- Email: [email protected]
Descriptive and injunctive norms of waterpipe smoking among college students
Accepted Manuscript Descriptive and injunctive norms of waterpipe smoking among college students
Eleanor L.S. Leavens, Emma I. Brett, Taylor L. Morgan, Susanna V. Lopez, Raees A. Shaikh, Thad R. Leffingwell, Theodore L. Wagener PII: DOI: Reference:
S0306-4603(17)30342-8 doi: 10.1016/j.addbeh.2017.09.006 AB 5293
To appear in:
Addictive Behaviors
Received date: Revised date: Accepted date:
10 May 2017 20 August 2017 14 September 2017
Please cite this article as: Eleanor L.S. Leavens, Emma I. Brett, Taylor L. Morgan, Susanna V. Lopez, Raees A. Shaikh, Thad R. Leffingwell, Theodore L. Wagener , Descriptive and injunctive norms of waterpipe smoking among college students. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ab(2017), doi: 10.1016/j.addbeh.2017.09.006
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running head: NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING
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Descriptive and Injunctive Norms of Waterpipe Smoking among College Students
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Eleanor L. S. Leavens, MS1,2 Emma I. Brett, MS2 Taylor L. Morgan, BA1 Susanna V. Lopez, BS2 Raees A. Shaikh, PhD1 Thad R. Leffingwell, PhD2 Theodore L. Wagener, PhD1,3
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1Oklahoma Tobacco Research Center, Oklahoma City, OK, USA 2Department of Psychology, Oklahoma State University, Stillwater, OK, USA 3Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Keywords: waterpipe, smoking, normative perceptions, college students Correspondence concerning this article should be addressed to Theodore L. Wagener, Oklahoma Tobacco Research Center, University of Oklahoma Health Sciences Center, 655 Research Parkway, Oklahoma City, OK 73104. Email: [email protected]. Abstract
ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING Introduction: Smoking tobacco via a waterpipe (WP) is on the rise, particularly among college students. One reason for this may be normative perceptions of WP tobacco smoking (WTS) among this population. The current study examined the perceived and actual descriptive and injunctive norms of WTS among a college student sample.
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Methods: Participants were 894 college students enrolled at a large, Midwestern university.
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Participants completed measures of WTS frequency and quantity and perceived/actual
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descriptive and injunctive norms of WTS.
Results: Over one-third of the sample reported ever trying WTS, while only 2% reported current
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(past month) use. When comparing ever and never WP smokers, ever smokers reported greater
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perceived peer approval of WTS. Both males and females overestimated WTS frequency of same-sex students at their university.
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Discussion: The current study is one of the first to investigate descriptive and injunctive norms
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of WTS among college students. Students who report WTS are more likely to overestimate descriptive norms of WTS among their peers, suggesting corrective normative feedback
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regarding actual use by peers may be an important target for WTS intervention among college
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students. Future research should investigate the temporal association between normative
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perceptions and WTS behaviors among college students.
Keywords: waterpipe, hookah, smoking, normative perceptions, descriptive norms, injunctive norms
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Introduction While use of most tobacco products in the US are declining, waterpipe (WP) tobacco smoking (WTS) continues to increase (Arrazola et al., 2015). College students represent a
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particularly at-risk group. 30-50% of college students report lifetime WTS (Heinz et al., 2013;
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Primack et al., 2013; Sutfin et al., 2011) with 6-22% reporting past 30-day WTS (Braun et al.,
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2012; Heinz et al., 2013; Jarrett et al., 2012; Primack et al., 2013). Importantly, WTS is associated with many of the same negative health outcomes as cigarette use (Cobb, Sahmarani,
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Eissenberg, & Shihadeh, 2012; El-Zaatari, Chami, & Zaatari, 2015).
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One possible reason WTS is increasing among college students may be normative perceptions of WTS. The theory of social normative behavior asserts individuals overestimate
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peer engagement in risky behaviors (Perkins, 2002). These misperceptions are posited to lead
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individuals to be less concerned about their own behaviors, resulting in increased engagement in risky behaviors (Baer, Stacy, & Larimer, 1991; Borsari & Carey, 2003; Perkins, 2002).
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Descriptive norms, or the perceptions of frequency of a behavior, and injunctive norms, or
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perceptions of acceptability or approval of the behavior, are types of normative perceptions (Larimer & Neighbors, 2003; Neighbors et al., 2007; Silvestri & Correia, 2016). Similarly, the
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False Consensus Effect asserts that individuals who engage in a target behavior believe that others engage in similar behaviors at relatively similar frequencies (Ross, Greene, & House, 1977). Existing research with college students suggests peer WTS is influential in personal WTS. Not only is greater perceived peer approval associated with increased WTS (Heinz et al., 2013; Sidani, Shensa, Barnett, Cook, & Primack, 2014), but WTS is innately social. WP smokers
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING note that they initiated use and currently smoke WP with friends (Maziak, 2014; Smith-Simone, Maziak, Ward, & Eissenberg, 2008; Ward et al., 2007). Additionally, gender differences have been shown in rates of WTS such that males are more likely than females to smoke WP (Eissenberg et al., 2008; Primack et al., 2010; Villanti et al., 2015). Assessment of gender-
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specific norms is important to avoid over-estimating female norms while under-estimating male
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norms.
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No studies have assessed descriptive norms and few have assessed injunctive norms of WTS among college students in the US Consistent with theories of social normative behavior
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(Perkins, 2002) and the False Consensus Effect (Ross et al., 1977) and previous research, it is
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hypothesized that (1) never WP smokers will report lower perceived peer approval of WTS, (2) overall, participants will overestimate the frequency of WTS among typical same-sex students at
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their university, (3) ever WP smokers will be more likely to overestimate the frequency of WTS
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of a typical same-sex student at their university compared with never WP smokers, and (4) ever WP smokers will be more likely to overestimate the frequency of WTS of their best same-sex
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friend compared with never smokers.
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Methods
Participants and procedure
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Undergraduate students, ≥ 18 years, attending a large Midwestern university self-selected into the study through the university’s online research system throughout the fall 2016 semester. Following informed consent, participants completed study procedures anonymously and remotely online and were compensated with class credit. The University’s Institutional Review Board approved all study procedures.
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING WTS Status, Frequency, and Descriptive Norms. Participants reported smoking status via two self-report items. The first asked if participants had smoked in their lifetime. Those who denied WTS were classified as “never users”. Those who reported lifetime WTS then responded to a question assessing past 30-day smoking. Those who indicated an affirmative response were
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classified as “current users.” Those who denied current WTS were classified as “ever users”. To
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assess actual descriptive norms, WP-adapted items from the Daily Drinking Questionnaire
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(Collins, Parks, & Marlatt, 1985) were utilized. Participants reported the number of WTS sessions on each day during a typical week. Participants completed similar items assessing
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number of hours spent smoking on each day during a typical week. Total scores were created,
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indicating the total number of sessions smoked and hours spent smoking. Perceived Injunctive Norms. Participants completed a single item assessing injunctive
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norms of WTS (Heinz et al., 2013): How many of your five closest friends would approve of you
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smoking a hookah?. Response options ranged from 0 (no friends would approve) to 5 (all five would approve).
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Perceived Descriptive Norms. Participants reported on perceived frequency of WTS on
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each day of a typical week during the past month for their best male/female friend and a typical male/female student at their school. Total scores were calculated, indicating perceived weekly
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WTS frequency for each target. These items were adapted for WTS from the Drinking Norms Rating Form (Baer, Stacy, & Larimer, 1991). Data analytic plan Data were screened for missingness and outliers prior to all analyses. 61 participants (6.3%) admitted random or dishonest responding and 20 (2.1%) did not complete the full survey and were excluded from analyses. Outliers (n = 18) were observed on variables assessing hours
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING smoking WP in a typical week (n = 1), and descriptive norms of WTS (n = 17). Outliers were replaced with the value that was three standard deviations and one integer above the mean (Tabachnick & Fidell, 2007). Outliers were retained to avoid masking normative misperceptions. Descriptive statistics were conducted to examine participants’ WTS and descriptive and
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injunctive norms. One-sample t-tests were used to determine whether participants misperceived
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the amount same-sex peers smoked WP. Analyses were conducted separately for male and
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female students. A one-way analysis of covariance controlling for gender was used to examine differences in perceptions of WTS between never and ever WP smokers.
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Results
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The final sample consisted of 894 participants (Mage = 19.67, SD = 5.84) and consisted of primarily Caucasian (77.5%) and female (66.4%) students (Table 1). Generalizability of the
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current sample to the student body as a whole was assessed by comparing age (19.67 vs. 21.6, p
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< .001), proportion Caucasian (77.5 vs. 73.6, p = 0.376), proportion female (66.4 vs. 46.3, p < .001), and proportion freshmen students (39.0 vs. 24.3, p < .001). Student body information was
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obtained from the university’s Institutional Research and Information Management site. 316
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(35.3%) participants reported having ever smoked WP, while 20 (2.2%) reported past month WTS. 578 (64.7%) participants reported never having smoked WP. Close to half (47.6%) of
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never users reported that none of their five closest friends would approve of their WTS compared with only 19.9% of ever users believing that none of their closest friends would approve of their smoking (Figure 1). 43.4% of ever users reported that all five of their five closest friends would approve of their smoking WP, while only 16.4% of never users believed that five of their five closest friends would approve. Controlling for gender, there were significant differences between
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING ever users and never users regarding their perceptions of how many of their closest friends would approve of their smoking WP (F(1,891) = 110.23, p < .001, partial η2 = .11). Participants reported smoking an average of 0.05 (SD = 0.45) WTS sessions per week, spending approximately 0.07 (SD = 0.77) hours per week smoking (Table 2). Both male [M =
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3.11, SD = 11.31; t(288) = 4.55, p < .001, CI95 = 1.72, 4.33] and female [M = 2.85, SD = 8.26;
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t(583) = 8.24, p < .001, CI95 = 2.14, 3.49] students significantly overestimated the number of
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weekly WTS sessions the typical same-sex student engages in each week.
Controlling for gender, differences between never and ever users in perceptions of how
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much the typical male student, typical female student, best male friend, and best female friend
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smokes WP each week were examined. Never (Mmale = 4.81, SDmale = 11.98; Mfemale = 2.75, SDfemale = 7.90) and ever WP smokers (Mmale = 4.30, SDmale = 13.85; Mfemale = 2.43, SDfemale =
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9.07) reported similar perceptions of how much the typical male [F(1, 871) = 0.14, p = .71,
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partial η2 = .00] and female [F(1,871) = 0.20, p = .66, partial η2 = .00] student engages in a session of WTS each week. However, marginally significant differences emerged between never
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(M = 0.24, SD = 1.73) and ever users (M = 1.02, SD = 9.74) in their perceptions of how much
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their best female friend engages in a session of WTS each week [F(1,886) = 3.83, p = .05, partial η2 = .004]. Differences between never (M = 0.33, SD = 2.76) and ever (M = 0.79, SD = 5.18)
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users in perceptions of how much participants’ best male friend smokes WP was approaching significance [F(1,886) = 3.36, p = .07, partial η2 = .004]. Discussion The present study is among the first to assess injunctive and descriptive norms of WTS within a US college sample. Ever users were more likely to report greater perceived peer approval of WTS compared to never users, providing evidence that students are likely to
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING overestimate injunctive norms for behaviors they engage in and that WTS is likely to occur among friends. Regardless of gender, participants overestimated WTS frequency of same-sex students at their university. Literature regarding other health risk behaviors indicates overestimation of other students’ behaviors is associated with increases in the target behavior
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(Baer et al., 1991; Borsari & Carey, 2003). If the same is true of WTS, these misperceptions
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regarding peer WTS have the potential to translate into increased WTS.
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Mixed findings were observed between never and ever WP smokers regarding perceived WTS frequency by their best male/female friend and typical same-sex students. Prior research
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illustrates individuals are often more accurate in their perceptions of a best friend’s substance use
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compared to the use of typical students at their university (Baer & Carney, 1993). It was hypothesized that ever users would report greater perceived WTS frequency by same-sex
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students at their university compared to never users. However, this hypothesis was not fully
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supported.
The current research may have implications for individual and campus-wide interventions
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for WTS among college students, an at-risk population. Young adults may be motivated to
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behave similarly to their peers, including with substance use (Unger & Rohrbach, 2002). This is concerning given their overestimates of peer WTS. To correct this, information regarding
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campus-specific social norms may be incorporated into WTS interventions for college students. Such interventions are inexpensive and effective in altering other health risk behaviors among college students (Cronce & Larimer, 2011; Miller et al., 2013). While the current study is an important first step, it is not without limitations. We enrolled only a small proportion of current users; comparisons between current, never, and ever users were not possible. Infrequent WP smokers may have experienced difficulty responding to
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING study questions regarding WTS during a typical week. Future research should investigate differences between never, ever, and current WP smokers in perceived and actual norms and adjust item presentation based on frequency of use. Second, longitudinal studies are needed to understand the temporal association between normative perceptions and actual WTS behaviors.
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Also, the current sample was primarily comprised of young, female college students. Findings
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may not generalize to other age groups or same-age non-college counterparts. However, young
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adults are at the highest risk for WTS and may be an ideal target for this research. Additionally, since women are less likely to smoke WP, our findings may underestimate norms of WTS.
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However, these concerns are decreased by the assessment of gender-specific norms. Finally,
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participants self-selected into the study; to address concerns of self-selection bias, WP smoking was not mentioned in the study title on the online research system.
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This research contributes to an important gap in the literature, as it is one of only a few to
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investigate normative perceptions of WTS. The results are consistent with existing literature examining other health risk behaviors and highlights the importance of social norms of WTS.
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Future research should employ longitudinal methods and WTS-specific measures of normative
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perceptions to assess the temporal association of social norms and WTS behaviors in addition to obtaining greater detail regarding the context of WTS. Further, research is needed to parse out
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differences in social normative perceptions between current and ever users of WP. Disclosures:
Funding: None. Contributors: All authors were involved in the design and conceptualization of the study. ELL, TLW, and TRL wrote the protocol. All authors were involved in data collection for the study. EIB conducted the statistical analysis. ELL, SVL, TLM, EIB, and TLW wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript. Conflict of Interest: All authors declare that they have no conflicts of interest.
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References
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Arrazola, R. A., Singh, T., Corey, C. G., Husten, C. G., Neff, L. J., Apelberg, B. J., . . . Prevention. (2015). Tobacco use among middle and high school students - United States, 2011-2014. MMWR Morb Mortal Wkly Rep, 64(14), 381-385. Baer, J. S., & Carney, M. M. (1993). Biases in the perceptions of the consequences of alcohol use among college students. J Stud Alcohol, 54(1), 54-60. Baer, J. S., Stacy, A., & Larimer, M. (1991). Biases in the perception of drinking norms among college students. J Stud Alcohol, 52(6), 580-586. Borsari, B., & Carey, K. B. (2003). Descriptive and injunctive norms in college drinking: a metaanalytic integration. J Stud Alcohol, 64(3), 331-341. Braun, R. E., Glassman, T., Wohlwend, J., Whewell, A., & Reindl, D. M. (2012). Hookah use among college students from a Midwest University. J Community Health, 37(2), 294298. doi:10.1007/s10900-011-9444-9 Cobb, C. O., Sahmarani, K., Eissenberg, T., & Shihadeh, A. (2012). Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative. Toxicol Lett, 215(1), 70-75. doi:10.1016/j.toxlet.2012.09.026 Collins, R. L., Parks, G. A., & Marlatt, G. A. (1985). Social determinants of alcohol consumption: the effects of social interaction and model status on the self-administration of alcohol. Journal of consulting and clinical psychology, 53(2), 189. Cronce, J. M., & Larimer, M. E. (2011). Individual- focused approaches to the prevention of college student drinking. Alcohol Res Health, 34(2), 210-221. doi:SPS-AR&H-33 SPS-AR&H-33 Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates. J Adolesc Health. 2008;42:526–529. El-Zaatari, Z. M., Chami, H. A., & Zaatari, G. S. (2015). Health effects associated with waterpipe smoking. Tob Control, 24 Suppl 1, i31-i43. doi:10.1136/tobaccocontrol-2014051908 Heinz, A. J., Giedgowd, G. E., Crane, N. A., Veilleux, J. C., Conrad, M., Braun, A. R., . . . Kassel, J. D. (2013). A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav, 38(11), 27512760. doi:10.1016/j.addbeh.2013.07.009 Jarrett, T., Blosnich, J., Tworek, C., & Horn, K. (2012). Hookah use among U.S. college students: results from the National College Health Assessment II. Nicotine Tob Res, 14(10), 1145-1153. doi:10.1093/ntr/nts003 Larimer, M. E., & Neighbors, C. (2003). Normative misperception and the impact of descriptive and injunctive norms on college student gambling. Psychol Addict Behav, 17(3), 235243. doi:10.1037/0893-164X.17.3.235 Maziak, W. (2014). The waterpipe: a new way of hooking youth on tobacco. Am J Addict, 23(2), 103-107. doi:10.1111/j.1521-0391.2013.12073.x Miller, M. B., Leffingwell, T., Claborn, K., Meier, E., Walters, S., & Neighbors, C. (2013). Personalized feedback interventions for college alcohol misuse: an update of Walters & Neighbors (2005). Psychol Addict Behav, 27(4), 909-920. doi:10.1037/a0031174
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PT
ED
M
AN
US
CR
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Neighbors, C., Lee, C. M., Lewis, M. A., Fossos, N., & Larimer, M. E. (2007). Are social norms the best predictor of outcomes among heavy-drinking college students? J Stud Alcohol Drugs, 68(4), 556-565. Perkins, H. W. (2002). Social norms and the prevention of alcohol misuse in collegiate contexts. J Stud Alcohol Suppl(14), 164-172. Primack BA, Fertman CI, Rice KR, Adachi-Mejia AM, Fine MJ.Waterpipe and cigarette smoking among college athletes in the United States. J Adolesc Health. 2010;46:45–51. Primack, B. A., Shensa, A., Kim, K. H., Carroll, M. V., Hoban, M. T., Leino, E. V., . . . Fine, M. J. (2013). Waterpipe smoking among U.S. university students. Nicotine Tob Res, 15(1), 29-35. doi:10.1093/ntr/nts076 Ross, L., Greene, D., & House, P. (1977). The “false consensus effect”: An egocentric bias in social perception and attribution processes. Journal of experimental social psychology, 13(3), 279-301. Sidani, J. E., Shensa, A., Barnett, T. E., Cook, R. L., & Primack, B. A. (2014). Knowledge, attitudes, and normative beliefs as predictors of hookah smoking initiation: a longitudinal study of university students. Nicotine Tob Res, 16(6), 647-654. doi:10.1093/ntr/ntt201 Silvestri, M. M., & Correia, C. J. (2016). Normative influences on the nonmedical use of prescription stimulants among college students. Psychol Addict Behav, 30(4), 516-521. doi:10.1037/adb0000182 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 Tob Res, 10(2), 393-398. doi:10.1080/14622200701825023 Sutfin, E. L., McCoy, T. P., Reboussin, B. A., Wagoner, K. G., Spangler, J., & Wolfson, M. (2011). Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend, 115(1-2), 131-136. doi:10.1016/j.drugalcdep.2011.01.018 Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics. Boston, MA: Pearson Education. Unger, J. B., & Rohrbach, L. A. (2002). Why do adolescents overestimate their peers' smoking prevalence? Correlates of prevalence estimates among California 8th-grade students. Journal of Youth and Adolescence, 31(2), 147-153. Villanti, A. C., Cobb, C. O., Cohn, A. M., Williams, V. F., & Rath, J. M. (2015). Correlates of hookah use and predictors of hookah trial in US young adults. American journal of preventive medicine, 48(6), 742-746. Ward, K. D., Eissenberg, T., Gray, J. N., Srinivas, V., Wilson, N., & Maziak, W. (2007). Characteristics of U.S. waterpipe users: a preliminary report. Nicotine Tob Res, 9(12), 1339-1346. doi:10.1080/14622200701705019
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING Table 1 Participant demographics (N = 894) Variable Total
Total Ever smokers (n = 316)
Male Ever smokers (n = 120)
19.67 (5.84)
20.19 (9.59)
19.41 (2.20)
19.74 (2.49)
19.78 (1.56)
693 (77.5) 63 (7.0) 47 (5.3) 38 (4.3) 22 (2.5) 31 (3.5)
227 (75.7) 18 (6.0) 20 (6.7) 9 (3.0) 13 (4.3) 13 (4.3)
466 (78.5) 45 (7.6) 27 (4.5) 29 (4.9) 9 (1.5) 17 (2.9)
236 (74.7) 25 (7.9) 19 (6.0) 15 (4.7) 4 (1.3) 7 (2.2)
93 (77.5) 8 (6.7) 5 (4.2) 3 (2.5) 3 (2.5) 5 (4.2)
349 (39.0) 303 (33.9) 143 (16.0) 96 (10.7)
117 (39.0) 101 (33.7) 50 (16.7) 32 (10.7)
232 (39.1) 202 (34.0) 93 (15.7) 64 (10.8)
107 (33.9) 101 (32.0) 65 (20.6) 42 (13.3)
39 (32.5) 44 (36.7) 21 (17.5) 16 (13.3)
20 (2.2) 843 (97.8)
10 (3.3) 290 (96.7)
10 (1.7) 584 (98.3)
20 (6.3) 287 (90.8)
10 (8.3) 107 (89.2)
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Female (n = 594)
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Age, M(SD) Ethnicity, n(%) Caucasian American Indian African American Latino/Hispanic Asian Other Class Status, n(%) Freshman Sophomore Junior Senior Past Month WP Smoking, n(%) Yes No
Male (n = 300)
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Table 2 WP sessions and hours spent smoking per week Variable Total Ever users (n = 310) Never users (n = 578) M(SD) M(SD) M(SD) Actual WP sessions per 0.05 (0.45) 0.14 (0.76) -week (all students) Female 0.03 (0.20) 0.08 (0.35) Male 0.09 (0.72) 0.23 (1.14) Actual hours per week 0.07 (0.77) 0.15 (0.79) -smoking (all students) Female 0.07 (0.80) 0.11 (0.49) Male 0.09 (0.71) 0.23 (1.12) Perceived WP sessions per week Typical Female Student 2.85 (8.26) 2.43 (9.07) 2.75 (7.90) Typical Male Student 3.11 (11.31) 4.30 (13.85) 4.81 (11.98) Note. WP = waterpipe. Analyses between never and ever WP smokers controlled for gender.
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Figure 1 Perceived injunctive norms of WP smoking by user status.
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Note. Perceived approval of WP smoking by their five closest friends (“how many of your five
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closest friends would approve of your WP smoking?”).
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Ever WP smokers reported greater perceived approval of WP use than never smokers Males and females overestimated WP smoking frequency of peers at their university Normative feedback regarding actual WP use may be efficacious for college students
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Eleanor L.S. Leavens, Emma I. Brett, Taylor L. Morgan, Susanna V. Lopez, Raees A. Shaikh, Thad R. Leffingwell, Theodore L. Wagener PII: DOI: Reference:
S0306-4603(17)30342-8 doi: 10.1016/j.addbeh.2017.09.006 AB 5293
To appear in:
Addictive Behaviors
Received date: Revised date: Accepted date:
10 May 2017 20 August 2017 14 September 2017
Please cite this article as: Eleanor L.S. Leavens, Emma I. Brett, Taylor L. Morgan, Susanna V. Lopez, Raees A. Shaikh, Thad R. Leffingwell, Theodore L. Wagener , Descriptive and injunctive norms of waterpipe smoking among college students. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ab(2017), doi: 10.1016/j.addbeh.2017.09.006
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running head: NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING
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Descriptive and Injunctive Norms of Waterpipe Smoking among College Students
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Eleanor L. S. Leavens, MS1,2 Emma I. Brett, MS2 Taylor L. Morgan, BA1 Susanna V. Lopez, BS2 Raees A. Shaikh, PhD1 Thad R. Leffingwell, PhD2 Theodore L. Wagener, PhD1,3
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1Oklahoma Tobacco Research Center, Oklahoma City, OK, USA 2Department of Psychology, Oklahoma State University, Stillwater, OK, USA 3Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Keywords: waterpipe, smoking, normative perceptions, college students Correspondence concerning this article should be addressed to Theodore L. Wagener, Oklahoma Tobacco Research Center, University of Oklahoma Health Sciences Center, 655 Research Parkway, Oklahoma City, OK 73104. Email: [email protected]. Abstract
ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING Introduction: Smoking tobacco via a waterpipe (WP) is on the rise, particularly among college students. One reason for this may be normative perceptions of WP tobacco smoking (WTS) among this population. The current study examined the perceived and actual descriptive and injunctive norms of WTS among a college student sample.
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Methods: Participants were 894 college students enrolled at a large, Midwestern university.
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Participants completed measures of WTS frequency and quantity and perceived/actual
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descriptive and injunctive norms of WTS.
Results: Over one-third of the sample reported ever trying WTS, while only 2% reported current
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(past month) use. When comparing ever and never WP smokers, ever smokers reported greater
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perceived peer approval of WTS. Both males and females overestimated WTS frequency of same-sex students at their university.
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Discussion: The current study is one of the first to investigate descriptive and injunctive norms
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of WTS among college students. Students who report WTS are more likely to overestimate descriptive norms of WTS among their peers, suggesting corrective normative feedback
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regarding actual use by peers may be an important target for WTS intervention among college
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students. Future research should investigate the temporal association between normative
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perceptions and WTS behaviors among college students.
Keywords: waterpipe, hookah, smoking, normative perceptions, descriptive norms, injunctive norms
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Introduction While use of most tobacco products in the US are declining, waterpipe (WP) tobacco smoking (WTS) continues to increase (Arrazola et al., 2015). College students represent a
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particularly at-risk group. 30-50% of college students report lifetime WTS (Heinz et al., 2013;
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Primack et al., 2013; Sutfin et al., 2011) with 6-22% reporting past 30-day WTS (Braun et al.,
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2012; Heinz et al., 2013; Jarrett et al., 2012; Primack et al., 2013). Importantly, WTS is associated with many of the same negative health outcomes as cigarette use (Cobb, Sahmarani,
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Eissenberg, & Shihadeh, 2012; El-Zaatari, Chami, & Zaatari, 2015).
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One possible reason WTS is increasing among college students may be normative perceptions of WTS. The theory of social normative behavior asserts individuals overestimate
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peer engagement in risky behaviors (Perkins, 2002). These misperceptions are posited to lead
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individuals to be less concerned about their own behaviors, resulting in increased engagement in risky behaviors (Baer, Stacy, & Larimer, 1991; Borsari & Carey, 2003; Perkins, 2002).
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Descriptive norms, or the perceptions of frequency of a behavior, and injunctive norms, or
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perceptions of acceptability or approval of the behavior, are types of normative perceptions (Larimer & Neighbors, 2003; Neighbors et al., 2007; Silvestri & Correia, 2016). Similarly, the
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False Consensus Effect asserts that individuals who engage in a target behavior believe that others engage in similar behaviors at relatively similar frequencies (Ross, Greene, & House, 1977). Existing research with college students suggests peer WTS is influential in personal WTS. Not only is greater perceived peer approval associated with increased WTS (Heinz et al., 2013; Sidani, Shensa, Barnett, Cook, & Primack, 2014), but WTS is innately social. WP smokers
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING note that they initiated use and currently smoke WP with friends (Maziak, 2014; Smith-Simone, Maziak, Ward, & Eissenberg, 2008; Ward et al., 2007). Additionally, gender differences have been shown in rates of WTS such that males are more likely than females to smoke WP (Eissenberg et al., 2008; Primack et al., 2010; Villanti et al., 2015). Assessment of gender-
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specific norms is important to avoid over-estimating female norms while under-estimating male
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norms.
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No studies have assessed descriptive norms and few have assessed injunctive norms of WTS among college students in the US Consistent with theories of social normative behavior
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(Perkins, 2002) and the False Consensus Effect (Ross et al., 1977) and previous research, it is
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hypothesized that (1) never WP smokers will report lower perceived peer approval of WTS, (2) overall, participants will overestimate the frequency of WTS among typical same-sex students at
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their university, (3) ever WP smokers will be more likely to overestimate the frequency of WTS
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of a typical same-sex student at their university compared with never WP smokers, and (4) ever WP smokers will be more likely to overestimate the frequency of WTS of their best same-sex
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friend compared with never smokers.
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Methods
Participants and procedure
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Undergraduate students, ≥ 18 years, attending a large Midwestern university self-selected into the study through the university’s online research system throughout the fall 2016 semester. Following informed consent, participants completed study procedures anonymously and remotely online and were compensated with class credit. The University’s Institutional Review Board approved all study procedures.
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING WTS Status, Frequency, and Descriptive Norms. Participants reported smoking status via two self-report items. The first asked if participants had smoked in their lifetime. Those who denied WTS were classified as “never users”. Those who reported lifetime WTS then responded to a question assessing past 30-day smoking. Those who indicated an affirmative response were
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classified as “current users.” Those who denied current WTS were classified as “ever users”. To
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assess actual descriptive norms, WP-adapted items from the Daily Drinking Questionnaire
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(Collins, Parks, & Marlatt, 1985) were utilized. Participants reported the number of WTS sessions on each day during a typical week. Participants completed similar items assessing
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number of hours spent smoking on each day during a typical week. Total scores were created,
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indicating the total number of sessions smoked and hours spent smoking. Perceived Injunctive Norms. Participants completed a single item assessing injunctive
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norms of WTS (Heinz et al., 2013): How many of your five closest friends would approve of you
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smoking a hookah?. Response options ranged from 0 (no friends would approve) to 5 (all five would approve).
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Perceived Descriptive Norms. Participants reported on perceived frequency of WTS on
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each day of a typical week during the past month for their best male/female friend and a typical male/female student at their school. Total scores were calculated, indicating perceived weekly
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WTS frequency for each target. These items were adapted for WTS from the Drinking Norms Rating Form (Baer, Stacy, & Larimer, 1991). Data analytic plan Data were screened for missingness and outliers prior to all analyses. 61 participants (6.3%) admitted random or dishonest responding and 20 (2.1%) did not complete the full survey and were excluded from analyses. Outliers (n = 18) were observed on variables assessing hours
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING smoking WP in a typical week (n = 1), and descriptive norms of WTS (n = 17). Outliers were replaced with the value that was three standard deviations and one integer above the mean (Tabachnick & Fidell, 2007). Outliers were retained to avoid masking normative misperceptions. Descriptive statistics were conducted to examine participants’ WTS and descriptive and
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injunctive norms. One-sample t-tests were used to determine whether participants misperceived
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the amount same-sex peers smoked WP. Analyses were conducted separately for male and
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female students. A one-way analysis of covariance controlling for gender was used to examine differences in perceptions of WTS between never and ever WP smokers.
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Results
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The final sample consisted of 894 participants (Mage = 19.67, SD = 5.84) and consisted of primarily Caucasian (77.5%) and female (66.4%) students (Table 1). Generalizability of the
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current sample to the student body as a whole was assessed by comparing age (19.67 vs. 21.6, p
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< .001), proportion Caucasian (77.5 vs. 73.6, p = 0.376), proportion female (66.4 vs. 46.3, p < .001), and proportion freshmen students (39.0 vs. 24.3, p < .001). Student body information was
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obtained from the university’s Institutional Research and Information Management site. 316
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(35.3%) participants reported having ever smoked WP, while 20 (2.2%) reported past month WTS. 578 (64.7%) participants reported never having smoked WP. Close to half (47.6%) of
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never users reported that none of their five closest friends would approve of their WTS compared with only 19.9% of ever users believing that none of their closest friends would approve of their smoking (Figure 1). 43.4% of ever users reported that all five of their five closest friends would approve of their smoking WP, while only 16.4% of never users believed that five of their five closest friends would approve. Controlling for gender, there were significant differences between
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING ever users and never users regarding their perceptions of how many of their closest friends would approve of their smoking WP (F(1,891) = 110.23, p < .001, partial η2 = .11). Participants reported smoking an average of 0.05 (SD = 0.45) WTS sessions per week, spending approximately 0.07 (SD = 0.77) hours per week smoking (Table 2). Both male [M =
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3.11, SD = 11.31; t(288) = 4.55, p < .001, CI95 = 1.72, 4.33] and female [M = 2.85, SD = 8.26;
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t(583) = 8.24, p < .001, CI95 = 2.14, 3.49] students significantly overestimated the number of
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weekly WTS sessions the typical same-sex student engages in each week.
Controlling for gender, differences between never and ever users in perceptions of how
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much the typical male student, typical female student, best male friend, and best female friend
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smokes WP each week were examined. Never (Mmale = 4.81, SDmale = 11.98; Mfemale = 2.75, SDfemale = 7.90) and ever WP smokers (Mmale = 4.30, SDmale = 13.85; Mfemale = 2.43, SDfemale =
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9.07) reported similar perceptions of how much the typical male [F(1, 871) = 0.14, p = .71,
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partial η2 = .00] and female [F(1,871) = 0.20, p = .66, partial η2 = .00] student engages in a session of WTS each week. However, marginally significant differences emerged between never
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(M = 0.24, SD = 1.73) and ever users (M = 1.02, SD = 9.74) in their perceptions of how much
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their best female friend engages in a session of WTS each week [F(1,886) = 3.83, p = .05, partial η2 = .004]. Differences between never (M = 0.33, SD = 2.76) and ever (M = 0.79, SD = 5.18)
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users in perceptions of how much participants’ best male friend smokes WP was approaching significance [F(1,886) = 3.36, p = .07, partial η2 = .004]. Discussion The present study is among the first to assess injunctive and descriptive norms of WTS within a US college sample. Ever users were more likely to report greater perceived peer approval of WTS compared to never users, providing evidence that students are likely to
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING overestimate injunctive norms for behaviors they engage in and that WTS is likely to occur among friends. Regardless of gender, participants overestimated WTS frequency of same-sex students at their university. Literature regarding other health risk behaviors indicates overestimation of other students’ behaviors is associated with increases in the target behavior
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(Baer et al., 1991; Borsari & Carey, 2003). If the same is true of WTS, these misperceptions
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regarding peer WTS have the potential to translate into increased WTS.
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Mixed findings were observed between never and ever WP smokers regarding perceived WTS frequency by their best male/female friend and typical same-sex students. Prior research
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illustrates individuals are often more accurate in their perceptions of a best friend’s substance use
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compared to the use of typical students at their university (Baer & Carney, 1993). It was hypothesized that ever users would report greater perceived WTS frequency by same-sex
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students at their university compared to never users. However, this hypothesis was not fully
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supported.
The current research may have implications for individual and campus-wide interventions
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for WTS among college students, an at-risk population. Young adults may be motivated to
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behave similarly to their peers, including with substance use (Unger & Rohrbach, 2002). This is concerning given their overestimates of peer WTS. To correct this, information regarding
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campus-specific social norms may be incorporated into WTS interventions for college students. Such interventions are inexpensive and effective in altering other health risk behaviors among college students (Cronce & Larimer, 2011; Miller et al., 2013). While the current study is an important first step, it is not without limitations. We enrolled only a small proportion of current users; comparisons between current, never, and ever users were not possible. Infrequent WP smokers may have experienced difficulty responding to
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING study questions regarding WTS during a typical week. Future research should investigate differences between never, ever, and current WP smokers in perceived and actual norms and adjust item presentation based on frequency of use. Second, longitudinal studies are needed to understand the temporal association between normative perceptions and actual WTS behaviors.
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Also, the current sample was primarily comprised of young, female college students. Findings
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may not generalize to other age groups or same-age non-college counterparts. However, young
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adults are at the highest risk for WTS and may be an ideal target for this research. Additionally, since women are less likely to smoke WP, our findings may underestimate norms of WTS.
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However, these concerns are decreased by the assessment of gender-specific norms. Finally,
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participants self-selected into the study; to address concerns of self-selection bias, WP smoking was not mentioned in the study title on the online research system.
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This research contributes to an important gap in the literature, as it is one of only a few to
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investigate normative perceptions of WTS. The results are consistent with existing literature examining other health risk behaviors and highlights the importance of social norms of WTS.
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Future research should employ longitudinal methods and WTS-specific measures of normative
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perceptions to assess the temporal association of social norms and WTS behaviors in addition to obtaining greater detail regarding the context of WTS. Further, research is needed to parse out
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differences in social normative perceptions between current and ever users of WP. Disclosures:
Funding: None. Contributors: All authors were involved in the design and conceptualization of the study. ELL, TLW, and TRL wrote the protocol. All authors were involved in data collection for the study. EIB conducted the statistical analysis. ELL, SVL, TLM, EIB, and TLW wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript. Conflict of Interest: All authors declare that they have no conflicts of interest.
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References
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Arrazola, R. A., Singh, T., Corey, C. G., Husten, C. G., Neff, L. J., Apelberg, B. J., . . . Prevention. (2015). Tobacco use among middle and high school students - United States, 2011-2014. MMWR Morb Mortal Wkly Rep, 64(14), 381-385. Baer, J. S., & Carney, M. M. (1993). Biases in the perceptions of the consequences of alcohol use among college students. J Stud Alcohol, 54(1), 54-60. Baer, J. S., Stacy, A., & Larimer, M. (1991). Biases in the perception of drinking norms among college students. J Stud Alcohol, 52(6), 580-586. Borsari, B., & Carey, K. B. (2003). Descriptive and injunctive norms in college drinking: a metaanalytic integration. J Stud Alcohol, 64(3), 331-341. Braun, R. E., Glassman, T., Wohlwend, J., Whewell, A., & Reindl, D. M. (2012). Hookah use among college students from a Midwest University. J Community Health, 37(2), 294298. doi:10.1007/s10900-011-9444-9 Cobb, C. O., Sahmarani, K., Eissenberg, T., & Shihadeh, A. (2012). Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative. Toxicol Lett, 215(1), 70-75. doi:10.1016/j.toxlet.2012.09.026 Collins, R. L., Parks, G. A., & Marlatt, G. A. (1985). Social determinants of alcohol consumption: the effects of social interaction and model status on the self-administration of alcohol. Journal of consulting and clinical psychology, 53(2), 189. Cronce, J. M., & Larimer, M. E. (2011). Individual- focused approaches to the prevention of college student drinking. Alcohol Res Health, 34(2), 210-221. doi:SPS-AR&H-33 SPS-AR&H-33 Eissenberg T, Ward KD, Smith-Simone S, Maziak W. Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates. J Adolesc Health. 2008;42:526–529. El-Zaatari, Z. M., Chami, H. A., & Zaatari, G. S. (2015). Health effects associated with waterpipe smoking. Tob Control, 24 Suppl 1, i31-i43. doi:10.1136/tobaccocontrol-2014051908 Heinz, A. J., Giedgowd, G. E., Crane, N. A., Veilleux, J. C., Conrad, M., Braun, A. R., . . . Kassel, J. D. (2013). A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav, 38(11), 27512760. doi:10.1016/j.addbeh.2013.07.009 Jarrett, T., Blosnich, J., Tworek, C., & Horn, K. (2012). Hookah use among U.S. college students: results from the National College Health Assessment II. Nicotine Tob Res, 14(10), 1145-1153. doi:10.1093/ntr/nts003 Larimer, M. E., & Neighbors, C. (2003). Normative misperception and the impact of descriptive and injunctive norms on college student gambling. Psychol Addict Behav, 17(3), 235243. doi:10.1037/0893-164X.17.3.235 Maziak, W. (2014). The waterpipe: a new way of hooking youth on tobacco. Am J Addict, 23(2), 103-107. doi:10.1111/j.1521-0391.2013.12073.x Miller, M. B., Leffingwell, T., Claborn, K., Meier, E., Walters, S., & Neighbors, C. (2013). Personalized feedback interventions for college alcohol misuse: an update of Walters & Neighbors (2005). Psychol Addict Behav, 27(4), 909-920. doi:10.1037/a0031174
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CE
PT
ED
M
AN
US
CR
IP
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Neighbors, C., Lee, C. M., Lewis, M. A., Fossos, N., & Larimer, M. E. (2007). Are social norms the best predictor of outcomes among heavy-drinking college students? J Stud Alcohol Drugs, 68(4), 556-565. Perkins, H. W. (2002). Social norms and the prevention of alcohol misuse in collegiate contexts. J Stud Alcohol Suppl(14), 164-172. Primack BA, Fertman CI, Rice KR, Adachi-Mejia AM, Fine MJ.Waterpipe and cigarette smoking among college athletes in the United States. J Adolesc Health. 2010;46:45–51. Primack, B. A., Shensa, A., Kim, K. H., Carroll, M. V., Hoban, M. T., Leino, E. V., . . . Fine, M. J. (2013). Waterpipe smoking among U.S. university students. Nicotine Tob Res, 15(1), 29-35. doi:10.1093/ntr/nts076 Ross, L., Greene, D., & House, P. (1977). The “false consensus effect”: An egocentric bias in social perception and attribution processes. Journal of experimental social psychology, 13(3), 279-301. Sidani, J. E., Shensa, A., Barnett, T. E., Cook, R. L., & Primack, B. A. (2014). Knowledge, attitudes, and normative beliefs as predictors of hookah smoking initiation: a longitudinal study of university students. Nicotine Tob Res, 16(6), 647-654. doi:10.1093/ntr/ntt201 Silvestri, M. M., & Correia, C. J. (2016). Normative influences on the nonmedical use of prescription stimulants among college students. Psychol Addict Behav, 30(4), 516-521. doi:10.1037/adb0000182 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 Tob Res, 10(2), 393-398. doi:10.1080/14622200701825023 Sutfin, E. L., McCoy, T. P., Reboussin, B. A., Wagoner, K. G., Spangler, J., & Wolfson, M. (2011). Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend, 115(1-2), 131-136. doi:10.1016/j.drugalcdep.2011.01.018 Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics. Boston, MA: Pearson Education. Unger, J. B., & Rohrbach, L. A. (2002). Why do adolescents overestimate their peers' smoking prevalence? Correlates of prevalence estimates among California 8th-grade students. Journal of Youth and Adolescence, 31(2), 147-153. Villanti, A. C., Cobb, C. O., Cohn, A. M., Williams, V. F., & Rath, J. M. (2015). Correlates of hookah use and predictors of hookah trial in US young adults. American journal of preventive medicine, 48(6), 742-746. Ward, K. D., Eissenberg, T., Gray, J. N., Srinivas, V., Wilson, N., & Maziak, W. (2007). Characteristics of U.S. waterpipe users: a preliminary report. Nicotine Tob Res, 9(12), 1339-1346. doi:10.1080/14622200701705019
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ACCEPTED MANUSCRIPT NORMATIVE PERCEPTIONS OF WATERPIPE SMOKING Table 1 Participant demographics (N = 894) Variable Total
Total Ever smokers (n = 316)
Male Ever smokers (n = 120)
19.67 (5.84)
20.19 (9.59)
19.41 (2.20)
19.74 (2.49)
19.78 (1.56)
693 (77.5) 63 (7.0) 47 (5.3) 38 (4.3) 22 (2.5) 31 (3.5)
227 (75.7) 18 (6.0) 20 (6.7) 9 (3.0) 13 (4.3) 13 (4.3)
466 (78.5) 45 (7.6) 27 (4.5) 29 (4.9) 9 (1.5) 17 (2.9)
236 (74.7) 25 (7.9) 19 (6.0) 15 (4.7) 4 (1.3) 7 (2.2)
93 (77.5) 8 (6.7) 5 (4.2) 3 (2.5) 3 (2.5) 5 (4.2)
349 (39.0) 303 (33.9) 143 (16.0) 96 (10.7)
117 (39.0) 101 (33.7) 50 (16.7) 32 (10.7)
232 (39.1) 202 (34.0) 93 (15.7) 64 (10.8)
107 (33.9) 101 (32.0) 65 (20.6) 42 (13.3)
39 (32.5) 44 (36.7) 21 (17.5) 16 (13.3)
20 (2.2) 843 (97.8)
10 (3.3) 290 (96.7)
10 (1.7) 584 (98.3)
20 (6.3) 287 (90.8)
10 (8.3) 107 (89.2)
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Female (n = 594)
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Age, M(SD) Ethnicity, n(%) Caucasian American Indian African American Latino/Hispanic Asian Other Class Status, n(%) Freshman Sophomore Junior Senior Past Month WP Smoking, n(%) Yes No
Male (n = 300)
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Table 2 WP sessions and hours spent smoking per week Variable Total Ever users (n = 310) Never users (n = 578) M(SD) M(SD) M(SD) Actual WP sessions per 0.05 (0.45) 0.14 (0.76) -week (all students) Female 0.03 (0.20) 0.08 (0.35) Male 0.09 (0.72) 0.23 (1.14) Actual hours per week 0.07 (0.77) 0.15 (0.79) -smoking (all students) Female 0.07 (0.80) 0.11 (0.49) Male 0.09 (0.71) 0.23 (1.12) Perceived WP sessions per week Typical Female Student 2.85 (8.26) 2.43 (9.07) 2.75 (7.90) Typical Male Student 3.11 (11.31) 4.30 (13.85) 4.81 (11.98) Note. WP = waterpipe. Analyses between never and ever WP smokers controlled for gender.
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Figure 1 Perceived injunctive norms of WP smoking by user status.
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Note. Perceived approval of WP smoking by their five closest friends (“how many of your five
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closest friends would approve of your WP smoking?”).
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Ever WP smokers reported greater perceived approval of WP use than never smokers Males and females overestimated WP smoking frequency of peers at their university Normative feedback regarding actual WP use may be efficacious for college students
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