco smoking by college students and its social/environmental/physical context. The following terms were used in this first search:
Hookahs: Hookah* or Waterpipe or Water-pipe or “Water pipe” or Argileh or Narghile or nargile or “arghile” or “shisha” or sheesha or “goza” or “hubble bubble” or “hooka” or “hukka” or “Non-cigarette tobacco” or “non cigarette” or noncigarette or “alternative tobacco product” or “National Youth Tobacco Survey” or “flavored tobacco”.
College students: “Young Adult” or young adult* or youth or “Universities” or universit* or college* or emerging adult* or freshman or sophomore* or undergraduate* or college*
Social and physical environment, health effects and health policy: “Lung/physiology” or “Lung Neoplasms/epidemiology” or “Lung Diseases/chemically induced” or “Respiratory Function Tests” or “Health Policy” or “Pregnancy” or “Inhalation Exposure” or contamination or women or advertising or schoolchildren or harmful* or bronchitis or waterpipe dependence or “health effects” or Internet.
The second search in PubMed focused on the epidemiology, regulatory policy, and environmental influences of tobacco smoking in this same population. This latter search primarily focused on research conducted in the United States. Other articles were also retrieved from both PubMed searches by using the “Related citations” feature.
The third and fourth searches were conducted in PsycINFO and Scopus, respectively. The PsycINFO database was used primarily to find articles regarding hookah tobacco smoking among women and regarding motivation for smoking. The Scopus database was searched for other relevant articles by using the “Author search” feature. Lastly, the reference lists of articles retrieved from the aforementioned databases were also searched for relevant articles.
Inclusion/exclusion criteria
Little is known about the smoking behavior of students enrolled in two-year colleges. Therefore, this review will focus on hookah tobacco smoking among US students enrolled in four-year colleges. Given that research on hookah tobacco smoking is nascent, there are several gaps in the extant literature including information on health risks, trajectories of hookah tobacco smoking, and the impact of policy actions on smoking behavior. Accordingly, this review discusses non-US-based studies on health effects and trajectories of hookah tobacco smoking. The review also draws on research findings on cigarette smoking to provide a foundation for the policy and research recommendations proposed herein. In instances where there is a paucity of empirical evidence regarding college-age adults, the discussion will focus on research findings on smoking behavior among youth and older adults.
Results
The initial PubMed search on hookah tobacco smoking resulted in 571 articles. The second search in PubMed resulted in 1036 articles, of which 962 were not in the first set. The PsycINFO search focused on women and their motivation for smoking. This third search resulted in 117 English language articles, and some of these articles overlapped with the results from the PubMed searches. These sets were initially reviewed using the titles, abstracts and indexing fields. Citations from the database searches were managed using EndNote software. Full text of pertinent articles was accessed for complete review. A total of 105 articles were utilized in this review and nine more articles were obtained from website sources.
Characteristics of college students prone to hookah tobacco smoking
In order to develop effective health policy, it is essential to understand the characteristics of college students who are at risk for hookah tobacco smoking.
Demographic characteristics
Among college students, the prevalence of hookah tobacco smoking is highest among freshmen (Citation9,Citation38,Citation39). Male students are more likely to have a history of hookah tobacco smoking than their female peers (Citation9,Citation15,Citation19). ACHA survey data collected biannually in the Fall of 2008 through the Spring of 2012 show that 28.5–36.2% of male students reported ever using hookah tobacco compared to 22.6–30.1% of female students (Citation7,Citation40–46). Although males have a higher prevalence of hookah tobacco smoking than females, females experience a faster decline in pulmonary function (Citation26,Citation30,Citation47), a greater likelihood for nicotine dependence, and a higher prevalence of respiratory symptoms and lung disease (Citation48).
The majority of hookah tobacco users in college are European-Americans of non-Hispanic ethnicity (Citation9,Citation19,Citation38,Citation49,Citation50). Less is known about other ethnicities among these users, but a few studies show that individuals of Arab ethnicity have the highest prevalence of hookah tobacco consumption among all hookah tobacco consumers (Citation51,Citation52).
Psychological profile
Social constraints at home and school may impede substance use during adolescence (Citation53). In the absence of these constraints, students have an opportunity to initiate hookah tobacco smoking in college. Hookah tobacco consumption is integrally related to psychological self-regulation (Citation39,Citation54,Citation55). The psychological characteristics of hookah tobacco smokers parallel those of other substance users (Citation56). There is some evidence that hookah tobacco smokers engage in novelty seeking, impulsive behaviors (Citation39) and other evidence that shows they have a proclivity for non-adherence to societal norms (Citation54). Exposure of these individuals to pro- hookah tobacco messages from social media and the Internet may prompt them to initiate hookah tobacco smoking (Citation4,Citation57).
Patterns of hookah smoking
Similar to other types of tobacco use (Citation58,Citation59), most hookah tobacco use occurs on a nondaily basis and in social settings (Citation11,Citation60). Unlike cigarette smoking, hookah tobacco use typically begins in adulthood (Citation60) after individuals have been exposed to alcohol, marijuana, and tobacco during their adolescence (Citation61). On average, individuals initiate hookah tobacco smoking at age 19 compared to age 15 for cigarette smoking (Citation62).
The majority of young adults who smoke hookah tobacco also consume other tobacco products and abusable substances (Citation49,Citation63). However, about 40% of current hookah tobacco users in college smoke only this product (Citation64) suggesting that hookah tobacco smoking substantially contributes to the initiation of tobacco use among tobacco-naïve individuals. Furthermore, cigarette-naïve hookah smokers have a two-fold higher risk of becoming cigarette smokers than never smokers (Citation65). There is a paucity of data on the persistence of hookah tobacco smoking among young adults, but one prospective study observed that half the sample continued to smoke hookah tobacco four years later (Citation66). Other longitudinal data show that hookah tobacco smoking increases the likelihood of persistent cigarette smoking among individuals who have a prior history of cigarette smoking (Citation67,Citation68).
Environments that promote hookah tobacco consumption in college
Social environment
The first hookah tobacco smoking experience among college students usually occurs in a social setting such as a hookah venue or a friend’s residence (Citation69), and hookah is usually shared (Citation11,Citation69). Most students reside in a socially permissive environment involving minimal parental oversight during college (Citation53,Citation70,Citation71). The first academic year in college is usually the time when the risk for initiating hookah tobacco smoking among students is highest (Citation9,Citation38,Citation39). Substance use behavior peaks at the beginning (Citation9,Citation38,Citation39) and again at the end of this year (Citation72,Citation73).
The peer environment is integral to the initiation of hookah tobacco smoking (Citation11,Citation19,Citation63), particularly among students living on campus or in a fraternity/sorority house (Citation49,Citation74). Female students are more susceptible to initiating hookah tobacco smoking in response to peer-pressure than their male peers (Citation75). Furthermore, intimate relationships may influence hookah tobacco consumption. One study showed that hookah tobacco smoking was more prevalent among college students who were not involved in an intimate relationship than their peers involved in such relationships (Citation55).
Media influences
Youth and young adults are exposed to media messages in social media and the Internet that have language and imagery that predominantly endorses hookah tobacco smoking but not cigarette smoking (Citation4,Citation57,Citation76). Retail websites that market or distribute hookah tobacco products rarely refer to hookah tobacco as “tobacco” or display warnings of its health hazards, and thus the belief that hookah tobacco is safer than cigarettes is propagated (Citation76).
Since the 1970s, the tobacco industry has segmented the young adult population based on demographics, personality, beliefs, and attitudes so as to tailor pro-tobacco marketing messages to young adults (Citation77). Research on the effects of pro-hookah tobacco media messages on subsequent hookah tobacco smoking is lacking. However, research on cigarette smoking shows that college student are more likely to smoke when they are exposed to pro-smoking media messages (Citation78–82).
Few public health messages have targeted young adults to counter the marketing campaigns tailored to young adults by the tobacco industry (Citation79–81). The preponderance of anti-smoking messages have either targeted youth or older adults (Citation78,Citation83), thereby limiting the relevance of these messages to college students (Citation84).
One study of college students showed that social cigarette smokers are less responsive to messages on health effects but more responsive to messages on nicotine dependence than regular smokers (Citation85). College students are typically nondaily smokers who confine their tobacco consumption to social settings (Citation86). Up to 50% of college students who report past 30-day cigarette smoking do not self-identify as cigarette smokers (Citation87). These smokers are likely to perceive themselves as insusceptible to nicotine dependence and smoking-related diseases (Citation88,Citation89). Consequently, they are unlikely to express any intention to quit smoking (Citation90,Citation91).
Physical environment
Hookah cafes are commonly located near college campuses (Citation19,Citation38). Easy access to hookah tobacco to youths and young adults who are not old enough to purchase alcohol facilitates initiation (Citation9). Thus, it is not surprising that young college-educated adults are more likely to smoke hookah and less likely to smoke cigarettes than their less-educated peers (Citation92).
There are health hazards associated with hookah venues. For example, college students often share hookah with their peers at hookah venues (Citation93); they are at heightened risk for acquiring communicable diseases such as herpes (Citation94) and tuberculosis (Citation95). A study on bacterial contamination of waterpipes used at hookah venues showed that waterpipes may harbor microbes that transmit respiratory infections (Citation95).
Another health hazard is the poor indoor air quality at hookah venues, commonly frequented by college students. Airborne toxins from the combustion of hookah tobacco and the charcoal persist longer than toxins produced by cigarettes (Citation96). The ambient air in hookah cafes has higher levels of particulate matter than restaurants that permit cigarette smoking and smoke-free restaurants (Citation31). These risks to health notwithstanding, the vast majority of hookah venues are exempt from compliance with clean air standards (Citation36,Citation37).
Methodological limitations
Current research indicates that hookah tobacco smoking is an emerging trend in tobacco consumption among college students in the US; however, there are several methodological limitations in this research. Few studies on hookah tobacco smoking provide information on the validity and reliability of instruments used to ascertain hookah tobacco smoking. To date, the assessment of hookah tobacco smoking dependence is primarily based on non-validated instruments (Citation97), thus increasing the likelihood that research findings on nicotine dependence will have measurement bias.
Much of the research on hookah tobacco smoking has focused on students attending 4-year colleges, and little research has been conducted to examine hookah tobacco smoking among non-college attending young adults. It is unclear if hookah tobacco smoking behavior observed among 4-year college students is also characteristic of other young adults. Thus, the research findings on 4-year college students may not be generalizable to all young adults.
This research is comprised of samples that may not be representative of all 4-year colleges. Participants have been most likely to be Caucasian and female. Also, many studies have used convenience samples of psychology students. The overall participation of college students in this research is generally low. Up to 30% of eligible students get involved in these studies (Citation19,Citation98). Therefore, it is likely that these study participants may be different from nonparticipants.
A major limitation in this research is the absence of longitudinal data on hookah tobacco smoking. Because of the cross-sectional design of most studies, causality and temporal relationships cannot be determined. Therefore, the profile of the hookah tobacco smoker who is most likely to initiate use and transition to regular use and dependence remains unknown. Despite the limitations of this research, these studies demonstrate that there is great need for more research on hookah tobacco smoking.
Discussion
Recommendations for policy actions
It is timely to address the gaps in the jurisdiction of the FDA over tobacco products. Specifically, regulatory oversight is required to advance primary prevention efforts targeted at college students, the population at greatest risk for hookah tobacco smoking. The following policy recommendations suggested are informed by the empirical literature reviewed above.
College students prone to initiating consumption
Gains in public health are greatest in primary prevention (Citation99). Hence, policy actions should focus on informing students about health hazards associated with hookah tobacco smoking and limiting access to hookah tobacco products. Hookah tobacco products should be accurately labeled with information on ingredients of hookah tobacco including nicotine and tar levels.
Risk communication strategies
College students are receptive to different antismoking messages depending on their smoking status (Citation25,Citation79). Accordingly, smoking status should be considered when antismoking messages for college-age adults are developed. Considering that the FDA coordinates public health messaging on the health hazards of other tobacco products (Citation100), this authority should be extended to hookah tobacco with a focus on college students who are the primary consumers of this tobacco product.
Limiting access to hookah tobacco products
Changing zoning ordinances can prevent new hookah cafes from being established in the vicinity of college campuses. Research on cigarette purchases shows that an increase in the density of tobacco retail stores results in higher smoking rates in the surrounding neighborhood (Citation101). Raising excise taxes on hookah tobacco products and accessories would deter some students from initiating hookah tobacco smoking. Research on cigarette sales has also shown that taxation is effective in lowering prevalence of consumption (Citation102) and that youth and young adults are two to three times more likely to reduce their tobacco use when prices increase than older adults (Citation23).
Setting the research agenda
We propose five areas of research that could facilitate the inclusion of hookah tobacco, along with cigarettes and smokeless tobacco, in omnibus tobacco regulations.
Develop standardized methods for the assessment of hookah tobacco exposure and nicotine dependence
Presently, there are few studies in the United States that characterize the hookah tobacco smoking topography. A typical smoking session at a hookah venue may involve up to three students sharing a waterpipe. The social nature of hookah tobacco smoking creates a challenge in the measurement of individual exposure because the number of smokers, depth of puffs, and frequency of replenishing the tobacco may vary from one smoking session to another (Citation103,Citation104). Furthermore, much of the current research has been based on self-report. Research is needed to identify biomarkers that can be used to validate self-reports of hookah tobacco use. Data on exposure to nicotine are necessary for the determination of the threshold levels of exposure that are associated with the onset of dependence.
To date, there is one instrument that has been developed to identify nicotine dependence related to hookah tobacco smoking. Two studies have validated the Lebanese Waterpipe Dependence Scale in Jordanian youth and young adults (Citation105) and in older Lebanese adults (Citation106). Large-scale research is needed to validate this instrument in the population of US college students. This research will enable the FDA to develop empirically derived standards for performance and quality control for hookah tobacco manufacturers with the goal of tobacco harm reduction (Citation107), especially since the FDA is not authorized to ban tobacco products.
Identify psychological and contextual factors involved in hookah tobacco smoking
Few studies have examined the role of hookah tobacco smoking in the transition to cigarette smoking and other substance use especially among students who are naïve to tobacco and other abusable drugs. Research is needed to determine the individual and contextual factors associated with the initiation of hookah smoking and progression to regular smoking and other substance use behavior. Ecological momentary assessment (EMA) empirical methods could be used to capture real time data in naturalistic settings for the elucidation of the psychological processes and contextual factors involved in hookah tobacco smoking among students (Citation108). This research could determine if these psychological processes and contextual factors vary between men and women in the college population. These data would enable the development of prevention and treatment programs tailored to the individual’s predisposing characteristics and contextual factors associated with hookah tobacco use (Citation109).
Develop effective risk communication strategies
Pro-smoking campaigns by the tobacco industry have been based on segmentation of young adults by demographics, personality, beliefs, attitudes, and lifestyle (Citation77). Given that college students are predominantly nondaily smokers, risk communication strategies should take into consideration that students perceive themselves as invulnerable to tobacco-related diseases and nicotine dependence. Hence, research is needed to identify the risk communication strategies, including marketing research approaches similar to those used by the tobacco industry (Citation77) that can be effective in preventing the initiation and continued consumption of hookah tobacco products.
Determine where hookah smoking fits within the spectrum of licit and illicit drug use
Little is known about hookah tobacco in the spectrum of other tobacco, alcohol and illicit drug use. Hookah tobacco smoking has been found to be associated with a clustering of other risky behaviors including binge drinking and marijuana use (Citation39,Citation57,Citation63,Citation110). Therefore, it is essential to document the location of hookah in relation to other tobacco products and other abusable substances in order to develop comprehensive substance use prevention and treatment programs that target college-age adults.
Identify risk factors for hookah tobacco use and nicotine dependence to be considered in tobacco control
Research is needed to elucidate genetic risk factors for initiation and progression to nicotine dependence. Genetic studies are needed to identify the genetic profiles associated with an increased susceptibility to hookah tobacco smoking behavior and nicotine dependence (Citation111). These findings could inform policy makers about the youth and young adults who would be at greatest risk for adverse health outcomes and who would be most likely to benefit from prevention efforts. Given that the empirical evidence that female hookah tobacco smokers experience a greater burden of disease and risk for nicotine dependence than their male counterparts (Citation48,Citation112), more research is needed to investigate how sex may interact with other risk factors for hookah tobacco smoking, nicotine dependence, and other adverse health effects.
Considering the widespread belief among students that hookah tobacco use is innocuous, research is needed to evaluate the effect of explicit and accurate labeling on hookah tobacco consumption across the continuum of substance use risk profiles. Whereas flavor and aroma are integral to the pleasant experience of hookah smoking, studies are needed to determine if these hookah tobacco additives increase the risk of nicotine dependence (Citation113) or tobacco-related diseases. Other investigations should be conducted to determine the potential impact of eliminating flavors on hookah tobacco smoking among college students. The Tobacco Control Act provides the framework conducive to the conduct of research that can systematically evaluate the impact of policy on decision-making about use of hookah tobacco among students (Citation114).
Conclusions
Hookah tobacco smoking may play a significant role in the initiation of tobacco consumption among tobacco-naïve college students and may portend persistence smoking among those who have smoked cigarettes. In the absence of regulatory policy by the FDA and public health measures to limit the use of this emerging tobacco product, hookah tobacco smoking among college students will likely remain unabated. The Tobacco Control Act provides an opportunity to address gaps in the tobacco regulatory policy in order to tackle the changing landscape of emerging non-cigarette products marketed to young adults. Given the health hazards associated with hookah tobacco use, this legislation needs to be expanded to include the control of emerging non-cigarette products, including hookah tobacco.
Under the auspices of this legislation, it is timely to undertake systematic research that informs empirically substantiated health policy. The college years are an opportune time to intervene in tobacco cessation as this first decade of adulthood yields the greatest benefit in the prevention of premature death. The infrastructure of student health centers present in college campuses across the nation could thus play a pivotal role in prevention of a new tobacco epidemic among young adults.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
References
- Pierce JP, Messer K, White MM, Cowling DW, Thomas DP. Prevalence of heavy smoking in California and the United States, 1965–2007. JAMA 2011;305:1106–1112
- Welte JW, Barnes GM, Tidwell MC, Hoffman JH. Tobacco use, heavy use, and dependence among adolescents and young adults in the United States. Subst Use Misuse 2011;46:1090–1098
- Halperin AC, Smith SS, Heiligenstein E, Brown D, Fleming MF. Cigarette smoking and associated health risks among students at five universities. Nicotine Tob Res 2010;12:96–104
- Carroll MV, Shensa A, Primack BA. A comparison of cigarette- and hookah-related videos on YouTube. Tob Control 2013;22:319--323
- Villanti AC, Richardson A, Vallone DM, Rath JM. Flavored tobacco product use among US young adults. Am J Prev Med 2013;44:388–391
- Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥ 18 years – United States, 2005–2010. Morb Mortal Wkly Rep 2011;60:1207–1212
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Spring 2012; Hanover (MD): ACHA; 2012
- 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;34:275–285
- Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates. J Adolesc Health 2008;42:526–529
- Smokeshop. Hookah cafes on the rise. In Smokeshop, 2004. Available from: http://www.gosmokeshop.com/0404/retail.htm. [last accessed 4 Jun 2015]
- Smith-Simone S, Maziak W, Ward KD, Eissenberg T. Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two US samples. Nicotine Tob Res 2008;10:393–398
- Scott D. Hookahs head mainstream? In Smokeshop, 2009. Available from: http://www.gosmokeshop.com/1209/feature.htm. [last accessed 4 Sept 2013]
- McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in the United States. J Environ Public Health 2012;2012:989474
- Morris DS, Fiala SC. Flavoured, non-cigarette tobacco for sale in the USA: an inventory analysis of Internet retailers. Tob Control 2015;24:101--102
- Noonan D. A descriptive study of waterpipe smoking among college students. J Am Assoc Nurse Pract 2013;25:11–15
- Hammal F, Mock J, Ward K, Eissenberg T, Maziak W. A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria. Tob Control 2008;17:e3
- DiFranza JR, Savageau JA, Fletcher K, Ockene JK, Rigotti NA, McNeill AD, Coleman M, Wood C. Recollections and repercussions of the first inhaled cigarette. Addict Behav 2004;29:261–272
- Ashare RL, Hawk LW Jr, Cummings KM, O’Connor RJ, Fix BV, Schmidt WC. Smoking expectancies for flavored and non-flavored cigarettes among college students. Addict Behav 2007;32:1252–1261
- Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among US university students. Ann Behav Med 2008;36:81–86
- Vansickel AR, Shihadeh A, Eissenberg T. Waterpipe tobacco products: nicotine labelling versus nicotine delivery. Tob Control 2012;21:377–379
- Nakkash R, Khalil J. Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories. Tob Control 2010;19:235–239
- Chaouachi K. The medical consequences of narghile (hookah, shisha) use in the world. Rev Epidemiol Sante Publique 2007;55:165–170
- Morris DS, Fiala SC, Pawlak R. Opportunities for policy interventions to reduce youth hookah smoking in the United States. Prev Chronic Dis 2012;9:E165
- Peters E, Romer D, Slovic P, Jamieson KH, Wharfield L, Mertz CK, Carpenter SM. The impact and acceptability of Canadian-style cigarette warning labels among U.S. smokers And nonsmokers. Nicotine Tob Res 2007;9:473–481
- Berg CJ, Thrasher JF, Westmaas JL, Buchanan T, Pinsker EA, Ahluwalia JS. College student reactions to health warning labels: sociodemographic and psychosocial factors related to perceived effectiveness of different approaches. Prev Med 2011;53:427–430
- Raad D, Gaddam S, Schunemann HJ, Irani J, Abou Jaoude P, Honeine R, Akl EA. Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chest 2011;139:764–774
- Boskabady MH, Farhang L, Mahmodinia M, Boskabady M, Heydari GR. Comparison of pulmonary function and respiratory symptoms in water pipe and cigarette smokers. Respirology 2012;17:950–956
- 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;39:834–857
- She J, Yang P, Wang Y, Qin X, Fan J, Wang Y, Gao G, et al. Chinese waterpipe smoking and the risk of chronic obstructive pulmonary disease. Chest 2014;146:924--931
- Frost-Pineda K, Liang Q, Liu J, Rimmer L, Jin Y, Feng S, Kapur S, et al. Biomarkers of potential harm among adult smokers and nonsmokers in the Total Exposure Study. Nicotine Tob Res 2011;13:182–193
- Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects. Nicotine Tob Res 2011;13:78–87
- Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res 2007;9:987–994
- Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis 2009;5:16
- Grekin ER, Ayna D. Waterpipe smoking among college students in the United States: a review of the literature. J Am Coll Health 2012;60:244–249
- Maziak W. The global epidemic of waterpipe smoking. Addict Behav 2011;36:1–5
- Noonan D. Exemptions for hookah bars in clean indoor air legislation: a public health concern. Public Health Nurs 2010;27:49–53
- Primack BA, Hopkins M, Hallett C, Carroll MV, Zeller M, Dachille K, Kim KH, et al. US health policy related to hookah tobacco smoking. Am J Public Health 2012;102:e47–e51
- 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;115:131–136
- 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;26:963–968
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Fall 2008. Baltimore (MD): ACHA; 2012
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Spring 2009. Linthicum (MD): ACHA; 2009
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Fall 2009. Linthicum (MD): ACHA; 2009
- American College Health Association (ACHA). ACHA-National College Health Asssement II: reference group executive summary Spring 2010. Linthicum (MD): ACHA; 2010
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Fall 2010. Linthicum (MD): ACHA; 2011
- American College Health Association (ACHA). ACHA-National College Health Asssement II: reference group executive summary Spring 2011. Hanover (MD): ACHA; 2011
- American College Health Association (ACHA). ACHA-National College Health Assessment II: reference group executive summary Fall 2011. Hanover (MD): ACHA; 2012
- Rahmanian SD, Diaz PT, Wewers ME. Tobacco use and cessation among women: research and treatment-related issues. J Women’s Health (Larchmt) 2011;20:349–357
- Salameh P, Waked M, Khoury F, Akiki Z, Nasser Z, Abou Abbass L, Dramaix M. Waterpipe smoking and dependence are associated with chronic bronchitis: a case-control study in Lebanon. East Mediterr Health J 2012;18:996–1004
- 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;14:1145–1153
- El-Sayed AM, Lauderdale DS, Galea S. Validation of an Arab name algorithm in the determination of Arab ancestry for use in health research. Ethn Health 2010;15:639–647
- Primack BA, Mah J, Shensa A, Rosen D, Yonas MA, Fine MJ. Associations between race, ethnicity, religion, and waterpipe tobacco smoking. J Ethn Subst Abuse 2014;13:58–71
- Grekin ER, Ayna D. Argileh use among college students in the United States: an emerging trend. J Stud Alcohol Drugs 2008;69:472–475
- Dugas E, Tremblay M, Low NCP, Cournoyer D, O’Loughlin J. Water-pipe smoking among North American youths. Pediatrics 2010;125:1184–1189
- Berg CJ, Schauer GL, Asfour OA, Thomas AN, Ahluwal JS. Psychosocial factors and health-risk behaviors associated with hookah use among college students. J Addict Res Ther 2011;S2:001
- Primack BA, Land SR, Fan J, Kim KH, Rosen D. Associations of mental health problems with waterpipe tobacco and cigarette smoking among college students. Subst Use Misuse 2013;48:211–219
- Tarter RE, Fishbein D, Kirisci L, Mezzich A, Ridenour T, Vanyukov M. Deviant socialization mediates transmissible and contextual risk on cannabis use disorder development: a prospective study. Addiction 2011;106:1301–1308
- Brockman LN, Pumper MA, Christakis DA, Moreno MA. Hookah’s new popularity among US college students: a pilot study of the characteristics of hookah smokers and their Facebook displays. BMJ Open 2012;2:e001709
- Moran S, Wechsler H, Rigotti NA. Social smoking among US college students. Pediatrics 2004;114:1028–1034
- Brown AE, Carpenter MJ, Sutfin EL. Occasional smoking in college: who, what, when and why? Addict Behav 2011;36:1199–1204
- Barnett TE, Smith T, He Y, Soule EK, Curbow BA, Tomar SL, McCarty C. Evidence of emerging hookah use among university students: a cross-sectional comparison between hookah and cigarette use. BMC Public Health 2013;13:302
- Arria AM, Caldeira KM, O’Grady KE, Vincent KB, Fitzelle DB, Johnson EP, Wish ED. Drug exposure opportunities and use patterns among college students: results of a longitudinal prospective cohort study. Subst Abuse 2008;29:19–38
- 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
- Heinz AJ, Giedgowd GE, Crane NA, Veilleux JC, Conrad M, Braun AR, Olejarska 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;38:2751–2760
- Primack BA, Shensa A, Kim KH, Carroll MV, Hoban MT, Leino EV, Eissenberg T, et al. Waterpipe smoking among U.S. university students. Nicotine Tob Res 2013;15:29–35
- Mzayek F, Khader Y, Eissenberg T, Al Ali R, Ward KD, Maziak W. Patterns of water-pipe and cigarette smoking initiation in schoolchildren: irbid longitudinal smoking study. Nicotine Tob Res 2012;14:448–454
- Dugas EN, O’Loughlin EK, Low NC, Wellman RJ, O’Loughlin JL. Sustained waterpipe use in young adults. Nicotine Tob Res 2014;16:709--716
- Jensen PD, Cortes R, Engholm G, Kremers S, Gislum M. Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Subst Use Misuse 2010;45:1245–1261
- 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;38:2729–2735
- 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;9:1339–1346
- Lundborg P. Having the wrong friends? Peer effects in adolescent substance use. J Health Econ 2006;25:214–233
- Oesterle S, Hawkins JD, Hill KG. Men’s and women’s pathways to adulthood and associated substance misuse. J Stud Alcohol Drugs 2011;72:763–773
- Fielder RL, Carey KB, Carey MP. Prevalence, frequency, and initiation of hookah tobacco smoking among first-year female college students: a one-year longitudinal study. Addict Behav 2012;37:221–224
- Dierker L, Stolar M, Lloyd-Richardson E, Tiffany S, Flay B, Collins L, Nichter M, et al. Tobacco, alcohol, and marijuana use among first-year U.S. college students: a time series analysis. Subst Use Misuse 2008;43:680–699
- Primack BA, Kim KH, Shensa A, Sidani JE, Barnett TE, Switzer GE. Tobacco, marijuana, and alcohol Use in university students: a cluster analysis. J Am Coll Health 2012;60:374–386
- Smith-Simone SY, Curbow BA, Stillman FA. Differing psychosocial risk profiles of college freshmen waterpipe, cigar, and cigarette smokers. Addict Behav 2008;33:1619
- Primack BA, Rice KR, Shensa A, Carroll MV, DePenna EJ, Nakkash R, Barnett TE. U.S. hookah tobacco smoking establishments advertised on the internet. Am J Prev Med 2012;42:150–156
- Ling PM, Glantz SA. Using tobacco-industry marketing research to design more effective tobacco-control campaigns. J Am Med Assoc 2002;287:2983–2989
- Terry-McElrath YM, Emery S, Wakefield MA, O’Malley PM, Szczypka G, Johnston LD. Effects of tobacco-related media campaigns on smoking among 20–30-year-old adults: longitudinal data from the USA. Tob Control 2013;22:38–45
- Berg CJ, Ling PM, Guo H, Windle M, Thomas JL, Ahluwalia JS, An LC. Using market research to characterize college students and identify potential targets for influencing health behaviors. Soc Mar Q 2010;16:41–69
- Suragh TA, Berg CJ, Nehl EJ. Psychographic segments of college females and males in relation to substance use behaviors. Soc Mar Q 2013;19:172–187
- Choi K, Forster JL. Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest. Am J Public Health 2014;104:2179–2183
- Shadel WG, Martino SC, Setodji C, Scharf D. Momentary effects of exposure to prosmoking media on college students’ future smoking risk. Health Psychol 2012;31:460–466
- McClure LA, Arheart KL, Lee DJ, Sly DF, Dietz NA. Young adult former ever smokers: the role of type of smoker, quit attempts, quit aids, attitudes/beliefs, and demographics. Prev Med 2013;57:690–695
- Staten RR, Ridner SL. College students’ perspective on smoking cessation: “if the message doesn’t speak to me, I don’t hear it”. Issues Ment Health Nurs 2007;28:101–115
- Debevec K, Diamond WD. Social smokers: smoking motivations, behavior, vulnerability, and responses to antismoking advertising. J Consumer Behav 2012;11:207–216
- Caldeira KM, O’Grady KE, Garnier-Dykstra LM, Vincent KB, Pickworth WB, Arria AM. Cigarette smoking among college students: longitudinal trajectories and health outcomes. Nicotine Tob Res 2012;14:777–785
- Berg CJ, Lust KA, Sanem JR, Kirch MA, Rudie M, Ehlinger E, Ahluwalia JS, et al. Smoker self-identification versus recent smoking among college students. Am J Prev Med 2009;36:333–336
- Berg CJ, Parelkar PP, Lessard L, Escoffery C, Kegler MC, Sterling KL, Ahluwalia JS. Defining “smoker”: college student attitudes and related smoking characteristics. Nicotine Tob Res 2010;12:963–969
- An LC, Berg CJ, Klatt CM, Perry CL, Thomas JL, Luo X, Ehlinger E, et al. Symptoms of cough and shortness of breath among occasional young adult smokers. Nicotine Tob Res 2009;11:126–133
- Berg CJ, An LC, Thomas JL, Lust KA, Sanem JR, Swan DW, Ahluwalia JS. Smoking patterns, attitudes and motives: unique characteristics among 2-year versus 4-year college students. Health Educ Res 2011;26:614–623
- Song AV, Ling PM. Social smoking among young adults: investigation of intentions and attempts to quit. Am J Public Health 2011;101:1291–1296
- 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;62:10–18
- Asfar T, Ward KD, Eissenberg T, Maziak W. Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers. BMC Public health 2005;5:19
- Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 2005;116:e113–e119
- Safizadeh H, Moradi M, Rad MR, Nakhaee N. Bacterial contamination of different components of the waterpipe. Int J Tuberc Lung Dis 2014;18:988–991
- Cobb CO, Vansickel AR, Blank MD, Jentink K, Travers MJ, Eissenberg T. Indoor air quality in Virginia waterpipe cafes. Tob Control 2013;22:338–343
- Akl EA, Aleem S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. Survey instruments used in clinical and epidemiological research on waterpipe tobacco smoking: a systematic review. BMC Public Health 2010;10:415
- Berg CJ, Ling PM, Hayes RB, Berg E, Nollen N, Nehl E, Choi WS, et al. Smoking frequency among current college student smokers: distinguishing characteristics and factors related to readiness to quit smoking. Health Educ Res 2012;27:141–150
- Diehr P, Hannon P, Pizacani B, Forehand M, Meischke H, Curry S, Martin DP, et al. Social marketing, stages of change, and public health smoking interventions. Health Educ Behav 2011;38:123–131
- Husten CG, Deyton LR. Understanding the Tobacco Control Act: efforts by the US Food and Drug Administration to make tobacco-related morbidity and mortality part of the USA’s past, not its future. Lancet 2013;381:1570–1580
- Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Prev Med 2008;47:210–214
- Cokkinides V, Bandi P, McMahon C, Jemal A, Glynn T, Ward E. Tobacco control in the United States – recent progress and opportunities. CA Cancer J Clin 2009;59:352–365
- Nakkash RT, Khalil J, Afifi RA. The rise in narghile (shisha, hookah) waterpipe tobacco smoking: a qualitative study of perceptions of smokers and non smokers. BMC Public Health 2011;11:315
- Blank MD, Brown KW, Goodman RJ, Eissenberg T. An observational study of group waterpipe use in a natural environment. Nicotine Tob Res 2014;16:93–99
- Primack BA, Khabour OF, Alzoubi KH, Switzer GE, Shensa A, Carroll MV, Azab M, et al. The LWDS-10J: Reliability and validity of the Lebanon Waterpipe Dependence Scale among university students in Jordan. Nicotine Tob Res 2014;16:915--922
- Salameh P, Waked M, Aoun Z. Waterpipe smoking: construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11). Nicotine Tob Res 2008;10:149–158
- Hatsukami DK, Perkins KA, Lesage MG, Ashley DL, Henningfield JE, Benowitz NL, Backinger CL, et al. Nicotine reduction revisited: science and future directions. Tob Control 2010;19:e1–e10
- Shiffman S, Kassel JD, Paty J, Gnys M, Zettler-Segal M. Smoking typology profiles of chippers and regular smokers. J Subst Abuse 1994;6:21–35
- Shiffman S, Kirchner TR, Ferguson SG, Scharf DM. Patterns of intermittent smoking: an analysis using Ecological Momentary Assessment. Addict Behav 2009;34:514–519
- Goodwin RD, Grinberg A, Shapiro J, Keith D, McNeil MP, Taha F, Jiang B, et al. Hookah use among college students: prevalence, drug use, and mental health. Drug Alcohol Depend 2014;141:16–20
- Caron L, Karkazis K, Raffin TA, Swan G, Koenig BA. Nicotine addiction through a neurogenomic prism: ethics, public health, and smoking. Nicotine Tob Res 2005;7:181–197
- Salameh P, Khayat G, Waked M. Lower prevalence of cigarette and waterpipe smoking, but a higher risk of waterpipe dependence in Lebanese adult women than in men. Women Health 2012;52:135–150
- Hecht SS. Research opportunities related to establishing standards for tobacco products under the Family Smoking Prevention and Tobacco Control Act. Nicotine Tob Res 2012;14:18–28
- Krishnamurti T, Eggers SL, Fischhoff B. The impact of over-the-counter availability of “Plan B” on teens’ contraceptive decision making. Soc Sci Med 2008;67:618–627
Appendix
Search strategies
PubMed hookah search
(((Hookah* OR Waterpipe OR Water-pipe OR “Water pipe” OR Argileh[tiab] OR Narghile OR nargile[tiab] OR “arghile”[tiab] OR “shisha” OR sheesha[tiab] OR “goza” OR “hubble bubble” OR “hooka” OR “hukka” OR “Non-cigarette tobacco” OR “non cigarette” OR noncigarette[tiab] OR “alternative tobacco product” OR “National Youth Tobacco Survey” OR “flavored tobacco”)) AND (((“Young Adult”[Mesh] OR young adult*[tiab] OR young adult*[ot] OR youth[tiab] OR “Universities”[Mesh] OR universit*[tiab] OR college*[tiab] OR emerging adult*[tiab] OR freshman[tiab] OR sophomore*[tiab] OR undergraduate*[tiab] OR college*[ot] OR universit*[ot])) OR (“Lung/physiology”[Majr] OR “Lung Neoplasms/epidemiology”[Mesh] OR “Lung Diseases/chemically induced”[Mesh:NoExp] OR “Respiratory Function Tests”[Mesh] OR “Health Policy”[Majr:NoExp] OR “Pregnancy”[Mesh:NoExp] OR “Inhalation Exposure”[Mesh] OR contamination[title] OR women[tiab] OR advertising[ot] OR schoolchildren[tiab] OR harmful*[tiab] OR bronchitis[title] OR waterpipe dependence[tiab] OR “health effects”[tiab] OR Internet[All fields]))) AND English[lang]
PubMed smoking/tobacco search
(((((((((“Smoking/epidemiology”[Majr] OR “Smoking/prevention and control”[Majr] OR “Smoking Cessation”[Majr] OR “Tobacco Use Cessation”[Majr] OR tobacco control[title] OR smoking behaviors[title] OR smoking patterns[tiab]))) AND (college student* OR college females[title] OR university students[title]))) OR ((((Smoking[title] OR smokers[title] or tobacco[title] OR Smoking/blood*[Majr]) AND (media[title] OR marketing[title] OR biomarkers[title] OR united states[title] OR social[title] OR patterns[title] OR cough[title] OR schools[title]))) AND (youth[tiab] OR young adult*[title] OR “Young adult”[Mesh])))) OR ((((((((((((“Marijuana Abuse”[Mesh] AND socialization[title]) OR (Tobacco use[title] AND women[title])) OR (Plan B[title] AND teens*[title])) OR (Peer effects[title] AND smoking[tiab])) OR (“Tobacco Use Disorder/genetics”[Majr] AND neurogenomic*[tiab]) OR (“Smoking/psychology”[Majr] AND chippers[title])) OR ((“Smoking/psychology”[Majr]) AND “Product Labeling/methods”[Majr])) OR (Family Smoking Prevention and Tobacco Control Act[tiab])) OR (first[title] AND inhaled[title] AND cigarette[tiab]))) OR ((Youth[ot] OR young adults[ot]) AND (tobacco cessation[ot] OR tobacco use cessation[ot])))) OR ((vital signs[title] AND cigarette smoking[title])))) OR ((“Advertising as Topic”[Majr] OR market research[title]) AND (“Smoking/epidemiology”[Majr] OR smoking[tiab] OR smokers[title] OR “Smoking/prevention and control”[Majr]) AND (“Adolescent Psychology”[Mesh] OR adolescent[title] OR Canadian[title] OR college students[title]))) AND English[lang]