Age of initiation of hookah use among young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013–2017

OBJECTIVE: To prospectively estimate the age of initiation of ever, past 30-day, and fairly regular hookah use among young adults (ages 18–24) overall, by sex, by race/ethnicity, and to explore the association of prior use of other tobacco products with these hookah use behaviors. METHODS: Secondary data analyses of the first four waves (2013–2017) of the PATH study, a nationally representative longitudinal cohort study of US young adults. Young adult never hookah users at the first wave of adult participation in PATH waves 1–3 (2013–2016) were followed-up into waves 2–4 (2014–2017) to estimate the age of initiation of three outcomes: (i) ever use, (ii) past 30-day use, and (iii) fairly regular hookah use. Weighted interval-censoring Cox proportional hazards regression models were used to examine the differences in the estimated age of initiation by sex and by race/ethnicity while controlling for the total number of other tobacco products ever used at participants’ first wave of PATH participation. In addition, to examine if prior use of other tobacco products was associated with the age of hookah initiation behaviors, six additional Cox models are reported for each hookah initiation behaviors. RESULTS: The largest increase in hookah use occurred between ages 18 and 19: 5.8% for ever use and 2.7% for past 30-day hookah use. By age 21, 10.5%, 4.7% and 1.2% reported initiation of ever, past 30-day and fairly regular hookah use, respectively. There were statistically significance differences in the age of initiation of hookah use behaviors by race/ethnicity. CONCLUSION: Educational interventions should target young adults before the age of 21, focusing efforts specifically on males, non-Hispanic Blacks and Hispanics, to stall initiation and progression of hookah use behaviors.