In future assessments, more details about frequency of use and levels of toxicants will be necessary to estimate and compare the total exposure to toxicants selleck chemicals associated with the different tobacco consumption behaviors. Although tobacco-related surveillance and interventions among adolescents have universally involved cigarette, cigar, and smokeless tobacco use (Centers for Disease Control and Prevention, 2010; Johnston, O��Malley, Bachman, & Schulenberg, 2010; Kilmer et al., 2008), they have not tended to involve waterpipe use. However, the findings in our study suggest that waterpipe use is common enough among U.S. university students to be of concern and to be included in future efforts.

Our results regarding individual and institutional factors associated with waterpipe use suggest that efforts toward intervention should primarily target young White men in universities located in large cities in the western United States. However, ��White�� in this study included those of Middle Eastern ethnicity who may be particularly at risk. Therefore, it would be valuable for future studies to more carefully assess ethnic origin. Our results also indicate that there are several specific groups of individuals who are at especially high risk and for whom targeted educational approaches may be particularly valuable, such as bisexual individuals, fraternity/sorority members, and students with relatively poor academic achievement.

But a closer examination of the data, which highlight ever use rates over 20% in nearly all sociodemographic subgroups, suggests that focusing solely on particular groups or particular types of institutions would result in missed opportunities to educate thousands of college-aged waterpipe users about the potential harms of waterpipe use. The prevalence rates of waterpipe use suggest that it may be valuable to address this problem from a policy perspective. Today, several well-intentioned policies may actually be contributing to increases in waterpipe use (Rutten, Augustson, Doran, Moser, & Hesse, 2009; Stulhofer, Busko, & Landripet, 2010). For example, clean air laws provide specific exemptions for ��tobacco retail establishments�� (Tobacco Control Legal Drug_discovery Consortium, 2011), a category under which many waterpipe-smoking establishments fall. Furthermore, while the recently enacted Family Smoking Prevention and Tobacco Control Act (signed into law in 2009) bans flavoring of cigarettes, the act does not ban flavoring of shisha, the special form of tobacco used in a waterpipe. Thus, waterpipe users can consume chocolate, strawberry, or caramel tobacco in waterpipes. Finally, while traditional bars often deny the entrance of individuals under the age of 21, the age limit at waterpipe-smoking establishments is 18.