Date of Award


Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Ramzi Salloum


Introduction: In the United States, young adults have the highest prevalence of waterpipe tobacco smoking (WTS) according to National Adult Tobacco Surveys (NATS) published by the Center for Disease Control (CDC). Experimentation of different tobacco products is highest among 18-24 year olds. Most recently, WTS has surged in popularity among this demographic group. The rapid diffusion of WTS among this population has been accelerated by marketing efforts on the Internet. There are misperceptions that WTS is less harmful than smoking cigarettes and there is a proliferation of WTS establishments due to tobacco retail exemptions. Presently, WTS establishments are almost completely unregulated and limited information exists about the actual number and locations of these businesses in the U.S.

Objectives: To survey WTS establishments in the U.S. and assess their proximity to this vulnerable population as well as evaluate socio-demographic variables and specific characteristics related to young adult tobacco users.

Methods: Information about WTS establishments was captured from phone directories, business, and commercial databases. Business addresses were geocoded in ArcGIS 10.2. Geographic spatial analyses were run to assess density and proximity of WTS businesses in relation to colleges. Next, bivariate analyses and logistic regressions were run on the NATS data to understand the usage characteristic for different tobacco products and combination of products within the 18-24 year old population.

Results: The first study found 1,690 WTS establishments, which is significantly higher than any other published study. Of the 1,454 colleges analyzed, 38.1% were within 3 miles of a WTS establishment. Proximity of WTS establishments to colleges was associated with full-time student enrollment and higher among private colleges and those without a smoke-free campus policy. The second study found 18-21 year olds, the level of education, and the region where the respondents live were associated with different use patterns for waterpipe and different tobacco products.

Conclusions: These studies could influence health policy initiatives that are aimed at reducing tobacco retail exemptions, which make it possible for many of these WTS establishments to open. Different intervention strategies are needed for specific characteristics and patterns within the 18-24 year old population for varying waterpipe and dual tobacco product usage.