Adolescents' Perceived Harms and Addictiveness of Hookah Tobacco Use and Associations with Trying Hookah

Introduction: Although cigarettes remain the most widely used form of tobacco, the popularity of non-cigarette tobacco products creates new challenges for tobacco control interventions and tobacco regulation. Hookah tobacco use is especially popular among young adults and perceptions of harm, addictiveness, and social acceptability of hookah have been associated with its use in prior studies. National data also indicate hookah use is increasing among adolescents. Understanding how adolescents perceive hookah and how perceptions relate to hookah use can inform future tobacco control efforts, especially as the Food and Drug Administration finalizes its proposed “deeming” rule that will likely bring hookah tobacco under the agency’s regulatory authority along with other tobacco products.

Methods: Healthy adolescents ages 12 to 17 (n = 197, M age 14.9, SD 1.6, 41% non-white, 65% female) presenting for well-checkups at an urban pediatric clinic were recruited for a study of tobacco prevention messaging. As part of the study follow-up assessment, participants completed measures of cigarette smoking, risk factors for smoking, hookah use, and perceptions of hookah, including perceived harms, addictiveness, social acceptability, and peer hookah use. Analyses examined associations among lifetime hookah use; perceived harms, addictiveness, social acceptability, and peer use of hookah; and other smoking risk factors.

Results: Overall, 14% of the sample had ever tried smoking hookah and 13% had ever tried cigarettes; 57% of those who tried hookah had also tried cigarettes (χ2 = 54.3, p < .001). More than a quarter (29%) indicated hookah was less harmful than cigarettes, and 37% indicated hookah is less addictive than cigarettes. In bivariate analyses, ever use of hookah was associated with older age; ever trying cigarettes; intentions to smoke cigarettes; and perceptions of hookah including harm, addictiveness, social acceptability, and peer hookah use. In multivariable analyses, hookah use was associated with older age (OR 1.68, 95% CI 1.02, 2.87), ever trying cigarettes (OR 8.29, 95% CI 2.20, 31.21), and perceptions that hookah is less addictive than cigarettes (OR 3.19, 95% CI 1.02, 9.96).

Conclusions: In the study sample, adolescents’ perceptions that hookah tobacco is less addictive than cigarette smoking are associated with trying hookah. Research indicates hookah tobacco use can precipitate nicotine dependence and exposes users to harmful toxicants similar to cigarettes. These data support broadening youth tobacco control interventions and policies to prevent initiation of non-cigarette tobacco products including hookah.