A waterpipe (also referred to as shisha, hookah, narghile, kalian, and hubble-bubble) is a nicotine delivery device in which tobacco smoke passes through water and then is inhaled by the smoker. There is a growing public health concern that waterpipe smoking is becoming widespread in the United States, especially among youth such as college students.  Among select college campuses, between 15% and 48% of college students have tried waterpipe smoking; between 9.5% and 20% have engaged in the activity within the last 30 days. The increase can be attributed partly to the popularity of flavored tobacco products, appeal of waterpipe smoking as a social activity, increasing access and advertisements of this product (e.g., hookah bars and cafes), and perceptions that waterpipe smoking is less addictive and safer than cigarettes. These latter perceptions are incongruent with the amassing data revealing that waterpipe tobacco smoke is no less lethal than cigarette smoke and associated with many of the same diseases as cigarette smoking.

The widespread misinformation about the toxicant exposure and related health risks associated with waterpipe tobacco smoking provides the perfect opportunity to engage students in a science education approach as part of a health risk communication intervention to modify perceptions of harm and motivate cessation. Indeed, interventions that have targeted misperceptions of other tobacco products as being “safer” (e.g., light cigarettes) have been effective in modifying beliefs and intentions to quit. Thus, the goal of the study is to compare two conditions: 1) provision of information about how waterpipe tobacco smoking works, the spread of waterpipe use, and the flavored additives in the tobacco (no/yes); and 2) the above plus information about risks of waterpipe smoking. This pilot project addresses aim 2 of the Administrative, Theory and Prevention Core in that it tests novel hypotheses and has the feasibility of conducting a larger study. It also falls under the C-StARR’s third aim: “to test the efficacy of novel, multi-level prevention programs”. This project which recruits subjects from several state universities will translate basic scientific discovery into novel prevention programs that will be implemented in community settings.

This pilot study surveyed college waterpipe smokers to test if their perceptions of harms and addictive potential of this nicotine delivery devise can be changed.  College waterpipe smokers were recruited from several universities around central North Carolina using newspaper advertisements and posting flyers on campuses, as permitted. To be eligible, individuals had to be enrolled in college and have smoked a waterpipe at least once within the last 30 days. Those who called about the study were given detailed information; those who continued to express interest were then screened for eligibility. Those found eligible were then asked to complete a consent form and a baseline survey on a study specific website. IRB approval was obtained for the first phase of the study on 9/24/2009 and an amendment was approved on 1/22/2010 for a second phase of the study with a slightly different design. The baseline survey assessed smoking history, perceptions of the harms and addictive potential of waterpipe smoking, perceived and factual knowledge of the harms of waterpipe smoking, and desire to quit. A total of 91 participants completed the baseline survey. The mean age of the 91 participants was 20.4.

Two weeks after completion of the baseline survey, participants were asked to go the site specific website to obtain information about waterpipe smoking. Upon entering the site, participants were randomized with equal probability to a non-interactive PowerPoint presentation that discussed either the:

1. spread of waterpipe use and flavored additives in the tobacco, or
2. the above information plus the risks of waterpipe tobacco smoking (e.g., exposure levels to toxins, negative health effects, addictive potential). There were 40 participants per condition.

The provision of risk information increased significantly feelings of worry and beliefs about personal harm and of becoming addicted as well as increased desire to quit relative to conditions that did not receive risk messages. We also found that the provision of risk information increased perceived and factual knowledge.

While successful, participants who reviewed risk messages continued to express low levels of risk and worry and desire to quit (e.g., means scores of less than 4 on seven point Likert scales). These results may be due to our interventions being devoid of in-depth explanations and illustrations of mechanisms of harm and addiction, making the science education less potent, while being delivered in a medium (PowerPoint) that lacked interactivity and vividness to engage participants. Based on this pilot findings, an R01 grant application was prepared, titled Exploring and Affecting College Students’ Perceived Risks of Waterpipe Smoking”, and
will be submitted for funding in fall 2011. The main goal of this grant proposal is to test whether an enhanced interactive science education web-based risk communication intervention that reviews the risks of waterpipe tobacco smoking is more effective at increasing perceptions of health risk and addiction and reducing frequency of use compared to our previous PowerPoint intervention. Further, we wish to test whether any science education based approach is more
effective at increasing perceptions of health risk and addiction and reducing frequency of use compared to an observational control group.

A manuscript was submitted based on findings from this pilot. Below is the citation:

Lipkus, I.M., Eissenberg, T., Schwartz-Bloom, R.D., Prokhorov, A.V., & Levy, J. (2011). Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine and Tobacco Research, 13, 599-610. doi: 10.1093/ntr/ntr049. Link to Article