HOOKAH SMOKING BEHAVIOR

INITIATION IN THE CONTEXT OF

MILLENNIALS
KELOMPOK 5
RIZSA FAUZIAH ICHWANI 25010115120100
UTUTYA LISYA WIJAYA 25010115130206
FRIDA KUSUMANINGTYAS 25010115140226
PARLIM SANTO PETRA 25010115130
INTAN HARDIAN PUTRI 25010115140325
 Nomor : 137
Tahun : 2016
IDENTITAS JURNAL Halaman : 124-130
Tingkat Kuartil : Q2
Penulis : G. Castaneda, T.E.
Barnett, E.K. Soule,
M.E. Young
Metode : Data dari enam wawancara kelompok fokus dengan perokok
hookah berusia antara 18 dan 24 tahun dianalisis menggunakan
pendekatan grounded theory. Kelompok fokus terbagi rata antara
pengguna hookah yang sering dan jarang, dan sebagian besar terdiri
dari mahasiswa, dengan dua kelompok pengguna hookah yang terdiri
dari 18 dan 24 tahun status non-siswa.

Desain Studi : Kualitatif

INTRODUCTION
• Literatur telah mengindikasikan efek kesehatan jangka panjang dan jangka
pendek yang terkait dengan merokok hookah, termasuk kanker paru-paru,
penyakit pernafasan, dan peningkatan paparan racun. Misalnya, dua studi
kondisi desain crossover mengungkapkan bahwa rokok hookah yang
diproduksi tingkat karboksihemoglobin (COHb) tertinggi tiga kali lebih
tinggi daripada yang diamati dalam satu sesi rokok, dan tingkat nikotin
plasma yang serupa dengan yang diamati dalam merokok. Selanjutnya,
data topografi puff dan analisis asap hookah menunjukkan 45 menit sesi
hookah yang dihasilkan. lebih dari 40 kali lipat volume asap yang dihasilkan
dari satu batang rokok dan, selain karbon monoksida (CO) dan nikotin, asap
mengandung paparan berbagai racun termasuk hidrokarbon aromatik
polisiklik karsinogenik, aldehida volatil, dan berbagai logam berat.
Meskipun penelitian yang tersedia menunjukkan hubungan yang kuat antara
merokok hookah dan hasil kesehatan yang buruk, tingkat prevalensi merokok
hookah menimbulkan kekhawatiran kesehatan global yang meningkat,
terutama di kalangan remaja dan dewasa muda. Berbagai studi cross
sectional berbasis universitas telah menggunakan penggunaan hookah yang
meningkat. tingkat prevalensi berkisar antara 20% hingga 40% untuk
penggunaan seumur hidup dan 5e20% untuk penggunaan saat ini.59
Selanjutnya, penggunaan ganda hookah dan rokok telah dilaporkan sebesar
58,7% dalam sampel studi universitas. Selain itu, tren pada hookah merokok
dini, seperti yang diamati dalam studi longitudinal 13 bulan, menunjukkan
tren naik bertahap di hookah peserta yang pernah digunakan dari prakondisi
(29%) ke tahun pertama kuliah (34%), dan dari akhir tahun akademik (41%)
ke akhir musim panas (45%) .
Tujuan dari penelitian ini adalah untuk menguji keyakinan dan sikap
normatif positif dan negatif normatif pengguna hookah saat ini,
sehubungan dengan penggunaan hookah, untuk lebih menjelaskan
peningkatan prevalensi merokok hookah di kalangan dewasa muda,
dan membantu mengungkap mengapa kegiatan konsumsi tembakau ini
dirasakan berbeda. Temuan penelitian ini diharapkan untuk
menginformasikan pendekatan kesehatan pendidikan yang ditargetkan
serta pemrograman penghentian untuk orang dewasa muda.
RESULTS
Pengguna Hookah pada Millennial dilihat dari perilaku niat, sikap, dan
norma subyektif. Selanjutnya, Model Integratif dari Prediksi Perilaku
meluas ruang lingkup norma subjektif dengan mengakui peran
keterampilan dan kendala lingkungan dan / atau fasilitator sebagai
moderator dari hubungan niat perilaku selain:
• Sikap (evaluasi individu terhadap preferensi perilaku);
• norma yang dirasakan (tekanan sosial yang diharapkan dari perilaku
kinerja);
• self-efficacy (kemampuan yang dirasakan untuk berhasil melakukan
perilaku).
Ketika dilihat bersamaan dengan model integratif, pengamatan pada
inisiasi merokok hookah di antara generasi millennial mengungkapkan
sebagian besar pengguna hookah tidak memiliki keterampilan yang
diperlukan (misalnya, persiapan perakitan dan pipa, metode inhalasi,
dll) untuk pengalaman merokok awal mereka. Oleh karena itu, faktor-
faktor kontekstual seperti dukungan jaringan sosial dan sebagian besar
anggota jaringan sosial individu juga terlibat dalam perilaku sebagai
fasilitator yang berpengaruh untuk proses inisiasi perilaku di antara
kelompok usia ini.
Selain itu, merokok hookah digambarkan sebagai pengalaman sosial
yang unik dengan karakteristik budaya yang sangat mirip dengan
Generasi Milenial. Banyak hubungan positif antara karakteristik
generasional dan penggunaan hookah muncul sebagai faktor penentu
utama dari inisiasi perilaku dalam data. Tren yang paling menonjol
diamati dalam kategori budaya, yang mencakup karakteristik Millenial
berikut: otonomi, personalisasi, daya tarik baru, kenyamanan,
berorientasi global, hiburan, kolaborasi, kesadaran kesehatan, dan
menilai jaringan sosial mereka.
• Otonomi
Mayoritas pengguna hookah menunjukkan perasaan yang kuat tentang
kontrol yang dirasakan atas penggunaan hookah mereka; faktor ini
menunjukkan dirinya sebagai penggerak untuk niat perilaku yang lebih
besar. Tren dalam data menunjukkan bahwa pengguna hookah
Millennial umumnya memegang keyakinan bahwa penggunaan hookah
tidak membuat ketagihan dan menganggap penggunaan berulang
mereka sebagai perilaku sementara yang merupakan bagian dari
pengalaman kuliah mereka.
• Personalisasi
Dari proses persiapan pipa hookah hingga pencampuran rasa dan trik
merokok, kemampuan untuk mempersonalisasi pengalaman merokok
hookah adalah fitur merokok yang sangat menarik yang berkorelasi
dengan keinginan Generasi Millenial untuk personalisasi, kreativitas,
dan individualitas dalam kelompok.
 Mayoritas peserta mengungkapkan daya tarik mistik
yang terkait dengan ketidakbiasaan awal mereka
dengan merokok hookah dan perannya sebagai
• Daya Tarik Baru praktik budaya. Dari dekorasi khas lounge hookah
hingga pencahayaan yang redup dan tempat duduk
yang nyaman, suasana yang diciptakan oleh setelan
merokok hookah dianggap sebagai novel dan ada
tingkat penghormatan yang penting yang terikat
untuk mengambil bagian dalam kebiasaan budaya
asing ini.
• Kenyamanan
Para peserta menegaskan kembali kemudahan dan kemudahan
memperoleh akses ke bar hookah atau membeli pipa hookah itu
sendiri. Banyak pengguna hookah menunjukkan bahwa persediaan
hookah tersedia secara massal di toko-toko bata-dan-mortir, online,
dan bahkan di pom bensin. Selain itu, pengguna Millennial juga
mencatat bahwa legalitas merokok hookah di dalam ruangan serta
batas usia 18 tahun adalah driver yang signifikan untuk digunakan di
kalangan individu di bawah usia 21 tahun.
• Berorientasi global
Terkait erat dengan hal-hal baru yang dirasakan dari kebiasaan budaya
asing, tingkat toleransi dan apresiasi yang tinggi terhadap keragaman
budaya juga ditemukan memainkan peran di antara inisiasi pengasuh
hookah para peserta. Banyak peserta mengungkapkan kerinduan untuk
pengalaman etnis otentik yang sangat mencirikan kelompok-kelompok
sebaya multikultural Generasi Milenium. Misalnya, seorang peserta
menyatakan: 'Sesuatu yang Anda lakukan dalam budaya mereka,
daripada,' Oh, saya merokok tembakau
• Kolaborasi
Seluruh proses perakitan hookah pipa, persiapan, dan merokok
sessionwas digambarkan sebagai upaya terorganisir. tugas yang
berbeda-beda dibagikan (seperti pengepakan mangkuk, pembersihan,
dan perakitan pipa. Kontingensi untuktingkat keterampilan yang
diperlukan minimal pada perakitan pipa dan persiapan juga kondusif
untuk withingroup peran bimbingan selama tahap awal transfer
pengetahuan dan keterampilan akuisisi.
• Sadar Kesehatan
Keyakinan perilaku yang terutama pada persepsi bahwa hookah
merokok adalah alternatif yang sehat (memiliki kurang racun)
dibandingkan dengan merokok. Hookah varietas produk alami juga
dijelaskan berkontribusi untuk ini persepsi komparatif sehat dari
merokok hookah dibandingkan dengan bentuk lain dari konsumsi
tembakau. Selain itu, keyakinan komparatif sehat yang diselenggarakan
oleh milenium juga dikaitkan erat dengan estetika hookah pipa, aroma
yang menyenangkan, 'halus ' merokok (untuk pejalan kaki dan perokok
sama), dan kemungkinan rendahnya penggunaan sehari-hari,
dibandingkan dengan rokok.
• Jaringan Sosial Nilai
Pengguna hookah Seribu terutama menggambarkan pengalaman
merokok hookah sebagai interaksi sosial rekreasi diterima sangat
dominan diprakarsai oleh rekan kuat dan (diikuti oleh) keluarga
pengaruh-pengaruh. Keluarga pengaruh-pengaruh sering digambarkan
sebagai sama sosial menekan pertemuan kecil dan intim, dengan
banyak anggota keluarga (misalnya, orang tua, sepupu, dan nenek).
Dengan demikian, keyakinan keampuhan yang ditingkatkan melalui
sosial pengaruh-pengaruh serta karakteristik hookah erat sesuai
dengan orang-orang dari budaya generasi millennium.
 Sementara fasilitator tampaknya lebih
besar daripada peserta kendala
• Akses Lingkungan lingkungan, orang-orang yang
diungkapkan oleh milenium termasuk
faktor-faktor yang terkait dengan
kenyamanan, seperti keterjangkauan dan
aksesibilitas.
• Pengalaman merokok hookah
Digambarkan sebagai pengalaman yang sangat kolaboratif, dengan
mayoritas group members mengungkapkan kesediaan mereka untuk
berbagi keterampilan hookah dan pengetahuan di antara anggota
kelompok memulai.
Meskipun mayoritas peserta memulai merokok hookah tidak memiliki
mantan pengalaman merokok, Selain itu, data peserta dengan
frekuensi hookah merokok lebih besar ditunjukkan tren dalam
menyuarakan lebih dari aspek-aspek negatif yang mungkin dari
merokok hookah, dibandingkan dengan merokok rekan-rekan frekuensi
yang lebih rendah.
DISCUSSION
Temuan penelitian ini menyoroti pengaruh kuat faktor lingkungan
kontekstual, seperti budaya generasi individu, sehubungan dengan
persepsi yang sesuai terhadap dan inisiasi merokok hookah. Temuan
dari penelitian ini konsisten dengan literatur yang menunjukkan
persepsi yang sebelumnya dipegang tentang merokok hookah sebagai
bentuk konsumsi tembakau yang kurang toksik (jika dibandingkan
dengan merokok) di antara individu berusia 18-24 tahun. Secara
keseluruhan , tanggapan peserta mencerminkan keselarasan dengan
teori inisiasi perilaku yang ada.
Determinan budaya generasi yang diidentifikasi diamati untuk
memperkuat inisiasi perilaku merokok hookah, tingkat keterampilan
merokok perorangan, serta kendala lingkungan (misalnya
keterjangkauan) atau fasilitator (aksesibilitas), ditemukan sebagai
inisiasi pengasapan hookah di kalangan Generasi Millenial.
Keterbatasan termasuk format yang sangat terstruktur di mana
wawancara kelompok fokus dilakukan, sehingga mengurangi kekayaan
data.
Misalnya, para peserta tidak dapat membentuk kategori mereka sendiri
untuk mengkategorikan kata-kata seperti yang dikembangkan dari
literatur. Demikian pula, meskipun penggunaan probe efektif
moderator selama wawancara kelompok fokus, latihan peringkat
(untuk masing-masing kategori hookah yang ditentukan sebelumnya)
menghambat pembuatan tanggapan yang lebih rumit dari peserta.
Selain itu, mengingat komposisi sampel, menggambar mahasiswa (4
kelompok, 30 peserta) vs kelompok non-siswa (2 kelompok, 10 peserta)
perbandingan adalah keterbatasan studi lain. Sementara upaya
dilakukan untuk merekrut orang dewasa muda yang tinggal di
komunitas, sangat sedikit yang menghubungi tim peneliti untuk
berpartisipasi dalam studi.
Perbedaan generasi, bagaimanapun, harus melampaui kuliah vs status
non perguruan tinggi dan dengan demikian mungkin tidak perbedaan
penting untuk penggunaan hookah, Mengingat data yang diteliti
memberikan pemahaman tentang faktor-faktor utama yang
mendorong inisiasi merokok hookah di kalangan populasi dewasa
muda, implikasi masa depan untuk temuan penelitian ini termasuk
peningkatan pencegahan merokok dan program penghentian merokok
yang memanfaatkan promosi perilaku kesehatan positif yang
mendukung dan / atau sejajar dengan karakteristik Milenial.
Untuk pengembangan intervensi, determinan budaya generasi yang
diidentifikasi dalam penelitian ini dapat berfungsi sebagai skema
generatif yang menyampaikan konstruksi memotivasi yang lebih luas
yang kondusif bagi pilihan Milenial untuk memulai merokok hookah.
Dengan menggunakan pendekatan generatif, inisiatif promosi
kesehatan kampus dapat berupaya mengembangkan model intervensi
yang memuaskan skema budaya generasi Milenial. Sesuatu positif yang
ideal akan mendorong peluang seperti otonomi, personalisasi, daya
tarik baru, kenyamanan, berorientasi global, hiburan, kolaborasi,
kesadaran kesehatan, dan jaringan sosial yang berharga untuk
berkembang di kalangan orang dewasa muda.
Selain itu, upaya promosi kesehatan pada kampus juga harus berusaha
untuk menghilangkan mitos yang berlaku mengenai merokok hookah
sebagai alternatif yang lebih sehat untuk merokok. Selain itu, prakarsa
pendidikan kesehatan anti hookah merokok harus dipaksakan oleh
upaya kebijakan yang bertujuan untuk memasukkan merokok hookah
dalam semua peraturan bebas asap rokok saat ini.
Kurangnya kebijakan membatasi merokok hookah di dalam ruangan
telah memperparah konsepsi yang salah mengenai keamanan merokok
hookah, dan pendirian hookah terus tetap dikecualikan dari undang-
undang udara dalam ruangan yang bersih. Upaya kebijakan dapat
membantu mengekang miskonsepsi dewasa muda mengenai
keamanan penggunaan hookah dan mengurangi aksesibilitas. Contoh
implikasi kebijakan untuk pengurangan inisiasi merokok hookah dan
penggunaan berkelanjutan di antara populasi dewasa muda dapat
meliputi: meningkatkan batas usia bar hookah, pembatasan untuk
merokok dalam ruangan, dan membatasi kepadatan kafe hookah di
sekitarnya dengan populasi dewasa muda yang tinggi, seperti dekat
kampus Universitas.
 KESIMPULAN
Pengguna hookah Millennial membutuhkan perhatian penuh baik pada
alasan negatif dan positif yang berasal dari penggunaan hookah yang
berkelanjutan; Namun, yang terpenting adalah keyakinan perilaku
terutama terpaku pada persepsi bahwa merokok hookah adalah
alternatif yang lebih sehat untuk merokok. Implikasi masa depan untuk
temuan penelitian ini termasuk menghasilkan cara yang lebih positif
untuk mengekspresikan sifat-sifat ini untuk orang dewasa muda;
implikasi kebijakan termasuk meningkatkan batas usia bar hookah,
menerapkan larangan merokok dalam ruangan, dan membatasi
kemudahan aksesibilitas untuk membeli persediaan hookah.
SEKIAN DAN TERIMAKASIH!
☺
 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0

Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Original Research

Hookah smoking behavior initiation in the context

of Millennials

~ eda a,*, T.E. Barnett b, E.K. Soule c, M.E. Young d

G. Castan
a
Social and Behavioral Sciences, College of Public Health and Health Professions, University of Florida, USA
b
Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of
Florida, USA
c
Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, USA
d
Department of Occupational Therapy, College of Public Health and Health Professions, University of Florida, USA

article info abstract

Article history: Objectives: This study aims to examine current hookah users' perceptions, attitudes, and
Received 1 July 2015 normative beliefs regarding hookah smoking to further elucidate the rise in hookah
Received in revised form smoking prevalence among young adults (aged 18e24 years) and reveal why hookah
19 January 2016 smoking is perceived as less harmful than other forms of tobacco consumption.
Accepted 13 February 2016 Study design: Qualitative.
Available online 20 April 2016 Methods: Data from six focus group interviews with hookah smokers aged between 18 and
24 years were analyzed using a grounded theory approach. Focus groups were evenly split
Keywords: between frequent and infrequent hookah users, and were predominantly composed of
Young adult tobacco use college students, with two groups of hookah users consisting of 18e24 year olds of non-
Hookah student status.
Qualitative research Results: Hookah users shared a much larger set of positive hookah smoking behavioral
beliefs as opposed to negative behavioral beliefs. Generational traits served as the over-
arching commonality among the behavior performance initiation determinants observed.
The most notable generational trends observed were within the cultural category, which
included the following millennial characteristics: autonomy, personalization, novelty ap-
peal, convenience, globally oriented, entertainment, collaboration, health conscious, and
valuing their social network.
Conclusions: Millennial hookah users revealed mindfulness regarding both potential nega-
tive and positive reasons stemming from continued hookah use; however, behavioral be-
liefs were primarily fixated on the perception that hookah smoking was a healthier
alternative to cigarette smoking. Future implications for this study's findings include
generating more positive ways to express these traits for young adults; policy implications
include raising hookah bar age limits, implementing indoor smoking restrictions, and
limiting the ease of accessibility for purchasing hookah supplies.
© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Social and Behavioral Sciences, College of Public Health and Health Professions, PO Box to 100182, University of
Florida, Gainesville, FL, 32610-0182, USA. Tel.: þ1 (352) 273 6745; fax: þ1 (352) 273 6048.
E-mail address: gcastane@phhp.ufl.edu (G. Castan ~ eda).
http://dx.doi.org/10.1016/j.puhe.2016.02.013
0033-3506/© 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0
Introduction
The literature has indicated both long and short-term haz-
ardous health effects associated with hookah smoking,
including lung cancer, respiratory illness, and increased
toxicant exposure.1e4 For instance, a two condition study
crossover design revealed that a single hookah smoking
episode produced peak carboxyhemoglobin (COHb) levels
three times higher than those observed in a single cigarette
session, and similar peak plasma nicotine levels to those
observed in cigarette smoking.3 Furthermore, puff topog-
raphy data and hookah smoke analyses indicated a 45 min
hookah session produced over 40-fold the smoke volume of
that produced from a single cigarette and, in addition to
carbon monoxide (CO) and nicotine, the smoke contained
exposure to various toxicants including carcinogenic poly-
cyclic aromatic hydrocarbons, volatile aldehydes, and
various heavy metals.3
Despite the available research indicating strong associa-
tions between hookah smoking and adverse health outcomes,
hookah smoking prevalence rates pose a rising global health
concern, particularly among adolescents and young adults.3
Various university-based cross sectional studies have estab-
lished rising hookah use prevalence rates ranging from 20% to
40% for lifetime use and 5e20% for current use.5e9 Further-
more, dual hookah and cigarette use has been reported at
58.7% in a university study sample.9 Moreover, trends in early
hookah smoking, as observed in a 13-month longitudinal
study, indicated a gradual upward trend in participant hookah
ever use from precollege (29%) to freshman year of college
(34%), and from the end of the academic year (41%) to the end
of summer (45%).8
Nonetheless, while downward trends have been observed
in college students' cigarette use, evidence based findings
suggest that hookah use has synchronously been on the
rise.10,2 This polarized phenomenon across cigarette users
and exclusive hookah users suggests attitudinal differences
among both forms of tobacco consumption. Cross-sectional
studies examining hookah smoking risk perceptions among
the college population have noted that positive perceptions
toward hookah smoking as well as perceptions of reduced
health risks (relative to cigarette smoking) were both signifi-
cantly associated with current hookah use and intention to
use hookah tobacco in the future.6,11,5 For instance, a cross-
sectional study among first and second year undergraduate
and graduate college students examining positive and nega-
tive attitudes as well as normative beliefs regarding hookah
use indicated positive attitudes toward hookah use were
significantly associated with current hookah use and inten-
tion to use hookah tobacco in the future.5 On the other hand,
results regarding negative attitudes toward hookah yielded
non-significant findings, for both current hookah use and
future intentions to engage in hookah use.
The purpose of this study was to examine current hookah
users' positive and negative normative beliefs and attitudes,
with respect to hookah use, in order to further elucidate the
rise in hookah smoking prevalence among young adults, and
help uncover why these tobacco consumption activities are
perceived differently. These study findings are expected to
125
inform targeted educational health approaches as well as
cessation programming for young adults.
Methods
Six focus groups were conducted with hookah smokers aged
18e24 years. Focus group size ranged from 5 to 9; totaling 40
participants in the study. Four groups were composed of col-
lege students from a large university in southeastern United
States, and two groups included non-college student young
adults. Focus groups were split between frequent and infre-
quent hookah users. Hookah use frequency was defined as
infrequent for individuals who had smoked hookah three
times per month or less and frequent for those who had
smoked more than three times per month, approximately
once a week or more. Participant recruitment consisted of: 1)
flyers posted around the community (targeted young adult
high traffic areas, such as movie theatre parking lots, bars,
malls, and restaurants); and 2) on-campus flyers posted at bus
stops, housing complexes, and near dorms. IRB approval was
obtained from the university prior to focus group data
collection and all participants received full study disclosure
from the research team before consenting to participate. The
data were analyzed using a grounded theory approach.12
Participant demographics included a mean age of 19 years
(SD 1.4) with just over half (55%) females. Overall, participants'
racial background was predominantly white (72%), followed
by Asian (10%), and black (7.5%). The ethnic composition
included 30% who identified as Hispanic, and 12.5% who
identified as Middle Eastern descent. Additionally, occupation
status primarily consisted of full-time students (75.5%); with
part-time workers (15%), full-time workers (10%), and unem-
ployed individuals (5%).
All six focus groups were structured in the same manner
and averaged 40 min in duration. Following past work using
Outcome Expectancy Theory applied to cigarettes,13 partici-
pants were asked to complete a word elicitation exercise,
whereby participants were asked to complete the phrase
‘Hookah smoking is ____’. The word elicitation exercise was
followed by a categorizing process, wherein participants were
asked to categorize the list of words that had been generated
during the word elicitation activity as either positive or
negative and into the following five hookah literature themes
identified by the researchers: social, harmful, toxins, socially
acceptable and other. Next, participants were asked to rank
each category in descending order with respect to level of
importance. Lastly, participants were asked to individually
describe their first hookah smoking experience, whether or
not they currently owned a hookah pipe, and if so, how they
had obtained the hookah pipe.
The research team conducting each focus group consisted
of one professor with expertise and training in qualitative data
collection (moderator) and one graduate research assistant
who took notes and audio recorded the focus group session;
recordings were then transcribed verbatim for data analysis.
The analysis was first performed by reading the data once
and listing the words elicited under the categories stated by
participants. All six focus groups indicated a much larger set
of positive perceptions and behavioral beliefs, with respect to
126 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0
hookah use, as opposed to negative perceptions and behav-
ioral beliefs. Closer examination comparing all six groups' lists
of positive and negative categories (derived from the word
elicitation process) eventually uncovered trends in intersect-
ing generational characteristics between hookah use and
positive perceptions and behavioral beliefs as key influencers
for hookah smoking initiation.
The data analysis was conducted using selective coding
procedures.12 Coding consisted of concepts that emerged from
each groups' list of positive and negative categories, such as
beliefs regarding hookah smoking's non-addictive nature,
ability to choose a variety of flavors and mix them, and
perception of a foreign cultural practice. The emergent iden-
tification of generational identity as an overarching phe-
nomenon within participants' hookah smoking behavior
allowed the researchers to draw across both positive and
negative categories.
The purpose of the project was to solicit hookah users to
provide outcomes associated with hookah smoking. Specif-
ically, the analysis aimed to uncover why hookah smoking is
appealing to the 18e24 years age group. During analysis
emerging similarities in generational traits to hookah smok-
ing characteristics within the data steered the analysis to a
focus on hookah smoking behavior initiation in the context of
the Millennial Generation, those born from 1977 to 1995
(demonstrated in Results section).
Emerging theme analyses and interpretations were
confirmed via a peer review process until no new themes
could be identified. This process led to the development of
nine major themes: autonomy, personalization, novelty ap-
peal, convenience, globally oriented, entertainment, collabo-
ration, health conscious, and valuing their social network.
Each of these themes represented key cultural determinants
which were explored as dimensions of the central phenome-
non: hookah smoking initiation among the Millennial
Generation.
Results
Millennial hookah users shared a much larger set of positive
behavioral beliefs, as opposed to negative behavioral beliefs,
with respect to hookah use, as evidenced by the data. These
observations are best understood through the application of
the Integrative Model of Behavioral Prediction (see Fig. 1).14
The Integrative Model is a revision of the reasoned action
approach, which adds control beliefs as a predictor of
behavioral intention to the original three constructs: behav-
ioral intention, attitude, and subjective norm. Furthermore,
the Integrative Model of Behavioral Prediction extends the
scope of subjective norm by acknowledging the role of skills
and environmental constraints and/or facilitators as moder-
ators of the intentionebehavior relationship in addition to: 1)
attitude (individual's evaluation of behavior favorability); 2)
perceived norms (social pressure expected from behavior
performance); and 3) self-efficacy (perceived capability to
successfully perform the behavior).14
When viewed concurrently with the integrative model,
observations on hookah smoking initiation among Millennials
revealed the majority of hookah users lacked the necessary
skills (e.g., assembly and pipe preparation, inhalation
methods, etc.) for their initial smoking experience. Therefore,
contextual factors such as social network support and the
large extent to which members of the individual's social
network were also engaging in the behavior served as influ-
ential facilitators for the behavior initiation process among
this age group. For instance, one participant noted the
following regarding his initial hookah smoking experience: ‘It
was also in a big group, people I was comfortable with, I
probably would have been more nervous and embarrassed
when I didn't know what I was doing. Yeah, it was fun.’
Additionally, hookah smoking was described as a unique
social experience with cultural characteristics closely aligning
to those of the Millennial Generation. Numerous positive links
between generational characteristics and hookah use
emerged as key determinants of behavior initiation in the
data. As illustrated in Fig. 1, Millennial characteristics15 served
as the overarching commonality among the hookah smoking
initiation characteristics observed in this sample. The most
notable trends were observed within the cultural category,
which included the following Millennial characteristics: au-
tonomy, personalization, novelty appeal, convenience, glob-
ally oriented, entertainment, collaboration, health conscious,
and valuing their social network.
Autonomy
The majority of hookah users expressed a strong sense of
perceived control over their hookah use; this factor presented
itself as a driver for greater behavioral intention. Trends in the
data suggested Millennial hookah users had commonly held
beliefs that hookah use was non-addictive and viewed their
recurrent use as a transient behavior that was a part of their
college experience. As one student stated: ‘Sometimes I will
smoke hookah a couple days a week, and then other times I'll
go several weeks or several days without doing it or consid-
ering it. I wouldn't say hookah is addictive.’
Personalization
From the hookah pipe preparation process to mixing flavors
and performing smoke tricks, the ability to personalize the
hookah smoking experience was a highly attractive smoking
feature that correlated with Millennials' desire for personali-
zation, creativity, and within-group individuality. Young Mil-
lennials noted the hookah pipe's preparation process as one
that catered to a wide array of smoker preferences ranging
from thicker smoke to longer lasting tobacco. For instance,
one participant noted ‘So, if you put two coals down you'll get
thicker smoke, but the tobacco will burn faster; it's kind of like
a preference.’
Similarly, participants communicated the ability to further
personalize the preparation process by experimenting with
combining flavor elements in the hookah pipe's setup process.
For instance, several preparation flavoring options noted
included: carving an orange or an apple to use as a bowl, and
using ice, wine, milk, or energy drinks in the water bowl that
serves to cool the smoke for the user. However, apart from the
wide variety of flavor choices and the ability to mix flavors,
some flavoring options were also distinguished as catering to
 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0
Fig. 1 e The integrative model of behavioral prediction in the context of millennial hookah smoking initiation.
particular ethnic preferences. For instance one participant
stated:
And also like, as your culture too, cause like we smoke ‘pan’. But
a lot of, like if you go to shops that are owned by I would say
maybe like just Americans or that they probably wouldn’t have
that flavor, but if you go to a shop that is owned by like Indian
people, they would definitely have that flavor.
These three distinct versatile areas of ‘expertise’ (prepa-
ration, flavor mixing, and smoke tricks), as termed by partic-
ipants, also served as both an opportunity to promote within-
group individuality (via a reputation corresponding to their
level of skill), as well as an opportunity for a dynamic expe-
rience, thus creating a ‘unique [hookah smoking] experience
every time’.
Novelty appeal
The majority of participants expressed a mystical appeal tied
to their initial unfamiliarity with hookah smoking and its role
cor
as a cultural practice. From the typical hookah lounge's de
to the dim lighting and comfortable seating, the atmosphere
created by hookah smoking settings was perceived as novel
and there was a notable level of respect tied to partaking in
this foreign cultural custom. One participant stated:
Even if it’s not a part of your culture I feel like that’s something
that makes it more acceptable is like the, you can look at it from
the perspective that like you’re trying someone else’s, like
something from their culture.
Convenience
Participants reiterated the ease and convenience of obtaining
access to a hookah bar or purchasing a hookah pipe them-
selves. Many of the hookah users indicated that hookah
127
supplies were widely available in bulk at brick-and-mortar
shops, online, and even at gas stations. In addition, Millen-
nial users also noted that the legality of hookah smoking in-
doors as well as the 18-year age limit were significant drivers
for use among individuals under the age of 21 years.
Globally oriented
Closely tied to the novelty perceived from a foreign cultural
custom, a high level of tolerance and appreciation for cultural
diversity was also found to play a role among participants'
hookah smoking initiation. Many participants expressed a
yearning for authentic ethnic experiences strongly charac-
terizing the multicultural peer groups of the Millennial Gen-
eration. For instance, one participant stated: ‘Something you
do in like their culture, rather than, ‘Oh, I'm smoking tobacco’.
Entertainment
Many socially entertaining elements also emerged as key de-
terminants of hookah smoking initiation. For instance, smoke
tricks such as blowing smoke rings or blowing smoke bubbles
were commonly described as ‘fun’ and ‘visually stimulating’.
Other subcategories identified within this theme included
competition and creativity with respect to the hookah smoke.
Individuals noted the hookah smoke served as a vehicle to
express creativity and their competitive nature via smoke
tricks. One participant stated: ‘It's entertaining. Like even just
to watch other people do it. Actually, you know some people
like to compete about who can be the most creative, so… like
‘O’s’.
Collaboration
The entire process of hookah pipe assembly, preparation, and
smoking session was described as an organized effort. Varying
tasks were shared (such as packing the bowl, cleaning, and
pipe assembly) and assigned among group members.
128 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0
Compromise played a key role in the process from taking
turns on assigned tasks to deciding flavor choices. Further-
more, participants described an element of trust in each
member's ability to carry out their tasks properly so as to not
ruin the group's hookah smoking experience via improper
setup or even breaking the hookah pipe. Similarly, an enjoy-
able hookah smoking experience was equally contingent on
all members' willingness to share hoses within the group.
Thus, the contingency for a minimal required skill level on
pipe assembly and preparation was also conducive to within-
group mentorship roles during the initial stages of knowledge
transfer and skill acquisition.
Health conscious
Millennial hookah users were notably aware of both the
negative and positive consequences that may stem from
continued hookah use; however, behavioral beliefs were pri-
marily fixated on the perception that hookah smoking was a
healthier alternative (had less toxins) as compared to cigarette
smoking. For instance, when participants were asked to
classify the elicited words or phrases, the following words or
phrases were classified as both enjoyable and harmful: stress
reliever, escape from other parts of the party, a lot of smoke at
once, light-headed, and complementary to other substances.
In addition, natural hookah-related product varieties were
also described to contribute to this healthier comparative
perception of hookah smoking as compared to other forms of
tobacco consumption. One participant stated: ‘Can it be
healthy too? There's like, instead of like fast acting coals
there's natural coals that they use so I guess that people think
that those are better.’
Additionally, healthier comparative beliefs held by Mil-
lennials were also closely associated with hookah pipe aes-
thetics, pleasant scent, ‘smoother’ smoke (for passersby and
smokers alike), and low likelihood of daily use, as compared to
cigarettes.
Value social network
Millennial hookah users primarily described the hookah
smoking experience as a highly accepted recreational social
interaction predominantly initiated by strong peer and
(closely followed by) family influences. Participant self-
efficacy was shown to be significantly enhanced via these
intimate and small social group settings, where peers were
often described as supportive and encouraging of the in-
dividuals' hookah smoking initiation via comments such as
‘it's easy’, ‘this is what you do’ or ‘it tastes good’. Family in-
fluences were often depicted as similarly socially pressing
small and intimate gatherings, with many family members
(e.g., parents, cousins, and grandmothers) gifting hookah
pipes for birthdays and high school graduations. Such social
influences were key drivers in shaping users' normative be-
liefs regarding hookah use. Thus, these findings are consistent
with the behavior initiation process as described by the Inte-
grated Model of Behavioral Prediction, being that social in-
fluences played a key role on all three determinants of
intention: outcome, normative, and efficacy beliefs.14 Thus,
efficacy beliefs were enhanced via social influences as well as
hookah characteristics closely corresponding to those of Mil-
lennials' generational culture.
Environmental access
While facilitators appeared to outweigh participants environ-
mental constraints, those that were expressed by Millennials
included factors linked to convenience, such as affordability
and accessibility. For instance, one participant noted he had
discontinued use after his initial hookah smoking attempt
until after he arrived to the college environment.
I didn't really get a chance to do it again after [high school] that up
until I got to college and one of the guys in the fraternity had one
and so I started back doing it again and then I eventually decided
to get my own.
On the other hand, facilitators were abundant and typically
included: the density of hookah shops and hookah bars/
lounges in surrounding neighborhood environments, legality,
age limit, convenience of online hookah-related purchases,
affordability, sorority/fraternity affiliation, and college party
environment (e.g., house parties). Affordability emerged as
both a constraint and facilitator depending upon the partici-
pant's locality, with urban environments tending to have
higher price points. Additionally, findings also revealed
smoking skill level to moderate behavior performance,
although social influences were typically strong enough to
boost individuals' confidence in initiating hookah smoking
despite their commonly low level of skill from the outset, as
many participants indicated that hookah smoking had been
their first smoking experience.
As previously mentioned, the hookah smoking experience
was described as a highly collaborative experience, with the
majority of the group members expressing their willingness to
share hookah skills and knowledge among initiating group
members. One participant stated:
Yeah the same, like, when they explain it to you, cause when you
don’t know how to do it, you breathe in through your lungs and
that’s when you cough. So, you just breathe in through your
mouth. When you get more used to it you get more confident. But
I wasn’t confident my first time.
Smoking experience
Although the majority of participants initiating hookah
smoking did not have former smoking experience, those who
did evidenced higher levels of self-efficacy for hookah smok-
ing. Moreover, data on participants with greater hookah
smoking frequency indicated trends in voicing more of the
possible negative aspects of hookah smoking, as compared to
their lower smoking frequency counterparts. Topics uncov-
ered included: discontent with group compromise over flavor
choice, boredom emerging from longer hookah sessions
(lasting more than 2 h), greater report of the negative side-
effects from prolonged hookah smoking (e.g., irritated
throat), and annoyance from others within the group (e.g.,
blowing too many smoke rings in another's face).
 p u b l i c h e a l t h 1 3 7 ( 2 0 1 6 ) 1 2 4 e1 3 0
Discussion
This study's findings highlight the powerful influence of
contextual environmental factors, such as individuals'
generational culture, with respect to corresponding percep-
tions toward and initiation of hookah smoking. Findings from
this study are consistent with the literature denoting a pre-
dominantly held perception of hookah smoking as a less toxic
form of tobacco consumption (when compared to cigarette
smoking) among individuals aged 18e24 years.6,11,5,16 Overall,
participant responses reflected congruence with existing
behavior initiation theory. The nine generational culture de-
terminants identified (autonomy, personalization, novelty
appeal, convenience, globally oriented, entertainment,
collaboration, health conscious, and valuing their social
network) manifested as key cultural determinants following
the schema for behavior performance initiation described by
the Integrative Model of Behavioral Prediction.14 While the
generational culture determinants identified were observed to
strengthen hookah smoking behavior initiation, individuals'
smoking skill level, as well as environmental constraints (e.g.,
affordability) or facilitators (accessibility), were found to
moderate hookah smoking initiation among Millennials.
Study limitations included the highly structured format in
which the focus group interviews were conducted, thus
reducing data richness. For instance, participants were not
able to form categories of their own in which to categorize the
words as these were developed from the literature. Similarly,
despite the moderators' effective use of probes during the
focus group interviews, ranking exercises (for each pre-
determined hookah category) hindered the generation of
more elaborate responses from participants. Moreover, given
the sample composition, drawing college student (4 groups, 30
participants) vs non-student group (2 groups, 10 participants)
comparisons was another study limitation. While efforts were
made to recruit community-dwelling young adults, very few
contacted the research team to participate in the study.
Generational differences, however, should transcend college
vs non-college status and thus are perhaps not important
distinctions for hookah use.
Given the data examined provided an understanding of key
factors driving hookah smoking initiation among the young
adult population, future implications for this study's findings
include enhanced hookah smoking prevention and cessation
programming capitalizing on the promotion of positive health
behaviors that support and/or align with Millennial charac-
teristics. For intervention development, generational culture
determinants identified in this study can serve as generative
schema17 conveying broader motivating constructs conducive
to Millennials' choice to initiate hookah smoking. Using a
generative approach,17 campus health promotion initiatives
can seek to develop intervention models satisfying identified
Millennial generational culture schemata via substitute posi-
tive recreational outlets for young adults. Ideal positive rec-
reational outlets would foster opportunities for schemata
such as autonomy, personalization, novelty appeal, conve-
nience, globally oriented, entertainment, collaboration, health
consciousness, and a valued social network to flourish among
young adults.
129
In addition, campus health promotion efforts must also
seek to dispel prevailing myths regarding hookah smoking as
a healthier alternative to cigarette smoking. Moreover, anti-
hookah smoking health education initiatives should be rein-
forced by policy efforts aiming to include hookah smoking in
all current smoke-free ordinances. The lack of policies
restricting hookah smoking indoors has exacerbated mis-
conceptions regarding hookah smoking's safety, and hookah
bar establishments continue to remain exempt from clean
indoor air legislation.18,19 Policy efforts can help curb young
adult misconceptions regarding the safety of hookah use and
reduce accessibility. Examples of policy implications for the
reduction of hookah smoking initiation and continued use
among the young adult population could include: raising
hookah bar age limits, restrictions for indoor smoking, and
limiting the density of hookah cafes surrounding areas with
high young adult populations, such as near University
campuses.
Author statements
Acknowledgements
All authors take full responsibility for the integrity of the data.
Ethical approval
University of Florida Institutional Review Board.
Funding
This project was funded by the National Institutes of Health:
National Cancer Institute (Grant Number CA165766, principal
investigator Tracey Barnett, PhD).
Competing interests
None declared.
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