Hookah is one of the most commonly used combustible tobacco products by young adults in the United States. Hookah smokers often perceive it as safer than cigarettes, but a growing literature points to deleterious health effects, including toxicant exposure, nicotine addiction and cardiorespiratory consequences. Existing evidence on the health effects of hookah shows it more than doubles the risk of lung cancer and respiratory illness, and case cardiovascular diseases. Moreover, multiple tobacco and nicotine product use with hookah is becoming more common. Emerging adulthood is a critical period for risk taking behavior, and use of tobacco and other nicotine containing products has been associated with increased risk of polysubstance use, particularly alcohol and marijuana. Among college students in the United States, the high rates of ever using hookah meet or exceed the lifetime prevalence of cigarette use. Initiation of hookah increases during the transition from high school to college, suggesting that the first few months of college is a particularly risky time for initiation. Similar to drinking, the risk of rapid transition to hookah use in college may be exacerbated by the trend of social influence, cannabis drying rack as hookah is most commonly used in groups in social settings.
Social Learning Theory and The Theory of Reasoned action emphasize the impact of socialization through peer influence and approval on substance use risk among young adults. Previous studies have identified risk factors for hookah use similar to those for cigarettes and associated risk behaviors such as marijuana and binge drinking. However, most studies have not included racial and ethnic minorities limiting our understanding of use among these growing populations, this is essential in understanding patterns in risk behaviors, as the US and its college populations become increasingly diverse. Nationally, less than one third of young adult past-30 day hookah users were exclusive hookah users. Thus, it is important to understand the risk of hookah use as a function of its use pattern . To help fill this gap, we conducted a study with a racially/ethnically diverse sample of urban college students to describe the patterns of hookah use , assessed the association between hookah use patterns and perceived social acceptance and peer influence, and explored the associations between hookah use patterns and other substance use risk behavior including binge drinking and marijuana use. Our main hypothesis was that hookah-specific social influence factors assessed by perceived social disapproval of hookah smoking and number of friends who smoke hookah are associated with patterns of hookah smoking.
Among a racially/ethnically diverse sample of young adults in one of the largest public urban university systems in the US, in contrast to prior studies, use of other tobacco and nicotine products along with hookah was less prevalent than exclusive hookah use among our young adult sample. Patterns of hookah use were significantly associated with past year alcohol binge drinking and marijuana use, where dual/poly hookah users were more likely to report binge drinking and marijuana use more than exclusive hookah use with never hookah users as the reference group. Historically, young adult males have had higher estimates of hookah use compared to females; however, trends have started changing with recent reports indicating that male and female prevalence is comparable. In contrast to the overall national US prevalence estimates, current hookah smoking was not significantly different between males and females, even when analyzed by hookah use pattern. However, there is a growing appeal for hookah smoking among urban female college students, including use of multiple tobacco and nicotine products in addition to hookah. Hookah is thought to be emerging during young adults’ transition to college, especially among females, which could be perceived a sign of independence among college age students. Hookah bars are usually located around college campuses, and where there is potentially high density of college students, particularly around the campuses included in our study. Around 121 out of 137 of the hookah bars in New York State are present in the 5 boroughs where the campuses included in our study are located. Given that females are reportedly more likely to smoke hookah in cafes/hookah bars compared to males, this high density of hookah bars might be a contributing risk factor for the higher hookah smoking prevalence among young adult females in our study compared to the national US estimates.
Race/ethnicity and social influences were independently associated with patterns of current hookah use.One significant difference by race/ethnicity was that Caribbean/West Indian origin students were less likely to be dual/poly users of hookah. We did not find higher hookah use rates among young adult White and Hispanic populations reported in other studies. This may be due to the unique pattern of smoking behavior within New York City, which limits hookah use disparities among college students. Future studies should assess in depth the racial and ethnic differences within patterns of hookah use while accounting for a more comprehensive set of hookah use predictors. These findings are consistent with the prior literature of substance use, as well as hookah use, which reflects a strong context for hookah use as a social activity. However, this finding can be interpreted in two ways; social influence could be impacting hookah use in general and whether an individual uses hookah exclusively or in combination with other products; a novel finding in the hookah literature. Moreover, having a greater number of friends who use hookah was more strongly associated with exclusive hookah smoking in contrast to dual/poly hookah smoking. On the other hand, indviduals who elect to use hookah may be prone to seek friends with similar behaviors ; especially since smoking hookah usually occurs in groups. Thus, future interventions could benefit from addressing groups rather than individuals; for example, by promoting and facilitating other group social activities and interactions to replace hookah-smoking gatherings. As hypothesized and consistent with prior studies, we found an incremental risk of past year binge drinking and marijuana use associated with current exclusive and dual/poly hookah user. Dual/poly hookah users had significantly higher odds of past year binge drinking and marijuana use, in contrast to never hookah users and exclusive hookah users. However, these associations may have been inflated due to limiting the comparisons between the least risky group of never users of hookah to the current dual/poly hookah users. Consistent with Problem Behavior Theory, risk behaviors assessed in our study clustered together. These findings suggest that current dual/poly hookah use relates to higher risk of binge drinking and marijuana use and reflects an emerging constellation of risky behaviors that might benefit from a brief intervention. Second, these results imply that many hookah users do not only need assistance with abstaining from hookah, but may need assistance abstaining from other forms of tobacco, as well as binge drinking and marijuana. Interventions and policies designed for prevention and cessation of hookah use may have an impact on other substances such as alcohol and marijuana use. Nevertheless, this also suggests that there is a need for cessation interventions that are designed to address multiple substances.
Hookah use continues to spread among young adults. To help reduce tobacco initiation among young adults, there has been growing advocacy and support for raising the tobacco purchasing age to 21 years old in the US. New York City was one of the first cities to implement this ban; this provision does not yet apply to hookah use and access to hookah bars. Given that the average age of initiation for hookah in the US is 18 years old, current regulations that raised the minimum purchasing age of other tobacco products to 21 should include clear provisions on types of tobacco covered to include hookah as well, mobile rolling shelving and also to include hookah tobacco and bars and cafes where hookah is served. Enforcing such regulations might also be particularly more impactful among young adult females transitioning to college, as they are more likely to be using hookah in cafes compared to young adult males.This is the one of the first studies we are aware of, which assesses patterns of hookah use among a racially/ethnically diverse college population including a large racial/ethnic minority group and its association with binge drinking and marijuana use. Limitations include a relatively low survey response rate. It did not account for other predictors of tobacco and substance use, such as religiosity or sensation seeking, that might interfere with some substance use assessed in our study. The analyses were based on self-reported data; recall and social desirability biases may have affected the results. We did not include former hookah users in the final analyses, this group may have had different patterns of use and risk behavior that our current analyses did not address. The survey utilizes cross-sectional data; therefore, it was not possible to assess the causality of relationships. There are potentially other important unexplored variables in this assessment of hookah use patterns. In addition, patterns of hookah or other tobacco use may be different in university systems with substantial suburban or rural populations, limiting the generalizability of these findings to other college populations.Despite the decline in adolescent use of substances such as cigarettes and alcohol in the last two decades, substance use continues to be a prevalent public health problem affecting adolescents in the United States. The rapid expansion of recreational marijuana legalization across the United States and vaping device use are recent factors that may affect newer trends in adolescent substance use. The potential negative effects of substance use on adolescent neurocognitive function have been well-documented. For example, marijuana use and alcohol use have been associated with decreased visual-spatial functioning, attention, memory, and psychomotor speed in adolescents. Furthermore, substance use during adolescence is associated with increased risk of substance abuse in adulthood. Studies have suggested that minoritized youth have higher prevalence of substance use when compared to peers. Specifically, transgender and gender-diverse youth—youth whose gender identity does not align with societal expectations ascribed to their sex designated at birth— have higher rates of substance use compared to their cisgender counterparts. Similarly, while frequent marijuana use is decreasing among White youth, frequent marijuana use has increased among both Black and Latinx youth. Divergent rates and patterns in substance use point to the need to compare youth subgroups by race, ethnicity, and gender identity to examine substance use disparities among minoritized youth populations. Moreover, specifically examining substance use among Black and Latinx transgender youth , who have minoritized experiences based on race, ethnicity, and gender, is critical to determine their specific risk for substance use. School is one of the most important socioecological domains for youth; thus, exploring factors that influence substance use among trans BLY in this setting is particularly salient. School is a key environment for engagement with peers, and peer influence is strongly associated with adolescent substance use. Negative peer experiences within schools are associated with increased substance use for youth among minoritized students. For example, among gender-diverse youth, school-based victimization is a risk factor for substance use. One study found that gender nonconformity increased risk of substance use, particularly among students who were assigned male at birth, and experiences of school-based victimization mediated this increased risk. Similarly, among racial and ethnic minoritized youth, school-based racial discrimination increases risk of substance use. Understanding school-based factors that impact risk of substance use among trans BLYis particularly relevant for developing culturally informed approaches to support them in reducing substance use. The minority stress theory posits that minoritized individuals experience social stressors unique to their minoritization. When these stressors are internalized, they increase the vulnerability of minoritized individuals to poor health outcomes and behaviors that may increase their risk for such outcomes. This theory initially focused on sexual minority individuals but later was expanded to apply to experiences of gender-diverse individuals with the gender minority stress framework. This framework helps to conceptualize how trans BLY may be vulnerable to substance use due to social stressors related to minoritized experiences of being both gender diverse and racial and ethnic minorities. There is a dearth of data focused specifically on substance use among trans BLY. Prior studies of substance use among gender-diverse youth populations have not explored differences between White transgender youth and trans BLY. To our knowledge, there have been no studies that have compared differences between trans BLY and Black and Latinx cisgender youth .