U.S. Hookah Tobacco Smoking Establishments Advertised on the Internet

BackgroundEstablishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities.PurposeTo conduct a comprehensive, qualitative assessment of websites promoting these establishments.MethodsIn June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009–2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohen's κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used.ResultsThe search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common.ConclusionsWebsites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.