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RESEARCH ARTICLE

Hookah Smoking and Harm Perception Among Asthmatic Adolescents: Findings From the Florida Youth Tobacco Survey* MARY P. MARTINASEK, PhD, RRT, CPHa LINDA GIBSON-YOUNG, PhD, ARNP, FNP-BCb JAMIE FORREST, MSc

ABSTRACT BACKGROUND: Hookah tobacco smoking has increased in prevalence among Florida adolescents and is often viewed as a safer alternative to cigarette smoking by young adults. Asthmatic adolescents are at increased risk of the negative health effects of hookah smoking. The purpose of this study is to examine if hookah use and harm perception vary by asthma status. METHODS: The Florida Youth Tobacco Survey was conducted in 2012 among 36,578 high school students. Secondary data analysis was conducted to compare the rates of hookah use among asthmatic youth to their nonasthmatic counterparts. Risk perception of hookah use compared to cigarette smoking was also assessed among asthmatic and nonasthmatic adolescents. RESULTS: One in 5 high school students reported lifetime asthma. These asthmatic students have a significantly higher prevalence of hookah smoking and greater perception of hookah use as being less harmful than cigarette smoking, than their nonasthmatic counterparts. Among asthmatics, 12th graders and Hispanic students had the highest prevalence of hookah smoking. CONCLUSION: Common misperceptions of hookah smoking as being less harmful than cigarette smoking are prominent among high school students in Florida and are greater among students with asthma than those students who do not have asthma. Efforts to increase education to dispel the myths surrounding hookah smoking as a safer alternative to cigarette smoking needs to exist at the high school level for both students with and without asthma. Keywords: asthma; adolescent; hookah; smoking; waterpipe. Citation: Martinasek MP, Gibson-Young L, Forrest J. Hookah smoking and harm perception among asthmatic adolescents: findings from the Florida Tobacco Youth Survey. J Sch Health. 2014; 84: 334-341. Received on May 31, 2013 Accepted on November 9, 2013

T

obacco use is a modifiable and preventable cause of disability, disease, and death. Tobacco use accounts for 443,000 deaths each year in the United States, which translates to 1 in 5 deaths.1 The incidence, or uptake of smoking is highest in adolescence, as 88% of daily adult smokers begin smoking as adolescents.2 Hookah smoking is a traditional form of smoking tobacco believed to have originated in India over 4 centuries ago.3 It has been popularized over the past decade in the United States, due in part to the false belief that it is a safe alternative to smoking cigarettes. Additionally, in the 1990s, a flavored form of tobacco (called ma’assel or shisha) was introduced

to the markets and led to a resurgence of hookah smoking in the eastern Mediterranean region and an uptake of hookah smoking in the United States.4 This form of tobacco, commonly referred to as shisha in the United States, consists of tobacco combined with a variety of fruit flavorings and sweeteners.5 A hookah, or waterpipe, is a device for smoking shisha and is usually smoked in a group setting. The hookah typically consists of a glass base containing water through which the tobacco smoke passes prior to entering the mouth/lungs of the smoker (Figure 1). Unlike cigarette smoking, hookah smoking involves the addition of burning charcoal that ‘‘bakes’’ the

a Assistant Professor, ([email protected]), Public Health, Department of Health Sciences and Human Performance, The University of Tampa, 401 W. Kennedy Boulevard, Box 30F, Tampa, FL 33606. b Assistant Professor, ([email protected]), College of Nursing, University of Central Florida, 12201 Research Parkway, Suite 489, Orlando, FL 32826. c Asthma Epidemiologist - Florida Asthma Program, ([email protected].fl.us), Florida Department of Health, Tallahassee, FL.

Address correspondence to: Mary P. Martinasek, Assistant Professor, ([email protected]), Public Health, Department of Health Sciences and Human Performance, The University of Tampa, 401W. Kennedy Boulevard, Box 30F, Tampa, FL 33606. *Indicates CHES continuing education hours are available. Also available at http://www.ashaweb.org/continuing_education.html

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Figure 1. Schematic of a Hookah Pipe (Retrieved From Creative Commons)

shisha as opposed to direct tobacco lighting as with a traditional cigarette. A typical lung volume of approximately 800 mLs is required to inhale from a hookah as opposed to approximately 60 mLs from a traditional cigarette.6 In addition, a hookah session lasts approximately 45 minutes compared to a typical 5-minute cigarette consumption. One common misperception in young adults is that hookah smoking is less harmful than traditional cigarette smoking.7-10 In a sample of high school students, this misperception of harm reduction was validated.11 As reported by the World Health Organization,12 when compared to a single cigarette, a session of hookah smoking contains over 100 times the amount of smoke. This amount of smoke equates to alarming amounts of nicotine, tar, and carbon monoxide as compared to the smoke emitted from a cigarette.13-15 Short-term concerns of hookah smoking include the potential for infectious disease transmission such as mononucleosis and tuberculosis from sharing the mouthpiece, as well as an increasing number of emergency room visits due to carbon monoxide toxicity.16-18 The carbon monoxide is primarily generated from the burning charcoal smoke which is inhaled along with heavy metals such as arsenic, cobalt, and nickel.15,19,20 Long-term effects of hookah smoking have been associated with lip carcinomas, lung cancer,21 cardiovascular disease,22 decreased lung function,23,24 chronic obstructive pulmonary disease,25 and addiction.26 The addictive nature of tobacco, under the guise of the surrounding misperceptions, may serve to increase uptake of hookah smoking among adolescents. Various US states have begun to collect annual data through state-wide monitoring surveillance to assess the prevalence of hookah smoking among high-school students with reported prevalence rates of ‘‘ever use’’ hookah smokers ranging from 10.3% 27 to Journal of School Health



11%.28 In Florida, the Florida Youth Tobacco Survey (FYTS)29 has monitored the prevalence of ever having smoked hookah among middle and high school students since 2007. ‘‘Current hookah smoking use’’ surveillance began in 2009. The prevalence of hookah smoking among high school students peaked in 2011 with a prevalence rate of 18.2% and has increased significantly from 2008 to 2012 (13.5% to 16.7%).30 Individuals who suffer from acute and chronic respiratory ailments are at high risk of tobacco smoke’s negative effects. For instance, secondhand tobacco smoke exposure has been found to be associated with increased asthma incidence and exacerbations among children and adolescents.31-33 It is reported that tobacco smoking can exacerbate asthma symptoms, increase health care utilization, and result in increased asthma morbidity.34 With both the firsthand and secondhand smoke exposure of hookah smoking and the increasing prevalence of asthma cases, hookah use among adolescents is of concern.35 The Florida Asthma Coalition35 monitors the prevalence of asthma across the life span. This statewide surveillance indicates that asthma cases are increasing among all ages in Florida. Current data on adolescents in Florida indicate a lifetime asthma prevalence rate of 20.5%, representing a 21% increase from 2006 to 2012.29 Reviewing the 2010 National Health and Nutrition Examination Survey (NHANES), Kit et al34 noted that 53.2% of the nonsmoking asthmatics were exposed to secondhand smoke. These researchers also noted that 17.3% of adolescents with asthma (12-19 years of age) smoked tobacco-containing products.34 It is concerning that adolescents with underlying respiratory compromise smoke any tobacco products; however, understanding the types of tobacco may lead to a better understanding of this uptake. In the NHANES data set there was no assessment of hookah use specifically as a tobacco-containing product among asthmatics. To the best of our knowledge, there have been no previous studies assessing the prevalence of hookah smoking among adolescents with asthma and adolescents’ perceived harm perception of hookah smoking. The purpose of this research was to determine if asthmatic adolescents had a different uptake of hookah smoking as nonasthmatic adolescents and if there was an association of misperceptions about harmlessness compared to cigarette smoking. Given the current misperceptions of hookah smoking as being a safer alternative to cigarette smoking, we hypothesized that asthmatic adolescents with lifetime asthma may uptake hookah smoking at different rates to those adolescents who do not report having lifetime asthma. We also hypothesized that risk perception of hookah smoking as less harmful than cigarette smoking is associated with hookah smoking among adolescents with reported lifetime asthma as compared to those students who reported no lifetime asthma.

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METHODS Participants The FYTS was conducted among a random sample of public high schools (grades 9 -12) selected for participation in the survey. Within each selected school, a random sample of classrooms was selected. Students in those classrooms were invited to participate voluntarily in the survey. Larger schools were sampled with greater probabilities of selection than smaller schools to ensure that every student in the state had the same probability of selection. The survey involved a 2-stage cluster probability sample design. Instruments The FYTS is a statewide, anonymous, school-based survey administered annually via pencil-and-paper to a random sample of Florida public middle and high school students. The 2012 FYTS survey was administered in the spring of 2012 to 36,578 high school students in 329 schools across the state. For this study, we conducted secondary data analyses on the high school sample. Procedures Parental consent was mostly obtained through passive permission forms that parents must return to opt out their child from participation. In a few counties, however, active permission was required and was obtained. Participation rates for the FYTS were calculated separately for schools and students as a ratio of number participating divided by number selected. Combined participation rates were calculated by multiplying the 2 separate school and student participation rates by each other. The overall participation rate in 2012 was 73% (N = 36,578). No identifying information was collected on these adolescents with asthma. Data Analysis Descriptive and inferential statistics were conducted on this data set. These analyses focused on selfreported hookah use among lifetime asthmatics and harm perception of hookah as related to cigarette smoking. FYTS data were statistically weighted to be representative of all Florida public high school students. SAS 9.3 quantitative software (SAS Institute Inc., Cary, NC)36 was used to establish prevalence rates of lifetime asthma status, lifetime hookah use, and current hookah use. Each of these variables was analyzed separately by sex, race/ethnicity, and grade. Significance was determined by assessing the overlap of the 95% confidence intervals. For the second part of this study, chi-square analyses were conducted to assess the relationships between lifetime asthma status and lifetime hookah use, current hookah use and hookah harm perception. 336 •

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Measures Demographic variables measured included sex, grade (9-12), and race/ethnicity. Two questions were asked to establish race/ethnicity. The first question was whether the student was Hispanic or Latino, and the second was: How do you best describe yourself ? Students were only allowed to choose 1 of the following options in response to this question: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, and Other. Students who responded affirmatively to the Hispanic or Latino question were coded as Hispanic, regardless of their response to the second question. Students who responded negatively to the Hispanic or Latino question were coded into 1 of 3 groups: non-Hispanic White, non-Hispanic Black, or Other. Lifetime asthma status was assessed by the question: Have you ever been told by a doctor or nurse that you have asthma? Students who responded yes were considered to have lifetime asthma. This statistic was chosen as the measure because asthma is a chronic condition, and if an adolescent has been diagnosed previously. We further investigated asthma and hookah use by assessing those students who reported current asthma by the question: Do you still have asthma? Students who responded yes were coded as current asthmatics and students who responded no were categorized as former asthmatics. Students also had the option of responding: I have never had asthma. These students were excluded from the analysis as our focus was on differentiating former from current asthmatics. Lifetime prevalence of hookah use was assessed by the question: Have you ever tried, even once, smoking tobacco out of a water pipe (also called a ‘‘hookah’’)? Current hookah use was assessed by asking: During the past 30 days, have you smoked tobacco out of a water pipe (also called a ‘‘hookah’’)? For measuring perception of hookah, students were asked: Compared to cigarette smoking, waterpipe/hookah smoking is . . . .’’ Response options included more harmful, equally harmful, less harmful, and not sure. For analysis, these categories were collapsed into a dichotomous variable. The 2 levels were students who respond that hookah is less harmful than cigarettes, and students who do not respond that hookah is less harmful than cigarettes.

RESULTS Looking first at the prevalence of lifetime asthma, there were some differences in this population based on the demographic variables of sex, ethnicity, and grade level; however, the only statistically significant difference was seen in race/ethnicity. Male and female lifetime asthma prevalence rates were 21.3% and 20.3%, respectively. Among the 4 defined race/ethnicity groups, students who self-reported © 2014, American School Health Association

Table 1. Descriptive Statistics of Lifetime Asthma

Table 2. Descriptive Statistics of Current Asthma

Lifetime Asthma

Current Asthma

N

%

95% CI

3565 3569

21.3 20.3

(20.4, 22.2) (19.4, 21.2)

3753 1162 1645 708

19.3 21.3 22.5 22.6

(18.5, 20.1) (19.8, 22.9) (21.2, 23.7) (20.4, 24.7)

2217 1914 1660 1345 7324

22.3 20.5 20.3 20.0 20.8

(21.1, 23.4) (19.2, 21.8) (19.0, 21.5) (18.6, 21.3) (20.2, 21.5)

Sex Boys Girls Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total

N

%

95% CI

1528 2068

9.3 11.8

(8.6, 9.9) (11.1, 12.5)

1916 661 756 330

9.8 12.3 10.4 10.5

(9.2, 10.4) (11.1, 13.6) (9.4, 11.4) (8.9, 12.0)

1128 1016 831 619 3687

11.2 11 10.3 9.3 10.6

(10.4, 12.1) (10.0, 11.9) (9.4, 11.3) (8.3, 10.3) (10.1, 11.0)

Sex

as Hispanic and Other had a significantly higher prevalence rates of lifetime asthma than non-Hispanic White students (22.5%, 22.6%, and 19.3% lifetime asthma prevalence, respectively). Non-Hispanic Black students did not differ significantly from any of the other racial/ethnic groups in terms of lifetime asthma prevalence (21.3% prevalence). Lifetime asthma prevalence was similarly distributed per grade level with 22.3% of 9th graders reporting asthma, 20.5% of 10th graders, 20.3% of 11th graders, and 20.0% of 12th graders (Table 1). Next we assessed current asthma rates in this sample. Overall, approximately 1 of 10 students reported current asthma (10.6%). Girls (11.8%) reported a significantly higher prevalence of current asthma than boys (9.3%). Among the 4 defined race/ethnicity groups, students who reported as non-Hispanic Black had a significantly higher prevalence of current asthma than non-Hispanic White students (9.8% vs. 12.3%). Students reporting as Hispanic (10.4%) and Other (10.5%) did not differ significantly from any of the other groups. As was seen with lifetime asthma, current asthma prevalence was similarly distributed per grade level, with 11.2% of 9th graders reporting current asthma, 11.0% of 10th graders, 10.3% of 11th graders, and 9.3% of 12th graders. However, students in 9th grade had a significantly higher prevalence of current asthma than students in 12th grade (Table 2). The Rao-Scott chi-square test is a design-adjusted version of the Pearson chi-square test. Results indicated significant associations of ‘‘ever hookah use’’ for students who reported lifetime asthma than those students who reported no lifetime asthma (χ 2 = 19.45, p < .01). When stratifying for sex, ethnicity, and grade, those students with lifetime asthma who have ever used hookah, the highest prevalence occurred among those students who were boys, Hispanic, or in the 12th grade. In comparison, students with lifetime asthma Journal of School Health



Boys Girls Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total

Table 3. Ever Hookah Use Between Lifetime Asthmatics and Never Having Asthma Separated by Demographic Descriptors

Ever Hookah Use

No Lifetime Asthma

Lifetime Asthma

N

95% CI

N

1803 16.1 1732 16.2

(15.0, 17.1) (15.1, 17.3)

660 19.9 (17.9, 21.9) 574 18.5 (16.5, 20.5)

2127 18.6 178 4.6 944 20.8 364 16.9

(17.5, 19.8) (3.7, 5.5) (19.1, 22.6) (14.7, 19.2)

654 19.6 (17.6, 21.6) 82 8.2 (5.7, 10.6) 380 26.7 (23.4, 29.9) 145 23.6 (18.8, 28.3)

591 811 1008 1117 3635

(7.6, 9.6) (11.4, 13.9) (17.8, 21.0) (22.9, 27.3) 15.3, 16.9

%

%

95% CI

Sex Boys Girls Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total

8.6 12.7 19.4 25.1 16.1

237 273 308 365 1270

11.1 15.2 21.4 30.6 19.3

(9.2, 13.0) (12.7, 17.7) (18.3, 24.5) (26.9, 34.2) (17.9, 20.8)

had a significantly higher prevalence of ever hookah use than those students who reported no lifetime asthma (19.3% vs. 16.1%, respectively; Table 3). Next, we examined the associations between ‘‘ever hookah use’’ for students who reported current asthma and never having asthma using the RaoScott chi-square test. Results indicated significant associations for students who reported current asthma than those students who reported never having asthma (χ 2 = 4.52, p < .033). When stratifying for sex, ethnicity, and grade, those students with current asthma who have ever used hookah mirror students with lifetime asthma, with the highest prevalence occurring among those students who were boys, Hispanic, or in the 12th grade. Students with current asthma (18.2%) had a higher prevalence of ever hookah use than those students who reported never having asthma (16.1%), but this difference was not statistically significant (Table 4).

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Table 4. Ever Hookah Use Between Current Asthmatics and Never Having Asthma Separated by Demographic Descriptors Never Asthma Ever Hookah Use

N

%

95% CI

Current Asthma N

%

Never Asthma

95% CI

Sex

Current Hookah Use

N

%

95% CI

842 722

7.4 (6.7, 8.2) 6.8 (6.1, 7.5)

Current Asthma N

%

95% CI

Sex

Boys Girls Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total

1803 1732

16.1 (15.0, 17.1) 281 16.2 (15.1, 17.3) 316

19.9 (16.8, 23.0) 16.5 (14.1, 18.9)

2127 178 944 364

18.6 (17.5, 19.8) 314 4.6 (3.7, 5.5) 45 20.8 (19.1, 22.6) 180 16.9 (14.7, 19.2) 73

18.1 7.7 27.1 22.2

(15.3, 20.8) (4.5, 10.9) (22.7, 31.6) (16.0, 28.4)

591 811 1008 1117 3635

8.6 12.7 19.4 25.1 16.1

9.7 13.8 21.1 29.7 18.2

(7.2, 12.2) (10.6, 17.1) (16.7, 25.5) (24.4, 34.9) (16.2, 20.1)

(7.6, 9.6) (11.4, 13.9) (17.8, 21.0) (22.9, 27.3) (15.3, 16.9)

107 142 153 165 616

Table 5. Current Hookah Use Between Lifetime Asthmatics and Nonasthmatics Separated by Demographic Descriptors No Lifetime Asthma Current Hookah Use

N

%

95% CI

Lifetime Asthma N

%

95% CI

Sex Boys 842 7.4 Girls 722 6.8 Ethnicity Non-Hispanic White 831 7.3 Non-Hispanic Black 101 2.5 Hispanic 480 10.4 Other 189 8.8 Grade 9th 282 3.9 10th 337 5.5 11th 415 8.2 12th 486 11.1 Total 1612 7.2

(6.7, 8.2) (6.1, 7.5)

363 11.1 (9.4, 12.9) 256 8.1 (6.7, 9.5)

(6.6, 8.1) (1.8, 3.2) (9.2, 11.6) (7.1, 10.5)

281 8.6 (7.2, 9.9) 52 4.7 (2.9, 6.5) 211 14.7 (12.1, 17.3) 93 13.6 (10.0, 17.3)

(3.2, 4.6) (4.7, 6.4) (7.2, 9.3) (9.6, 12.6) (6.6, 7.7)

118 5.3 (4.0, 6.7) 138 7.8 (5.6, 10.1) 128 9.5 (7.2, 11.7) 180 15.5 (12.6, 18.4) 643 9.8 (8.7, 11.0)

We then examined the associations of current use of hookah and lifetime asthma status. Significant associations were found with current hookah use and students who reported lifetime asthma (χ 2 = 24.65, p < .01). Students who were current hookah smokers with lifetime asthma were more often boys, Hispanic and in the 12th grade, representing a similar target population as ever hookah smokers. In comparison, students with lifetime asthma had a significantly higher prevalence of current hookah use than those students who reported no lifetime asthma (9.8% vs. 7.2%, respectively; Table 5). Current hookah use was then assessed between students who self-reported as current versus never having asthma. Results indicated significant associations for students who reported current asthma than those students who reported never having asthma (χ 2 = 6.20, p < .013). When stratifying for sex, ethnicity, and 338 •

Table 6. Current Hookah Use Between Current and Nonasthmatics Separated by Demographic Descriptors

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Boys Girls Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Grade 9th 10th 11th 12th Total

163 132

11.7 (9.1, 14.2) 6.6 (5.0, 8.1)

831 101 480 189

7.3 2.5 10.4 8.8

(6.6, 8.1) 132 (1.8, 3.2) 28 (9.2, 11.6) 98 (7.1, 10.5) 46

8.1 (6.1, 10.1) 3.7 (1.7, 5.7) 13.5 (10.1, 16.9) 13.9 (9.0, 18.9)

282 337 415 486 1612

3.9 5.5 8.2 11.1 7.2

(3.2, 4.6) 55 (4.7, 6.4) 65 (7.2, 9.3) 58 (9.6, 12.6) 86 (6.6, 7.7) 308

5.1 (3.3, 7.0) 5.5 (3.6, 7.4) 8.7 (5.7, 11.8) 15.4 (11.3, 19.5) 8.9 (7.5, 10.3)

grade, those students with current asthma who were current hookah users mirror students with lifetime asthma for sex and grade, with 1 exception. The highest prevalence occurred among those students who were boys or in the 12th grade, but for race/ethnicity, students falling into the other category (13.9%), as well as Hispanic students (13.5%), reported the highest prevalence of current hookah use. Students with current asthma (8.9%) had a significantly higher prevalence of current hookah use than those students who reported never having asthma (7.2%) (Table 6). When examining perception of harm, students with lifetime asthma had a statistically significant association of believing hookah smoking is less harmful than cigarette smoking versus students without lifetime asthma (16.1% vs. 14.4%, respectively) and (χ 2 = 6.02, p = .014). When examining perception of harm, students with current asthma (14.8%) did not have a statistically significant association of believing hookah smoking is less harmful than cigarette smoking versus students who never had asthma (χ 2 = 0.245, p = .62).

DISCUSSION Hookah is becoming more widely used and is frequently misperceived by adolescents and young adults as being a safer alternative to cigarette smoking.5 Asthmatic adolescents are more vulnerable to the negative pulmonary effects of hookah smoking due to their underlying airway compromise. In this study, we hypothesized that asthmatic adolescents with lifetime asthma experimenting with hookah use may utilize hookah smoking at different rates to those adolescents who do not report having lifetime asthma. Subsequently, this study found that students with lifetime asthma had a significantly higher prevalence © 2014, American School Health Association

of hookah use than students without asthma, for both lifetime and current use. We also hypothesized that students with asthma have similar misperceptions of hookah as a safer alternative to cigarette smoking as do students without asthma. This study provided evidence that students with asthma actually perceive hookah smoking as being less harmful than cigarette smoking at a higher rate than students without asthma. It is imperative to note the harmful effects that hookah has on the lungs, and the entire respiratory system. Because asthma is an inflammatory process on the respiratory system, further research is required to evaluate the effects of hookah smoking at the airway, alveolar, and cellular level.5 More information is needed to examine if there is irreversible damage to the airways when cells are already compromised and denuded from asthma. More research is needed to examine long-term effects or if there is irreversible damage that might occur during this time. This study indicated that, among students who reported having lifetime asthma, the prevalence of lifetime asthma spans all sex, ethnic, and grade levels. For lifetime asthmatics, those who reported as Hispanic ethnicity had a higher prevalence of current and ever smoking hookah. This study also found an increase in hookah smoking lifetime asthmatics as grade level increased. There are similar increases of cigarette smoking with age as found in previous asthma studies.37,38 This study confirmed that among lifetime asthmatics there is a higher prevalence of boys currently and having ever smoked hookah compared to girls. Other studies show boys are more likely to smoke hookah.39 When examining harmful behaviors and prevalence, boys are significantly more likely to participate in unhealthy activities.11,39 Attention needs to be focused on adolescents with chronic conditions who are choosing to participate in behaviors in which they perceive as less risky, when in fact they are harmful and unhealthy. Further, we must recognize and assess risky behavior choices in adolescents when diagnosed with a chronic condition, and begin to both understand the underlying reasons for uptake and to tailor educational interventions on specific populations. In recent literature, an association was identified in socioeconomic status and health behaviors with adolescents.40 Although this study did not assess economic status in the families of adolescents, we must recognize the vulnerability of adolescents and consider the emerging risky and novel behaviors like hookah use. This analysis was the first to assess the prevalence of current and ever hookah use differences among asthmatic and nonasthmatic adolescents by sex, ethnicity, and grade level. These findings help to look categorically at groups who could best be targeted with specific education and interventions. Journal of School Health



Our findings indicate a need for social marketing campaigns utilizing audience segmentation, especially considering the steady increase of Hispanics in Florida. It is estimated that by 2030, the Hispanic population will increase from 22% to 26% of the total Florida population.41 Limitations This is one of the first studies to examine asthma and hookah smoking in large population of adolescents. The data utilized for this study relied on adolescent self-report and inherent in self-report data is the uncertainty of truthfulness of responses. It is possible with certain behaviors that underreporting could occur in this population; however, we were not able to assess validity and/or reliability in this secondary data set. Another limitation is this data set was for students attending public schools in Florida and the generalizability to other population is limited. Furthermore, the data may not represent or be representative of all students with asthma if there is stigma associated with disease labeling. Future studies would need to explore barriers to student’s responses to these types of studies and benefits to students to report truthful responses. Conclusion Consistent with previous studies conducted among college students, hookah smoking is viewed as a less harmful form of smoking when compared to cigarettes.9,10 Given that this misperception of not being harmful was found in this sample of asthmatics, it may have led these asthmatic adolescents to smoking hookah. This uptake in smoking may contribute to increasing respiratory complications in asthmatic adolescents as compared to their nonasthmatic counterparts. Overall findings in this study identified that students with lifetime asthma had a significantly higher prevalence of believing that hookah smoking was less harmful than cigarette smoking and used higher rates of hookah than students without asthma. Widespread misperceptions of hookah smoking being less harmful are apparent in high schools in Florida and are elevated among students with asthma. Because hookah smoking poses a health risk to adolescents with asthma, more directed health information regarding the negative effects of hookah smoking are justified, but purposely among adolescents with asthma. Finally, hookah use among Hispanic boys is prevalent and needs to be further examined with interventions posed. Future quantitative research should explore and quantify the amount of carcinogens, pollutants, and harmful chemicals to determine the extent of filtering through the water base of the hookah device.

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Additionally, it would be important to understand potential difference in hookah tobacco products and flavors related to potential toxicity and do other liquids besides water moderate or mediate toxicity. Potential studies could also explore the effects of hookah smoking on the respiratory tissue regarding inflammation, mucus production, and the ciliary effects. Future research should involve multivariable analysis of predictors among current and lifetime asthmatics and investigate if there are differences between types of tobacco products. Future qualitative studies are needed to explore perceptions of hookah smoking among important others, such as parents, guardians, teachers, and health care leaders in the community. For intervention programs it would be important to improve understanding of youth’s smoking behaviors in terms of location, access to products or hookah bars, and frequency/duration of use. Given our findings, it would be important to examine potential predictors of hookah smoking among asthmatic youth to inform health campaigns. Finally, the findings indicate a high prevalence rate of lifetime asthma for the ‘‘other’’ ethnicity. To address health disparities, it would be important to further explore asthma among minority populations and multiethnic populations.

IMPLICATIONS FOR SCHOOL HEALTH These findings support the need for additional education regarding the real risks of hookah smoking. In particular, we must begin education among all adolescents and families, but in particular Hispanic families, on this novel form of tobacco smoking. Not only do the typical triggers and treatment of asthma need to be considered for adolescents with asthma, but also modifiable health risk behaviors should be addressed in this population to help reduce tobacco consumption. Social marketing strategies using audience segmentation approaches are needed to gather formative data to develop targeted marketing and messaging toward Hispanic boys in high school. Education about the negative health effects of hookah use should be provided for students as early as middle school in order to educate them on the ill effects, as hookah use increases with grade level. This is especially important among those students who have chronic respiratory conditions, as these individuals could fare much worse from the consequences of inhaling large amounts of smoke laden with chemicals, heavy metals, and tar. As asthma is an inflammatory process in the lungs, the potentially harmful effects that hookah use has on the lungs, and the entire respiratory system must be assessed. Dispelling the myths that surround hookah use, such as it being a safer alternative or that the water filters the nicotine, is paramount in 340 •

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both educating adolescents and helping them make informed decisions. As with the trend of cigarette smoking, educators must encourage nonsmoking hookah behaviors from becoming more of the norm. With tobacco usage down in current years, parents, educators, and health care professionals must stay attuned to other forms of tobacco-smoking behaviors that carry misperceptions of safety and that are likely to impact students with asthma. Human Subjects Approval Statement The study protocol was reviewed and approved by the Institutional Review Board at The University of Tampa.

REFERENCES 1. Centers for Disease Control and Prevention. Smokingattributable mortality, years of potential life lost, and productivity losses—United States, 2000-2004. MMWR Morb Mortal Wkly Rep. Available at: http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5745a3.htm. Accessed May 1, 2013. 2. Centers for Disease Control and Prevention. Youth and tobacco use. 2013. Available at: http://www.cdc.gov/tobacco/data_ statistics/fact_sheets/youth_data/tobacco_use/index.htm. Accessed March 14, 2013. 3. Gilman S. Smoke: A Global History of Smoking. London, UK: Reaktion Books; 2004. 4. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control. 2004;13(4):327-333. 5. Cobb C, Ward K, Maziak W, Shihadeh A, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav. 2010;34(3):275-285. 6. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking direct comparison to toxicant exposure. Am J Prev Med. 2009;37:518-522. 7. Lipkus IM, Eissenberg T, Schwartz-Bloom RD, Prokhorov AV, Levy J. Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine Tob Res. 2011;13(7):599-610. 8. Noonan D, Patrick ME. Factors associated with perceptions of hookah addictiveness and harmfulness among young adults. Subst Abuse. 2013;34(1):83-85. 9. Sutfin E, McCoy T, Reboussin B, Wagoner K, Spangler J, Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend. 2011;115(1-2):131-136. 10. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med. 2008;36(1):81-86. 11. Smith JR, Novotny TE, Edland SD, Hofstetter CR, Lindsay SP, Al-Delaimy WK. Determinants of hookah use among high school students. Nicotine Tob Res. 2011;13(7):565-572. 12. World Health Organization (WHO). Tobacco Use in Shisha: Studies on Waterpipe Smoking in Egypt. Geneva, Switzerland: WHO; 2007. 13. Sepetdjian E, Shihadeh A, Saliba NA. Measurement of 16 polycyclic aromatic hydrocarbons in narghile waterpipe tobacco smoke. Food Chem Toxicol. 2008;46(5):1582-1590. 14. Katurji M, Daher N, Sheheitli H, Saleh R, Shihadeh A. Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique. Inhal Toxicol. 2010;22(13):1101-1109.

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15. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, ”tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol. 2005;43:655-661. 16. Lim BL, Lim GH, Seow E. Case of carbon monoxide poisoning after smoking shisha. Int J Emerg Med. 2010;11(2):121-122. 17. La Fauci G, Weiser G, Steiner IP, Shavit I. Carbon monoxide poisoning in narghile (water pipe) tobacco smokers. CJEM. 2012;14(1):57-59. 18. Uyanik B, Arslan ED, Akay H, Ercelik E, Tez M. Narghile (hookah) smoking and carboxyhemoglobin levels. J Emerg Med. 2011;40(6):679. 19. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics. 2005;116(1):e113119. 20. Shihadeh A, Salman R, Jaroudi E, et al. Does switching to a tobacco-free waterpipe product reduce toxicant intake? A crossover study comparing CO, NO, PAH, volatile aldehydes, ”tar” and nicotine yields. Food Chem Toxicol. 2012;50(5):14941498. 21. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;39(3):834-857. 22. Jabbour S, El-Roueiheb Z, Sibai A. Nargileh (water-pipe) smoking and incident coronary heart disease: a case-control study. Ann Epidemiol. 2003;13(8):570. 23. Kiter G, Ucan ES, Ceylan E, Kilinc O. Water-pipe smoking and pulmonary functions. Respir Med. 2000;94(9):891-894. 24. Ben Saad H, Khemis M, Bougmiza I, et al. Spirometric profile of narghile smokers. Rev Mal Respir. 2011;28(7):e39-e51. 25. Waked M, Khayat G, Salameh P. Chronic obstructive pulmonary disease prevalence in Lebanon: a cross-sectional descriptive study. Clin Epidemiol. 2011;3:315-323. 26. Maziak W, Ward KD, Eissenberg T. Factors related to frequency of narghile (waterpipe) use: the first insights on tobacco dependence in narghile users. Drug Alcohol Depend. 2004;76(1):101-106. 27. Primack BA, Walsh M, Bryce C, Eissenberg T. Water-pipe tobacco smoking among middle and high school students in Arizona. Pediatrics. 2009;123(2):e282-288. 28. Barnett T, Curbow B, Weitz J, Johnson T, Smith-Simone S. Water pipe smoking among middle and high school students. Am J Pub Health. 2009;99(11). 29. Florida Department of Health (FDOH). Florida Youth Tobacco Survey. 2013. Available at: http://www.doh.state.fl.us/Disease _ctrl/epi/Chronic_Disease/FYTS/Intro.htm. Accessed February 13, 2013. 30. Florida Department of Health. Youth Hookah Use. 2013. Available at: http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_

Journal of School Health



31.

32.

33.

34.

35. 36. 37.

38.

39.

40.

41.

42.

43.

44.

Disease/FYTS/2012_FYTS/FS9-Hookah.pdf. Accessed May 1, 2013. Butz AM, Halterman JS, Bellin M, et al. Factors associated with second-hand smoke exposure in young inner-city children with asthma. J Asthma. 2011;48(5):449-457. Halterman JS, Borrelli B, Tremblay P, et al. Screening for environmental tobacco smoke exposure among inner-city children with asthma. Pediatrics. 2008;122(6):1277-1283. Gonzalez-Barcala FJ, Pertega S, Sampedro M, et al. Impact of parental smoking on childhood asthma. J Pediatr (Rio J). 2013;89(3):294-9. Kit BK, Simon AE, Brody DJ, Akinbami LJ. US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma. Pediatrics. 2013;131(3):407-414. Florida Asthma Coalition. 2013. Available at: http://florid aasthmacoalition.com/. Accessed May 1, 2013. SAS software. 2013. Available at: http://www.sas.com/. Accessed March 15, 2013. Van De Ven MO, Engels RC, Sawyer SM. Asthma-specific predictors of smoking onset in adolescents with asthma: a longitudinal study. J Pediatr Psychol. 2009;34(2):118-128. Cory S, Ussery-Hall A, Griffin-Blake S, et al. Prevalence of selected risk behaviors and chronic diseases and conditionssteps communities, United States, 2006-2007. MMWR Surveill Summ. 2010;59(8):1-37. Aljarrah K, Ababneh Z, Al-Delaimy W. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009;5(16):1-7. Hanson MD, Chen E. Socioeconomic status and health behaviors in adolescence: a review of the literature. J Behav Med. 2007;30(3):263-285. Yearbook of Immigration Statistics. 2009. Available at: http:// www.dhs.gov/xlibrary/assets/statistics/yearbook/2008/ois_ yb_2008.pdf. Accessed May 1, 2013. Tobacco Free Kids. Harm to Kids From Secondhand Smoke. 2012. Available at: http://www.tobaccofreekids.org/research/ factsheets/pdf/0104.pdf. Accessed May 1, 2013. American Cancer Society. Secondhand Smoke Mass Media Campaigns—Lessons Learned Globally. 2013. Available at: http:// www.cancer.org/aboutus/globalhealth/globaltobaccocontrol/ acsinternationaltobaccocontrolgrantprograms/fctcresearch grants/shs_media_campaigns. Accessed May 1, 2013. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Surgeon General’s Report. 2006. Available at: http://www.surgeongeneral.gov/library/reports/secondhand smoke/index.html. Accessed May 1, 2013.

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