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University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 1 Perceive d Peer Tobacco Use a s a Predictor of Actual Tobacco Use in College Students Allison Y. Reddick, Dr. Tracey E. Barnett, and Erik K. Soule College of Public Health and Health Professions University of Florida Tobacco companies target 18 2 4 year olds due to their high risk taking behavior and their resulting potential for life long addiction. The overall purpose of this study was to evaluate the effect of perceived peer use of tobacco products among college students on actual personal use. Based on the literature reviewed tobacco products (cigarettes and hookah) will be more likely to be users themsel ves. Data included assessment of 26,685 student participants from 40 institutions around the United States. Statistical analysis of the data included the chi square test of independence. Current cigarette smokers were more likely to overestimate current pe er use of cigarettes compared to non smokers (89.8% vs. 81.1%; X 2 =188.699, p<.001). Current hookah smokers were also more likely to overestimate current peer use of hookah compared to non smokers (87.9% vs. 64.5%; X 2 = 58 6.729, p<.001). There was an overwhel mingly hi gh peer effect of tobacco use, and t his was further increased by smoking status. Compared to non smokers, s tudents who were current smokers (both cigarettes and hookah) were more likely to overestimate that t heir peers were smokers as well. INTRODUCTION In the United States, the tobacco industry concentrates the majority of its marketing efforts on young adults between the ages of 18 and 24 (Smith, Curbow, & Stillman, 2007). Tobacco companies target this age group because adolescents/young adults tend to engage in risky behaviors at a higher rate during these years of life (Emmons, Wechsler, Dowdall, & Abraham, 1998). If these young patrons become addicted to tobacco products, they become a source of long term custo mers for the tobacco industry College freshme n are at particularly high risk for tobacco use due to their new found independence, new environment, and need to make friends (Sm ith et al., 2007). Gatrad, Gatrad, and Sheikh (2007) found that 40% of college students had smoked at least one cigarette in the past year. Similarly, many hookah smokers are young college students including many within Greek (fraternity and sorority) organizations (Primack, Walsh, Bryce, & Eissenberg, 2009 ). The increase of hookah smoking may be connected to the fact that this stratum is too young to drink alcohol so they socialize through hookah smoking cafes (Eissenberg, Ward, Smith Simone, & Maziak, 2008). Predictors of Smoking According to the World Health Organization, approxi mately 250 million women smoke daily around the world (as cited by Lombardi, Prado, Santos, & Fernandes, 2011). Cigarette smoking prevalence in college students is slightly higher for & Schulenberg, 2009) Though worldwide male prevalence is higher, the prevalence of smoking in young women is growing internationally and in some countries is higher than male smoking prevalence (Lombardi et al., 2011). Tobacco companies have been focusing on young women in a dvertising and specific product lines through images of liveliness, slenderness, freedom, sophistication and sexual attraction (Mackay & Amos, 2003). Tobacco products have developed features to allure women into smoking including flavored cigarettes and extra slim style (Mackay & Amos, 2003). For young women, previous studies have found a strong association between smoking and the presence of smoking among friends and family (Lombardi et al., 2011). Research by Eissenberg et al. (2008) found that more fem ales had never used hookah (75.8%) compared to males (63.1%) and more males were current hookah users (36.9%) compared to fema les (24.2%). Smith Simone Maziak, Ward, and Eissenberg (2008 ) conducted hookah research and found the same findings of more males ever using hookah (80.1%) compared to females (19.9%) in their sample population. The association between stated use and perceived use of cigarettes and hookah will b e assessed with a focus on college students. It is hypothesized that
ALLISON Y R EDDICK DR TRACEY E BARNETT AND ERIK K S OULE University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 2 college students who over cigarettes and hookah will be more likely to be users themselves. This involves the factors of social context and peer influence which implies that if the majority are engaging in the use of these tobacco products that they too will most likely engage in the behavior at some point. METHODS This study was approved by the University of Florida IRB as an exempt study for the de identified NCHA II dataset. The ACHA NC HA II provides the largest known comprehensive data set on the health status and activities of college students nationwide (ACHA NCHA, 2009). The data for this study were collected from the ACHA NCHA II during the fall of 2008. Forty five postsecondary in stitutions participated in this assessment with a total of 28,144 surveys completed by students. Institutions that either surveyed all students enrolled in their institution or those that used a random sampling technique were included in the final analysis Taking those factors into consideration, the final analysis included 40 (88.9%) institutions with 26,685 (94.8%) student participants who completed the survey. The survey instrument assessed self r eported demographic information. Those identifying as tra nsgender (0.2%) were excluded due to the sma ll number. Only participants 18 25 years of age were included in the sample as they represent the typical college studen t age range. Race was coded as white and non w hite to combine minorities for more power for analysis. Class status was recoded into two categories: underclassmen and upperclassmen. Students who identified as being in their first or second year of college (in pursuit of an undergraduate degree) were coded as underclassmen. Students who identi fied as being in their third, fourth or fifth year or more of college (in pursuit of an undergraduate degree) were coded as upperclassmen. Degree seeking was coded as those who identified as being an undergraduate student and those who identified as being a gra duate student, including both in analysis. Grade point average was coded into three categories: 3.0 or higher, 2.0 2.9, and below 2.0. Current residence was condensed to living on or off campus. O n campus r esidence included campus residence halls, fraternity/sorority housing, and other college university housing. Fraternity/sorority housing was considered on campus due to proximity to campus as well as the high involvement in university activities. Off c hom e and other off campus housing. Being a member of a social fraternity or sorority (involvement in Greek life) was coded as yes or no and included National Interfraternity Conference, National Panhellenic Conference, National Pan Hellenic Council, and Natio nal Association of Latino Fraternal Organizations. For the tobacco use questions, the responses were coded in terms of current use and ever used. Originally in the survey the respondent tobacco use and typical (perceived) student use responses were split i nto never used, have used but not in the last 30 days, and varying degrees of choices of use within the last 30 days (1 2 days, 3 5 days, 6 9 days, 10 19 days, 20 29 days, and used daily). For current use, the varying choices within the last thirty days we re recoded as current smoker if any days were indicated. Have used, but not in the last 30 days and never used were coded as nonsmoker (for current). For ever use, any selection was coded as while no use was coded as never smoked RESULTS A greater number of females responded to the survey than males (69.5% vs. 30.5%). Also, more whites were participants compared to non whites (75.8% vs. 24.2%). The average age of participants was 19.86, with most of the participants (89.5%) reporting that t hey were seeking an undergraduate degree. Within the undergraduate degree seeking participants, 55.3% identified with being underclassmen (1 st or 2 nd year of college) and 44.7% identified with being upperclassmen (3 rd year or more) More students (52.7%) l ived on campus than off campus (47.3%). The majority of participants (92.0%) were not involved in Greek life. For grade point average, 89.2% had a GPA of 3.0 or high er, 10.2% had a GPA between 2.0 2.9, and 0.6% h ad a GPA below 2.0. The demographic characte ristics of the respondents are depicted in Table 1.
PERCEIVED TOBACCO US E OF COLLEGE STUDENT S University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 3 Table 1. Demographic Characteristic s Cigarette Ever Use Males reported ever smoking cigarettes more often than females (35.2% vs. 30.9%; X 2 =40.585, p<.001). For race, more whites (34.4%) than non whites (24.6%) reported ever using cigarettes in their lifetime (X 2 = 176.417, p<.001). Upperclassmen reported a higher total percent age of ever using cigarettes than underclassmen (37.0% vs. 28.1%; X 2 = 192.599, p<.001). Respondents seeking a graduate degree reported more ever using cigarettes than respondents seeking an undergraduate degree (34.9% vs. 32.0%; X 2 = 4.429, p=.035). For ever use of cigarette s, 39.4% of students living off campus reported ever using cigarettes in their lifetime compared to 27.2% of students living on campus (X 2 = 377.977, p<.001). For students involved in Greek organizations, 38.7% responded that they have smoked cigarettes compared to 31.6% of students not involved in Greek organizations (X 2 = 38.712, p <.001). The statistics of the respondents who have ever used cigarettes are depicted in Table 2. Hookah Ever Use Females reported a higher percentage of ever using hookah than males (37.0% vs. 29.6%; X 2 =124.402, p<.001). More white students reported ever using hookah compared to non white students (33.7% vs. 26.7%; X 2 = 90.325, p<.001). Ever using hookah was higher for upperclassmen than underclassmen (36.0% vs. 28.9% ; X 2 = 124.675, p<.001). For degree seeking students 32.0% of undergraduate students reported ever using hookah whereas 29.6% of graduate students reported ever using hookah (X 2 = 3.064, p=.080). For ever used hookah 34.7% of off campus residents reported u sing hookah in their lifetime compared to 29.9% of on campus residents. More Greek member students reported ever using hookah than students not involved in Greek organizations (40.6% vs. 31.1%; X 2 = 71.267, p<.001). The statistics of the respondents who have ever used hookah are depicted in Table 3. Current Cigarette Use Males reported more often being current cigarette smokers than females (19.6% vs. 14.8%; X 2 = 84.483, p<.001). For race, 17.5% of whites and 11.6% of non whites identified as being a current cigarette smoker (X 2 =101.706, p<.001). Of those who identified as upperclassmen (3 rd year or greater ), 18.0% were current cigarette smokers compared to 15.2% of underclassmen (1 st or 2 nd year). Students seeking an undergraduate degree reported higher curre nt cigarette smoking than students seeking a graduate degree (16.4% vs. 13.0%; X 2 = 10.183, p<. 001). More students living off campus reported being a cur rent smoker Demographics N=26,685 N (%) Sex Male 7,955 (30.5%) Female 18,107 (69.5%) Race White (Non Hispanic) 19,589 (75.8%) Non White 6,265 (24.2%) Age 18 25 23,099 (88.5%) Mean Age 19.86 Class Status Underclassmen (1 st or 2 nd year) 12,729 (55.3%) Upperclassmen (3 rd year or greater) 10,279 (44.7%) Degree Seeking Undergraduate 23,008 (89.5%) Graduate 2,691 (10.5%) Residence On Campus 13,764 (52.7%) Off Campus 12,335 (47.3%) Fraternity/Sorority member No 23,865 (92.0%) Yes 2,065 (8.0%) Grade Point Average 3.0 or higher 21,848 (89.2%) 2.0 2.9 2,490 (10.2%) Below 2.0 144 (0.6%)
ALLISON Y R EDDICK DR TRACEY E BARNETT AND ERIK K S OULE University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 4 (20.5%) compared to those living on campus (13.2%; X 2 =216.380, p< .001). Students involved in Greek organizations reported more current cigarette use compared to those who were not involved in Greek life (19.0% vs. 16.0%; X 2 = 11.143. p=.001). The statistics of the respondents who are current cigarette smokers are depicted in Table 2. Table 2 S tudent Cigarette Demographics Characteristics Current Ever N (%) p value N (%) p value Sex Male 1,034 (14.9%) p<.001 4,694 (29.6%) p<.001 Female 1,511 (9.5%) 2,578 (37.0%) Class Status Underclassmen (1 st or 2 nd yr) 1, 520 (12.6%) p<.001 3 473 (28.9%) p<.001 Upperclassmen (3 rd yr or greater) 948 (10.2%) 3 365 (36.0%) Degree Seeking Undergraduate 2,468 (11.5%) p<.001 6,838 (32.0%) p =.080 Graduate 53 (4.2%) 370 (29.6%) Current Residence On Campus 1,565 (11.6%) p=.011 4,043 (29.9%) p<.001 Off Campus 976 (10.5%) 3,223 (34.7%) Greek member Yes 277 (14.9%) p<.001 753 (40.6%) p<.001 No 2,251 (10.8%) 6,469 (31.1%) Race White 2,003 (11.6%) p<.001 5,797 (33.7%) p<.001 Non white 502 (9.7%) 1,380 (26.7) Current Hookah Use More males reported current hookah use than females (14.9% vs. 9.5%; X 2 = 139.207, p<.001). Respondents that identified as white reported more often being a current hookah smoker compared to those who identified as non white (11.6% vs. 9.7%; X 2 = 15.118, p<.001). Underclassmen reported more current hookah use than upperclassmen (12.6%. vs. 10.2%; X 2 = 31.568, p<.001). Respondents seeking a graduate degree reported less current hookah use than those seeking an undergraduate degree (4.2% vs. 11.5%; X 2 = 63.594, p<.001). On campus residents reported higher current hookah use than off campus residents (11.6% vs. 10.5%; X 2 =6.433, p=.011). Of those involved in Greek life, 14.9% identified as being a current hookah user compared to 10.8% of those not involved in Greek life (X 2 = 29.242, p<.001). The statistics of the respondents who are current cigarette smokers are depicted in Table 3.
PERCEIVED TOBACCO US E OF COLLEGE STUDENT S University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 5 Table 3 S tudent Hookah Demographics Characteristics Current Ever N (%) p value N (%) p value Sex Male 1,366 (19.6%) p<.001 2,447 (35.2%) p<.001 Female 2,343 (14.8%) 4,904 (30.9%) Class Status Underclassmen (1 st or 2 nd yr) 1,825 (15.2%) p<.001 3,383 (28.1%) p<.001 Upperclassmen (3 rd yr or greater) 1,681 (18.0%) 3,454 (37.0%) Degree Seeking Undergraduate 3,506 (16.4%) p=.001 6,837 (32.0%) p=.035 Graduate 162 (13.0%) 435 (34.9%) Current Residence On Campus 1,788 (13.2%) p<.001 3,675 (27.2%) p<.001 Off Campus 1,907 (20.5%) 3,662 (39.4%) Greek member Yes 352 (19.0%) p=. 001 7 18 (38.7%) p<.001 No 3,327 (16.0%) 6, 586 (31.6%) Race White 3,015 (17.5%) p<.001 5, 923 (34.4%) p<.001 Non white 602 (11.6%) 1, 272 (24.6%) Perceived Peer Ever Cigarette Use Females perceived that 94.5% of peers had ever used cigarettes whereas males perceived 92.7% of peers had ever used cigarettes (X 2 = 27.997, p<.001). Undergraduate and graduate students perceived vs. 94.8%; X 2 =1.548, p=.213). Upperclassmen perceived 94.8% of peers had ever use of cigarettes by their peers compared to underclassmen w ho perceived 93.3% of peers had ever used cigarettes (X 2 =21.326, p<.001). Students who live off campus perceived higher peer ever use of cigar ettes than students who live on campus (95.8% vs. 92.7%; X 2 = 94.349, p<.001). Students involved in Greek life perce ived that 95.1% of their peers had ever used cigarettes whereas students not involved in Greek life perceived that 93.9% of their peers had ever used cigarettes (X 2 =4.262, p= .039). Perceptions of typical peer cigarette ever use statistics are depicted in T able 4.
ALLISON Y R EDDICK DR TRACEY E BARNETT AND ERIK K S OULE University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 6 Table 4 Perceptions of Typical Peer Cigarette Use Characteristics Current Ever N (%) p value N (%) p value Sex Male 5,577 (80.7%) p<.001 6,410 (92.7%) p<.001 Female 13,290 (84.5%) 14,871 (94.5%) Class Status Underclassmen (1 st or 2 nd yr) 10,004 (83.7%) p<.589 11,146 (93.3%) p<.001 Upperclassmen (3 rd yr or greater) 7,721 (83.5%) 8,772 (94.8%) Degree Seeking Undergraduate 17,725 (83.6%) p=.001 19,918 (94.0%) p=.213 Graduate 969 (78.5%) 1,171 (94.8%) Current Residence On Campus 10,837 (80.8%) p<.001 12,438 (92.7%) p<.001 Off Campus 8,013 (87.0%) 8,825 (95.8%) Greek member Yes 1,571 (85.1%) p=.026 1,754 (95.1%) p<.039 No 17,166 (83.1%) 19,384 (93.9%) Race White 14,105 (82.6%) p<.001 16,141 (94.6%) p<.001 Non white 4,381 (85.2%) 4,754 (92.4%) Perceived Peer Ever Hookah Use Females perceived a higher percentage of peers ever smoking hookah (88.3% vs. 86. 0%; X 2 = 23.447, p<.001). White students perceived a higher percentage of peers ever using hookah than non whites (88.6% vs. 85.7%; X 2 =30.650, p<.001). Upperclassmen perceived higher peer ever use of hookah compared to underclassmen (89 .6% vs. 86.5%; X 2 =50.856, p<.001). Undergraduates also perceived more peer ever use of hookah than graduate students (87.9% vs. 82.8%; X 2 =28.102, p<.001). Students who live off campus perceived more peers ever used h ookah than students who live on campus ( 87.1% vs. 88.2%; X 2 =5.181, p=.023). Students affiliated with Greek life perceived higher peer ever use of hookah than students not affiliated with Greek life (90.7% vs. 87.3%; X 2 =17.796, p<.001). Perceptions of typical hookah ever use statistics are depict ed in Table 5. Perceived Peer Current Cigarette Use Females perceived more peer use in current cigarette smoking than males (84.5% vs. 80.7%; X 2 =50.289, p<.001). Respondents who identified as being white perceived 82.6% of peers were current smokers whereas more respondents who identified as being non white perceived peers were current smokers (85.2%; X 2 = 18.387, p<.001). Undergraduate students perceived more of their peers as current cigarette
PERCEIVED TOBACCO US E OF COLLEGE STUDENT S University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 7 smokers (83.6%) than graduate students (78.5%; X 2 =22.250, p<.001). Underclassmen and upperclassmen perceived similar current cigarette use among peers (83.7% vs. 83.5%; X 2 =.292, p=.589) Students who live on campus perceived 80.8% of their peers were current cigarette smokers whereas more students (87.0%) who lived off campus perceived their peers were current cigarette smokers (X 2 = 153.098, p<.001). Students involved in Greek life perceived higher peer use of current cigarette use than those not affiliated with Greek life (85.1% vs. 83.1%; X 2 = 4.951, p =.026). Perceptions of typical peer cigarette current use sta tistics are depicted in Table 4. P erceived Peer Current Hookah Use Females perceived higher peer current hookah smokers than males (71.2% vs. 67.4%; X 2 =32.726, p<.001). White studen ts perceived lower peer current hookah smokers than students who identified as non white (69.4% vs. 73.0%; X 2 =25.068, p<.001). Underclassmen and upperclassmen perceived similar peer current hookah use (71.3% vs. 70.7%; X 2 =.647, p=.412). Undergraduate stude nts perceived more peer current hookah smokers than graduate students (71.0% vs. 55.5%; X 2 =132.621 p<.001). Students who live on campus and off campus perceived similar peer hookah use (70.0% vs. 70.1%; X 2 =.015, p=.902). Students affiliated with Greek lif e perceived higher peer current hookah smokers than those not affiliated with Greek life (73.8% vs. 69.8%; X 2 =13.085, p<.001). Perceptions of typical hookah current use statistics are depicted in Table 5. Table 5 Perce ptions of Typical Peer Hookah Use Characteristics Current Ever N (%) p value N (%) p value Sex Male 4,632 (67.4%) p<.001 5,904 (86.0%) p<.001 Female 1 1,132 (71.2%) 1 3,795 (88.3%) Class Status Underclassmen (1 st or 2 nd yr) 8,456 (71.3%) p<. 412 10,268 (86.5%) p<.001 Upperclassmen (3 rd yr or greater) 6,504 (70.7%) 8, 251 (89.8%) Degree Seeking Undergraduate 14,960 (71.0%) p=.001 1 8,519 (87.9%) p<.001 Graduate 678 (55.5%) 1, 011 (82.8%) Current Residence On Campus 9,350 (70.0%) p<. 902 1 1,631 (87.1%) p=.023 Off Campus 6,401 (70.1%) 8, 047 (88.2%) Greek member Yes 1,354 (73.8%) p<.001 1, 663 (90.7%) p<.0 01 No 1 4,313 (69.8%) 1 7,900 (87.3%) Race White 1 1,763 (69.4%) p<.001 1 5,014 (88.6%) p<.001 Non white 3,732 (73.0%) 4, 378 (85.7%)
ALLISON Y R EDDICK DR TRACEY E BARNETT AND ERIK K S OULE University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 8 Estimation of Peer Use Current cigarette smokers were more likely to overestimate peer current use of cigarettes compared to non smokers (89.8% vs. 81.1%; X 2 =188.699, p< .001). Current hookah smokers were more likely to overestimate peer current use of hookah compared to non smokers (87.9% vs. 64.5%; X 2 = 586.729, p<.001). Students who had ever used cigarettes were more likely to overestimate peer ever use of cigarettes comp ared to students who had never used cigarettes (97.6% vs. 91.4%; X 2 = 358.598, p<.001). Students who had ever used hookah were more likely to overestimate peer ever use of hookah compared to students who have never used hookah (96.2% vs. 80.2%; X 2 = 1085.358, p<.001). DISCUSSION The results of this study confirm that there is an association between stated use and perceived use of cigarettes and hookah. Similar to the findings by Eissenberg et al. (2008 ) and Smith Simone et al. (2008 ) more whites reported being current hookah smokers. When asked about perceived tobacco use among their peers, college students who reported using these tobacco products, whether current or ever, dramatically over cigarettes an d hookah. College students who are current smokers tend to believe that, since they are smoking, their peers are probably smoking as well. The se findings are consistent with those of Kypri and Langley (2003) who found a positive correlation between a stud perceived norm drinking level. When college students engage in such behaviors there is a desire to assume that their peers are also engaging in the behaviors as well. Females reported higher hookah rates of ever use in contra st to previous results (Eissenberg et al., 2008; Primack et al., 2008; Smith Simone et al., 2008 ). There are many possible factors that could be contributing to this statistic. The higher ever use of hookah by females could be due to lack of awareness of t he health effects the use of hookah for social network ing or introduction of hookah to females by their male peers This could be an emerging trend. Nonetheless, it is something that needs continued tracking. Underclassmen reported higher current hookah use than upperclassmen but lower ever use of hookah. These results are similar to the trends reported by the research of Eissenberg et al. (2008) and Smith Simone et al (2008 ). Eissenberg et al (2008) also found that waterpipe use was associated with pe ople younger than 20 and believes that this may be due to the fact that these individuals cannot access bars and instead socialize in hookah bars. College freshme n may be engaging in hookah smoking due to the social aspects or as Smith et al. (2007) c lai ms, f reshme n are at high risk for tobacco use due to their newfound independence and need to make friends. Upperclassmen may have engaged in hookah smoking when they were under 21 and then ceased to do so once they reach 21, an age when they could socializ e through alcohol consumption at bars This could explain the higher ever use in upperclassmen and higher current use in underclassmen. Between stated, actual cigarette and hookah use and perceived peer use, students greatly overestimated the amount of peers who are current or have ever used cigarettes or hookah. The results of this study are in concordance with the data that males have higher percentages of current cigarette smoking than females. Female peer perception, however, is higher than males an d this could be due to the increased targeting of young females by tobacco companies as expressed by Mackey & Amos (2003). Upperclassmen have higher peer perceptions of cigarette and hookah use. On the other hand, undergraduate students have more current h ookah and cigarette smokers and perceived more peer smokers than graduate students. The social aspect of smoking may be affecting undergraduates in the ways they socialize compare d to graduate students. Regardless of the demographic variable, whether curre nt or ever tobacco users, students vastly over estimated the number of peers who are current users, or who have ever used tobacco. Limitations in this study include the extremely large sample size. The sample size is so large that it tends to make most of the rate comparisons statistically significant which may inflate findings. Regarding perceived use, the wording of the questions allows for over estimation and thus limits meaningful comparison. One possible confounder that was not accounted for could be s ocioeconomic status since college students typically represent middle and upper socioeconomic strata.
PERCEIVED TOBACCO US E OF COLLEGE STUDENT S University of Florida | Journal of Undergraduate Research | Volume 14, Issue 1 | Fall 2012 9 CONCLUSION Despite these limitations, the study results indicate that college students who are current tobacco users are more likely to over estimate pe er tobacco use. Potential intervention programs could include educating college students about actual peer tobacco and socially accepted. Reducing the normative attitudes around tobacco would likely reduce rates as well. REFERENCES American College Health Association National Health Colle ge Assessment. 2009. Retrieved May 15, 2011 from http://www.acha ncha.org/. Eissenberg T., Ward, K. D., Smith Simone, S., & Mazaik, W. (2008). Waterpipe tobacco smoking on a U.S. college campus: Prevalence and correlates. The Journal of Adolescent Health, 42 (5), 526 5 29. doi: 10.1016/j.jadohealth.2007.10.004 Emmons, K. M., Wechsler, G. D., & Abraham, M. (1998). Predictors of smoking among US college students. American Journal of Public Health, 88 (1), 9 11.doi:10.2105/AJPH.88.1.104 Gatrad, R., Gatrad, A., & Sheikh, A. (2007). Hookah smoking. BMJ Publishing Group, 335 (7650), 20. doi: 10.1136/bmj.39227.409641.AD Kypri, K. & Langley, J. D. (2003). Perceived social norms and their relation to university student drinking. Journal of Studies on Alcohol 64(6), 829 834 Retrievedfromhttp://uh7qf6fd4 h.search.serialssolutions.com.lp.hscl.ufl.edu/?V =1.0&pmid=14743946 Lombardi, E., Prado, G., Santos, U., & Fernandes, F. (2011). Women and smoking: Risks, impacts and challenges. Bras. pneumol. [onli ne]. 2011, vol.37, n.1, pp. 118 128. ISSN 1806 3713. Mackay, J., and Amos, A. (2003). Women and tobacco. Respirology 8(2), 123 130. DOI: 10.1046/j.1440 1843.2003.00464. Primack, B. A., Walsh, M., Bryce, C., & Eissenberg, T. (2009). Water pipe tobacco smoking among middle and high school students in Arizona Pediatrics, 123 (2), e282 e288. doi:10.1542/peds.2008 1663 Primack, B. A., Sidani, J., Agarwal, A. A., Shadel, W. G., Donny, E. C., & Eissenberg, T. E. (2008). Prevalence of and associations with wat erpipe tobacco smoking among U.S. university students. The Society of Behavioral Medicine, 36 (1), 81 86.doi:10.1007/s12160 008 9047 6 Smith, S. Y., Curbow, B., & Stillman, F. A. (2007). Harm perception of nicotine products in college freshme n. Nicotine and Tobacco Research, 9 (9), 977 982. doi:10.1080 /14622200701540796 Smith Simone, S., Maziak, W., Ward K. D., & Eissenberg, T. (2008 ). Waterpipe tobacco smoking: Knowledge attitudes, beliefs, and behavior in two U.S. samples. Nicotine and Tobacco Research, 10 (2), 393 398. doi: 10.1080/14622200701825023