During a time in which efforts and resources are devoted to reducing tobacco use, some decreases in cigarette smoking may be replaced by alternative tobacco products, such as hookah. At the University of Florida, hookah use has surpassed cigarette use for ever and past year use; while current use rates for both hookah and cigarettes are around 10%.
Prevalence
Other studies [3, 4, 7, 8] have reported similar rates of hookah use, but hookah smoking lagged behind cigarette smoking in those studies. The overall prevalence for ever use (46.4%), past year (28.4%), and current use (9.9%) are similar to those reported for a University sample in 2008 by Primack et al. [3], who reported ever use at 40.5%, past year use of 30.6% and current use of 9.5%. Grekin and Ayna [2], however, found much lower rates in a university sample with only 15% ever use and 12.4% past year use (this study did not report current use). Eissenberg et al. [4] reported higher rates (ever 48.4%, past year 43.4%, and current 20%) in their college study of Introduction to Psychology students. However, the cigarette rates from the same sample [4] were significantly higher than their hookah rates and they were higher than the national averages for cigarette use with ever cigarette use at 73%, past year use at 57.7% and current cigarette use at 41.5%. Finally, in a sample of eight universities, Sutfin et al. [7] also reported similar ever use prevalence of 40.3%, but a much higher current use of 17.4%. All of these studies indicate popularity of hookah, while the current study shows it may even be more popular than cigarettes.
Though prior studies [1–5, 8] found higher rates of hookah use among males, in the present study females and males reported similar rates of hookah use. This finding held even when covariates were added into a logistic regression model to predict hookah use, controlling for age and race differences. Similar trends were found for cigarette use. Again, prior research indicated higher prevalence of cigarette use for males [8, 11] across all levels of use, while this study found no sex differences in cigarette smoking rates for ever or past year use, although males surpassed females for current smoking. This is a potential trend to monitor, or there may be something unique with this sample given the high rates of hookah use for females as well.
The racial differences in both cigarette and hookah use in our sample also appeared different from past studies. We found that all levels of hookah and cigarette use (ever, past year, and current use) were most prevalent among Hispanics, followed by whites, Asians, then other. Past research on both adolescent [14] and college samples [15] indicated the highest tobacco prevalence among non-Hispanic whites, followed by Hispanics and lastly African Americans. Similar to the sex differences found in the current study, the higher hookah and cigarette use prevalence among Hispanic participants could be a reflection of this university sample which draws heavily upon students from the Miami area. Although many studies are only able to statistically assess white vs. other race (combining minority respondents), hookah use is typically reported more often for whites [4, 5, 8, 16]. Sutfin et al. [7] found no difference between white and Hispanic hookah prevalence in their sample. These inconsistent trends need to be further assessed in future studies, with enough sampling of minorities to provide detailed information.
Age
Hookah use was more likely to be reported by younger students. This pattern is also seen in research by Primack et al. [3]. In the present study, current and past year users were found to be younger compared to those who reported not using in the past month or year. The fact that individuals only need to be 18 years of age to enter the relatively large number of hookah venues available in this university town may be influential in this regard.
Age at first use findings indicated differences between cigarette and hookah users as well. Participants who reported trying cigarettes as their first tobacco product were more likely to be under age 18 at first use, while those who reported trying hookah first were more likely to be over age 18 at first use. While tobacco can be purchased and used at age 18 legally, this pattern is of concern as traditionally it was thought that not trying tobacco products by the age of 18 reduced the odds that a young adult would ever become a tobacco user [17]. The pattern of hookah use and its acceptability among these novice users may change the rates of multiple tobacco products used later into young adulthood. Cigarette users were also highly predictive of hookah use, indicating that many young adults already using cigarettes are now using at least two forms of tobacco.
Social setting
Hookah smoking is a social activity for many adolescent and young adult users. This fact held true in the current study in which the overwhelming majority reported using hookah while with others, which is supportive of previous research regarding the situation in which respondents use hookah [18]. Also supportive of past research [16, 18], participants from the current sample indicated cafes/restaurants/bars were the most common place to use hookah, followed by at friends’ houses, further supporting the social nature of this form of tobacco use.
Predictors of hookah use
There is concern that concurrent tobacco product use might potentially multiply tobacco’s deleterious effects. In this study, 35% of current hookah users also were current cigarette smokers as compared with the 55% found in other recent research [7]. Sterling and Mermelstein [1] reported that adolescent current cigarette users also report a high prevalence of hookah use, and trying cigarettes is associated with using a variety of other tobacco products. In this study, cigarette use was highly predictive of hookah used in the same time frame, even after controlling for demographic characteristics. Surveillance systems need to continue to monitor all tobacco products, including adding hookah and other alternative forms to studies on adolescent cigarette use, to understand the role certain tobacco products play in influencing multiple forms of tobacco use.
While the relationship between cigarette and hookah use is of concern, it is also important to note that of the hookah users, 65% reported not being current cigarette users. Over one-fourth (28.8%) of current hookah users reported never having tried a cigarette. This is particularly interesting as it indicates that a substantial number of the participants may have been nicotine naïve had it not been for hookah. Multiple interventions are needed to target dual users, but interventions also need to target the potential myths adopted by hookah users regarding its relative safety, even if they understand the risks in cigarette smoking [5].
Acceptance and availability
Sutfin et al. [7] demonstrated that the number of hookah venues in a geographical area was related to hookah smoking prevalence, which potentially holds true for this study as well. At the time of data collection, the community surrounding the University of Florida had seven establishments that offered hookah smoking as part business. While there is no comparison community included in this study, college towns appear to be a major target market areas for hookah venues. For example, Primack et al. [19] reported four hookah venues opening within five miles of Carnegie Mellon University and the University of Pittsburgh. Primack et al. [20] also mapped the concentration of 144 U.S. hookah establishments that advertised on the internet. They found that while those establishments were located in all regions of the country, the heaviest concentrations per population were in 11 states, including Florida. Smith et al. [16] reported that adolescents first learned about hookah from friends (50.3%) but also from seeing a hookah lounge (20.9%). The availability and acceptance of this social arena to share tobacco smoking is one possible explanation for the dramatic increase in prevalence observed among adolescents and young adults.
Limitations
The intercept sampling method remains a form of convenience sampling; however, every 10th student was approached in the effort to reduce systematic bias. Additionally, the data were then weighted to the registrar’s list of currently enrolled students in the same academic semester to further create a more representative sample of the general student population. The prevalence results presented here are also only representative of one university in the southeast region of the United States. In general, the prevalence and patterns of tobacco use vary by locale. Similarly, states differ on policy restrictions for tobacco use in work places, public spaces, restaurants, and bars. However, the present information is helpful for understanding the use of traditional and emerging tobacco products at a major U.S. university.