BUFFALO, N.Y. — The findings of two recently published studies on the emergence of hookah use indicate that public health officials may need to consider broadening their tobacco prevention efforts beyond traditional cigarettes.

“Taken together, the results from these two studies underscore the important role hookah has played in the tobacco product landscape,” said Jessica Kulak, the lead author on both papers. Kulak, PhD, is a postdoctoral fellow in the Primary Care Research Institute, housed in the Department of Family Medicine in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo.

Kulak published both papers as part of her dissertation through collaborations with colleagues at the Rutgers University School of Public Health and Roswell Park Comprehensive Cancer Center.

The first study, published in March in the American Journal of Health Behavior, examined patterns and trends of hookah use among public high school students in New Jersey. The Rutgers School of Public Health has collected the New Jersey Youth Tobacco Survey (NJYTS) biennially since 1998. Questions about hookah use were introduced in 2008; Kulak analyzed four waves of NJYTS from 2008 to 2014.

The findings show significant increases in hookah use across three indicators – those who have ever used hookah, those who currently do and those who smoke hookah frequently.

Overall, 23.6 percent of New Jersey high school students had ever used hookah in 2014, significantly higher than the nearly 18 percent who reported ever using it in 2008, Kulak and her colleagues reported.

In 2014 past 30 day hookah use (11.8 percent) was as high as e-cigarettes (12.1 percent) and higher than other tobacco products. Among all high school students, frequent hookah use increased from 1.6 percent in 2008 to 2.9 percent six years later.

Researchers noted significant increases among girls and Hispanics, which is inconsistent with some previous studies that report data on “current” hookah use among youth. “It may indicate the demographics of those who use hookah are shifting,” Kulak said. “However, previous reports on findings by demographics do show mixed results.”

“Whereas previous work exists examining trends in current product use, this is the first study to provide an assessment of the patterns and trends of hookah products, in a representative sample, across three different indicators – ever, current and frequent use,” adds Cristine Delnevo, director of the Center for Tobacco Studies at Rutgers School of Public Health.

“Most surveillance data do not include enough detail to look at trends in ever or frequent product use, but these are important indices to consider.”

Kulak and her colleagues cite a variety of factors that may be contributing to the popularity of hookah among teens. For example, hookah tobacco is taxed at a lower rate than cigarettes, and it’s sold in a variety of flavors, many of which have been banned in cigarettes. Many hookah users also believe that it’s not as harmful as other tobacco products.

Kulak’s second dissertation-based paper, also published in March in Substance Use & Misuse, looks at hookah’s role in nicotine product initiation among college students. For this study, Kulak surveyed 832 college students in Western and Central New York. Among study participants who reported having used a nicotine product at some point, 25 percent said hookah was the first product they tried. Only combustible cigarettes (39.5 percent) were reported more frequently.

Among students who ever smoked cigarettes, most reported these as their introductory product. Nearly half of the students who have never smoked cigarettes reported that hookah was the first tobacco product they smoked.

This particular study also suggests that hookah users are less likely to use multiple tobacco products — such as combustible cigarettes, cigars and chewing tobacco — compared to combustible cigarette users.

“That surprised me, because I expected to find that hookah is just one of a number of nicotine products that youth and young adults are experimenting with,” Kulak said.

“It may be the case that hookah appeals to youths and young adults who really do not experiment with nicotine products overall because of the perception that hookah is ‘safer’ or that it does not contain nicotine,” she added. “That may be supported by the finding that half of never cigarette users start with hookah – a finding that, I believe, has implications for the important role hookah is having in nicotine product initiation.”

It is the first study to report that half of participants who have never smoked combustible cigarettes initiated nicotine product use with hookah. “This finding suggests that there is a growing interest in non-traditional nicotine products among college-aged young adults,” Kulak said.

Based on the findings of the two studies, Kulak says public health agencies may need to consider revising the surveys and other data collection instruments they use to more accurately account for hookah use.

“These projects highlight opportunities for youth tobacco surveillance systems in other states or at the national level to update their questionnaires in a way that will provide more detailed surveillance data that can better indicate the effectiveness of tobacco prevention and control policies,” Kulak said.

In addition, she said, there are opportunities for further regulation by the U.S. Food and Drug Administration, especially banning flavors in hookah tobacco.