Knowledge and Attitudes Toward Hookah Usage Among University Students

Transcription

1 JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 61, NO. 6 Major Article Knowledge and Attitudes Toward Hookah Usage Among University Students Adam L. Holtzman, MD; Dara Babinski, MA; Lisa J. Merlo, PhD, MPE Abstract. Objective: Hookah smoking is a popular form of tobacco use on university campuses. This study documented use, attitudes, and knowledge of hookah smoking among college students. Participants: The sample included 943 university students recruited between February 2009 and January Respondents (M age = 20.02) included 376 males, 533 females, and 34 who did not report sex. Methods: An anonymous online questionnaire was completed by respondents. Results: In this sample, 42.9% of college students had tried hookah, and 40% of those individuals had used it in the past 30 days. Students perceived fewer negative consequences of hookah smoking compared with cigarette smoking. Age, sex, racial background, marijuana/cigarette use, and perceptions of side effects were significantly associated with hookah use. Conclusions: University students are misinformed regarding the health consequences of hookah smoking. Programs aimed at education, prevention, and intervention for hookah use are needed to address this growing public health concern. Keywords: attitudes, health risk perceptions, hookah, tobacco T he popularity of hookah smoking, also referred to as waterpipe smoking, narghile, shisha, or goza, 1 has increased rapidly over the past 2 decades. 2 Although hookah-based tobacco smoking had historically been a predominantly Middle Eastern practice, with roots dating back as far as the 12th century, its worldwide popularity has grown substantially since the production of maasel (or shisha in the United States), which is a fruit-flavored tobacco introduced by Egyptian tobacco corporations in Hookah use has become particularly popular among college-aged youth in the United States. 2,3 A recent survey of college students indicated that 6% had used hookah in the past 30 days, 4 although others have shown rates as high as 17% to 20%. 2,5 This considerable rate of hookah use is nearly equal to the Dr Holtzman, Ms Babinski, and Dr Merlo are with the McKnight Brain Institute at University of Florida in Gainesville, Florida. Copyright 2013 Taylor & Francis Group, LLC rate of cigarette use among college students. 6 However, unlike cigarette smoking, which is a focus of much research and public health initiatives, 7 relatively little research exists on understanding hookah use among college youth. Thus, further exploration of characteristics related to hookah smoking was greatly needed. The popularity of hookah smoking among college students may result from several factors. First, hookah smoking appears to be a social activity, with many users sharing a bowl of tobacco and passing the pipe around to others. Hookah cafes offer an alternative social scene for students under the legal drinking age who do not have access to bars, 8 and a disproportionate number of hookah cafes have been established near university campuses. In addition, hookah cafes are often exempt from indoor smoking laws, providing a legal venue for consuming tobacco products in public settings. Furthermore, hookah smoking is often marketed as natural, 8 which may be perceived by students as less potentially harmful than cigarette smoking. However, emerging evidence demonstrates that hookah smoking is associated with a range of negative consequences similar to those of cigarette smoking, including cardiovascular disease, cancer, 9 abnormal pulmonary functions, elevated heart rate and blood pressure, high carboxyhemoglobin, decreased fertility, and death. 10 According to a report from the World Health Organization (WHO), 11 an hour-long hookah smoking session may be equivalent to smoking 100 cigarettes, which likely results from inhaling smoke from both the tobacco and the coal used to heat the tobacco in the waterpipe. The hookah device essentially includes a head, body, waterbowl, and hose. When the coal placed in the head is lit, it heats the tobacco below it, which flows and diffuses into the waterbowl and is smoked through the hose. Although smoke is diffused into the waterbowl, the smoke inhaled through the hookah contains the harmful contents of the tobacco smoke, as well as the carcinogens of the coal heating the tobacco. 362

2 Hookah Usage Among University Students Despite the known toxicants found in hookah smoke and its presumed health consequences, the popularity of hookah smoking in the United States is expanding, 12 even at a time when cigarette consumption is at its lowest levels in over 5 decades. 13 Much research has shown that early exposure to nicotine is associated with a higher likelihood of developing addiction, so the increase and popularity among college youth may be a particular long-term public health concern. Furthermore, although hookah smoke composition both for the primary and secondhand smoker is different from other forms of tobacco, it has the potential to pose systemic health hazards and therefore deserves further exploration. Relatively few studies exist on the epidemiology, perceptions, and knowledge of hookah smoking among university students, and only recently have efforts begun to identify the characteristics of hookah smokers in the United States. Given the rise of hookah smoking, these efforts are greatly needed. Furthermore, without adequate knowledge of the use and attitudes that college students have towards hookah smoking, researchers and policy makers will be uninformed or misinformed about how best to intervene. The purpose of the present study was to assess patterns, perceptions, and knowledge of university students hookah use, as well as to identify psychosocial factors associated with hookah use. METHODS Participants This study included 943 students (376 male, 533 female, 34 did not report sex) who ranged in age from 17 to 35 years old (M = 20.02, SD = 1.74) at a university in the southeastern United States. The study sample was ethnically diverse (ie, 16.3% Asian, 9.5% African American, 13.7% Hispanic or Latino, 59.4% Caucasian, 1.1% other), and was relatively representative of the overall student population, which is 7.7% Asian, 8.0% African American, 18.1% Hispanic/Latino, 58.4% Caucasian, 5.0% other, and 2.7% not reported, although Asian students were overrepresented in the sample. The sample was composed primarily of undergraduate students (98.7%). Specifically, the sample included 20.7% college freshmen, 24.7% sophomores, 29.0% juniors, 20.3% seniors, 1.3% fifth year or higher, and 1.3% graduate or professional students. The remaining 2.7% of participants did not report student status. Procedures The University of Florida Institutional Review Board approved all study procedures. The majority of participants were recruited through announcements in online undergraduate courses. The students were provided with a link to access the survey and complete it at their convenience. Some course professors offered extra credit to students who either completed the survey or an alternative assignment relevant to the course. The remaining participants were recruited by research staff who visited several areas frequented by university students, including the student union, local hookah bars/cafes, campus libraries, dormitories, and local coffeehouses, and asked students if they would like to participate in a brief anonymous study on tobacco use, knowledge, and attitudes. Interested individuals were given a flyer containing the link to the online survey, which was hosted on surveymonkey.com. The Web link first directed participants to the informed consent. To protect anonymity, participants were required to choose Yes, I consent in order to access the anonymous online survey, rather than signing their names. The survey required approximately 10 to 20 minutes to complete. With the exception of students who received extra credit for study participation, participants were provided no compensation for completing the survey. Data were collected between February 2009 and January Measures After completing the consent, participants were presented with an online questionnaire that was adapted from an earlier survey on hookah use in the United States, 14 plus additional questions added for this study. The measure assessed whether respondents had ever used a hookah to smoke tobacco (1 item) and frequency of use (1 item). It also included 3 items describing hookah users initial use experience (ie, age, company, location). Items assessing the importance of 14 factors associated with smoking and the importance of 14 reasons for smoking were rated on a 5-point Likert-type scale. Three items assessed concerns about addiction, perceived ability to quit and desire to quit. Eight additional items assessed patterns and characteristics of hookah use (ie, where waterpipe is obtained, flavor of tobacco, type of charcoal used, etc). Furthermore, for respondents who endorsed using hookah within the past 30 days, additional items assessing patterns of use (ie, length of typical smoking session, number of bowls smoked per session, number of sessions per day, company and location while smoking) were administered. All respondents, whether they ever used a hookah pipe or not, were asked to estimate prevalence of hookah pipe use, and were asked about other substance use, including other forms of tobacco use. Four questions asked their perceptions of the relative risk of hookah pipe use compared with cigarette use. Four additional questions were added to assess perceptions and attitudes towards passive smoke exposure. In all, the questionnaire contained 53 items. Demographic data were also gathered from students including age, sex, racial/ethnic background, and educational status (see Tables 1 to 3 for survey items and response options). Data Analytic Plan Respondents were categorized dichotomously as hookah users versus hookah nonusers based on their self-reported history of use. Demographics, substance use behaviors, perceptions of hookah use, and attitudes towards secondhand smoke were compared by group using chi-square analysis, and logistic regression was used to explore predictors of VOL 61, AUGUST/SEPTEMBER

3 Holtzman, Babinski, & Merlo TABLE 1. Characteristics of Hookah Nonusers Versus Users Nonusers Ever-users (n = 522) (n = 392) Characteristics % % Crude OR 95% CI Adjusted OR 95% CI Demographics Sex (female = 0, male = 1) , , 1.98 Male Female Race (black/african American = 0, all other races = 1) , , Asian Black/African American Caucasian Hispanic/Latino Other Age (under 21 = 0, 21 or older = 1) , , 1.65 Under or older Previous substance use Previous marijuana use (no = 0, yes = 1) , , 5.31 Yes No Past year cigarette use (no = 0, yes = 1) , , 3.24 Yes No Perceptions of side effects Health effects (cigarettes more harmful = 1, all others = 0) , , 1.31 Cigarettes much more harmful Cigarettes slightly more harmful Same Waterpipe slightly more harmful Waterpipe much more harmful Addictive effects (cigarettes more addictive = 1, all others = 0) , , 5.11 Cigarettes much more addictive Cigarettes slightly more addictive Same Waterpipe slightly more addictive Waterpipe much more addictive Nicotine content (cigtarettes more nicotine = 1, all others = 0) , , 1.49 Cigarettes much more nicotine Cigarettes slightly more nicotine Same Waterpipe slightly more nicotine Waterpipe much more nicotine Health risk switch from cigarette to waterpipe (reduction = 1, all others = 0) , , 1.67 Large increase Moderate increase Small increase No reduction Small reduction Moderate reduction Large reduction Secondhand exposure (no = 0, yes = 1) If people are smoking cigarettes I would rather be somewhere else , , 1.10 Yes No If people are smoking waterpipe I would rather be somewhere else , , 0.35 Yes No (Continued on next page) 364 JOURNAL OF AMERICAN COLLEGE HEALTH

4 Hookah Usage Among University Students TABLE 1. Characteristics of Hookah Nonusers Versus Users (Continued) Nonusers Ever-users (n = 522) (n = 392) Characteristics % % Crude OR 95% CI Adjusted OR 95% CI If people are smoking cigarettes it does not bother me , , 1.07 Yes No If people are smoking waterpipe it does not bother me , , 3.16 Yes No Note. OR = odds ratio; CI = confidence intervals. The total sample included 943 participants. Crude ORs are presented to explore the effect of each variable on ever using hookah. Follow-up binary logistic regressions were conducted to explore the impact of the variable controlling for other related variables and the resultant adjusted ORs are also presented. Follow-up analyses of demographic and previous substance abuse variables controlled for all other demographic and substance use variables. Demographic and side effect variables were controlled for in follow-up analyses of perceptions of side effects variables. hookah use. Given that very little is known about predictors of hookah use, separate logistic regressions were conducted for each potential predictor variable. Demographics (ie, sex, age, and race), substance use behaviors (ie, previous marijuana use and cigarette use within the last year), perceptions of side effects (ie, health effects, addictive effects, nicotine content, and secondhand exposure), and attitudes toward secondhand smoke were first explored individually and unadjusted odds ratios were calculated. Next, to determine the relation between the predictor and hookah use after controlling for other significant predictors of hookah use, logistic regressions were again conducted and adjusted odds ratios were calculated. Given the significant correlations between demographic and substance use behavior variables, they were added to the first step of the follow-up logistic regression. Perceptions of health effects and attitudes towards secondhand smoke were also intercorrelated with each other, and thus follow-up logistic regressions for perceptions of side effects and secondhand smoke controlled for these other perceptions as well as demographic variables. To simplify the interpretation of these analyses, binary logistic regressions were conducted. Thus, for variables with more than 2 levels, meaningful comparison groups were created (ie, race: African American/black compared with all other races; health effects: cigarettes much more harmful or slightly more harmful compared with all other categories; addictive effects: cigarettes much more addictive or cigarettes slightly more addictive compared with all other categories; nicotine content: cigarettes much more nicotine or cigarettes slightly more nicotine compared with all other categories; health risk switch from cigarette to waterpipe: any increase [ie, small, moderate, or large] compared with all other categories). Follow-up descriptive analyses were conducted only for those participants who endorsed ever using hookah. Descriptive analyses of recent (ie, within the last 30 days) hookah users were also conducted. Data were analyzed using IBM SPSS Statistics 20 software (SPSS, Chicago, Illinois). RESULTS Hookah Users Versus Nonusers Of the participants who responded (n = 914), 42.9% reported ever smoking hookah. As seen in Table 1, male students were more likely to have tried hookah smoking than female students (χ 2 = 15.22, p <.001), and non-african American/black students were more likely than African American/black students to smoke hookah (χ 2 = 44.87, p <.001). Individuals 21 years or older were more likely to have ever tried hookah smoking than those under 21 (χ 2 = 5.92, p <.05); however, rates of hookah use in the past 30 days were higher for individuals under 21 (43.9%) than for those 21 or older (32.6%; χ 2 = 4.47, p <.05). Individuals who had ever smoked marijuana (χ 2 = , p <.001) or had smoked cigarettes in the past year (χ 2 = 76.84, p <.001) were significantly more likely to have tried smoking hookah than those who had not. Unadjusted and adjusted odds ratios (ORs) are presented in Table 1. All demographics and substance use behaviors remained significantly related to hookah use when controlling for other demographics and substance use behaviors, with the exception of age. The plurality of students reported believing that smoking tobacco from a waterpipe was as addictive or harmful as smoking cigarettes (see Table 1), but many respondents reported believing that cigarettes were more harmful and addictive than hookah. This trend was also seen regarding perceived nicotine content, where a large proportion of respondents thought that cigarettes have more nicotine than hookah smoke does. Perceptions of hookah use were related to history of ever using hookah. Individuals reporting that cigarettes were more harmful than hookah were more likely to have used hookah (χ 2 = p <.001) compared with other respondents; individuals who indicated that cigarettes contained more nicotine were more likely to have smoked hookah (χ 2 = 40.50, p <.001) than other respondents; individuals indicating lower risk from switching from cigarettes to hookah smoking were more likely to have smoked hookah VOL 61, AUGUST/SEPTEMBER

5 Holtzman, Babinski, & Merlo TABLE 2. Characteristics of Hookah Users Ever users Past 30-day (n = 392) users (n = 150) Characteristics % % Initiation of use Age at initial use Younger than 9 years old years old years old years old years old years old years old 0.8 Company at initial use Alone 0.8 With one friend 5.3 With more than one friend 85.4 With a family member 2.6 With more than one family member 3.7 With a new acquaintance 1.9 Other 0.3 Location of initial use In a café or restaurant 45.9 In my own home 6.8 In my dorm room 0.6 At a family member s home 2.8 At a fraternity/sorority house 3.1 At a friend s or acquaintance s house 38.7 In someone else s dorm room 2.0 Frequency of hookah use Less than once a year 33.1 At least once a year, but not monthly 41.0 At least once a month, but not weekly 18.5 At least once a week, but not daily 6.1 At least once a day, or most days each week 1.3 Method of hookah use Number of hookahs owned None More than Frequency of flavored tobacco hookah use Never 4.1 Sometimes 9.1 Always 86.8 Ever used hookah to smoke anything other than tobacco No 77.3 Yes 22.7 Addicted to hookah No 98.4 Yes 1.6 Confidence in ability to quit Not at all confident 0.3 A little confident 0.8 Moderately confident 1.6 Very confident 97.3 Plans to quit No 55.9 In the next month 21.8 In the next six months 2.5 In the next 12 months 1.1 In the future (not in the next 12 months) 18.7 (Continued on next page) 366 JOURNAL OF AMERICAN COLLEGE HEALTH

6 Hookah Usage Among University Students TABLE 2. Characteristics of Hookah Users (Continued) Ever users Past 30-day (n = 392) users (n = 150) Characteristics % % Frequency of hookah use in past 30 days None 60.0 Once times times times times or more times 0.5 Frequency of hookah use each day (past 30 days) About 1 time per day 89.7 About 2 times per day 7.5 About 3 times per day 1.4 More than 3 times per day 1.4 Length of typical hookah session (past 30 days) 0 10 minutes minutes minutes minutes or more minutes 0.7 Number of bowls smoked per occasion (past 30 days) None 2.1 One or more bowls 1.4 Note. The total sample included 943 participants. The items in this table were only presented to respondents who endorsed ever using hookah (n = 392). As indicated, additional follow-up items were presented only for individuals endorsing hookah use within the last 30 days (n = 150). TABLE 3. Self-reported Reasons for Hookah Use Survey item M SD It s a good way to socialize with friends It helps control my weight It helps control my appetite It helps me not smoke cigarettes If I don t smoke waterpipe, I think about it a lot It helps me not smoke other tobacco products besides cigarettes It s something to do when I get bored I enjoy the smell It helps me feel less stressed It helps me to feel relaxed If I don t smoke a waterpipe, I experience unpleasant feelings such as irritability and/or have trouble concentrating and/or feel sad. I enjoy the taste Waterpipe smoke is less harsh than cigarette smoke I like trying things that are new, different, or hip Note. Participants were asked to rate reasons on a 1 (not at all) to5(the most important) scale about how specific factors determine their usage. Only participants who had endorsed ever using hookah were administered these questions about reasons for use. All reasons displayed a range of 1 5, based on participant report. VOL 61, AUGUST/SEPTEMBER

7 Holtzman, Babinski, & Merlo than other respondents (χ 2 = 21.15, p <.001), and individuals reporting that cigarettes were more addictive than hookah were more likely to have used hookah (χ 2 = , p <.001) than other respondents. Individuals indicating that they would rather be elsewhere when people are smoking cigarettes (χ 2 = 55.46, p <.001) or hookah (χ 2 = , p <.001) were less likely to use hookah compared with other respondents, whereas individuals indicating that they were not bothered by either cigarette (χ 2 = 16.35, p <.001) or hookah (χ 2 = , p <.001) smoke were more likely to use hookah than other respondents. The relations between health perceptions and hookah use were no longer significant when controlling for other health perception and demographic variables, with the exception of addictive effects and secondhand exposure related to hookah use (see Table 1). Regarding attitudes towards secondhand smoke, participants were overall less bothered by hookah smoke compared with cigarette smoke, and most respondents were subjected to passive hookah smoke during the year. More respondents indicated preferring not to be around cigarette smoke compared with hookah smoke. The majority of participants (including nonusers) said they would be willing to spend some time (ranging from < 1 hour up to an hour) around other people 2 smoking hookah, even if they were not smoking. Hookah users were more likely to report spending time around other people using hookah (χ 2 = , p <.001), and reported being willing to spend more time around others using hookah (χ 2 = , p <.001). Initiation of Use Most respondents reported using hookah for the first time between the ages of 16 and 18, and the second largest proportion of respondents reported beginning between 19 and 21 years old. The majority of participants reported that their first use of hookah occurred in the presence of more than 1 friend, typically outside of their own home in either a restaurant/café or the house of a friend/acquaintance (see Table 2). Characteristics of Hookah Use Of the respondents who had reported hookah use, the largest proportion of respondents indicated smoking 1 11 times per year, followed by smoking less than once a year, then 1 4 times per month, 1 6 times per week, and finally everyday or almost every day (see Table 2). As illustrated in Table 3, respondents did not strongly endorse any reasons for hookah smoking. However, the most important reasons reported for hookah use, in descending order, were socializing, its taste, relaxation, its smell, the fact that the smoke is less harsh than tobacco smoke, and combating boredom. Most self-reported hookah users indicated that they did not own a hookah, and the vast majority reported using flavored tobacco during hookah use. Finally, a small but significant number of both hookah smokers and nonsmokers reported using a waterpipe to smoke substances other than tobacco. Hookah Use Patterns of Current Smokers To further assess hookah smoking behaviors, participants who reported smoking hookah in the 30 days prior to completing the questionnaire were administered additional questions. The majority of respondents indicated smoking 1 5 times in the past 30 days, typically for minutes at a time. They generally indicated smoking 1 5 bowls of tobacco in the past 30 days combined. Desire to Quit Few respondents reported feeling addicted to hookah, and the majority of respondents indicated feeling very confident in their ability to quit smoking hookah at any time. However, over half of hookah users did not intend to quit. COMMENT The current study explored the perceptions and knowledge of university students related to hookah use, and identified psychosocial factors associated with hookah use in this group. For the current sample, nearly half of all respondents reported ever smoking tobacco from a hookah (waterpipe). Several risk factors, including older age, male sex, racial background (ie, not African American or black), history of cigarette and/or marijuana smoking, as well as perceptions generally indicating a lower health risk of hookah use compared with cigarette use, were related to a greater likelihood of having ever tried hookah smoking. Overall, respondents, and particularly those who had tried hookah smoking, perceived hookah smoke to be less harmful and addictive, and to contain less nicotine than cigarette smoke. Relatively few respondents indicated a desire to quit. It is noteworthy that, in this sample, rates of hookah smoking in the past 30 days were higher among individuals under age 21 than among individuals 21 and over. In addition, respondents indicated socializing as the primary reason for smoking hookah, and described engaging in this behavior primarily in restaurants/cafes with a group of friends. These results are consistent with previous research showing that hookah smoking was particularly popular among young college students, who were below the legal drinking age, as smoking at a hookah café may offer an alternative social scene for younger students. 15 This trend is concerning, as the social acceptance/promotion of hookah smoking among underage college students may prompt even younger students (ie, high school or middle school) to view experimentation with hookah smoking as cool and desirable. Given the increased risk of developing addiction to tobacco when smoking is initiated by the age of 12, 16 any conditions that encourage tobacco use in younger individuals should be avoided. Whereas rates of cigarette smoking have significantly declined in the past 5 decades, 6 hookah smoking may provide an alternative method of tobacco use that does not have the negative stigma, social constraints, or perceived risks of smoking cigarettes. Furthermore, there are significant public health concerns related to secondhand smoke exposure associated with hookah use. A recent WHO report suggested 368 JOURNAL OF AMERICAN COLLEGE HEALTH

8 Hookah Usage Among University Students that hookah smoking may be more problematic than smoking cigarettes. 11 In addition, emerging studies show that hookah smoking is related to similar negative health outcomes as cigarette smoking, and there may be negative side effects of secondhand smoke associated with hookah smoking. 17 Indeed, even in states with strong smoke-free indoor air laws, hookah cafes may be exempt. This suggests that college students have easier access to hookah use and greater exposure to secondhand hookah smoke, making it a particularly significant area of public health concern. 18 It is important to note that individuals who endorsed using hookah at least once also reported spending more time around others who are smoking hookah, which would increase their risk associated with secondhand exposure, in addition to their increased risk from primary use. Although in general respondents indicated that they engaged in hookah smoking only rarely, and perceived few benefits of doing so, the students generally did not endorse wanting to quit. It is noteworthy that the positive effects of hookah use endorsed most often included social benefits, taste, stress relief, and relaxation. These effects are similar to positive expectancies endorsed by college students for alcohol and other substance use. This may suggest increased abuse potential for hookah use, 19 despite relatively minimal concerns from the respondents in the study. Limitations Although the current results are generally consistent with other studies of hookah use among college youth, 2,5 it is important to mention that our results may not generalize to all college youth. A considerable proportion (26%) of respondents in the current sample endorsed at least monthly hookah use. The rate of monthly use in our sample is consistent with previous surveys of hookah use among college students. 2,5 Sutfin and colleagues 5 reported that having more hookah bars near the college campus increases the rate of current hookah smoking. Despite being located in a midsize town, at the time of the current study, there were at least 8 to 10 restaurants, cafes, and bars that offered hookah smoking in close proximity to the campus where this study was conducted. Further, this study was conducted at a large university in the southeastern United States, a region that has demonstrated higher rates of hookah smoking than other areas of the country, such as the midwestern United States. 5 We did not collect information on other potential risk factors for hookah use, such as affiliations with sororities/fraternities or emotional and behavior problems, which may predispose individuals to greater hookah use. 20 All data were collected using self-report, which may have introduced social desirability bias or recall bias to the results. Finally, the study was cross-sectional, which precluded exploration of long-term patterns of hookah use among college students. Given previous research suggesting higher rates of hookah use among younger college students, as well as high rates of hookah use among high school students, 12 further attention to longitudinal use patterns may help to clarify efforts to decrease hookah smoking and increase awareness of its harmful effects. To our knowledge, no studies have yet evaluated the longitudinal patterns of hookah smoking for longer than a 1-year period. 19 However, it may be that hookah use is somewhat age specific, and that typically developing young adults age out of their risk for hookah use as they mature, similar to patterns of risky alcohol consumption. 21 Future research should explore this question further. Conclusions In conclusion, results of the present study demonstrated that a large proportion of the college student sample had experimented with hookah smoking, and many students did not perceive hookah smoking to be as harmful or addictive as cigarette smoking. Given the mounting evidence of negative consequences of hookah smoking, as well as the growing popularity of hookah use, these results suggest that efforts are needed on college campuses to educate students and college officials about risks of hookah use, and to develop hookah smoking prevention programs. Based on the study results, particular benefit may result from targeting high-risk groups (ie, former marijuana and cigarette users, males, and individuals under 21 years of age). ROLE OF FUNDING SOURCES DISCLOSURE No funding was used to support this research and/or the preparation of the manuscript. CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University of Florida. NOTE For comments and further information, address correspondence to Lisa J. Merlo, PhD, MPE, McKnight Brain Institute, University of Florida, PO Box , Gainesville, FL , USA ( lmerlo@ufl.edu). REFERENCES 1. Chaouachi KT. The narghile (hookah, shisha, goza) epidemic and the need for clearing up confusion and solving problems related with model building of social situations. Sci World J. 2007;7: Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates. J Adolesc Health. 2008;42: Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics. 2005;116: Braun RE, Glassman T, Wholwen, J, Whewell A, Reindl DM. Hookah use among college students from a Midwest university. J Community Health. 2012;37: Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. 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