Positive hookah expectations, attitudes, and beliefs among young adult users

Hookah smoking has emerged as a new form of tobacco use in the U.S., particularly among adolescents and young adults. Previous quantitative research with hookah users has found that this behavior is generally perceived as “socially acceptable” and “looks cool.” However, no known studies have qualitatively assessed hookah users' attitudes and beliefs regarding this behavior. Therefore, we conducted four focus groups (N=6-9 each) comprised of young adults aged 18-24 (total N=30). Using outcome expectancy theory, we posed the question “Hookah smoking is _______?” to elicit words that users associate with hookah. More than 75% of responses were a positive experience from hookah use. In addition to reporting the social nature of hookah smoking and the acceptability among their peers, participants frequently reported feeling “light headed,” “dizzy,” or a “head high,” as positive, desirable physical effects. Some participants reported modifying their smoking behaviors in order to obtain a more rapid “head high,” potentially leading to a desirable feeling of their “whole body going limp.” Respondents also reported the creative ways in which they used hookah, from doing tricks with the smoke to creating new mixes of flavors with both the tobacco and the fluid (milk, energy drinks, alcohol, etc.) used. While surveys have assessed users' knowledge and attitudes towards hookah, many involved negative words such as harm or addiction and neglected potential positive aspects of hookah use. For effective prevention and intervention programs, it is imperative to understand the positive attitudes and beliefs associated with hookah use.