Waterpipe use among high school students in Ontario: demographic and substance use correlates.
Hamilton, Hayley A. ; Ferrence, Roberta ; Boak, Angela 等
Public health efforts targeting the reduction of tobacco cigarette
smoking have generally been successful, cigarette smoking being at a low
point among youth. (1) There are increasing concerns, however, that
other forms of tobacco consumption, such as waterpipe smoking, are
increasing along with associated health risks. (2,3)
The health risks associated with waterpipe tobacco smoking are
generally expected to be similar to those of tobacco cigarette smoking.
(4,5) Research indicates that the smoke from waterpipes contains large
amounts of toxic ingredients, including carbon monoxide and polycyclic
aromatic hydrocarbons (benzene), as well as tar and nicotine. (5,6)
Health risks associated with waterpipe smoking include cancer, (3,7-9)
respiratory disease, (7-10) nicotine dependence, (7,9,10) periodontal
disease (8) and low birth weight or other adverse fetal outcomes. (7-9)
Research suggests that tobacco-free waterpipe products are also
associated with health risks, such as damage to lung cells. (11) In
addition, communicable diseases are a concern when a waterpipe
mouthpiece is shared if smoking occurs in groups. (7,9)
Despite concerns about waterpipe smoking, there are limited data on
the demographic characteristics associated with waterpipe use in younger
populations. The introduction of highly flavoured tobacco mix, the
advent of waterpipe stores and hookah bars, and the marketing of
waterpipe smoking as a social event have contributed to the popularity
of waterpipes. (12) US research suggests that approximately 28% of
college students had smoked a waterpipe in the previous year, with
lifetime use as high as 46%. (13) There is also evidence that males,
users of tobacco cigarettes and individuals of Arab ethnicity have
greater odds of waterpipe smoking. (14)
There is less research on waterpipe use among younger students, but
figures from a 2006 study indicate that 7% of middle and high school
students in Canada had used a waterpipe to smoke tobacco in their
lifetime and 3% had done so in the previous 30 days. (15) US research
shows that 4% of middle and 11% of high school students had smoked
tobacco from a waterpipe in their lifetime (16) and 18% to 21% of high
school seniors had engaged in waterpipe tobacco smoking in the previous
year. (17,18) Prevalence of use among adolescents is particularly
important to consider, because the increase in the popularity of
waterpipe use among their slightly older peers (13) heightens the risk
that adolescents will adopt the behaviour, thus increasing concerns
about associated health risks including the impact of nicotine on brain
development in adolescents. (19) There is also little research on the
association between waterpipe smoking and the use of other common
substances, with the exception of tobacco cigarettes. Given that
substance use tends to cluster within individuals (20) and that
waterpipe smoking often occurs in social groups and settings, (21) it is
important to examine the association of this type of smoking with
alcohol and electronic cigarette (e-cigarette) use, the latter of which
is also increasing in popularity. (22) This study examines the
prevalence of waterpipe smoking among Ontario high school students as
well as the demographic and substance use correlates.
METHOD
Data
Data for this study were derived from the 2013 Ontario Student Drug
Use and Health Survey (OSDUHS), a province-wide survey of students in
grades 7 through 12 attending publicly funded schools in Ontario.
Conducted every two years since 1977, this repeated cross-sectional
survey monitors substance use, mental and physical health, gambling and
delinquent behaviour. The 2013 survey, based on a stratified two-stage
(school, class) cluster design, consisted of 10,272 students, 198
schools and 671 classrooms. Overall, 61% of selected schools and 87% of
selected classes participated in the survey. Sixty-three percent of
students in participating classes completed an in-class questionnaire,
(1) which is considered above average for a student survey requiring
active parental consent. (23) Absenteeism (11%) and parental refusal or
unreturned consent forms (26%) were the main reasons for non-completion.
Comparisons of drug use prevalence between classes with lower versus
higher response rates indicated no appreciable difference in drug use
between groups.
Within each classroom, two versions of the questionnaire, with
about one-half of the content common to both, were randomly distributed
to students. The question on waterpipe use was included in one version
of the questionnaire and thus was only asked of a random half-sample of
students. The analyses presented here were restricted to 2,873 high
school students in grades 9 through 12 who were 19 years of age or
younger. Additional information on the study design and methods is
provided elsewhere. (1) The 2013 OSDUHS was approved by the Research
Ethics Boards of the Centre for Addiction and Mental Health as well as
York University.
Measures
Waterpipe use was determined from the question: "In the LAST
12 MONTHS, how often did you smoke a WATERPIPE (also known as a hookah,
shisha, hubble-bubble, gouza)?" Response choices ranged from
"Only a few puffs once just to see what it's like" to
"40 or more times". Additional response choices were
"Used, but not in the last 12 months", "Never used in
lifetime" and "Don't know what a waterpipe is". A
dichotomous measure was constructed to reflect waterpipe smoking one or
more times in the preceding 12 months (excludes a few puffs) versus no
waterpipe smoking (includes those who had had only a few puffs of a
waterpipe and those who had never heard of a waterpipe).
Additional substances were also considered in the analyses. The
smoking of tobacco cigarettes was constructed as a dichotomous measure
reflecting not smoked versus smoked in the previous 12 months (excludes
a few puffs). Ever use of e-cigarettes was a dichotomous measure
reflecting use or non-use and was derived from the following question:
"Electronic cigarettes, or e-cigarettes, are electronic devices
made in the shape of cigarettes that create an inhaled mist without
odour. Have you ever smoked at least one puff from an ELECTRONIC
CIGARETTE?" Alcohol use in the previous 12 months was constructed
as a 3-category measure--non-use, special occasion use and regular use.
Students who had never drunk alcohol, had not drunk in the previous 12
months or had only had a sip of alcohol were classified as non-drinkers.
Drinking on special occasions only was classified as occasional
drinking. Drinking outside of special occasions was classified as
regular drinking.
Sex (male/female), grade (9-12), and ethnic and racial background
were included as additional covariates in analyses. Ethnic and racial
background was constructed from a question asking students to choose one
or more of 11 categories that best described their background. (24) For
descriptive purposes, students who selected a single response were
grouped into five larger categories: White/Caucasian, Black/African,
East Asian, South Asian and Other. Multiple responses across the five
categories (7.8% of the sample) were coded as "Other". In
multivariate analyses, categories were further reduced to two
(White/Caucasian versus non-White) because the limited sample precluded
more specific racial or ethnic categories.
Statistical analysis
Design-based survey estimation within Stata 1325 was used in all
analyses to adjust for the stratified and clustered complex survey
design. Analyses included sampling weights to adjust for unequal
probability of selection. (1) The associations between waterpipe smoking
and other substance use, as well as demographic covariates, were
examined using multivariate logistic regression. Missing data within the
logistic regression represented 2.4% (70 cases) of the sample and were
handled through listwise deletion.
RESULTS
The sample of high school students had a mean age of 16 years,
52.1% were male, and 60.4% were of White or Caucasian background. An
estimated 12.5% (95% confidence interval [CI]: 10.6%-14.7%) of students
reported using a waterpipe in the previous year (excludes a few puffs),
compared with 11% (95% CI: 8.8%-13.7%) who reported smoking a tobacco
cigarette in the previous year. An additional 68.4% of high school
students were aware of waterpipes but had not used one in the previous
year, and 19.1% had never heard of waterpipes. The frequency of
waterpipe use varied considerably, with 4.5% of Ontario students using
1-2 times and 3.3% using 20 times or more in the previous year (Table
1). An examination of lifetime use found that 14.4% (95% CI:
12.3%-16.7%) of students had used a waterpipe in their lifetime (not
presented in table). Thus, only 1.9% of students had used a waterpipe in
their lifetime but not in the previous year.
Bivariate analyses of waterpipe use by demographic characteristics
and cigarette and alcohol use showed significant associations (Table 2).
Waterpipe use was more prevalent among males (14.4%); among students in
higher grades (18.8% among 12th graders); and among those who smoked
conventional tobacco cigarettes (44.4%), had ever used e-cigarettes
(35.3%) and drank alcohol regularly (25%). Waterpipe use was less
prevalent among students of East and Southeast Asian background (7.2%)
and Black/African background (estimates suppressed as a result of a high
coefficient of variation).
Analyses that examined other substance use among students who
reported past-year use of a waterpipe showed that a majority of
waterpipe users had not used a tobacco cigarette in the previous year
(59.9%, 95% CI: 50.4%-68.8%) and a majority had never used an
e-cigarette (58.8%, 95% CI: 51.5%-65.8%). In contrast, only 28.1% (95%
CI: 21.8%-35.2%) of past-year waterpipe users had not used alcohol
regularly in the previous year.
Results from the multivariate logistic regression analyses, with
waterpipe use as a binary measure of use versus nonuse, are outlined in
Table 3. Demographic characteristics and tobacco cigarette use were
included as covariates in Model 1; ever use of e-cigarette was added in
Model 2; and alcohol use was added in Model 3. Whereas the results for
most variables remained substantively consistent across the three
models, there were some differences for sex and racial background.
Findings for sex differences in Model 1, which included covariates for
demographic characteristics and tobacco cigarette use, indicated that
males had significantly greater odds of waterpipe use than females (odds
ratio [OR] = 1.40, CI = 1.01-1.94). However, sex differences were no
longer significant after adjusting for e-cigarette and alcohol use in
subsequent models.
The binary measure of racial background was significantly
associated with waterpipe use, but only after adjusting for alcohol use.
This association is evident in Model 3, in which the odds of waterpipe
use were greater among non-White/non-Caucasian students (OR = 1.89, CI =
1.18-3.01). Thus, lower alcohol use among non-White/non-Caucasian
students suppressed the association between racial background and
waterpipe use in earlier models that failed to show significant
differences.
Substantively, the findings for school grade, tobacco cigarette use
and ever use of e-cigarettes were similar across the models in Table 3.
The findings for school grade indicated a significant association with
waterpipe use in each of the three models. This association was
highlighted by findings that students in Grades 11 and 12 had more than
twice the odds of waterpipe use (OR = 2.29, CI = 1.31-3.97 and OR =
2.47, CI = 1.48-4.14 respectively) than Grade 9 students (see Model 3).
Findings for cigarettes indicated that students who used tobacco
cigarettes had greater odds of waterpipe use, although the OR estimate
was much reduced after controlling for other substance use, specifically
e-cigarettes and alcohol (Model 3; OR = 4.10, CI = 2.36-7.12). With
regard to e-cigarettes, students who had ever used e-cigarettes had
greater odds of waterpipe use. This association between e-cigarettes and
waterpipe use remained even after controlling for regular alcohol use
(Model 3; OR = 3.48, CI = 2.40-5.06).
The association between regular alcohol use and waterpipe use is
highlighted in Model 3. Students who drank alcohol regularly had greater
odds of waterpipe use than those who never drank (OR = 3.58, CI =
2.22-5.77). However, there was no significant difference in waterpipe
use between those who drank occasionally and those who never drank.
DISCUSSION
The current study found that the prevalence of waterpipe use was
similar to that of tobacco cigarette use among high school students.
Overall, 12.5% of high school students (1 in 8) had used a waterpipe in
the previous year, and 14.4% (1 in 7) had used a waterpipe in their
lifetime. The minor difference in prevalence between past-year and
lifetime use highlights the popularity of waterpipes, in that most
students who had used the device continued to do so; alternatively, the
difference suggests a recent diffusion of waterpipe use among these
students. These figures are generally higher than in some reports of
lifetime (16,26) and current waterpipe tobacco smoking (26) among high
school students, although the latter studies tend to focus on 30-day
rather than past-year use. Previous research, however, has also
indicated a higher prevalence of waterpipe tobacco use among high school
students than that reported for waterpipe use generally in the current
study. (27)
It is noteworthy that 1 in 5 students had never heard of a
waterpipe (or hookah), which is slightly higher than the 17% reported in
a recent US study. (27) This suggests a potential for waterpipe use to
increase once awareness and popularity expand in this age group. The
social aspect of waterpipe use, the increasing number of hookah cafes
and the introduction of highly flavored tobacco mixes have increased the
appeal of these devices. (28,29) Thus, there is a need to increase
awareness of the potential risks associated with waterpipe use.
Past-year prevalence of waterpipe use among high school students
was lower than estimates reported for college students in the US.
(10,13,14) However, the odds of waterpipe use were found to be greater
in older grades, with the prevalence of 19% among grade 12 students
similar to that found among college students. Thus, as with college
students, a sizeable proportion of older high school students have
embraced the use of waterpipes.
Our findings indicate that, after adjusting for demographic and
behavioural factors, waterpipe use did not vary between males and
females, but there was some variation by racial background. Research on
college students has often reported sex differences, (30) but other
studies involving college (10) and high school students have reported no
sex differences. (31) The findings that students of non-White or
non-Caucasian background had greater odds of waterpipe use are somewhat
consistent with those of other research showing broad racial or ethnic
differences in waterpipe use, (10,14,30,32) although the categories of
race or ethnicity compared often differed between studies. Students of
Arab descent, for example, have been found to have higher odds of
waterpipe use, (14) which tends to be attributed to their cultural
heritage, given the origins of waterpipe use. (28,29) The current study,
however, could not examine specific ethnic groups separately within
multivariate analyses, and thus the category of non-White or
non-Caucasian is a broad group consisting of several different racial or
ethnic groups.
The findings of this study indicate that tobacco cigarette,
e-cigarette and alcohol use were associated with greater odds of
waterpipe use. The findings with regard to tobacco cigarettes are
consistent with those of other research. (14,16,26,31,32) Like college
students, (10,32) many high school students who have used a waterpipe
have not smoked tobacco cigarettes (60%), suggesting that the two
behaviours are perceived differently. (14) This may relate to
students' heightened awareness of the risks of tobacco cigarette
use compared with the portrayal of waterpipe use as safer and a social
activity that can be enjoyed with peers. (26,30) Recent prospective
research findings that pre-college waterpipe use is associated with
later tobacco cigarette use suggest that waterpipe use may be a gateway
to tobacco cigarette smoking. (33)
The association between ever use of e-cigarettes and waterpipe use
is not surprising given that both e-cigarettes and waterpipes are
alternative smoking devices that have grown in popularity through
targeted marketing and social media. (12,22) As with tobacco cigarettes,
a large percentage (59%) of waterpipe users had never used an
e-cigarette. Although differing perceptions may be a factor, the social
context of waterpipe use may also differ from that of e-cigarette use.
Greater odds of waterpipe use among students who drink alcohol are
consistent with findings from other research. (20,33) Almost 3 of 4
students who used a waterpipe also drank alcohol regularly. While this
study cannot address whether waterpipe and alcohol use occurred at the
same time, it is consistent with other research that has highlighted a
clustering of substance use and other problem behaviours within
individuals. (20)
There are several limitations to this study. First, it is based on
cross-sectional data, and thus the temporal order of associations
between waterpipe use and the use of tobacco cigarettes, e-cigarettes
and alcohol cannot be determined. Longitudinal research on these
associations would contribute to understanding the temporal order and
potential causal pathways. Second, the survey question focused on
waterpipe use broadly and did not identify what substance was being
smoked in the waterpipe. Thus, it is possible that a substance other
than tobacco (e.g., cannabis, herbal waterpipe preparations that do not
contain tobacco) was used within the device. Research has indicated,
however, that health risks are associated with both tobacco and
tobacco-free waterpipe smoke. (11) Research is needed to examine the use
of waterpipes with different substances. Third, analyses involving race
or ethnicity were limited by sample size. More detailed examinations of
racial or ethnic differences would aid in a greater understanding of how
predictors of substance use may vary among groups and perhaps how they
diffuse across groups.
CONCLUSION
Despite public health concerns about the associated risks,
waterpipe use has become popular among high school students. This study
indicated that the percentage of students who used a waterpipe was
similar to the percentage using tobacco cigarettes. The increasing
proportion of students using waterpipes (12,18) indicates a need to
address the safety of individual use as well as the risk to others.
Increasing use may expose a greater proportion of the population to
secondary harms, particularly when tobacco is being smoked within a
waterpipe. (5) Direct harm from waterpipe use and concerns that such use
may elicit other health risk behaviours, including the use of other
substances, (33) are particularly important for high school students.
The co-occurrence of substance use behaviours places students at risk of
continued use over a longer period of time. As debates about safety
concerns and regulation needs continue, more research evidence is
necessary to guide policy and public health action.
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Received: August 29, 2014
Accepted: January 24, 2015
Hayley A. Hamilton, PhD, [1,2] Roberta Ferrence, PhD, [1,2,3]
Angela Boak, MA, [1] Shawn O'Connor, PhD, [2,3] Robert E. Mann,
PhD, [1,2] Robert Schwartz, PhD, [1,2,3] Edward M. Adlaf, PhD [1,2]
Author Affiliations
[1]. Centre for Addiction and Mental Health, Toronto, ON
[2]. Dalla Lana School of Public Health, University of Toronto,
Toronto, ON
[3]. Ontario Tobacco Research Unit, University of Toronto, Toronto,
ON
Correspondence: Hayley A. Hamilton, PhD, Centre for Addiction and
Mental Health, 33 Russell St., Toronto, ON M5S 2S1, Tel: [telephone]
416-535-8501, E-mail: hayley.hamilton@camh.ca
Funding sources: This research is based on the Ontario Student Drug
Use and Health Survey, a Centre for Addiction and Mental Health
initiative funded in part through ongoing support from the Ontario
Ministry of Health and Long-Term Care, as well as targeted funding from
several provincial agencies. The Ontario Tobacco Research Unit receives
funding from the Ontario Ministry of Health and Long-Term Care.
Conflict of Interest: None to declare.
Table 1. Estimates of past-year waterpipe use among Ontario
high school students, 2013 Ontario Student Drug
Use and Health Survey
Percentage 95% confidence n
of total * interval
Never used in past 12 months 68.4 65.3-71.3 2008
(includes 3.4% who reported a
few puffs once to see what it
was like)
1 or 2 times 4.5 3.6-5.7 134
3 to 9 times 3.6 2.8-4.5 114
10 to 19 times 1.1 0.7-1.8 32
20 or more times 3.3 2.3-4.8 73
Don't know what a waterpipe is 19.1 16.6-21.8 512
* N = 2873.
Table 2. Estimates of past-year waterpipe use among Ontario high
school students by demographic factors and substance use, 2013
Ontario Student Drug Use and Health Survey
Demographic Never used waterpipe
factors/substance use
Used waterpipe,
%
n = 353
Sex F (1.9, 190.7) = 3.5 ([dagger]) *
Male 14.4
Female 10.5
Grade F (4.5, 439.5) = 6.9 ([dagger]) ***
9 4.3
10 8.5
11 15.1
12 18.8
Ethnic/racial background F (6.5, 632.1) = 3.2 ([dagger]) **
White/Caucasian 12.7
Black/African -- ([double dagger])
East/Southeast Asian 7.2
South Asian 16.1
Other 16.2
Racial background F (1.9, 189.6) = 0.1 ([dagger])
White/Caucasian 12.7
Non-White/Other 12.7
Tobacco cigarette F (2, 195.7) = 56.3 ([dagger]) ***
use, past year
Not used 8.2
Used 44.4
E-cigarette use, ever F (1.9, 185.3) = 88.8 ([dagger]) ***
Not used 8.6
Used 35.3
Alcohol use, past year F (3.6, 351.2) = 36.2 ([dagger]) ***
None/sip 4.2
Occasional 7.4
Regular 25.0
Age F (1, 98) = 45.8 ([section]);
F(1,98) = 35.4 ([parallel]);
F (1, 98) = 3.9 ([paragraph])
Mean M = 16.7
95% CI 16.5, 16.8
Total % 12.5
95% CI 10.6, 14.7
Demographic Never used waterpipe
factors/substance use
Heard of but never Don't know what a
used, % waterpipe is, %
n = 2008 n = 512
Sex
Male 68.6 17.0
Female 68.2 21.3
Grade
9 70.7 25.0
10 70.8 20.7
11 68.1 16.8
12 65.4 15.8
Ethnic/racial background
White/Caucasian 68.7 18.7
Black/African -- ([double dagger]) -- ([double dagger])
East/Southeast Asian 64.8 28.0
South Asian 74.0 9.8
Other 64.9 18.9
Racial background
White/Caucasian 68.7 18.7
Non-White/Other 67.8 19.5
Tobacco cigarette
use, past year
Not used 71.0 20.7
Used 49.1 6.5
E-cigarette use, ever
Not used 70.0 21.4
Used 58.7 6.0
Alcohol use, past year
None/sip 70.9 24.9
Occasional 68.4 24.2
Regular 65.7 9.3
Age
Mean M = 16.0 M =15.8
95% CI 15.9, 16.1 15.6, 16.0
Total % 68.4 19.1
95% CI 65.3, 71.3 16.6, 21.8
Demographic Never used
factors/substance use waterpipe
Overall % of
sample
n = 2873
Sex
Male 52.1
Female 47.9
Grade
9 21.3
10 22.3
11 24.1
12 32.4
Ethnic/racial background
White/Caucasian 60.4
Black/African 5.5
East/Southeast Asian 8.7
South Asian 11.0
Other 14.3
Racial background
White/Caucasian 60.4
Non-White/Other 39.6
Tobacco cigarette
use, past year
Not used 89.0
Used 11.0
E-cigarette use, ever
Not used 85.4
Used 14.6
Alcohol use, past year
None/sip 39.0
Occasional 25.1
Regular 35.9
Age
Mean M= 16.0
95% CI 16.0, 16.1
Total %
95% CI
([dagger]) Pearson chi-square adjusted for the survey design and
transformed into an F-statistic (Rao-Scott F-statistic). Decimal
degrees of freedom are a consequence of the Rao-Scott
second-order design corrections.
([double dagger]) Percentage suppressed because of a high
coefficient of variation of students who used a waterpipe.
([section]) Adjusted Wald test showing significant difference
between used and not used a waterpipe.
([parallel]) Adjusted Wald test showing significant difference
between used and not heard of waterpipes.
([paragraph]) Adjusted Wald test showing non-significant
difference between not used and not heard of waterpipes.
*** p < 0.001; ** p < 0.01; * p <0.05.
Table 3. Logistic regression of waterpipe use among Ontario high
school students by demographic factors and substance use, 2013
Ontario Student Drug Use and Health Survey
MODEL 1 Model 2
DEMOGRAPHICS & Demographics,
TOBACCO CIGARETTE tobacco &
AOR (95% CI) * e-cigarette AOR
(95% CI) *
Sex
Female 1.00 1.00
Male 1.40 (1.01-1.94) 1.18 (0.84-1.66)
Grade
9 1.00 1.00
10 1.61 (0.93-2.79) 1.65 (0.87-3.12)
11 2.96 (1.83-4.81) 3.18 (1.89-5.34)
12 3.45 (2.23-5.33) 3.75 (2.29-6.12)
Racial background
White/Caucasian 1.00 1.00
Non-White/Other 1.17 (0.78-1.77) 1.34 (0.87-2.08)
Tobacco cigarette
use, past year
Not used 1.00 1.00
Used 8.20 (5.06-13.29) 5.54 (3.18-9.66)
E-cigarette use, ever
Not used 1.00
Used 4.32 (3.00-6.21)
Alcohol use, past year
None
Occasional
Regular
Constant 0.03 (0.02-0.05) 0.02 (0.01-0.04)
Model 3
Demographics,
tobacco,
e-cigarette &
alcohol AOR
(95% CI) *
Sex
Female 1.00
Male 1.16 (0.81-1.66)
Grade
9 1.00
10 1.32 (0.71-2.44)
11 2.29 (1.31-3.97)
12 2.47 (1.48-4.14)
Racial background
White/Caucasian 1.00
Non-White/Other 1.89 (1.18-3.01)
Tobacco cigarette
use, past year
Not used 1.00
Used 4.10 (2.36-7.12)
E-cigarette use, ever
Not used 1.00
Used 3.48 (2.40-5.06)
Alcohol use, past year
None 1.00
Occasional 1.28 (0.72-2.28)
Regular 3.58 (2.22-5.77)
Constant 0.01 (0.01-0.03)
* Adjusted odds ratios with 95% confidence intervals. Based on
sample that provided non-missing responses to all variables
within the table (n = 2803).
