Consistent with findings from national-level data and a growing number of studies, our results suggest that hookah smoking is an emerging public health concern for adolescents, particularly for those with a history of tobacco use. Among our restricted sample of participants who reported ever smoking a cigarette, more than half (58.5%) reported ever smoking hookah and about one-third (30.2%) reported smoking hookah at least once in the past thirty days at the 24-month assessment. National prevalence data suggest that 17% of 12th
grade students had used hookah annually (Johnston et al., 2011
). Compared with these data, our findings suggest that adolescents who have reported ever smoking cigarettes have a much higher prevalence of hookah use.
With regard to demographic variables, though more than half of the females (52.5%) in our sample reported ever hookah use at 24 months, our findings suggest that males had increased odds of ever and 30-day hookah use. This is consistent with findings presented in national-level data and in previous studies (Barnett et al., 2009
; Johnston et al., 2010
; Martinasek, McDermott, & Martini, 2011
; Primack et al., 2009
; Sutfin et al., 2011
). Though males are more likely to report using hookah than females, studies that seek to understand gender differences in hookah use may be warranted. In a recent qualitative study that examined water pipe usage among Lebanese participants (both sexes, ages 18 years and older), Nakkash, Khalil, and Afifi (2011)
found notable differences among males and females with regard to beliefs about water pipes. The women participants in this study frequently endorsed several qualities about water pipes, including their affordability of use (i.e., saying that you can share the cost with friends), their attractiveness (i.e., noting they are delicate, ornate, and have attractive designs), and the availability of the varieties of tobacco flavors that can be smoked in the water pipe. Women participants also noted the use of women in media to attract and motivate other women to initiate water pipe use. Findings from the Nakkash et al. study perhaps suggest that aspects of hookah smoking are appealing, or are even targeted, to women smokers. Coupled with those from Nakkash et al., our findings suggest that additional studies may be needed to examine hookah smoking prevalence and beliefs related to use by sex.
Consistent with other studies (Aljarrah et al., 2009
; Ward et al., 2006
), past thirty-day hookah users in our sample reported higher rates of concurrent tobacco use, including cigarette, cigar, and kretek use, than non–hookah users. An issue that has received considerable attention in the field is the temporal relationship between hookah use and use of other tobacco products among adolescents and young adults. Several have questioned whether hookah smoking leads to cigarette and other tobacco use or is a substitute behavior for those who have quit smoking cigarettes (Asfar, Ward, Eissenberg, & Maziak, 2005
; Hammal, Mock, Ward, Eissenberg, & Maziak, 2008
; Maziak, 2011
). Recently, Jensen, Cortes, Engholm, Kremers, and Gislum (2010)
found that hookah smoking frequency predicted regular cigarette smoking among boys in a sample of 762 Danish youth (ages 14–16 years). A limitation of our study was the inability to examine the temporal relationship among hookah smoking and use of other tobacco products as hookah use was assessed cross-sectionally. The temporality between hookah smoking and use of other tobacco products, particularly cigarette smoking, is important and requires further study among other samples of adolescents. Our data do suggest the importance of assessing multiple forms of tobacco use, including hookah, among adolescents.
That hookah smoking increases one’s risk of nicotine dependence (Maziak, 2011
; Neergaard, Singh, Job, & Montgomery, 2007
) and that some 30-day hookah smokers report concurrent tobacco use are a cause for concern. The concurrent use of these tobacco products may increase adolescents’ risk for developing nicotine dependence (Jordan & Delnevo, 2010
; Knishkowy & Amitai, 2005
), thus making it difficult to quit smoking and achieve long-term abstinence (Curry, Sporer, Pugach, Campbell, & Emery, 2007
). A growing body of literature has examined the development and progression of nicotine dependence among adolescent cigarette smokers (DiFranza et al., 2007
; O’Loughlin et al., 2002
). While researchers have examined the features of nicotine dependence among adult hookah samples (see Maziak, 2011
for further discussion), additional studies are needed to understand the influence of hookah smoking on the development of nicotine dependence among adolescents. Furthermore, new treatment programs may need to be developed, or already existing adolescent-specific treatment programs may need to be modified to address the prevention and reduction of hookah use among adolescents, especially those who are concurrent tobacco users.
As was found in other studies, our results also highlight the co-occurrence of hookah use and other substance use, notably alcohol and marijuana use. Sutfin et al. (2011)
found that current water pipe tobacco smokers were twice as likely to report using alcohol in the past thirty days. Though this association requires further study, perhaps the social context in which hookah use occurs (i.e., use with friends or at a party, see Sutfin et al. for further discussion) can shed light on the association between hookah and alcohol use. Prior evidence has also suggested that some adult smokers use hookah pipes to smoke marijuana (Smith-Simone et al., 2008
; Swift et al., 1998
). For instance in a study examining knowledge, attitudes, beliefs, and smoking patterns of 201 adults (ages 18 years and over) who were water pipe smokers, Smith-Simone et al. (2008)
found that 10% of their sample used their water pipe to smoke both tobacco and marijuana. Furthermore, 36% of their sample reported using marijuana within the past thirty days. Whether marijuana use is part of a constellation of problem behaviors for adolescent hookah smokers or adolescent hookah smokers are using the water pipe to smoke other substances requires further study. It is important to note that the item that assessed hookah use in our study did not specifically ask if participants were smoking tobacco in the hookah. Though this item has been used to assess hookah tobacco use in other studies (i.e., Sutfin et al., 2011
), it may bias findings because the item may capture other substances, in addition to tobacco, that participants’ may smoke with the hookah. Thus, our findings may slightly overestimate the prevalence of adolescents who smoke tobacco from a hookah. As noted by Sutfin et al., it is important for future studies to use items that ask participants if they have smoked tobacco from a hookah pipe.
Attending a hookah bar, lounge, or restaurant was an important predictor of both ever and past thirty-day hookah smoking among participants in our sample. According to a report issued by the American Lung Association, between 300 and 1,000 hookah cafes, bars, and lounges opened from 1999 to 2007 (TheBACCHUSNetwork, 2007
). As noted by Primack et al. (2009)
, hookah bars, lounges, and restaurants often do not sell alcohol, making them readily accessible to adolescents. Additionally, these venues may be quite alluring to adolescents because they are often the focal gathering point where one can socialize with friends in what is perceived as an enticing, cool, and hip activity. Our findings suggest that hookah bar, lounges, and restaurants may be an important source of exposure to hookah smoking for adolescents who are using hookah and those who are non–hookah smokers and should be further explored in future studies. Though additional evidence is needed, perhaps restricting adolescents’ access to hookah bars and lounges should be considered (Maziak, 2011
In conclusion, our findings suggest that adolescents with a history of ever smoking cigarettes are using hookah. Additionally, these hookah smokers are using multiple substances and forms of tobacco. Evidence-based programs may be needed to prevent initiation or reduce hookah smoking, as well as address cooccurring problem behaviors, to lessen the health risks associated with use among adolescents. To inform the development of interventions, additional studies may be needed to understand adolescents’ attitudes toward hookah smoking, to understand their sources of exposure to hookah smoking, and to understand perceived messages received from those sources of exposure.