U.S. Hookah Tobacco Smoking Establishments Advertised on the Internet

Background

Establishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities.

Purpose

To conduct a comprehensive, qualitative assessment of websites promoting these establishments.

Methods

In June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009–2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohen's κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used.

Results

The search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common.

Conclusions

Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.

Introduction

Although cigarette use has declined substantially over the past 2 decades,1, 2, 3 smoking tobacco with a hookah (water pipe, narghile, or shisha-pipe) is an emerging trend in the U.S.4, 5, 6, 7, 8 The WHO estimates that one hookah tobacco smoking session delivers 50–100 times the smoke volume of a single cigarette.9, 10 Further, the smoke from one hookah session contains about 40 times the tar,11, 12 30 times the carcinogenic polycyclic aromatic hydrocarbons,¹³ two times the nicotine,11, 12 and ten times the carbon monoxide11, 12, 14 of the smoke from a single cigarette. Hookah smokers are exposed to these toxicants when they smoke,15, 16, 17, 18, 19 and blood nicotine levels of daily hookah tobacco users are similar to those of an individual who smokes ten cigarettes per day.11, 12, 17 These data are consistent with preliminary reports linking hookah tobacco smoking to cancer, cardiovascular disease, decreased pulmonary function, and nicotine dependence.20, 21, 22, 23 Despite these reports, many individuals continue to perceive hookah tobacco smoking as having low potential for harm and addictiveness.4, 6, 7, 24, 25

Although definitive population-based studies are lacking, localized samples suggest ever-use prevalence of 20%–40%.4, 6, 24 Additionally, hookah tobacco use may be increasing.4, 6, 24 One reason is that it may have more aesthetic appeal than cigarette use. The tobacco used in hookahs is generally flavored and sweetened, resulting in a sweet-smelling smoke, and the hookah pipes are often made of intricately carved glass and polished metal.9, 17, 26, 27 Another reason may be the recent proliferation of establishments that are dedicated to hookah tobacco smoking and are helping to introduce the practice to U.S. communities.28, 29, 30 Yet another reason may be the manner in which hookah use is advertised.

In the past, increases in cigarette smoking have often been fueled by well-funded marketing promotions,31, 32, 33 but this currently does not appear to be the case with hookah tobacco use. Because many experts consider a website to be a crucial element of the marketing of a new business,³⁴ especially if the business targets young and socially connected individuals,²⁹ it may be helpful to determine how many websites are dedicated to advertising hookah smoking establishments and what types of messages they are providing. This information, which has not been published previously, may help researchers and practitioners understand the appeal of hookah use and ultimately help them develop intervention programs to reduce the use of all forms of tobacco consumption. Therefore, the purpose of the present study was to conduct a systematic, comprehensive, qualitative assessment of websites advertising hookah tobacco smoking establishments in the U.S.