INT J TUBERC LUNG DIS 16(11):1551–1557 © 2012 The Union http://dx.doi.org/10.5588/ijtld.12.0152 E-published ahead of print 18 September 2012
Ethnicity and waterpipe smoking among US students S. Abughosh,* I-H. Wu,* R. J. Peters,† F. Hawari,‡ E. J. Essien*† * Institute of Community Health, College of Pharmacy, University of Houston, Houston, Texas, † School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA; ‡ King Hussein Cancer Center, Cancer Control Office, Amman, Jordan SUMMARY OBJECTIVES:
To examine the effect of ethnicity on waterpipe smoking among college students. D E S I G N : A cross-sectional study utilized data from University of Houston students through an online survey (n = 2334) from March to April 2011. The survey included questions on demographic characteristics (sex, age, race/ ethnicity), tobacco use experience, risk perception, social acceptability and popularity. Multivariate logistic regression was used to determine predictors of waterpipe use with three outcomes: ever-use vs. no use, past-year use vs. no use and past-month use vs. no use. R E S U LT S : Half of the sample had previously smoked tobacco using a waterpipe, approximately a third in the past year and 12.5% in the past month. Significant pre-
dictors included Middle Eastern ethnicity, Middle Eastern friend, past cigarette or cigar use. Perception of harm was associated with less use in the ever-use model, while perceived addictiveness, social acceptability and popularity of waterpipes were predictors in all models. C O N C L U S I O N : Our findings underscore the importance of developing culturally appropriate interventions to control waterpipe smoking among Middle Eastern Americans and those of Indian/Pakistani descent to curb further spread in US society, and highlight the importance of developing interventions that target the perceived addictiveness, social acceptability and popularity of waterpipe smoking. K E Y W O R D S : tobacco use; hookah; Middle Eastern
SMOKING remains the leading preventable cause of premature death both in the United States and worldwide,1,2 with approximately 443 000 premature deaths annually in the United States3 and 5.4 million worldwide2 attributed to smoking. Yearly economic losses to US society are estimated at $193 billion, of which $96 billion are in direct medical costs.3 Waterpipe smoking is an understudied form of tobacco use with growing popularity among adolescents and young adults.4 Waterpipes have been widely produced in the Middle East, India and segments of Asia, and their use is on the rise in Western countries. Smoking a waterpipe involves passing the smoke through water prior to inhalation,4,5 conveying the unsubstantiated belief that the practice is relatively safe.4,6–8 Furthermore, many sweetened flavors are available, giving the smoke an inviting scent,4,9 and creating a fashion trend among the youth. Compared to cigarette smoking, waterpipe use is associated with more carbon monoxide, smoke exposure6,10 and comparable nicotine exposure.10 Waterpipe smoke has also been reported to have significant amounts of carcinogens, including hydrocarbon, heavy metals,6,11,12 and tar.13 As noted by the American Lung Association,14 the World Health Organization15 and the American Cancer Society,6 waterpipe smoking is expected to have health risks similar to
those of cigarette smoking.14,15 Reported health risks include cancer,4,9,13,16,17 cardiovascular disease,4,9,16 pulmonary disease,4,9,13,17 increased risk of poor fetal outcomes,4,13,17 nicotine dependence4,9,13,16 and periodontal diseases.17 Furthermore, waterpipe smoking may be a cause of chronic obstructive lung disease,18 and sharing the waterpipe mouthpiece when smoking in social groups can pass on communicable diseases.4,13 In the United States, waterpipe smoking is spreading among the youth, particularly in and around college campuses.4,19 Since 1999, an estimated 200– 300 new hookah bars have opened in the United States.4,8,19 Although a number of studies aimed to identify predictors of waterpipe use among college students, and included race as one of the explored variables,9,20–22 Middle Eastern Americans were not coded as a separate group, as they are usually coded White, despite reports of having a distinct health and burden of disease compared with other ethnic and racial groups.23 Waterpipe smoking originated in the Middle East,24 where it is fairly common in both sexes.25–28 There is therefore a tremendous need to examine the cultural link that began spreading this health hazard in the United States. The University of Houston (UH), with its culturally diverse student population, provides a unique
Correspondence to: Susan Abughosh, Clinical Science and Administration, University of Houston, 1441 Moursund St, Houston, TX 77030, USA. Tel: (+1) 713 795 8395. Fax: (+1) 713 795 8383. e-mail:
[email protected] Article submitted 24 February 2012. Final version accepted 20 May 2012.
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opportunity to examine waterpipe smoking and correlates of its use among students of different ethnic origins. Our objectives were to study the association between Middle Eastern ethnicity and having friends of Middle Eastern descent on waterpipe smoking habits among college students at UH as well as other predictors of waterpipe use.
STUDY POPULATION AND METHODS A cross-sectional study was conducted using data collected from UH students through an online survey created with Qualtrics© (Qualtrics Labs Inc, Provo, UT, USA). An e-mail was sent to the UH student body in February 2011, inviting them to participate in the study. The e-mail directed students to an online link which included an informed consent form explaining that participation is voluntary and anonymous. Students would click the appropriate box to accept and the survey would then be accessible. To increase the response rate, all participants were placed in a draw to win one of ten $50 Starbucks gift cards. After completion of the survey, the participants were instructed to click on another link that opened a separate page to enter their e-mail address. This allowed the participants to record their e-mail for the purpose of the random draw, but maintained the anonymity of the unlinked survey data. The protocol was approved by the UH Institutional Review Board. Data collection was carried out through March 2011. The survey was one that had been previously used,20,21,29 and included questions on demographic characteristics (including sex, age and race/ethnicity), tobacco use, perception of risk and perceived social acceptability. Race/ethnicity was categorized as follows: White with non-Middle Eastern descent, White with Middle Eastern descent, African American, Hispanic, Indian/Pakistani Asian and Other (biracial/ American Indian/Other Asian). Three outcome variables were identified: Model 1) Ever-use of a waterpipe to smoke tobacco vs. no use, based on a survey question: Have you ever tried smoking tobacco in a waterpipe (hookah, shisha, narghile, argeela), even one or two puffs? Model 2) Past-year use of a waterpipe to smoke tobacco vs. no use, based on the question: During the past year, have you tried smoking tobacco in a waterpipe, even one or two puffs? Model 3) Past month use of a waterpipe to smoke tobacco vs. no use, based on the question: During the past 30 days, have you tried smoking tobacco in a waterpipe, even one or two puffs? Descriptive statistics and χ2 analyses were used to determine the frequencies and associations of participant characteristics with the three outcomes. Univariate logistic regression analyses of participant characteristics were carried out with the three outcomes, and results were presented as unadjusted odds ratios (ORs) with 95% confidence intervals (CIs). Three
Figure 1 Proportion of waterpipe smoking as defined by the three outcomes.
multivariate logistic regression models were carried out to determine predictors of being a waterpipe user with the three outcomes after assessing co-linearity between the independent variables. Variables with P < 0.2 in the univariate analyses were included, and backward elimination was used to arrive at the final models that included all significant variables with P < 0.05. Sex was included in all multivariate models. Results were presented as adjusted ORs with 95%CIs. All statistical analyses were carried out using SAS 9.2 (SAS Institute Inc, Cary, NC, USA).
RESULTS A total of 2334 students participated in the survey. The overall rates of waterpipe smoking in the sample are presented in Figure 1, while the sex-specific rates are shown in Figure 2. Participant characteristics are described in Table 1. Slightly more than half of the participants were male (56.3%); 65.1% were aged