摘要：Objectives. Although US cigarette smoking is decreasing, hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposure. We assessed how a representative sample of US tobacco control policies may apply to HTS. Methods. We examined municipal, county, and state legal texts applying to the 100 largest US cities. We developed a summary policy variable that distinguished among cities on the basis of how current tobacco control policies may apply to HTS and used multinomial logistic regression to determine associations between community-level sociodemographic variables and the policy outcome variable. Results. Although 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars, 69 of these cities have exemptions that allow HTS; 4 of the 69 have passed legislation specifically exempting HTS, and 65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation. Conclusions. Although three fourths of the largest US cities disallow cigarette smoking in bars, nearly 90% of these cities may permit HTS via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS. A hookah, also known as a water pipe, consists of a head, body, bowl, and hose. Moist, sweetened, flavored tobacco is placed in the head, and lit charcoal is placed on it. Users inhale through the mouthpiece, drawing smoke through the hookah. This practice is associated with substantial inhalation of smoke. For example, the World Health Organization 1 has estimated that a hookah smoker may inhale as much smoke during 1 standard hookah tobacco smoking (HTS) session as a cigarette smoker would from 100 cigarettes. Other studies have suggested that, compared with a single cigarette, 1 hookah smoking session may expose the user to more inhaled tar, carbon monoxide, nicotine, and polycyclic aromatic hydrocarbons. 1–5 In vivo studies have shown HTS to be associated with plasma nicotine concentrations comparable to those seen with cigarette smoking and increases in carbon monoxide levels that are much higher than those typically observed with cigarette smoking. 6 Secondhand smoke exposure from a hookah may also be a concern. Although more study is needed, a published report 7 has suggested that expired air from nonsmokers in a hookah tobacco café had a higher concentration of carbon monoxide than expired air from nonsmokers in a regular bar allowing cigarette smoking. The increase in HTS in the United States 8–13 has coincided with a decrease in the rate of cigarette smoking to its lowest level in nearly 60 years. 14,15 The rate of HTS is highest among young people, with 30% of college students having ever used and 10% having used in the past 30 days, making HTS nearly as common as cigarette use. 8,9,11,16 The rate of HTS has also increased substantially among high school students and noncollege populations, 10,13,17 and it is popular across gender, age, race, geographic location, and socioeconomic status. 9,11,16,18 Although some hookah users also smoke cigarettes, as many as half of users would have otherwise been naïve to nicotine. 12,13 Clean air policies have successfully curbed cigarette smoking in certain regions of the United States. As of July 1, 2011, 35 states and thousands of local municipalities had passed smoke-free laws. Whether HTS is affected by laws such as these or whether provisions included in these laws may have intentionally or unintentionally exempted HTS is, however, not known. 19,20 Because of the importance of HTS establishments in promoting use of these products, these exemptions are likely to contribute to the prevalence of HTS. 15,16 Thus, a systematic assessment of extant clean air laws, with special attention paid to implications for HTS, would be valuable. Moreover, determining what community factors are associated with HTS policy status may be valuable; this information may ultimately help focus interventions on communities in which the need is greatest. The purposes of this study were to assess how a representative sample of US tobacco control policies may apply to HTS and to determine associations between community-level sociodemographic factors and HTS policy status.
