Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina

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Abstract

Background

Known most commonly in the U.S. as “hookah,” waterpipe tobacco smoking appears to be growing among college students. Despite beliefs that waterpipe use is safer than cigarette smoking, research to date (albeit limited) has found health risks of waterpipe smoking are similar to those associated with cigarette smoking, including lung cancer, respiratory illness, and periodontal disease. The goals of this study were to estimate the prevalence of use among a large, multi-institution sample of college students and identify correlates of waterpipe use, including other health-risk behaviors (i.e., cigarette smoking, alcohol, marijuana, and other illicit drug use) and availability of commercial waterpipe tobacco smoking venues.

Methods

A cross-sectional sample of 3770 college students from eight universities in North Carolina completed a web-based survey in fall 2008.

Results

Forty percent of the sample reported ever having smoked tobacco from a waterpipe, and 17% reported current (past 30-day) waterpipe tobacco smoking. Correlates associated with current waterpipe use included demographic factors (male gender, freshman class); other health-risk behaviors (daily and nondaily cigarette smoking, alcohol use, marijuana use, other illicit drug use); perceiving waterpipe tobacco smoking as less harmful than regular cigarettes; and having a commercial waterpipe venue near campus.

Conclusions

The results highlight the popularity of waterpipe tobacco smoking among college students and underscore the need for more research to assess the public health implications of this growing trend.

Introduction

Waterpipes are known by different names depending on the region of the world, including hookah, narghile, arghile, and hubble-bubble (Maziak et al., 2005). In the U.S., a waterpipe is commonly known as hookah. Waterpipes involve the passage of smoke through water prior to inhalation. Although used to smoke other substances, including marijuana and hashish, waterpipes are most often used to smoke flavored tobacco, which is made by mixing shredded tobacco with honey or molasses and dried fruit. In the U.S., this sweetened, flavored tobacco mix is most commonly known as shisha.

Despite perceptions among young adults that waterpipe tobacco smoking is safer than cigarette smoking (Smith et al., 2007), studies to date do not support these perceptions (Maziak et al., 2004c, Maziak, 2008, Asfar et al., 2005). Although research is limited, the existing evidence suggests that waterpipe smoking-associated health risks are similar to those of cigarette smoking. A recent meta-analysis concluded that waterpipe tobacco smoking was significantly associated with lung cancer, respiratory illness, low birth-weight and periodontal disease (Akl et al., 2010). An analysis of mainstream waterpipe smoke (i.e., inhaled by the user) found large amounts of carcinogens, hydrocarbons, and heavy metals, including 36 times the amount of tar as in cigarette smoke (Shihadeh, 2003).

Waterpipe tobacco smoking often occurs in a social setting, among friends at a private residence, or in venues that offer ready-to-smoke waterpipes to customers. Recently, commercial waterpipe venues have proliferated in the U.S. Many such venues have opened in college towns, suggesting that college students are a target market for waterpipe venues. For example, in 2003 alone, four waterpipe tobacco smoking venues opened within five miles of Carnegie Mellon University and the University of Pittsburgh (Primack et al., 2006); similar patterns have been observed elsewhere (American Lung Association, 2007). However, research has yet to assess the association between commercial waterpipe availability and use.

There is growing evidence that smoking tobacco through a waterpipe by youth and young adults is on the rise worldwide, including the U.S. (Maziak, 2011, WHO, 2005). In a recent sample of university students in Karachi Pakistan, 54% reported ever use (Jawaid et al., 2008); while ever use was reported by 38% of a sample of British university students (Jackson and Aveyard, 2008, for a review, see Maziak, 2011).

To date, only six reports have focused on waterpipe tobacco smoking by U.S. college students, all within the last four years, suggesting the recent increase of this trend (Primack et al., 2008, Primack et al., 2010, Eissenberg et al., 2008, Grekin and Ayna, 2008, Smith et al., 2007, Smith-Simone et al., 2008a). Five were conducted at single institutions, and had relatively small sample sizes (ranging from 411 to 744), limiting generalizability. The sixth and most recent study included eight institutions across the U.S. and had a large sample size (N = 8745) (Primack et al., 2010). Current (past month) waterpipe smoking in these studies ranged from 9.5% to 20.4%. Variations in the rates of current use may represent real differences in smoking patterns, but may also reflect differences in the year of the survey and non-representative samples (four of the six studies used convenience samples). Ever-use also varied considerably, from 12.7% to 48.4%. However, even the lowest prevalence suggests that substantial numbers of college students are waterpipe users.

These studies also assessed variables associated with waterpipe use, including demographics, cigarette smoking, perceived harm and addictiveness of waterpipe smoking. Younger age (Primack et al., 2008, Primack et al., 2010, Eissenberg et al., 2008), male gender (Smith-Simone et al., 2008a, Primack et al., 2010, Eissenberg et al., 2008) and White race (Primack et al., 2008, Primack et al., 2010, Eissenberg et al., 2008) were associated with waterpipe smoking. Among studies that assessed cigarette smoking as a correlate of waterpipe use, all found that the two were associated (Eissenberg et al., 2008, Grekin and Ayna, 2008, Primack et al., 2008). Additionally, ever and current waterpipe users were more likely to perceive waterpipe tobacco smoking as less harmful than cigarettes. Primack et al. (2008) also reported that over 52% of college students sampled believed waterpipes are less addictive than cigarettes.

To date, only one study has included multiple institutions, but the focus was limited to waterpipe tobacco smoking among college athletes (Primack et al., 2010). Data from larger random samples at multiple institutions are needed to better understand the spread and correlates associated with waterpipe smoking among college students. Additionally, the relationship between waterpipe smoking and other health-risk behaviors popular among college students (e.g., alcohol, marijuana, and other illicit drugs) remains unclear. Thus, the purpose of this study was: (1) to estimate the prevalence of waterpipe tobacco smoking in a large, multi-institution sample of college students; and (2) to assess correlates associated with waterpipe tobacco smoking, including demographics, other health-risk behaviors, and availability of commercial establishments for waterpipe tobacco smoking.

Section snippets

Sample

In fall 2008, a stratified random sample of undergraduate students attending eight universities in North Carolina were invited to complete a web-based survey as part of a randomized group trial of an intervention to reduce high-risk drinking behaviors and their consequences, the Study to Prevent Alcohol-Related Consequences (SPARC). Participating schools included both public and private universities (seven public and one private), ranging from 5000 to over 40,000 students. Students from each

Results

The survey was completed by 3770 students. The response rate across all eight schools was 26.9% and ranged from 18.0% to 44.1%. There were proportionally more females (63%) in our sample, which is similar to the overall undergraduate population at the eight universities (59.8% female) (Table 1). Respondents were evenly divided among class years and 80% of respondents were White. Fourteen percent were members or pledges of a Greek organization. Student demographics and self-reported behaviors

Discussion

Our large sample of undergraduate students from eight universities in North Carolina reported high rates of lifetime waterpipe tobacco smoking. In fact, almost as many students reported ever smoking tobacco from a waterpipe as had ever tried a cigarette. Current waterpipe smoking was reported by almost a fifth of the sample, while a quarter of the sample reported current cigarette smoking. These results suggest that waterpipe tobacco smoking is a popular activity among college students and is

Role of funding source

This work was supported by funding from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) at the National Institutes of Health (RO1AA014007). NIAAA had no further role in study design; collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

All authors were involved in the design of the study. Mr. McCoy and Dr. Reboussin conducted the statistical analysis and Dr. Sutfin wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflict of interest.

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