Waterpipe Tobacco Smoking on a U.S. College Campus: Prevalence and Correlates
Article Outline
Abstract
Purpose
Waterpipe tobacco smoking is reported to be growing in popularity, particularly among college students. This study examined the prevalence of waterpipe tobacco smoking prevalence and perceptions in a university-based population.
Method
This was a cross-sectional Internet-based survey of first-year university students, which examined waterpipe tobacco smoking and other tobacco use, risk perceptions, influences, and perceived social acceptability.
Results
Waterpipe tobacco smoking within the past 30 days was reported by 20% (151/744). Relative to never users, users were more likely to perceive waterpipe tobacco smoking as less harmful than cigarette use.
Conclusions
Because waterpipe tobacco smoking is increasing in prevalence and because it can involve toxicant inhalation at even greater levels than with cigarette smoking, it represents a growing public health issue.
Keywords: Waterpipe, Tobacco, Prevalence, Risk perception, College students
See Editorial p. 434
Waterpipe smoking is a traditional method of tobacco use, especially in the Eastern Mediterranean region [1]. Its use is spreading worldwide [1], and its prevalence in the United States is uncertain. One anecdotal report suggests it may be particularly common among college students [2], and a recent survey of 411 first-year university students indicated 15.3% of respondents reported waterpipe use within the past 30 days [3]. This use may be driven by a perception of lower health risk relative to cigarette smoking, as reported elsewhere [3], [4].
A waterpipe (hookah, shisha) has a mouthpiece, hose, water bowl, body, and a “head” that is filled with sweetened and flavored tobacco and then heated with charcoal [1], [5]. During inhalation from the mouthpiece, charcoal and tobacco smoke pass through the body, bowl, and hose and into the user's lungs. Waterpipe and cigarette smoke contain some of the same toxicants [6]. However waterpipe use may be associated with greater toxicant exposure because longer use episodes as well as more and larger puffs lead to inhalation of as much as 100 times more smoke than from a cigarette [5], [6], [7].
Only one other published study has reported the prevalence of waterpipe use in a representative sample of university students from the U.S., and that study did not examine correlates of use [3]. This survey of Virginia Commonwealth University (VCU) students examined waterpipe tobacco smoking prevalence and smokers' health-related perceptions.
Methods
A cross-sectional, institutional review board–exempt, Internet survey was conducted among the 1,194 students enrolled in VCU Introduction to Psychology courses (March 8 through May 4, 2006). Participants were at least 18 years of age and earned course credit for research participation. Except for university-specific content, survey items were as reported elsewhere [3] and covered demographics, tobacco use, risk perceptions, and perceived social acceptability. The survey was completed by 744 respondents. The response rate of 62.3% may reflect the popularity of research participation as a method for earning course credit and the convenience of on-line surveys.
All statistical analyses were conducted using SAS Version 9.1 (SAS Institute, Cary, NC). Logistic regression was used to compare use in the past 30 days versus no previous use (never use) of waterpipe tobacco smoking in terms of surveyed individuals' (1) sociodemographic characteristics, (2) ever and past-month cigarette and cigar use, (3) perceptions related to harm potential, (4) peer influences on use, and (5) social acceptability of use. Bivariate logistic analyses were conducted as a first step, after which age, gender, race/ethnicity, and income were forced into a multivariable logistic model. All variables that were statistically significant (p < .05) in bivariate analyses were then entered as a block, and nonsignificant (p > .05) variables were removed using backward elimination to arrive at a final model. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for variables in the final model.
Results
Participant demographics are described in detail in Table 1. Of the 744 participants, 65% were women, 72% were 18 or 19 years old, 57% were of white ethnicity, and 20% had smoked a waterpipe in the past 30 days.
Table 1. Sociodemographic and tobacco use characteristics of sample (n = 744)
| Characteristic | % of Sample |
|---|---|
| Gender | |
 Male | 35.1 |
| Female | 64.9 |
| Age (years) | |
| 18–19 | 71.9 |
| ≥20 | 28.1 |
| Race/ethnicity | |
| White | 56.6 |
| African American/black | 23.1 |
| Other | 20.3 |
| Citizenship | |
| U.S | 92.2 |
| Non-U.S. | 7.8 |
| Money spent during average week | |
| <$10.00 | 13.6 |
| $10.00–19.99 | 23.4 |
| $20.00–29.99 | 22.8 |
| ≥$30.00 | 40.2 |
| Ever used a waterpipe | 48.4 |
| Used waterpipe in past year | 43.4 |
| Used waterpipe in past 30 days | 20.4 |
| Ever used cigarettes | 73.0 |
| Used cigarettes in past year | 57.7 |
| Used cigarettes in past 30 days | 41.5 |
| Ever used cigars/cigarillos | 56.8 |
| Used cigars/cigarillos in past year | 45.0 |
| Used cigars in past 30 days | 19.7 |
In a multivariable model (Table 2), use of a waterpipe during the past 30 days, compared to never-use, was associated with greater likelihood of having smoked cigarettes (OR = 10.44) and cigars or cigarillos (OR = 6.31) in the past 30 days, greater likelihood of believing that waterpipe makes peers look “cool” (OR = 2.47), and belief that waterpipe use is socially acceptable among peers (OR = 3.71). In addition use of a waterpipe was associated with younger age (OR = 0.39), lower likelihood of being African American than white (OR = 0.35), lower perceived harmfulness (OR = 0.31) and addictiveness (OR = 0.65) of waterpipe use compared with cigarette smoking, and lower perceived social acceptability of cigarette use among peers (OR = 0.43). The negative association between social acceptability of cigarette use and waterpipe use (OR = 0.43), was opposite of that observed in the bivariate model (OR = 1.51), and was driven by two confounders: past 30-day cigarette use and perceived social acceptability of waterpipe use.
Table 2. Characteristics of past 30-day users and nonusers of a waterpipe: Frequencies and odds ratios from logistic regression models
| Never-users (n = 381) | Past 30-day users (n = 151) | Unadjusted OR (95% CI)a | Adjusted OR (95% CI)b | |
|---|---|---|---|---|
| Sociodemographics | ||||
| Gender (%) | ||||
| Female (reference) | 75.8 | 24.2 | 1.84(1.24–2.72)⁎ | 1.24(.64–2.37) |
| Male | 63.1 | 36.9 | ||
| Age (%) | ||||
| 18–19 years(reference) | 68.3 | 31.7 | .54(.34–.85)⁎ | .39(.19–.80)⁎ |
| ≥20 years | 80.0 | 20.0 | ||
| Race/ethnicity (%)c | ||||
| White (reference) | 64.5 | 35.5 | ||
| African-American | 90.9 | 9.1 | .18(.10–0.34)⁎ | .35(.14–.88)⁎ |
| Other | 66.3 | 33.7 | .99(.63–1.57) | .94(.45–1.96) |
| Money spent during average weekd | ||||
| <$10.00 | 74.0 | 26.0 | 1.11(.93–1.32) | 1.15(.86–1.54) |
| $10.00–19.99 | 75.4 | 24.6 | ||
| $20.00–29.99 | 70.7 | 29.3 | ||
| ≥$30.00 | 69.4 | 30.6 | ||
| Tobacco use | ||||
| Used cigarettes in past 30 days (%) | ||||
| No (reference) | 90.0 | 10.0 | 12.84(8.14–20.26)⁎ | 10.44(5.08–21.46)⁎ |
| Yes | 41.3 | 58.7 | ||
| Used cigars/cigarillos in past 30 days(%) | ||||
| No (reference) | 81.6 | 18.4 | 8.97(5.61–14.33)⁎ | 6.31(2.94–13.57)⁎ |
| Yes | 33.0 | 67.0 | ||
| Perceptions of tobacco products | ||||
| Compared to a regular cigarette, how harmful do you think waterpipe is? (%) | ||||
| Less (reference) | 55.9 | 44.1 | .29(.20–.44)⁎ | .31(.16–.58)⁎ |
| As harmful or more harmful | 81.2 | 18.8 | ||
| What is the likelihood of getting addicted with a waterpipe when using the product socially?e | ||||
| None | 41.9 | 58.1 | .50(.41–.61)⁎ | .65(.48–.89)⁎ |
| Low | 63.2 | 36.8 | ||
| Medium | 76.7 | 23.3 | ||
| High | 85.9 | 14.1 | ||
| What is the social acceptability of using a waterpipe among your peers?e | ||||
| None | 96.2 | 3.8 | 3.62(2.75–4.76)⁎ | 3.71(2.38–5.80)⁎ |
| Low | 91.7 | 8.3 | ||
| Medium | 76.8 | 23.2 | ||
| High | 43.4 | 56.6 | ||
| What is the social acceptability of using cigarettes among your peers?e | ||||
| None | 89.0 | 11.0 | 1.51(1.23–1.85)⁎ | 0.43(.28–.66)⁎ |
| Low | 79.8 | 20.0 | ||
| Medium | 66.8 | 33.2 | ||
| High | 65.7 | 34.3 | ||
| How “cool” do your peers look when they use a waterpipe?f | ||||
| Not at all | 86.6 | 13.4 | 5.34(3.83–7.44)⁎ | 2.47(1.53–4.01)⁎ |
| Cool | 54.0 | 46.0 | ||
| Very cool | 19.2 | 80.8 |
⁎p < .05. |
aORs are from bivariate logistic regression models, regressing waterpipe use (past 30 days vs. never) on the selected variable. |
bORs are from multivariate logistic regression models, regressing waterpipe use (past 30 days vs. never) on the selected variable and adjusting for all other variables in the table. |
cTwo dummy-coded vectors for race (African-American vs. white, and other vs. white) were entered in a single logistic model. |
dCoded as 0 = <$10.00; 1 = $10.00–19.99; 2 = $20.00–29.99; 4 = ≥$30.00. |
eCoded 0 = none; 1 = low; 2 = medium; 3 = high. |
fCoded 0 = not at all; 1 = cool; 2 = very cool. |
Discussion
Results from this survey of 744 undergraduates indicate that past 30-day waterpipe tobacco smoking was 20%. Given previous reports [2], [3], [8], [9], waterpipe tobacco smoking seems common on U.S. college campuses and the potential health risks of this behavior [5], [7] suggest that it may become a significant public health problem. Results also indicate that those who had used waterpipes in the past 30 day were much less likely than never-users to believe that waterpipe use is as harmful as cigarette smoking. These perceptions of lower risk may contribute to the spread of waterpipe tobacco smoking in the U.S.
We also observed that, relative to respondents who had never smoked tobacco using a waterpipe, those who had engaged in waterpipe tobacco smoking within the past 30 days were more likely to be men, younger than 20 years, and of white ethnicity. Although the influences of gender and race/ethnicity are uncertain, the popularity of waterpipe use among younger students may be related to the fact that these individuals cannot access bars where alcohol is served and may instead socialize in alcohol-free waterpipe cafes.
Waterpipe tobacco smokers in this sample also reported using other tobacco products (Table 2). Concurrent use of other tobacco products may contribute to development of nicotine/tobacco dependence, which can then maintain tobacco use through a variety of mechanisms [10]. In addition concurrent use of other tobacco products can make the study of long-term health effects of waterpipe tobacco smoking challenging. Controlling for other tobacco products will be essential if we are to learn the influence of waterpipe tobacco smoking on cancer, cardiovascular disease, and lung disease.
These results, from a convenience sample taken from a single university in one U.S. state, along with other reports from other states [2], [3], [9], should be a clarion call to the U.S. public health and medical communities. An appropriate response could include nationwide surveillance that can be used to identify the extent of waterpipe's spread and gauge the effectiveness of interventions designed to reduce it. Future studies in the U.S. should assess prevalence of waterpipe in nationally representative samples, potential health-damaging and dependence-producing effects, and whether waterpipe use among youth serves as a “gateway” for use of other tobacco products or psychoactive substances.
Acknowledgments
This work was supported by United States Public Health Service grants R01CA103827, R01DA011082, R01TW005962, and R03TW07233.
References
- . TobReg Advisory Note (Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators). Geneva, Switzerland: World Health Organization; 2005;
- . An old custom, a new threat to tobacco control. Am J Public Health. 2006;96:1339
- . Harm perception of nicotine products in college freshmen. Nicotine Tob Res. 2007;9:977–982
- Smith-Simone SY, Maziak W, Ward KD, et al. Waterpipe tobacco smoking: Knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine Tob Res (in press).
- . Tobacco Smoking Using a Waterpipe: Product, Prevalence, Chemistry/Toxicology, Pharmacological Effects, and Health Hazards. In: Waterpipe Tobacco Smoking—Building the Evidence Base (Part 1: The Smoke Chemistry. RITC Monograph Series No. 2). Ottawa, Ontario: International Development Research Center; 2005;p. 1–29
- . Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol. 2005;43:655–661
- Tobacco smoking using a waterpipe: A re-emerging strain in a global epidemic. Tob Control. 2004;13:327–333
- . Hookah cafés on the rise [Online]. Accessed October 7, 2007 http://www.smokeshopmag.com/0404/retail.htm
- . Collegians Smoking Hookahs … Filled with Tobacco [Online] (New York Times, April 2006). Accessed October 7, 2007 http://www.nytimes.com/2006/04/19/education/19hookah.html?ei=5070&en=e29cc03a601b322a&ex=1190001600&pagewanted=print
- . Measuring the emergence of tobacco dependence: The contribution of negative reinforcement models. Addiction. 2004;99(Suppl 1):5–29
PII: S1054-139X(07)00413-2
doi:10.1016/j.jadohealth.2007.10.004
© 2008 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Hookahs and Waterpipes: Cultural Tradition or Addictive Trap?
