© The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. doi:10.1093/ntr/ntt160 ORIGINAL INVESTIGATION Hookah Use Among Adolescents in the United States: Results of a National Survey Stephen M. Amrock SM 1 , Terry Gordon PhD 2 , Judith T. Zelikoff PhD 2 , Michael Weitzman MD 1,2 1 Department of Pediatrics, New York University School of Medicine, New York, NY; 2 Department of Environmental Medicine, New York University School of Medicine, New York, NY Corresponding Author: Stephen M. Amrock, SM, Department of Pediatrics, New York University School of Medicine, 550 First Avenue, NBV-8 South 4–11, New York, NY 10016, USA. Telephone: 212-263-0656; Fax: 212-263-4113; E-mail: stephen.amrock@med.nyu.edu Received May 19, 2013; accepted August 28, 2013 ABSTRACT Introduction: U.S. adolescents increasingly use alternative tobacco products (ATPs), including hookah. No study has previ- ously assessed correlates of adolescent hookah use in a nationally representative sample. Methods: Cross-sectional, nationally representative data of adolescents from the 2011 National Youth Tobacco Survey (NYTS) were used. Student demographics and their use of, exposure to, and beliefs about tobacco were examined as correlates of hookah use. Results: Of adolescents nationwide, 7.3% reported ever trying hookah and 2.6% reported using hookah within the past month. Increasing age was associated with trying hookah, but not current hookah use. Sex was unassociated with hookah use. Asians were most likely to have tried hookah; Hispanics and those of another race reported greater current hookah use. Hookah use increased with perceived ease of access to and willingness to try tobacco. Students with a hookah user at home were more likely to have tried hookah and to currently use hookah. Current cigarette use was not associated with current hookah use (odds ratio [OR] = 1.3, 95% CI: 0.8–2.1), but was associated with trying hookah (OR = 1.5, 95% CI: 1.1–2.2). Non-cigarette tobacco use was associated with trying hookah (OR = 2.7, 95% CI: 2.1–3.5) and current hookah use (OR = 4.8, 95% CI: 2.7–8.7). Conclusions: A sizeable minority of U.S. adolescents use hookah, particularly those living with hookah users, those who use other ATPs, and those who perceive tobacco as easily accessible. Current cigarette use was not associated with current hookah use. Future studies assessing the dangers of hookah use and interventions to curb this emerging problem appear warranted. INTRODUCTION Despite declines in cigarette (Centers for Disease Control and Prevention [CDC], 2011) and smokeless tobacco (Nelson et al., 2006) use, evidence from the past decade suggests that U.S. ado- lescents (Bhattacharyya, 2012; Saunders & Geletko, 2011) and adults (Bhattacharyya, 2012) have increasingly turned to alter- native tobacco products (ATPs). Why this has occurred remains unclear. Efforts by the tobacco industry to promote alternative tobacco forms may appeal to certain consumers (Carpenter, Connolly, Ayo-Yusuf, & Wayne, 2009). Many new immigrants come from areas in which ATPs are culturally rooted (World Health Organization, 2005) or where ATP use may be more socially acceptable than cigarettes (Akl et al., 2013). Amidst changing immigration patterns (United States Department of Homeland Security, 2011), new forms of tobacco have entered the American market and become popular. Hookah, also known as shisha, nargile, hubble-bubble, or waterpipe, is one such ATP. Its tobacco, commonly flavored and smoked socially, has to date evaded regulation. It remains unregulated by the Food and Drug Administration (Martinasek, McDermott, & Martini, 2011) despite recent federal efforts to ban flavored tobacco (Morris, Fiala, & Pawlak, 2012). Hookah bars can claim exemption from clean air indoor ordinances (Noonan, 2010) even though higher levels of carbon monoxide have been found in patrons of hookah bars than those of tradi- tional bars (Barnett, Curbow, Soule, Tomar, & Thombs, 2011). In at least one state, efforts against secondhand smoking may have inadvertently spurred a growth in hookah lounges due to such exemptions (Maher, Morris, Girard, & Pizacani, 2012). Alarmingly, hookah users perceive hookah as a safer and less addictive alternative to cigarettes (Barnett et al., 2011; Jackson & Aveyard, 2008; Primack et al., 2008; Roskin & Aveyard, 2009; Ward, Vander Weg, Relyea, Debon, & Klesges, 2006), though prior reviews have suggested that hookah use is no less addictive (Cobb, Ward, Maziak, Shihadeh, & Eissenberg, 2010; Noonan & Kulbok, 2009) and no less harmful (Eissenberg & Shihadeh, 2009; Knishkowy & Amitai, 2005; Shihadeh, 2003) than cigarettes. Meta-analyses have linked hookah use to lung cancer and low birth weight outcomes (Akl et al., 2010). Nicotine & Tobacco Research Page 1 of 7 Nicotine & Tobacco Research Advance Access published October 23, 2013 by guest on July 27, 2016 http://ntr.oxfordjournals.org/ Downloaded from