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Official websites use. Share sensitive information only on official, secure websites. Correspondence concerning this article should be addressed to Robyn L. Better understanding of the temporal sequence of hookah, cigarette, and marijuana use will help to inform smoking prevention efforts. To address this gap in the literature, we assessed all three of these smoking behaviors in a sample of first-year college women. The initial i. We controlled for sensation-seeking, impulsivity, binge drinking, and other smoking behaviors in our multivariate logistic regression models. The findings highlight the co-occurrence of smoking behaviors as well as the need for bundling preventive interventions so that they address hookah, cigarette, and marijuana use. Smoking behaviors, including cigarette, marijuana, and hookah use, all undermine the health of young people. Cigarette smoking and marijuana use have been well-characterized in the United States. Much is known about the antecedents of both cigarette smoking U. However, less is known about hookah use in the U. Given that all three behaviors involve smoking, it is reasonable to consider whether initiation of one might predispose to initiation of another. Hookah use has been increasing worldwide Akl et al. Hookah lounges, now ubiquitous in college towns Sutfin et al. Hookah smoking is less common among Americans beyond traditional college age i. Thus, the college years appear to be a particularly high risk period for hookah experimentation. Hookah tobacco smoking is a growing public health concern Cobb et al. Research on the health effects of hookah smoking indicates a harmful impact on lung function Raad et al. Research suggests there may be gender differences in patterns of hookah use. Several studies with adolescent samples have found that boys are more likely to report lifetime use of hookah compared to girls Barnett et al. Hookah smoking has been associated with cigarette smoking Barnett et al. Hookah tobacco use may lead to uptake of cigarette smoking. Indeed, hookah, with its flavored tobacco and smoother smoke, may introduce non-smokers to nicotine in a manner that is less harsh than cigarettes. Over time, because hookah smoking requires an apparatus and is time-consuming Braun et al. Hookah use may also re-introduce those who have already quit smoking to tobacco, triggering relapse Maziak, Because hookah smoking delivers nicotine, it confers risk for tobacco dependence Cobb et al. Alternatively, cigarette smokers who try hookah may favor the latter given the flavored tobacco and less harsh smoke, leading them to substitute hookah smoking for cigarette use. Hookah smoking is also associated with marijuana use Braun et al. Hookah and marijuana use reflect similar motives, such as social enhancement, relaxation, and experimentation Braun et al. Peer influence can create availability and exposure opportunity Pinchevsky et al. Also, the route of administration may be a factor, as some hookah users smoke marijuana out of the same waterpipe they use for tobacco Smith-Simone et al. As with cigarette use, hookah and marijuana use may both be related to a shared genetic predisposition to disinhibition, general problem behavior, and substance use Agrawal et al. Only two longitudinal studies have explored hookah as a predictor of cigarette use. The second sampled Jordanian adolescents and found that hookah smokers were twice as likely as non-smokers to become cigarette smokers two years later Mzayek, et al. Interestingly, in the latter study, the reverse pattern was also true; that is, cigarette smokers were twice as likely as non-smokers to become hookah smokers, but this association was not statistically significant. To our knowledge, no longitudinal studies have sampled Americans or college students or examined hookah as a predictor of marijuana use. The primary purpose of this study was to examine the relationship between hookah tobacco smoking and a cigarette and b marijuana use using a prospective design. We focused on women because tobacco use patterns differ by gender Branstetter et al. Using data from a larger study of women, we examined pre-college hookah use as a predictor of initiating cigarette and marijuana use during the first year of college. The secondary purpose of this study was to examine pre-college cigarette and marijuana use as a predictor of initiating hookah use during the first year of college. To control for a general propensity toward substance use, we controlled for binge drinking as well as two personality constructs that have been linked to smoking behaviors viz. We did not make any predictions for the opposite direction of effect. The sample size was chosen to reach a large proportion of the population while maintaining feasibility. On average, participants were We focused this investigation on the academic year given the link between higher rates of hookah smoking and the presence of hookah cafes in college towns Sutfin et al. We used a prospective cohort design with a baseline survey and eight monthly follow-up surveys waves 2—9. The study was conducted at a private university in upstate New York. Participants were recruited for the larger study via a mass mailing sent to incoming first-year female students supplemented with campus flyers, word of mouth, and the psychology department research pool. Eligibility criteria were: at least 18 years of age, first-year student, and not a scholarship athlete excluded due to National Collegiate Athletic Association policies. Interested women signed up on a website, were screened to ensure eligibility, and attended an orientation, at which time research staff explained study procedures and obtained written informed consent, and participants completed the baseline survey on lab computers. Follow-up surveys were administered online using a secure survey website. On the last day of each month, participants received emails containing an embedded link to a confidential survey. Follow-up surveys required 10—20 minutes to complete, and participants had one week to respond. Survey responses were linked over time by unique identification codes, and identifying information was stored separately to protect privacy. Participants who missed surveys could resume participation with the next available survey. At baseline, participants provided their age, race, ethnicity, and two personality variables. We included sensation-seeking and impulsivity in our models as covariates. For all substance use measures, specific anchor dates e. At every assessment, participants indicated whether they had smoked a cigarette even one puff in the last month; if so, they were asked the number of cigarettes they smoked each day in a typical week in the last month. Due to the low frequency of smoking in our sample, we used number of days of cigarette smoking per typical week for pre-college cigarette use as a predictor. We also created a dichotomous indicator of pre-college cigarette use for classification purposes. At baseline, participants indicated the number of times they had ever used marijuana in their entire lives; this frequency variable served as the pre-college marijuana use predictor. At each follow-up, participants indicated on how many days in the last month they used marijuana. To be consistent with the other outcomes, we created a dichotomous indicator of marijuana initiation during the first year of college collapsing across waves 2—9 for our outcome variable; we also created a dichotomous indicator of pre-college marijuana use for classification purposes. At baseline, participants indicated on how many days in the last month they had four or more standard drinks of alcohol on one occasion i. We used this variable as a covariate. We tested demographics as potential covariates of hookah, cigarette, and marijuana initiation using logistic regression. Alpha was set a priori at. Based on prior research and theory, we controlled for impulsivity, sensation-seeking, and binge drinking in all analyses. Because of our research question i. By excluding these participants, within each predictive analysis, we had a true prospective design with pre-college or baseline use of the predictor substance occurring before initiation of the predicted substance. We used binary logistic regression for the primary analyses, with continuous indicators of pre-college substance use: pre-college lifetime number of instances of hookah and marijuana use and baseline typical week in the last month number of days of cigarette smoking. We ran three separate multivariate logistic regression models with dichotomous outcomes of initiation of substance use during the first year of college. For hookah and marijuana use, the outcome of interest was initiation, or the first ever use of the substance. However, because we did not assess lifetime cigarette use at baseline, the outcomes of interest for cigarette smoking were initiation or resumption after at least one month of non-use. Multivariate models controlled for personality i. Predictors were mean-centered to facilitate interpretation. Table 1 displays the prevalence of initiation of each smoking behavior during the first year of college among women who reported no pre-college use of each substance. Pre-college marijuana use was also a significant predictor. Controlling for covariates, pre-college hookah use did not predict initiation of marijuana use during the first year of college see Table 3. Only impulsivity and pre-college binge drinking predicted initiation of marijuana use. Controlling for covariates, pre-college marijuana use, but not baseline cigarette use, significantly predicted initiation of hookah tobacco use during the first year of college see Table 4. Pre-college binge drinking was also predictive of hookah initiation. This study—the first prospective study to test the association between hookah and cigarette use among American students and to test the association between hookah and marijuana use—produced three main findings. In contrast, tests of the reverse relationship did not support the idea that pre-college cigarette use predicts initiation of hookah tobacco smoking. Our results corroborate findings from two previous studies of hookah predicting later cigarette smoking Jensen et al. Collectively, these three studies provide some evidence that hookah tobacco use may precede initiating or resuming cigarette smoking. Hookah smoking may increase risk for initiating cigarette smoking by introducing non-smokers to nicotine. Because users inhale nicotine, hookah tobacco smoking presents potential for nicotine dependence Cobb et al. Hookah users may supplement their use with cigarette smoking, or switch methods, in an attempt avoid withdrawal symptoms or cravings Rastam et al. Cigarettes are more convenient than hookah; they are easily accessible, highly portable, and less time-consuming. In contrast, for some, hookah smoking may only be accessed at a hookah lounge, and it requires a waterpipe apparatus and, on average, 45 minutes Braun et al. Hookah use may also re-expose those who have previously quit smoking cigarettes to nicotine, perhaps resulting in resumed cigarette smoking Maziak, Furthermore, being in settings where friends are partying may present more opportunities to try cigarettes. Third, the hypothesis that hookah tobacco smoking increases the likelihood of marijuana initiation was not supported. Marijuana use may lead to more positive attitudes towards substances and greater access through peers to substance use opportunities, including hookah. This is the first study to examine hookah as a predictor of marijuana initiation, so these results need to be replicated. The absence of a link from hookah to marijuana use may be related to the context and legality of use. Many youth smoke hookah at hookah lounges Sutfin et al. Exposure to hookah culture may not be sufficient to reduce barriers to illicit drug use for most youth, so they are unlikely to transition from hookah to marijuana. However, in practice it is challenging to test the gateway theory empirically. Longitudinal studies that enrolled participants prior to hookah, cigarette, and marijuana initiation would be necessary to evaluate this hypothesis in a methodologically rigorous way. Given that smoking behaviors can begin very young, researchers would need to recruit youth early e. Retaining samples and obtaining funding for such long-term and large-scale studies would be difficult. Research designed to test competing theories will benefit prevention science. This view posits that the so-called gateway pattern of substance use reflects, at least in part, unmeasured common causes rather than causal effects of specific drugs on subsequent use of others. For instance, tobacco and marijuana use may result from individual differences e. The common liability model has received some empirical support and appears to be more parsimonious than the gateway model Lynskey et al. An even more parsimonious perspective focuses on the route of drug administration. It will be helpful for future studies to directly compare these different theoretical frameworks to evaluate their relative value. This co-occurrence of health compromising behaviors suggests the need for bundling health education, promotion, and prevention interventions Ickovics, , or identifying a sequence of approaches that aligns with the behavior development process Prochaska, Several methodological strengths enhance confidence in our results. Second, we followed a large sample of young women during the transition to college, which is an important developmental period that may be a vulnerable time for initiating hookah use Fielder et al. Fourth, we used monthly surveys of substance use behavior to reduce recall burden and improve reliability of self-reports. Fifth, in our analyses, we controlled for other forms of substance use, as well as personality characteristics, to rule out alternative explanations. Limitations of this study suggest directions for future research. First, we recruited only first-year female students from one university, which may limit the generalizability of our findings. To enhance generalizability, future research should sample male and female students from multiple regions of the country, community college students, and non-college attending young adults. Third, owing to our use of data from a broader study, the substance use measures were more general than would be optimal. For example, we did not have a measure of lifetime cigarette use at baseline, and we relied on dichotomous outcomes of smoking initiation. Future studies might assess a wider range of substances and obtain more fine-grained estimates and counts of recent and lifetime use. Although hookah smoking has been associated with poor health outcomes Akl et al. Thus, from a public health perspective, it is more important to focus on frequency of use. Future studies spanning longer follow-ups should use count measures. More comprehensive measures of sensation-seeking and impulsivity may also be useful. Overall, the findings provide mixed support for the notion that hookah tobacco use leads youth to initiate other substance use. In this sample of college women, pre-college hookah smoking increased risk for initiating or resuming cigarette smoking, but not for initiating marijuana use, during the first year of college. In addition, pre-college marijuana use increased risk for initiating hookah tobacco use. If replicated, these findings have public health implications. Identifying risk factors for cigarette initiation is critical because cigarette smoking is responsible for one out of every five deaths in the U. Moreover, the prospective link between different forms of smoking behavior is concerning. Research suggests that co-morbid smoking e. These findings have implications for health promotion and disease prevention. For example, they point to the value in educating young people about the potential pathway from hookah to cigarettes. In addition, because many youth mistakenly perceive hookah smoking to be less harmful than cigarettes Nuzzo et al. Identifying unique and common pathways to substance use initiation can strengthen prevention and treatment approaches for all addictive substances. NIAAA had no role in the study design, data collection, data analysis or interpretation, writing of the manuscript, or the decision to submit the manuscript for publication. At the time of data collection, all authors were with the Center for Health and Behavior at Syracuse University. The authors thank Annelise Sullivan for her assistance with data collection. Robyn L. Fielder, Kate B. Carey, and Michael P. Carey designed the study. Fielder collected and analyzed the data, reviewed the literature, and wrote the first draft of the manuscript. All authors contributed to and critically reviewed the manuscript, and all have approved the final manuscript. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. As a library, NLM provides access to scientific literature. Addict Behav. Published in final edited form as: Addict Behav. Find articles by Robyn L Fielder. Find articles by Kate B Carey. Find articles by Michael P Carey. Issue date Nov. All rights reserved. The publisher's version of this article is available at Addict Behav. Open in a new tab. Contributors Robyn L. Conflict of Interest All authors declare that they have no conflicts of interest. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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