These findings demonstrate that hookah tobacco smoking establishments are promoted on the Internet, with representation from all U.S. regions. Hookah establishments commonly offered food, alcohol, and popular social activities such as dancing. While only 26% of the websites mentioned the word tobacco on the opening page, this page was more frequently used to promote flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah tobacco smoking. No websites required age verification.
These findings are consistent with previous research about the perceptions and attitudes of hookah smokers in which hookah use has been described as a convivial and pleasurable way to spend good times with friends45,46
and as an enticingly novel experience47
that sometimes occurs in the presence of sexually suggestive behavior in social settings and gatherings.48
Similarly, misperceptions regarding safety and negative health consequences, often stemming from the fruit flavoring of the tobacco and lightness of the smoke produced by hookahs, have been reported.47-49
These user perceptions mirror messages promoted on the websites described in the current study.
It is not clear whether the misperceptions stem from images in popular media (including websites such as those assessed) or whether these websites merely reflect prevailing beliefs. The elaboration likelihood model,50
a prevailing model of communication theory, suggests that persuasive messages are highly constructed by message architects who (consciously or not) use various techniques to de-emphasize cognitive processing of the message in favor of emotional processing. Cultivation theory further suggests that the messages may subsequently alter viewers’ perceptions.51
Thus, while this study cannot definitively conclude that exposure to messages such as the ones assessed can directly alter perceptions, it is likely that these types of media messages play a role in enhancing or propagating popular myths related to hookah tobacco smoking.
In the Eastern Mediterranean region, accessibility to hookah smoking in places that also serve food and beverages has contributed to an increase in hookah use.46,52
The same may be true in the U.S., where most hookah tobacco smoking establishments concurrently offer other products, such as food, alcohol, and coffee. Although some people may visit these establishments only to socialize and consume food or beverages, they are still at risk of exposure to hookah tobacco smoke. This is of particular concern in view of recent evidence that environmental carbon monoxide is more concentrated in hookah establishments than in traditional bars.14
Ironically, clean air laws designed to protect patrons and workers from traditional tobacco smoke often exempt hookah tobacco smoking establishments, which may ultimately expose patrons to larger toxin loads.14,46,52,53
Also of concern is the lack of age requirements for viewing the websites of hookah establishments, entering the establishments, and using their tobacco products. Although major tobacco companies are required to limit access to website content to those aged ≥18 years, to demand registration that includes proof of age, and to list their products as being available only to people aged ≥18 years, there are no such requirements for hookah establishments. This may have contributed to hookah use among individuals aged <18 years. Published statewide data from Florida and Arizona, for example, show steady increases in hookah tobacco smoking from 6th grade to 12th grade, at which time the prevalence of this form of tobacco use is about 15%.7,54
While hookah tobacco use is less prevalent than cigarette use, it may continue to increase if hookah use is left unregulated. For this reason, extension of cigarette-related policy measures to the use of hookah tobacco and related paraphernalia may be warranted.46
For example, the recently enacted legislation which gave the U.S. Food and Drug Administration authority to regulate cigarettes should similarly address hookah tobacco smoking. As an illustration, flavorings in cigarettes are now substantially limited while hookah tobacco is universally flavored. Thus, it may be valuable to standardize these types of policies to include all types of tobacco.
Similarly, it may be valuable to systematically assess how policies already in place apply to hookah tobacco smoking. For example, many of the establishments represented in the 144 sites in the current study are located in municipalities with explicit policies limiting indoor cigarette smoking. Although some hookah tobacco smoking establishments may have received formal exemptions from these policies, others may be in violation with extant codes.
The lack of the word tobacco
throughout the websites of hookah establishments is notable. Hookah users as well as nonusers tend to perceive low harm from hookah tobacco smoking.4,6,24,25
Omitting the word tobacco
, intentionally or not, may further the misconceptions about hookah smoking. It therefore may be valuable for educational programs to emphasize that the product is tobacco and that its smoke contains combustion products similar to those in cigarettes.
These results suggest two other reasons that users might perceive low harm. First, some sites include information directly stating that hookah smoking is milder or safer than cigarette smoking. Additionally establishments often describe themselves as “cafés” and “bars.” By using this terminology and promoting the social, fun, relaxing atmosphere of a coffee shop or bar, the establishments de-emphasize that the product being used is tobacco, rather than something many students feel is more benign, such as coffee or alcohol. Because these establishments tend to feature activities and amenities that overlap with those offered by cafés and bars, such as food, dancing, and live music, they may be particularly compelling to participants aged <21 years, who are not yet permitted to enter traditional bars.
This study had several limitations inherent in Internet studies and qualitative studies. Any study of data accessed via the Internet is limited by the fact that data are captured at only one point in time (although search engine results continually change over time). Because each search engine uses a different proprietary algorithm for retrieval of documents, and because some algorithms are more robust than others for different searches, there may be websites that were not included in the search results. Similarly, utilization of more key words may have increased the number of sites captured. Therefore, the study sample may not be representative of all hookah establishments. However, because the three search engines obtained relatively consistent results, and because a snowball-sampling method yielded substantial redundancy of sites, it is likely that the majority of sites were captured. Additionally, although researchers noted prominence of the different codes by describing whether a certain code was present on the first page or the remainder of the document, relative numbers of images on each site were not coded.
This study focused only on descriptive analysis of content. Although the search strategy aimed to capture the most frequently assessed sites by utilizing the most common “hits” from the largest search engines, it did not explicitly measure traffic to websites. Similarly, this study did not assess the effect of content on smoking behavior. It may be valuable for future studies to address how frequently sites such as these are accessed and whether smoking behavior is affected by hookah smoking portrayed in the media.