Tobacco, Water Pipes and the Rise of E-cigsSamuel D. BatesResearch Chair:Dr. Jason Ford

Statistics in the dropping rate of tobacco sales are deceptive because electronic cigarettes and hookah, also known as water pipe smoking (WPS), are not included in the sample (McMillen, R., Maduka, J., & Winickoff, J., 2012). This implies that tobacco sales are low, albeit a high (and potentially growing) population is still dependent upon nicotine (Mermelstein, 2014). This creates not a decrease in tobacco sales, but rather a shift in who profits from nicotine sales. In order to properly research the recent shift in the distribution of profits and determining if the shift itself is beneficial to research, more studies need to be aimed specifically at hookah. Hookah has much of the same health risks associated with cigarettes. Some medical researchers believe it may be worse than cigarettes (Mermelstein, R. J., 2014; Chan, A., & Murin, S., 2011). The majority of studies done on hookah are done on college campuses; this study will be no different. This is for convenience, college campuses have a large pool of young adults that are relatively easy to research. The methodologies used to reach other populations such as forums or snow ball samples generally prove ineffective (Heinz, A. J., Giedgowd, G. E., Crane, N. A., Veilleux, J. C., Conrad, M., Braun, A. R., & Kassel, J. D., 2013). An understanding of the motives for WPS as well as the social forces at work in a college campus are necessary for understanding the decrease in cigarette use and the rise in hookah use.

Hookah is popular among college aged students. In the year 2011, it was estimated that 20-40 percent of college aged students participate in WPS (Hakim, et al. 2011). A team of researchers combined a plethora of academic articles and did a content analysis to develop this estimate. Most studies in regard to hookah are done with a convenience sample of college students at specific universities. This method is used because campuses are a large pool of young adults who are generally experimenting with alcohol, illicit substances, and different forms of tobacco. The popularity of this is hypothesized by Holtzman and his colleagues (2013) to be due to the availability of hookah bars in reference to students who are under the drinking age. Other ideologies state the rise in hookah smoking is due to the availability of the tobacco, peer influence, and the perception that WPS is less harmful than other tobacco products. The activity is generally done in special “hookah cafes” (Knishkowy, 2005) or in the privacy of a home. The nature of WPS allows it to be considered the most socially acceptable form of tobacco use among university students. In these hookah bars, the tobacco is generally marketed as “natural tobacco” creating the illusion that there are less health risks compared to traditional tobacco products. Ideas of the fewer risks associated with hookah are also related to the water filtration process of the smoke. Some of the health risks associated with hookah are: a variety of cancers and diseases, raised blood pressure, increased heart rate, and breathing problems, abnormal pulmonary functions and decreased fertility (Holtzman, 2013).

The American Lung Association refers to hookah as “an emerging deadly trend” (The American Lung Association, 2007). The popularity of WPS creates concern among medical researchers because hookah is unhealthy, and researchers are concerned that hookah could lead to smoking other tobacco products (American Lung Association, 2007). The American Lung Association proposed an idea that hookah may be more damaging than cigarettes. The concept is as follows: When an individual smokes a cigarette, their lungs are exposed to the smoke for

about five minutes. Then the lungs have time to rejuvenate before the next cigarette. When the individual smokes hookah, their lungs are exposed to the smoke for potentially a full hour. The American Lung Association supplies a study to support this: “[A] cigarette involves… approximately 500-600 ml of smoke…a single water pipe episode involves 90,000 ml of smoke…as many of 44% [of water pipe smokers] reported episodes of 60 minutes or longer”(American Lung Association, 2007). Along with the increased exposure to the smoke comes an increase to carbon monoxide. This is due to the fumes from the coal used to heat the tobacco. What most WPS participants do not realize is that hookah is still nicotine, and nicotine is addictive, regardless of the inhalation process. Medical workers have also found that hookah use caries all of the health problems associated with cigarettes, as well as a few others because of the shared pipe or hose (Braun et al. 2012). There is also concern of hookah being an initiation drug to cigarettes. Studies done on various adolescents in America, in other countries, and studies done on soldiers show that WPS users are eight times more likely to start smoking cigarettes than non users (American Lung Association).  In 2013, Heinz found that WPS may lead to a relapse to cigarette products for hookah smokers who have “quit” or “cut down” their tobacco products.

Past studies have shown that students who use illicit drugs generally smoke cigarettes too (Gudjonsson, G.H., Sighurddon, J., Sigfusdottir, I., & Young, S., 2012). Because hookah is a much newer trend, the correlation between hookah and illicit substances is not known. There also appears to be a lack of knowledge examining the relationship between alcohol use and WPS. A few studies show that some young adults will smoke hookah in a place of residence and have a few alcoholic beverages, but there is not enough research in this to make it significant (Heinz, A. J., Giedgowd, G. E., Crane, N. A., Veilleux, J. C., Conrad, M., Braun, A. R., & Kassel, J. D., 2013). It is difficult to assume the correlation will be the same because studies done on the demographics of hookah users are different than research on the demographic of traditional tobacco products. Cigarette use is decreasing while hookah use is increasing (McMillen, R., Maduka, J., & Winickoff, J., 2012).  In 2013 Barnett et al., found that twice as many men used traditional tobacco products as women. In that same research, they found no difference between gender for WPS. Hookah users tend to be slightly younger than cigarette users (Barnett, T. E., Smith, T., He, Y., Soule, E. K., Curbow, B. A., Tomar, S. L., & McCarty, C., 2013). Barnett’s study was a content analyses of several peer reviewed articles written by other researchers. In contrast to other research that says there is no difference among race, class, or gender for hookah users, he found the only difference to be race. A potential explanation for this finding could be the  financial expense to smoke Hookah. Another explanation is the participants in other studies are in different income categories. Knowledge of the health risks associated with cigarettes increased in recent years thus stigmatizing cigarette use in many groups. Hookah has not received the same type of stigma. Hookah could be a venue for students to fulfill their nicotine addiction in a socially acceptable atmosphere. It could also be a social addiction due to the structure of college campuses. This research also seeks to learn how students are being educated about risks associated with hookah, this is important so harm reduction techniques could be implemented. It is generally known that students use various substances because of peer pressure and stresses from school (Heinz, A. J., Giedgowd, G. E., Crane, N. A., Veilleux, J. C., Conrad, M., Braun, A. R., … & Kassel, J. D., 2011).

This creates a few topics of interest for new research.  Because of the stigma associated with cigarettes, hookah may be a popular substitute to fulfill an addiction (physical or social). Hookah is used differently then cigarettes, therefore there may be variance in what other

substances people use with the hookah, or at different times. A common theme throughout most of the research found in this paper is that that the use of hookah and the emergence of hookah bars allows students under the drinking age to engage in the same type of camaraderie that they believe they students at the bar partake in (Akl, E. A., Jawad, M., Lam, W. Y., Obeid, R., & Irani, J., 2013). There is a shortage in the amount of research focused on young adults that are not enrolled in a secondary education institution. This creates a problem in examining if college campuses are unique in the phenomenon of hookah users, or if WPS is something that young adults do. In 2013 researchers found four reasons for use: socializing (or being influenced ) with family and peers, relaxing, and the smell. Heinz and his colleagues (2012) proposed three social forces that help explain the popularity of hookah among adolescents. First, it is an experience in which multiple people may engage. The legal age for hookah is eighteen, alcohol bars generally do not allow admission for anyone under twenty-one. This contributes to more people being able to engage in the behavior. Finally, there is a shortage of campaigns and media adds that portray the risk of hookah. This creates the illusion it is less harmful. Other researchers found the popularity is due to the affordability of WPS relative to other activities (Nakkash et al. 2011). Other water pipe smokers claimed that it is peaceful to participate (Holtzman, A. L., Babinski, D., & Merlo, L. J., 2013). The sound of the hookah itself is peaceful, along with the physical feelings. The smoke has an appealing smell as well. Others say it is seeing the hookah in movies and television shows that creates interest (German, D., Sherman, S. G., Sirirojn, B., Thomson, N., Aramrattana, A., & Celentano, D. D., 2006). All of these variables are combined to initiate and continue hookah use. Studies such as these are rarely done with a national sample; this creates difficulties in generalizing findings to all students. The majority of studies are done on a convenience sample of a college campus. There are several social forces that contribute to the peer influence in initiation and continued hookah use. Medical researchers have concern about hookah because they believe it may lead to a nicotine addiction. This study will examine the social aspect and offer an explanation for the phenomenon; whether it be a social need or a physical addiction.

A general behavior of people who use drugs recreationally is they tend to switch drugs, or quit drugs because of perceived risk. This perceived risk is either a social stigma, or a health risk. Other populations tend to believe that their drug use is manageable. The idea is that people base their behavior on perceived risk (German et al. 2006; Madden, T. J., Ellen, P. S., & Ajzen, I., 1992). The same idea may be applied to tobacco products. It is more appealing and more socially acceptable to smoke hookah than cigarettes (is this your primary research question) This review has examined the various ways students use hookah in.  It has examined perceived risks from WPS users and the social factors that may influence initiation. This study will attempt to explain if students use hookah as a way to fulfill a nicotine addiction or to feel accepted (social addiction) among their peers. This is a tough study because it requires an examination of not just hookah smokers but a specific samples within hookah users: daily, weekly, and sometimes users. Even though hookah is as damaging as cigarettes, there is little stigma attached.  This works to initiate never-smokers into the smoking culture, and it could cause a form of relapse for previous smokers. It is a type of ritual students at colleges do (McMillen, 2012). It has been established through past literature that students smoke hookah as a way to bond (Dew, B., Elifson, K., & Dozier, M., 2007). This will explore if students crave hookah the same way people crave cigarettes, or if it is just a social event. This research also looks to explore if cigarette smokers are substituting WPS for traditional tobacco cigarettes because of the stigmatation attached to cigarettes.

Work cited

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