ORI GIN AL PA PER

Pilot Study of Waterpipe Tobacco Smoking Among USMuslim College Students

Cynthia L. Arfken • Wahiba Abu-Ras • Sameera Ahmed

� Springer Science+Business Media New York 2014

Abstract Waterpipe smoking is common among the young in Muslim-majority countries

despite recent Islamic rulings on tobacco. US Muslim college students, especially immi-

grants, may be at high risk for smoking, but information is lacking. In this pilot study,

respondent-driven sampling was used to sample 156 Muslim college students. Waterpipe

smoking was common (44.3 %). Leading motivations to smoke were social and perceived

low tobacco harm. Independent risk factors among the Muslim students were perception

that friends and other students smoked, and ever drank alcohol. Personal belief that

waterpipe smoking is prohibited in Islam was not significant. This pilot suggests that

Muslim students are at high risk for waterpipe smoking and more definitive studies are

needed.

Keywords Waterpipe smoking � Muslim � College students � Religiosity � Social

influences

Introduction

Waterpipe smoking (also known as Hookah) is centuries-old nicotine delivery system from

the Middle East and South Asia. Unlike cigarette smoking, waterpipe smoking often occurs

in a social context where the waterpipe is shared with family or friends. Waterpipe use is

C. L. Arfken (&) � S. AhmedDepartment of Psychiatry and Behavioral Neurosciences, Wayne State University, 3901 ChryslerService Drive, Ste 1B, Rm 156, Detroit, MI 48201, USAe-mail: carfken@med.wayne.edu

W. Abu-RasSchool of Social Work, Adelphi University, Garden City, NY, USA

S. AhmedFamily and Youth Institute, Canton, MI, USA

123

J Relig HealthDOI 10.1007/s10943-014-9871-x

on the increase worldwide (Maziak 2011), particularly among young people residing in

Muslim-majority countries (Akl et al. 2011). In the USA, waterpipe smoking is growing in

popularity among college students with a lifetime prevalence ranging from 15 to 48 %

(Grekin and Ayna 2012; Eissenberg et al. 2008; Primack et al. 2008; Sutfin et al. 2011).

The high prevalence in Muslim-majority countries and recent increase in the USA is a

health concern as waterpipe smoking has been associated with harmful effects from both

the acute and chronic exposure to tobacco smoke (Akl et al. 2010). These harmful effects

include lung cancer, respiratory illness, and low birth weight. Other diseases may also be

associated with its use, but establishing the link to waterpipe smoking is complicated

because people who engage in waterpipe smoking are also more likely to smoke cigarettes

(Eissenberg et al. 2008; Smith et al. 2011) and/or drink alcohol (Jarrett et al. 2012; Sutfin

et al. 2011).

To address the growing epidemic of waterpipe smoking, effective interventions are

needed. These interventions, in turn, can be tailored based upon reported motivations for

waterpipe smoking, and the identification of risk and protective factors for it. Such

interventions have to be sensitive to religious affiliation to be effective. Currently, there is

a lack of information about motivations and risk factors for waterpipe smoking among

Muslim college students in the USA

In Muslim-majority countries, there is a high exposure to tobacco from cigarettes and

waterpipe smoking (Eriksen et al. 2012). To reduce the harmful effects, tobacco use has

been declared prohibited by many Islamic scholars due to Islam’s injunction to avoid

harming oneself (El Awa 2004, 2008). However, one study in rural Egypt found men more

likely to believe cigarette smoking was prohibited than waterpipe smoking (Singh et al.

2012). Although it is only one study, it suggests the need to clarify these rulings as well as

increase awareness of the negative health effects of waterpipe smoking among Muslims.

A recent review of waterpipe smoking among US college students highlighted that Arab

American students had a higher prevalence than other students (Grekin and Ayna 2012).

The higher prevalence among Arab American students may reflect cultural acceptance of

waterpipe smoking or even viewing the practice as part of their cultural identify. However,

it is also possible that the higher prevalence is due to other factors. Arab American students

differ by religious affiliation (i.e., there are Christian Arab American students and Muslim

Arab American students) and nativity (i.e., there are Arab Americans students born in the

USA and Arab American students born in other countries). If there is a difference in

prevalence by nativity, the difference in prevalence may be due to differences in accul-

turation between groups of immigrant Arab American students. However, the review and

original articles did not provide information on religious affiliation, nativity, or accultur-

ation among immigrant students that may inform public health interventions.

Motivations for Waterpipe Smoking

Motivations for waterpipe smoking in the general US college student population include

social acceptability and perception that it is less harmful or less addictive than cigarettes

(Eissenberg et al. 2008). Another motivation for waterpipe smoking not explored in US

studies may be cultural identity. One study reported that students of Arab heritage (the

study did not state if they were Muslim or Christian) identified waterpipe smoking as part

of their culture (Roskin and Aveyard 2009). As waterpipe smoking originated from the

Middle East and South Asia, it is possible that students of South Asian heritage would also

identify waterpipe smoking as part of their culture. Thus, potential motivators for Muslim

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US college students for waterpipe smoking may include cultural identity. If it is a common

motivation, public health interventions would need to address cultural identification.

Risk and Protective Factors

Identified risk factors for waterpipe smoking include younger age, male gender, white race

(Primack et al. 2013), cigarette smoking and alcohol use (Akl et al. 2011; Jarrett et al.

2012), and family and friends’ waterpipe smoking. In contrast, protective factors against

waterpipe smoking have not been identified. Borrowing from the substance abuse litera-

ture, protective factors against waterpipe smoking may include academic achievement

(Giovino 2002), religiosity (i.e., public actions or personal importance attached to religious

behaviors) (Ford and Hill 2012), and belief that one’s religion prohibits the behavior

(Michalak et al. 2007). Also borrowed from the substance abuse literature, a potential risk

factor for waterpipe smoking is having friends who smoke (Salame et al. 2013). This list of

risk and protective factors is drawn from Bronfenbrenner’s ecological systems theory

(1992) by including the social aspects of family, friends, religious community, and social

environment.

Objectives

The objectives of this study were to determine the prevalence, motivations, and risk/

protective factors for waterpipe smoking among Muslim US college students in a pilot

study as it has never been assessed before. Although waterpipe smoking among Arab

American students (some of whom are Muslims) and Muslim students elsewhere in the

world has been shown to be elevated, there is no information on waterpipe smoking among

Muslim US students. It would also advance our understanding of the association of reli-

gious beliefs and religiosity with waterpipe smoking.

Methods

Participants

Eligible participants were self-identified Muslim undergraduate students who were at least

18 years of age at one Midwestern university. The University is primarily a commuter

campus, located in an urban environment in an area with a large Muslim population. The

number and racial backgrounds of Muslim students at the University are unknown; fur-

thermore, there is no listing of Muslim students at the University from which to sample.

Likewise, there is no national information on characteristics of Muslim college students.

Sampling

Due to the lack of a list of enrolled Muslim students, we turned to a sampling technique

used to recruit samples without traditional sampling frames, namely respondent-driven

sampling. Briefly, respondent-driven sampling was developed to address the challenge of

sampling ‘‘hidden populations’’ of injection drug users (Heckathorn 1997). It has been used

in over 15 countries (Semaan et al. 2009) and online with college students (Wejnert

and Heckathorn 2008). It is based upon social networking with the assumption that if the

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chain-referral sampling (such as snowball sampling) was allowed to continue until satu-

ration, all the target population would be included in the final sample. Chain-referral

sampling has a number of known difficulties: A few individuals may be responsible for

most referrals, people with large social networks have a greater pool from which to make

potential referrals and within the chains of referred/referees observations are not inde-

pendent. Respondent-driven sampling differs from chain-referral sampling by restricting

the number of referrals, inverse weighting by size of potential network, and controlling for

dependence between referrals in the analysis. It is extensively used in the HIV literature

and increasingly used in the substance abuse field (e.g., Wang et al. 2007).

Sampling was initiated with officers of Muslim and predominately Muslim student

organizations. The officers were selected for two reasons: We wanted to establish an easily

replicated protocol for future studies and we hoped the officers were respected members of

the Muslim community whose word and referral would be trusted by other Muslim stu-

dents. Prior to participating in the survey, the officers verified they were Muslim. After

completing a 15-min online survey, each officer was emailed a gift certificate and three

codes to pass to other eligible students (i.e., Muslim undergraduate student at the Uni-

versity who was 18 years or older). After each of their coupons was used by an eligible

student to complete the survey, the referring student received another gift certificate

through university email. Sampling continued until 156 students were recruited. Students

were only eligible to participate once. All students indicated that they were Muslim on the

survey. The study was approved by the University Institutional Review Board. Recruitment

occurred from May 2010 to March 2011.

Measures

Demographic questions included racial/ethnic heritage, place of birth and parents’ place of

birth (to categorize the student as first generation, second generation, or later generation),

receipt of scholarship (a crude measure of academic achievement), what language they

predominately thought in (a crude measure of acculturation), marital status, and living

arrangement (e.g., alone or with parents/relatives). For social influences, we asked the

students’ perception of the proportion of Muslims in their current neighborhood and in

their high school using categorical responses of ‘‘almost none,’’ ‘‘some but less than

10 %,’’ ‘‘10–30 %,’’ ‘‘30 % but less than 50 %,’’ and ‘‘50 % or more.’’ To measure the size

of their social network, we asked the number of other Muslim undergraduate students at the

University with whom they had reciprocal knowledge of names and social contact in the

past 2 weeks (in person, phone, text, email, or social media).

Individual questions asked about students’ waterpipe smoking, cigarette smoking, use of

cigars, bidi (a small cigarette popular in India) or snuff, and alcohol drinking for the

periods: (1) ever use, (2) past year use, and (3) past 30-day use. Questions also asked how

many other students, Muslim students, and their friends engage in waterpipe smoking with

response options of ‘‘none,’’ ‘‘some,’’ ‘‘most,’’ and ‘‘almost all or all.’’ Parental attitude

toward and history of ever smoking waterpipe were also queried. Motivations for water-

pipe smoking were adapted from alcohol use motivations questions in the College Alcohol

Survey (Wechsler and Nelson 2008) with the addition of two questions (Part of my culture

and Safer than cigarettes).

Questions on Islam’s stance on using alcohol, cigarettes, or waterpipe (anchored

1 = actively encourages and 5 = prohibits) were asked with a lead-in reassuring the

students that it was not a test and we were interested in their beliefs. Religiosity measures

were also included in the survey. Two measures were from the annual US National Survey

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of Drug Use and Health (NSDUH) and one from a study on American Muslim physicians

(Abu-Ras 2013). These religiosity measures were selected for analysis as they measure

importance of belief on behavior (My religious beliefs influence how I make decisions in

my life), publicly observed actions (During the past 12 months how many times did you

attend religious services?), and Islamic-specific (In general, to what extent do you adhere

to the practices of Islam?).

Analysis

Respondent-driven sampling requires specialized software to weight by the inverse of the

social network size and control for dependence within referrals (available at www.

respondentdrivensampling.org). More information about the statistical process can be

obtained at the Web site; it is based on Markov chain and biased network theories.

Adjusted population prevalence and 95 % confidence intervals (CI) were obtained along

with adjusted network size and homophily. The latter measure ranges from 1 when

smokers only refer other smokers and nonsmokers only refer nonsmokers to -1 when

smokers only refer nonsmokers and nonsmokers only refer smokers. Ideally, homophily is

close to zero.

For bivariate and multivariate analyses, we used the unweighted sample. Response

frequencies for individual motivations were calculated only for students with a lifetime

history of waterpipe smoking. For the risk and protective factors analyses, results are

summarized as odds ratios (OR) with 95 % CI. As risk factors may be correlated, multi-

variate logistic regression models with stepwise selection of factors significant in bivariate

analyses were used to detect independent associations with waterpipe smoking. As part of

sensitivity analysis, we also used other selection strategies to assess robustness of results.

One selection strategy was entering religiosity measures followed by demographic or

social factors. Analyses were conducted with both the original coded responses and the

responses dichotomized for ordinal questions. For ease of interpretation, the dichotomized

responses are presented here.

Results

Sample Characteristics

The sample was predominately female (67.9 %) and immigrants with 55.8 % being born

outside the USA (Table 1). Self-reported heritage for the students (whether they were

immigrants or native born) was predominately South Asian (46.8 %) and Arab (35.3 %).

Almost all (91 %) of the sample graduated from US high school with about a third

(38.5 %) of the students reporting that they thought exclusively in English. Most of the

sample (82.1 %) lived with their parents and received a scholarship (60.3 %). At the time

of the survey, 70 % of undergraduates at the university received scholarships.

Prevalence of Waterpipe Smoking

Lifetime waterpipe smoking was reported by almost half (44.3 %; 95 % CI 30.3–63.8 %

after adjustment for sampling technique) of the sample; past 30-day waterpipe smoking

was much less common (10.6 %). Lifetime waterpipe smoking was higher than lifetime

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Table 1 Sample characteristics and unadjusted odds ratios for lifetime waterpipe use

Characteristics % Of totalsample(n = 156)(%)

% Of those whohave never smokedwaterpipe (n = 83)(%)

% Of those whohave smokedwaterpipe (n = 73)(%)

Odds ratio (95 %confidenceintervals)

Demographic

Gender

Male 30.1 23.5 38.9 2.08 (1.03, 4.18)

Female 67.9 76.5 61.1 1.00

Nativity

Immigrants 56.9 59.3 54.2 0.81 (0.43, 1.54)

US born 43.1 40.7 45.8 1.00

Ethnic/racial heritage

South Asian 46.8 53.0 39.7 0.44 (0.17, 1.11)

Arab 34.0 31.3 37.0 0.69 (0.26, 1.82)

African 3.2 3.6 2.7 0.44 (.06, 3.16)

Other 16.0 12.0 20.5 1.00

Scholarship cover part of tuition

Yes 60.3 73.5 45.2 0.30 (0.15, 0.58)

No 39.7 54.8 26.8 1.00

Social influences

Living arrangements past year

Live with Parents 83.7 77.8 90.3 2.65 (1.04, 6.79)

All other livingarrangements

16.3 22.2 9.7 1.00

Parents ever smoked waterpipe

Yes 19.6 17.3 22.2 1.00

No 80.4 82.7 77.8 0.73 (0.33, 1.63)

Parents are against the use of waterpipe

Yes 58.7 58.5 58.9 1.02 (0.54, 1.93)

No 41.3 41.5 41.1 1.00

Proportion of neighborhood Muslim

30 % but less than50; 50 % or more

53.3 53.1 53.5 1.02 (0.54, 1.93)

Almost none; somebut less than 10;10–30 %

46.7 46.9 46.5 1.00

Proportion of students a the high school you attended were Muslim,

30 % But less than50; 50 % or more

51.0 53.8 47.9 0.79 (0.42, 1.50)

Almost none;some but less than10; 10– 30 %

49.0 46.2 52.1 1.00

Friends engage in waterpipesmoking

Most or almost all;all

42.0 19.8 68.1 8.68 (4.12, 18.29)

None; some 58.0 81.2 31.9 1.00

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alcohol use (9.1 %, 95 % CI 1.8–19.8 %). However, lifetime waterpipe smoking did not

differ from lifetime cigarette use (28.3 %, 95 % CI 13.8–47.7 %) due to the overlapping

95 % CIs. Lifetime history of any tobacco use was 51.3 %. The homophiles were very low

(0.15 for waterpipe smokers and -0.08 for nonsmokers of waterpipe), indicating that

Table 1 continued

Characteristics % Of totalsample(n = 156)(%)

% Of those whohave never smokedwaterpipe (n = 83)(%)

% Of those whohave smokedwaterpipe (n = 73)(%)

Odds ratio (95 %confidenceintervals)

Undergraduate students engage in waterpipe smoking

Most or almost all;all

57.2 43.2 73.2 3.60 (1.81, 7.14)

None; some 42.8 56.8 26.8 1.00

Substance use

Lifetime alcohol use

Yes 8.3 2.4 15.1 7.19 (1.54, 33.60)

No 91.7 97.6 84.9 1.00

Lifetime cigarette use

Yes 22.4 6.0 41.1 3.31 (1.20, 9.15)

No 77.6 94.0 58.9 1.00

Religiosity

During the past 12 months how many times did you attend religious services?

25 times or more 34.6 34.6 34.7 1.01 (0.52, 1.96)

0; 1–2; 3–5;or 6–24

65.4 65.4 65.3 1.00

In general, to what extent do you adhere to the practices of Islam?

All of the time 28.8 34.6 22.2 0.54 (0.26, 1.11)

Never; rarely;sometimes; mostof the time

71.2 65.4 77.8 1.00

My religious beliefs influence how I make decisions in my life

Strongly agree 59.5 66.7 51.4 0.53 (0.28, 1.02)

Strongly disagree;disagree; agree

40.5 33.3 48.6 1.00

How do you believe your religion views each of the following: waterpipe

Prohibit 26.1 29.6 22.2 0.68 (0.33, 1.41)

Activelyencourages;supports; nostance;discourages

73.9 70.4 77.8 1.00

Frequencies not adjusted using respondent-driven sampling software. Similar results were obtained usingordinal responses for variables with multiple response categories. Statistically significant (at .05 level) oddsratios bolded

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referrals were made independent of smoking status. Adjusted mean social network sizes

were higher for ever smokers (11.2) than for never smokers (9.6).

Motivations for Waterpipe Smoking

The majority (54.8 %) of students who had ever smoked waterpipes did not rate any

motivation as very important (Table 2). Among the remaining students, top-rated items

were to have a good time with my friends (24.7 %) and safer than cigarettes (20.5 %). The

item least frequently selected as ‘‘Very Important’’ was everyone else is doing it (2.7 %).

Part of my culture was rated as very important by only 4.2 %; this rating did not differ by

ethnicity or nativity of the participant.

Risk Factors for Lifetime Waterpipe Smoking

In bivariate analysis, males had twice the odds of lifetime waterpipe smoking (OR = 2.08)

compared to female students (Table 1). Lifetime waterpipe smoking was also strongly

associated with ever drinking alcohol (OR = 7.19) and ever smoking cigarettes

(OR = 3.31). Several social influences were also risk factors including living with parents

(OR = 2.65), ‘‘most or all’’ of friends engage in waterpipe smoking (OR = 8.68), and the

perception that ‘‘most or all’’ of undergraduate students engage in waterpipe smoking

(OR = 3.60). Ethnicity and nativity and ethnicity were not associated with waterpipe

smoking.

Protective Factors for Lifetime Waterpipe Smoking

In bivariate analysis, students receiving scholarship were less likely to report lifetime

waterpipe smoking (OR = 0.30) than other students. However, none of the religiosity

items was significantly associated with waterpipe smoking (Table 1), for either lifetime or

current waterpipe smoking. Only 26.1 % of Muslim students reported waterpipe smoking

was prohibited in Islam similar to the 29.4 % of the student who reported cigarette

Table 2 Potential motivations for smoking waterpipe (n = 73)

Reason Very Important Important Not Important

To have a good time with my friends 24.7 45.2 30.1

Safer than cigarettes 20.5 19.2 60.3

To relax or relieve tension 15.7 25.7 58.6

To celebrate 15.1 35.6 49.3

To try something new 11.1 44.4 44.5

As a reward for working hard 8.2 20.5 71.3

To get away from my problems and troubles 6.9 18.1 75.0

To fit in with my friends 5.5 9.6 84.9

Part of my culture 4.2 26.4 69.4

To feel more comfortable when I am with the opposite sex 2.7 9.6 87.7

Everyone else is doing it 2.7 12.3 85.0

Responses tallied only for students who have ever smoked waterpipe. Students were asked to rate theimportance of each reason using the response categories of ‘‘very important,’’ ‘‘important,’’ and ‘‘notimportant’’

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smoking was prohibited in Islam. Believing that waterpipe smoking was prohibited in

Islam was not a protective factor against lifetime waterpipe use (OR 0.68, 95 % CI

0.33–1.41), even when analysis was limited to those reporting high religiosity. In

exploratory analysis, the only demographic or substance use variable that was statistically

associated with believing that Islam prohibited waterpipe smoking was reporting that both

parents discourage waterpipe smoking (p \ .001).

Multivariate Analysis

The findings from the bivariate analysis were then examined in multivariate analysis.

Independent risk factors for lifetime waterpipe smoking were (1) ‘‘most or all’’ of friends

engage in waterpipe smoking, (2) ‘‘most or all’’ of undergraduate students engage in

waterpipe smoking, and (3) ever use of alcohol (Table 3). The other risk factors identified

in bivariate analysis were not statistically associated in multivariate analysis. No protective

factors were significant in the multivariate analysis. No protective factors were identified

when we conducted the analyses using current waterpipe smoking. Ethnicity, nativity, male

gender, or where the student lived were not statistically significant independent risk factor

for waterpipe smoking among Muslim college students.

Discussion

In this pilot study, we estimated the prevalence, motivations, and risk/protective factors for

waterpipe smoking among Muslim US college students, a group that potentially could be at

high risk due to elevated prevalence among young people in Muslim-majority countries

and increasingly in the USA. We found that lifetime prevalence of waterpipe smoking was

alarmingly high and that specific religious beliefs on waterpipe and religiosity were not

protective factors. Furthermore, specific motivations for waterpipe use focused more on

social aspects and much less on cultural issues. Finally, although many Islamic scholars

have ruled that tobacco is prohibited in Islam, few of the Muslim students reported that

tobacco, whether in cigarettes or in waterpipes, was prohibited in Islam.

Table 3 Independent risk factors for lifetime waterpipe smoking

Risk factor Adjusted odds ratios(95 % confidence interval)

Alcohol use

Ever 8.03 (1.47–43.81)

Never 1.00

Friends engage in waterpipe smoking

Most; almost all; all 6.62 (3.00–14.6)

None; some 1.00

Undergraduate students engage in waterpipe smoking

Most; almost all; all 2.34 (1.05–5.25)

None; Some 1.00

Variables initially entered into model included variables identified in bivariate analysis as significant(bolded odds ratios in Table 1). Unadjusted for sampling strategy

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In this pilot, we found that waterpipe smoking was widespread. Even among students

who rated religious beliefs as very important and believed that tobacco was prohibited by

Islam, waterpipe smoking was found. This result may reflect the highly social context of

smoking where the waterpipe is shared with family and friends. Social influences on

waterpipe smoking have also been found in the general population of US college students

(Eissenberg et al. 2008; Primack et al. 2013; Smith-Simone et al. 2008) and in Muslim-

majority countries for alcohol use (Salame et al. 2013).

Independent of social factors, alcohol use among the Muslim students was a risk factor

for waterpipe smoking. Although our sample did not examine whether alcohol use or

waterpipe smoking occurred first, almost every participant who ever drank alcohol had also

engaged in smoking waterpipe. For that reason, alcohol use was identified as a risk factor

for waterpipe smoking in this sample. However, tailoring anti-smoking interventions to

target alcohol use would miss the majority of Muslim students who ever smoked waterpipe

as they never drank alcohol. In the general student population where alcohol use is much

higher, some studies examined alcohol use and found it a significant risk factor for

waterpipe smoking (Jarrett et al. 2012; Sutfin et al. 2011).

Our pilot findings support that some of the Muslim students appeared misinformed

about the health hazards of waterpipe smoking, a gap also found in the general population

of students (Nuzzo et al. 2012; Primack et al. 2013). Knowledge of harm by itself may not

influence waterpipe smoking (Nuzzo et al. 2012), but it is important to build support for

any restrictions on the behavior similar to what occurred with cigarette smoking.

After controlling for social influences, protective factors against waterpipe smoking

were not identified in this sample. Although some Islamic scholars have declared tobacco

use prohibited, few of the Muslim students in this study reported believing that waterpipe

smoking was prohibited by Islam. In contrast to findings from the study of rural Egyptian

men (Singh et al. 2012), the students in our sample were equally likely to report

waterpipe and cigarette smoking as prohibited. However, it was a minority of the stu-

dents who reported tobacco was prohibited. Even with analysis is restricted to students

who rate religious beliefs as highly important, there was no association between religious

belief on waterpipe smoking and actual waterpipe smoking. This general lack of asso-

ciation was not due to students’ mismarking religiosity questions, as we have previously

reported strong associations between the religiosity measures and alcohol use (Arfken

et al. 2013). Instead, the lack of an association may reflect the social aspects of

waterpipe smoking.

Limitations

Our pilot study was limited by the reliance on self-report without laboratory confirmation

and small sample size. Additionally, the sampling was conducted at one university and

needs replication. It is possible that we never reached Muslim students who had little

interactions with formal student organizations. Finally, the survey was cross-sectional and

cannot address changing motivations or patterns of use.

However, recruitment showed no pattern with the individual’s experience of water-

pipe smoking (i.e., homophiles were near zero), as is desired in respondent-driven

sampling. These low homophiles for waterpipe smoking are in contrast to the higher

homophiles for alcohol use where students who drank tended to recruit their friends who

drank and students who abstained tend to recruit other abstainers (Arfken et al. 2013).

The lack of such a recruitment pattern for waterpipe smoking may reflect greater social

acceptance or less social stigma of the behavior among the Muslim students compared to

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alcohol use. If this is true, it would suggest that underreporting of waterpipe smoking

due to stigma was low.

New Contributions to the Literature

Waterpipe smoking was common and independently associated with social influences and

alcohol use in this sample of Muslim predominately immigrant college students. Religious

belief on tobacco, religiosity, ethnicity, and nativity did not significantly impact the

prevalence of waterpipe smoking within the sample of Muslim students. Although a cul-

turally distinct minority in the USA, few Muslim students rated cultural identification as a

motivation for waterpipe smoking. This pilot study shows it is feasible to sample Muslim

college students on tobacco use, but a larger more definitive study is needed to make public

health intervention recommendations.

Acknowledgments This work was supported by a grant from the Institute on Social Policy and Under-standing (www.ispu.org).

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