What are young adults smoking in their hookahs? A latent class analysis of substances smoked
Introduction
Declines in cigarette smoking among adolescents and young adults may be offset, at least in part, by the spread of hookah tobacco in the U.S. Current cigarette smoking among young adults dropped from 24% in 2005 to 20% in 2010 (Centers for Disease Control and Prevention, 2011), and for adolescents it dropped from 36% in 1997 to 20% in 2009 (Centers for Disease Control and Prevention, 2010). However, hookah smoking may be increasing, especially among adolescents and young adults. For example, data from Monitoring the Future show that annual prevalence of hookah use among 12th graders increased from 17% in 2010 to 19% in 2011 (Johnston, O’Malley, Bachman, & Schulenberg, 2012). Data from the New Jersey Youth Tobacco Survey show an increase in both lifetime and current hookah use from 2008 (18% and 10%, respectively) to 2010 (21% and 11%, respectively) in a large sample of high school students (Bover Manderski, Hrywna, & Delnevo, 2012).
The existing evidence suggests that hookah smoking-associated health risks are at least comparable with, and perhaps greater than, those of cigarette smoking. A systematic review concluded that hookah use 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 (Shihadeh, 2003). Additionally, the charcoal used to roast the tobacco results in high levels of carbon monoxide (Jawad, McEwen, McNeill, & Shahab, 2013).
Waterpipes are commonly used to smoke flavored tobacco (Maziak, Ward, Afifi Soweid, & Eissenberg, 2004). Known as shisha in the U.S., hookah tobacco contains shredded tobacco mixed with honey or molasses and dried fruit and flavorings (Primack, Aronson, & Agarwal, 2006). In addition to tobacco shisha, non-tobacco or herbal shisha, which is made from herbs and molasses, is also available. Herbal shisha is often labeled as having fewer toxicants, such as “0% tar”, which may increase perceptions that it is a safer product, leading in turn to increased use. Additionally, studies have shown associations between marijuana and hookah smoking (Dugas et al., 2010, Sutfin et al., 2011), but few have assessed the use of a hookah waterpipe to smoke marijuana.
Brockman and colleagues (Brockman, Pumper, Christakis, & Moreno, 2012) conducted an online survey of 216 college students recruited via Facebook to assess hookah smoking practices, and to measure references to hookah smoking on Facebook profile pages. Results revealed that 27.8% reported lifetime hookah use. Of those who used a hookah, 78% reported mostly smoking tobacco, 22% smoked marijuana, 12% smoked only hashish, and 10% smoked both marijuana and hashish. These findings suggest that hookahs are used to smoke substances other than tobacco. However, the study was limited to participants from only two colleges and those that had a publically available Facebook page. Therefore, generalizability is limited.
The goals of this study were to: (1) describe the variety of substances that young adults smoke from hookahs; (2) determine whether subtypes or classes of hookah users exist based on the types of substances smoked and (3) describe the correlates associated with these classes. Research on tobacco use among college students has shown associations with several contextual and behavioral factors. For example, affiliation with Greek organizations is associated with tobacco use among college students, particularly social smoking (Morrell et al., 2005, Sutfin et al., 2009, Sutfin et al., 2012). Residence location is also associated with cigarette smoking. Students who report smoking only a few puffs in the past month are more likely to live on-campus than heavy, moderate or social smokers (Sutfin et al., 2009). Finally, a large body of research has documented the association of tobacco use and other substance use, including alcohol and illicit drugs (Morrell et al., 2005, Ridner, 2005, Sutfin et al., 2012). In this paper, we aim to describe classes of hookah users based on demographic and behavioral correlates. To our knowledge, this is the first study to explore classes of users based on substances smoked.
Section snippets
Sample
In fall 2010, a stratified random sample of undergraduate students attending eight universities in North Carolina was 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) (Wolfson et al., 2012). Participating schools included public and private universities (seven public and one private), ranging from 5000 to over 40,000 students.
Results
The survey was completed by 3447 students (62% female, 83% White) for a 34% response rate. Forty-four percent (N = 1509) of students reported ever smoking tobacco from a hookah; these participants make up the analysis sample for this paper.
Among lifetime hookah users, 54% of participants were female, and 86% Non-Hispanic White. Participants were fairly equally distributed by class year, including 21% freshmen, 24% sophomore, 27% juniors, and 29% seniors or 5th year students. Just over half (53%)
Discussion
The purpose of this study was to identify the substances young adults smoke in hookahs and to determine whether certain patterns of use exist, as represented by latent classes of users. Results indicated that within a large, random sample of college students from eight colleges in North Carolina, 44% of students reported lifetime hookah smoking. Among hookah users, the majority smoke flavored tobacco. Hookah tobacco is available in a wide variety of fruit, candy, and cocktail flavors (Morris,
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. Drs. Reboussin and Song 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 conflicts of interest.
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