Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2013 Feb 1.
Published in final edited form as: Addict Behav. 2011 Oct 13;37(2):221–224. doi: 10.1016/j.addbeh.2011.10.001

Prevalence, Frequency, and Initiation of Hookah Tobacco Smoking Among First-Year Female College Students: A One-Year Longitudinal Study

Robyn L Fielder a,*, Kate B Carey a,1, Michael P Carey a,2
PMCID: PMC3230723  NIHMSID: NIHMS331411  PMID: 22037255

Abstract

Hookah tobacco smoking has become increasingly prevalent among college students, but little is known about frequency of use or patterns of use over time, including during the transition to college. The goals of this longitudinal cohort study were to assess the: (a) lifetime prevalence, (b) current prevalence, (c) frequency of use, and (d) pattern of initiation of hookah tobacco smoking among female students during the first year of college. First-year female college students (N = 483) at a large private university in upstate New York completed 13 monthly online surveys about their hookah tobacco use from August 2009 to August 2010. Lifetime prevalence of hookah use increased from 29% at college entry to 45% at one-year follow-up. The highest rates of hookah initiation occurred in the first two months of students' first semester of college. Current (past 30 days) hookah use ranged from 5% to 13% during the year after college entry. On average, hookah users reported smoking hookah two days per month. Hookah tobacco use is common among female college students. The transition to college is a vulnerable time for hookah initiation. Preventive efforts should begin in high school and continue through college, with a focus on students' first few months on campus.

Keywords: hookah, waterpipe, tobacco, smoking, college students

1. Introduction

Hookah tobacco smoking, also known as waterpipe or narghile, has been identified as an emerging threat to public health (Knishkowy & Amitai, 2005; World Health Organization [WHO], 2005). Its defining feature is that smoke passes through water before being inhaled (Maziak, 2008). Initial findings suggest that using hookah to smoke tobacco “poses a serious potential health hazard” (WHO, 2005, p. 5). Compared to smoking a single cigarette, a single hookah tobacco session exposes users to a higher nicotine dose, greater carbon monoxide, and more than 40 times the smoke volume (Eissenberg & Shihadeh, 2009). Hookah use is associated with impaired lung function (Raad et al., 2011) and increased odds of lung cancer and respiratory illnesses (Akl et al., 2010).

Consistent with global trends (Akl et al., 2011), the prevalence of hookah use has increased recently among American youth (Cobb, Ward, Maziak, Shihadeh, & Eissenberg, 2010; Sutfin et al., 2011). In a random sample of college students, the lifetime and past 30 day prevalence rates were 41% and 10%, respectively (Primack et al., 2008). The first year of college may be a vulnerable time for hookah initiation due to increased freedoms, permissive social norms, and identity exploration (Arnett, 2005). The transition to college is an important developmental period when risky behaviors, such as alcohol and drug use, tend to increase (Fromme, Corbin, & Kruse, 2008). Furthermore, hookah lounges are frequently located in college towns (Sutfin et al., 2011), and the majority of hookah lounge patrons are under age 21 (Barnett, Curbow, Soule, Tomar, & Thombs, 2011).

Although research has established the prevalence of hookah smoking among college students, several gaps remain. First, all extant studies have used cross-sectional designs, so little is known about how patterns of hookah use change over time, including during the transition to college. Second, there is a dearth of information on the frequency of hookah use, as almost all studies have reported only dichotomous indicators of use (e.g., lifetime and current prevalence). Therefore, the goals of this study were to (a) determine the lifetime and (b) current prevalence of hookah tobacco use, (c) assess the frequency of hookah tobacco use, and (d) assess the pattern of hookah initiation among female students over the first year of college. This research advances the literature by using a longitudinal design with monthly assessments during a key developmental transition and by providing frequency of use data.

2. Methods

2.1. Study Design and Procedure

All procedures were approved by the University's Institutional Review Board. Participants were 483 first-year female college students who participated in a larger 13-month longitudinal study on health behaviors and relationships from August 2009 to August 2010. Participants were recruited via a mass mailing sent to all incoming first-year female students who would be at least 18 years old by the start of the study and were not international students or scholarship athletes (excluded due to postal lags and policies of the National Collegiate Athletic Association, respectively). Campus flyers, word of mouth, and the psychology department participant pool were also used to bolster recruitment; women responding to these methods were screened to ensure eligibility. Interested students signed up on a study website and were invited to brief in-person orientation sessions, during which research staff explained study procedures and obtained written informed consent, and participants completed the baseline survey online. Twelve subsequent monthly surveys were sent out electronically on the last day of the month, and participants had one week to complete them remotely (online). Surveys were linked by unique identification codes, and survey data were stored separately from identifying information. Participants who missed surveys were allowed to resume participation with the next available survey. Participants received $20 (or one hour of research credit for those from the participant pool) for the baseline survey, $10 for each of the next 10 surveys, and $15 and $20 for the final two surveys; higher compensation was offered at baseline because that survey was the longest, and for the final two surveys to reduce attrition during the summer months.

2.2. Measures

At baseline, participants were asked demographic information and “before starting college (before August 26, 2009), how many times did you ever smoke hookah?” At each follow-up, participants were asked “during the last month, on how many days did you use hookah to smoke tobacco?” All last-month intervals were specified with anchor dates (e.g., July 1–31) to enhance recall.

We created dichotomous indicators of current (i.e., past 30 days) hookah use for each wave (based on the sample size for that wave; see Table 1) as well as hookah initiation (i.e., trying hookah for the first time ever) during the year-long follow-up. We summed the number of days of hookah use across (a) waves 2–13 and (b) waves 1–13 to obtain the total number of days of hookah use (a) during the year after college entry and (b) lifetime.

Table 1.

Number of Days of Hookah Tobacco Smoking in the Last Month, by Wave
All Participants Hookah Users
Wave/Month N Mean SD Median Range n Mean SD Median IQ Range
1 August 483 2.0 7.0 0 0–100 140 7.0 11.7 3 2–5
2 September 466 0.3 1.7 0 0–25 51 3.1 4.2 2 1–3
3 October 458 0.2 1.0 0 0–10 50 2.1 2.2 1 1–2
4 November 456 0.1 0.7 0 0–10 29 2.0 1.9 1 1–2
5 December 435 0.1 0.6 0 0–7 26 2.0 1.5 1.5 1–2
6 January 441 0.2 1.0 0 0–15 36 2.2 2.8 1 1–2
7 February 441 0.1 0.5 0 0–5 20 2.1 1.3 2 1–3
8 March 427 0.2 0.8 0 0–9 35 2.1 1.9 1 1–3
9 April 411 0.2 0.8 0 0–10 32 2.2 2.1 1 1–3
10 June 402 0.2 0.9 0 0–10 36 2.3 2.0 2 1–3
11 July 390 0.2 0.9 0 0–10 35 2.3 1.9 2 1–4
12 August 400 0.2 1.1 0 0–15 43 2.3 2.6 1 1–2
13 september 424 0.3 1.0 0 0–10 54 2.4 1.9 2 1–3
Open in a new tab

Note. IQ = Interquartile. N for each wave is the number of participants who completed that wave's survey and did not leave the hookah question blank. Wave 1 frequency of use covers lifetime prior to college entry; for waves 2–13, frequency of use covers the last month only. The right-hand panel (“Hookah Users”) provides descriptive statistics for only those participants who reported hookah use during that particular wave. Among all participants, the interquartile range is not shown in the table because it was 0–0 for all waves except wave 1, for which it was 0–1.

We also calculated the cumulative lifetime prevalence of hookah use at each wave. Because the sample size changed at each wave due to participants missing surveys, lifetime prevalence was calculated based on the full sample of 483 participants. We used a conservative approach in that participants who missed one or more surveys and did not report hookah use on any other surveys (n = 89, 18%), or who left the hookah question blank on one or more surveys and did not report hookah use on any other surveys (n = 12, 2%), were categorized as non-users. Therefore, the reported prevalence may be an underestimate of the actual prevalence. Lastly, we also determined the proportion of participants who initiated hookah tobacco use at each wave, calculated based on the full sample (for consistency in the denominator).1

3. Results

3.1. Sample Characteristics

Most participants (94%) were 18 years old at baseline (M = 18.1, SD = 0.3). Eleven percent were Asian American, 10% Black, 66% White, and 13% other/multiple ethnicities; 9% self-identified as Hispanic. Per university enrollment data, the sample represented 26% of all incoming female students, with an equivalent ethnic breakdown. Sixty-four percent reported their mother had completed college or graduate school.

Most participants (61%) responded to the mass mailing; 28% were from the participant pool, and 11% were recruited through word of mouth or flyers. Participants completed an average of 11.7 surveys (SD = 2.5, median = 13); 64% completed all 13 surveys. Response rates for the 12 follow-up surveys were: 97%, 95%, 95%, 91%, 92%, 92%, 89%, 85%, 83%, 81%, 83%, and 88%.

3.2. Lifetime Hookah Use

Pre-college hookah use was reported by 29% of participants (n = 140). During the year after college entry (i.e., waves 2–13), 34% (n = 164) reported hookah use. Lifetime prevalence increased slightly almost every month (see Figure 1), to 41% at the end of the academic year (at wave 9) and 45% at the end of the summer (at wave 13).

Figure 1.

Figure 1

Open in a new tab

Lifetime Prevalence, Current Prevalence, and Initiation of Hookah Use, by Wave. N = 483 for lifetime prevalence and hookah initiation. Sample sizes for current prevalence vary by wave (see Table 1).

3.3. Current Hookah Use

Current hookah use prevalence (see Figure 1) was 11% for the first two months of college, then decreased to a low of 5% in the middle of the academic year and increased to a high of 13% during the summer.

3.4. Frequency of Hookah Use

Among pre-college hookah users, 21% reported only one day of use prior to college, 30% reported 2 or 3, 31% reported 4–9, and 19% reported 10 or more. Descriptive statistics for the number of days of hookah use are presented by wave in Table 1. Throughout the study, hookah users reported smoking an average of two days per month. The median number of days of use per month was usually 1 or 2, but the ranges indicate that some heavier users reported 10–15.

During the year after college entry, the average total number of days of hookah use (summed across waves 2–13) was 2.2 (SD = 5.9, median = 0, range: 0–56, interquartile range: 0–2) for all participants, and 6.3 (SD = 8.6, median = 3, interquartile range: 1.5–7.5) for the 164 participants who used hookah between waves 2–13. Among those who used hookah during the year-long follow-up, 25% reported only one day of use, 26% reported 2 or 3, 29% reported 4–9, and 20% reported 10 or more.

For lifetime use, the average total number of days of hookah use (summed across waves 1–13) was 4.2 (SD = 10.8, median = 0, range: 0–108, interquartile range: 0–4) for all participants, and 9.3 (SD = 14.7, median = 4, interquartile range: 2–10) for the 216 lifetime hookah users. Among lifetime users, 21% reported only one day of use, 21% reported 2 or 3, 31% reported 4–9, 13% reported 10–19, and 13% reported 20 or more.

3.5. Hookah Initiation

Of the 343 participants who denied pre-college hookah use, 76 (22%) tried hookah (for the first time ever) during the year after college entry. Of these, 34% reported only 1 day of use, 28% reported 2 or 3, 29% reported 4–9, and 9% reported 10 or more. Figure 1 illustrates the proportion of participants who initiated hookah use each month. The first two months of college had the highest rates of hookah initiation, with 3% trying hookah for the first time each month.

4. Discussion

Almost one-third of first-year female students reported hookah tobacco use before college, confirming that high school students are at risk for engaging in this health risk behavior (Smith et al., 2011). By the end of the summer after the first year of college, 45% reported lifetime use, which is consistent with other college samples (e.g., Sutfin et al., 2011). Notably, 42% of lifetime hookah users reported three or fewer days of hookah use, suggesting that many young women only experiment with hookah. More concerning is the subset of women reporting more frequent use. Given that hookah smokers inhale nicotine, report pleasurable subjective effects, and experience a reduction of nicotine abstinence symptoms, the potential for abuse and dependence exists (Cobb, Shihadeh, Weaver, & Eissenberg, 2011).

Rates of hookah initiation were highest during the first two months on campus. New freedoms available to residential students, the developmental task of role exploration for emerging adults (Arnett, 2005), the social nature of hookah use (Ward et al., 2007), and commercial marketing likely make the transition to college a prime time for hookah initiation. Smaller peaks at the end of the academic year and summer may be due to increased socializing (“partying”) before friends depart for home and college, respectively.

Limitations of this study suggest directions for future research. First, data were from female students at one university. Future studies might employ multisite sampling and should include males, who are more likely to smoke hookah than females (Sutfin et al., 2011). Second, a more detailed assessment of hookah tobacco use during the high school years is needed. Strengths of this study include data on frequency and initiation of hookah use and monthly longitudinal assessment of hookah tobacco use during a key developmental transition.

The prevalence of hookah smoking suggests a need for public health policies to help reduce and prevent hookah use among youth (Knishkowy & Amitai, 2005). The higher current prevalence and initiation rates at the beginning of college suggest that preventive efforts should be concentrated in this time frame. Future research should assess the harmfulness of experimental hookah use and determine characteristics that distinguish experimenters from more frequent users, as it may be more cost-effective to focus intervention efforts on the latter group. Research is also needed to explore predictors of, motives for, and norms about hookah use to aid the development of preventive interventions.

Highlights

  • 29% of female students reported hookah use prior to college entry

  • Of pre-college never-users, 22% tried hookah for the first time by 1-year follow-up

  • 34% of women used hookah to smoke tobacco during the year after college entry

  • Among lifetime hookah users, 42% reported three or fewer days of use

  • Preventive efforts should begin in high school and continue through college

Acknowledgements

Role of Funding Sources This research was supported by grant R21-AA018257 from the National Institute on Alcohol Abuse and Alcoholism to Michael P. Carey. NIAAA had no role in the study design, data collection, data analysis or interpretation, writing of the manuscript, or the decision to submit the manuscript for publication.

The authors thank Annelise Sullivan for her assistance with data collection.

Footnotes

Conflict of Interest All authors declare that they have no conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

1

The proportion reporting hookah initiation was also calculated based on the number of participants still eligible to initiate hookah use at each wave. The number of participants reporting hookah initiation at each wave was divided by the number of participants who had not reported previous hookah use. Thus, the denominator decreased at each wave as the number of hookah users increased over time. The proportions initiating hookah use from waves 2–13 were: 4.7%, 4.3%, 1.3%, 1.0%, 1.6%, 1.7%, 1.0%, 2.4%, 1.4%, 1.4%, 1.4%, and 2.6%.

References

  1. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: A systematic review. International Journal of Epidemiology. 2010;39:834–857. doi: 10.1093/ije/dyq002. doi:10.1093/ije/dyq002. [DOI] [PubMed] [Google Scholar]
  2. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, Irani J. The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. BMC Public Health. 2011;11:244. doi: 10.1186/1471-2458-11-244. doi:10.1186/1471-2458-11-244. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Arnett JJ. The developmental context of substance use in emerging adulthood. Journal of Drug Issues. 2005;35:235–253. [Google Scholar]
  4. Barnett TE, Curbow BA, Soule EK, Tomar SL, Thombs DL. Carbon monoxide levels among patrons of hookah cafes. American Journal of Preventive Medicine. 2011;40:324–328. doi: 10.1016/j.amepre.2010.11.004. doi:10.1016/j.amepre.2010.11.004. [DOI] [PubMed] [Google Scholar]
  5. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: A direct comparison of toxicant exposure and subjective effects. Nicotine and Tobacco Research. 2011;13:78–87. doi: 10.1093/ntr/ntq212. doi:10.1093/ntr/ntq212. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: An emerging health crisis in the United States. American Journal of Health Behavior. 2010;34:275–285. doi: 10.5993/ajhb.34.3.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: Direct comparison of toxicant exposure. American Journal of Preventive Medicine. 2009;37:518–523. doi: 10.1016/j.amepre.2009.07.014. doi:10.1016/j.amepre.2009.07.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Fromme K, Corbin WR, Kruse MI. Behavioral risks during the transition from high school to college. Developmental Psychology. 2008;44:1497–1504. doi: 10.1037/a0012614. doi:10.1037/a0012614. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics. 2005;116:e113–e119. doi: 10.1542/peds.2004-2173. doi:10.1542/peds.2004-2173. [DOI] [PubMed] [Google Scholar]
  10. Maziak W. The waterpipe: Time for action. Addiction. 2008;103:1763–1767. doi: 10.1111/j.1360-0443.2008.02327.x. doi:10.1111/j.1360-0443.2008.02327.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Annals of Behavioral Medicine. 2008;36:81–86. doi: 10.1007/s12160-008-9047-6. doi:10.1007/s12160-008-9047-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Raad D, Gaddam S, Schunemann HJ, Irani J, Jaoude PA, Honeine R, Akl EA. Effects of water-pipe smoking on lung function: A systematic review and meta-analysis. Chest. 2011;139:764–774. doi: 10.1378/chest.10-0991. doi:10.1378/chest.10-0991. [DOI] [PubMed] [Google Scholar]
  13. Smith JR, Novotny TE, Edland SD, Hofstetter CR, Lindsay SP, Al-Delaimy WK. Determinants of hookah use among high school students. Nicotine and Tobacco Research. 2011;13:565–572. doi: 10.1093/ntr/ntr041. doi: 10.1093/ntr/ntr041. [DOI] [PubMed] [Google Scholar]
  14. 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. Drug and Alcohol Dependence. 2011;115:131–136. doi: 10.1016/j.drugalcdep.2011.01.018. doi:10.1016/j.drugalcdep.2011.01.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Ward KD, Eissenberg T, Gray JN, Srinivas V, Wilson N, Maziak W. Characteristics of U.S. waterpipe users: A preliminary report. Nicotine and Tobacco Research. 2007;9:1339–1346. doi: 10.1080/14622200701705019. doi:10.1080/14622200701705019. [DOI] [PubMed] [Google Scholar]
  16. World Health Organization Study Group on Tobacco Product Regulation . Advisory note: Waterpipe tobacco smoking: Health effects, research needs and recommended actions by regulators. WHO Press Geneva; Switzerland: 2005. Retrieved from http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf. [Google Scholar]

RESOURCES