Hooked on hookah: Waterpipe tobacco products and those who use them
Kulak, Jessica A.
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Youth and young adults have a greater susceptibility to the initiation of cigarette smoking, and despite its declining prevalence, adolescence and young adulthood continue to be an important time for the initiation of other tobacco products, including emergent products like hookah. The prevalence of ever hookah use and current hookah use has been assessed in population-based surveys and has increased in recent years, particularly among youth. This dissertation seeks to add to the science base of hookah, in order to inform the development of effective public health policies. Manuscript 1 describes the use of gas chromatography to determine the nicotine levels and pH of waterpipe tobacco products. In this sample, the nicotine content of waterpipe tobacco ranged from nicotine-free for ‘herbal’ products to 3.30 mg/g for products claiming to contain nicotine (mean = 1.13 mg/g; std dev = 0.65; N = 140). In products that claimed to and contained tobacco (N = 120), the label did not predict actual nicotine content. Studies 2 and 3 were based on secondary data analysis. Study 2 explored correlates of hookah as the first nicotine product used among a sample of college students in western and central New York State. Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. Among students who ever smoked cigarettes, most (58.3-73.7%) reported cigarettes as their introductory product. Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. Among ever nicotine users, current hookah smoking was relatively common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. While Study 2 focused on college students’ hookah use, Study 3 focused on hookah use among high school students. Study 3 used four waves of data from representative cross-sectional samples of high school students in New Jersey to explore patterns and correlates of ever, current, and frequent hookah use over time. Ever, current, and frequent hookah use all significantly increased from 2008 to 2014. Hookah was one of only two products to demonstrate increases in both ever and current use across the four survey administrations, and was the second most currently used product in 2014. Increases in hookah use were especially high among ever and current cigarette users. Taken together, results from Studies 2 and 3 underscore the important role hookah is playing in the tobacco product landscape: many students are introduced to nicotine through the use of hookah, and this is likely happening at young ages, as hookah use is increasing among youth. Study 1 highlights opportunities for product regulation, an important and necessary first step in strengthening the regulatory framework for hookah products, in order to stem the increasing rates of hookah use among youth and young adults.