JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 61, NO. 6 Major Article Knowledge and Attitudes Toward Hookah Usage Among University Students Adam L. Holtzman, MD; Dara Babinski, MA; Lisa J. Merlo, PhD, MPE Abstract. Objective: Hookah smoking is a popular form of tobacco use on university campuses. This study documented use, attitudes, and knowledge of hookah smoking among college students. Par- ticipants: The sample included 943 university students recruited between February 2009 and January 2010. Respondents (M age = 20.02) included 376 males, 533 females, and 34 who did not report sex. Methods: An anonymous online questionnaire was completed by respondents. Results: In this sample, 42.9% of college students had tried hookah, and 40% of those individuals had used it in the past 30 days. Students perceived fewer negative consequences of hookah smoking compared with cigarette smoking. Age, sex, racial background, marijuana/cigarette use, and perceptions of side effects were significantly associated with hookah use. Conclusions: Uni- versity students are misinformed regarding the health consequences of hookah smoking. Programs aimed at education, prevention, and intervention for hookah use are needed to address this growing public health concern. Keywords: attitudes, health risk perceptions, hookah, tobacco T he popularity of hookah smoking, also referred to as waterpipe smoking, narghile, shisha, or goza, 1 has in- creased rapidly over the past 2 decades. 2 Although hookah-based tobacco smoking had historically been a pre- dominantly Middle Eastern practice, with roots dating back as far as the 12th century, its worldwide popularity has grown substantially since the production of “maasel” (or “shisha” in the United States), which is a fruit-flavored tobacco intro- duced by Egyptian tobacco corporations in 1990. Hookah use has become particularly popular among college-aged youth in the United States. 2,3 A recent survey of college students indicated that 6% had used hookah in the past 30 days, 4 al- though others have shown rates as high as 17% to 20%. 2,5 This considerable rate of hookah use is nearly equal to the Dr Holtzman, Ms Babinski, and Dr Merlo are with the McKnight Brain Institute at University of Florida in Gainesville, Florida. Copyright © 2013 Taylor & Francis Group, LLC rate of cigarette use among college students. 6 However, un- like cigarette smoking, which is a focus of much research and public health initiatives, 7 relatively little research exists on understanding hookah use among college youth. Thus, fur- ther exploration of characteristics related to hookah smoking was greatly needed. The popularity of hookah smoking among college stu- dents may result from several factors. First, hookah smoking appears to be a social activity, with many users sharing a “bowl” of tobacco and passing the pipe around to others. Hookah cafes offer an alternative social scene for students under the legal drinking age who do not have access to bars, 8 and a disproportionate number of hookah cafes have been es- tablished near university campuses. In addition, hookah cafes are often exempt from indoor smoking laws, providing a le- gal venue for consuming tobacco products in public settings. Furthermore, hookah smoking is often marketed as “natu- ral,” 8 which may be perceived by students as less potentially harmful than cigarette smoking. However, emerging evidence demonstrates that hookah smoking is associated with a range of negative consequences similar to those of cigarette smoking, including cardio- vascular disease, cancer, 9 abnormal pulmonary functions, elevated heart rate and blood pressure, high carboxyhe- moglobin, decreased fertility, and death. 10 According to a report from the World Health Organization (WHO), 11 an hour-long hookah smoking session may be equivalent to smoking 100 cigarettes, which likely results from inhaling smoke from both the tobacco and the coal used to heat the tobacco in the waterpipe. The hookah device essentially in- cludes a head, body, waterbowl, and hose. When the coal placed in the head is lit, it heats the tobacco below it, which flows and diffuses into the waterbowl and is smoked through the hose. Although smoke is diffused into the waterbowl, the smoke inhaled through the hookah contains the harmful contents of the tobacco smoke, as well as the carcinogens of the coal heating the tobacco. 362