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UC San Diego
UC San Diego Electronic Theses and Dissertations
Title
A Geospatial Analysis of Public 4-Year Universities and Open Hookah Bars in the United
States
Permalink
https://escholarship.org/uc/item/62114083
Author
Carrillo, Angelina Salina
Publication Date
2020
Peer reviewed|Thesis/dissertation
eScholarship.org Powered by the California Digital Library
University of California
UNIVERSITY OF CALIFORNIA SAN DIEGO
A Geospatial Analysis of Public 4-Year Universities and Open Hookah Bars in the United States
A thesis submitted in partial satisfaction of the requirements for the Master’s degree
in
Public Health
by
Angelina Carrillo
Committee in charge:
Professor Yuyan Shi, Chair
Professor Jesse Nodora
Professor Shu-Hong Zhu
2020
i
Copyright
Angelina Carrillo, 2020
All rights reserved.
iiThe thesis of Angelina Carrillo is approved, and it is acceptable in
quality and form for publication on microfilm and electronically:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Chair
University of California San Diego
2020
iiiDEDICATION
To my family:
You gave so much to ensure that I made it this far in my education. The master’s degree
that I will receive after submitting this thesis is not just for me- it is for all of you. I would have
not been able to do this without your support. I love you.
To my friends:
You were a lifeline to me during my higher education. Your support has been invaluable
to me. I love you.
ivTABLE OF CONTENTS
Signature Page............................................................................................................................... iii
Dedication ………….…................................................................................................................ iv
Table of Contents............................................................................................................................ v
List of Figures and Tables..............................................................................................................vi
Acknowledgements .......................................................................................................................vii
Abstract of the Thesis...................................................................................................................viii
Background..................................................................................................................................... 1
Methods …………………………………………...……............................................................... 5
Results........................................................................................................................................... 13
Discussion......................................................................................................................................16
Conclusion.....................................................................................................................................19
References..................................................................................................................................... 20
vLIST OF TABLES AND FIGURES
Figure 1: A model of the typical device used to consume hookah................................................. 2
Table 1: The number of hookah bars within a 5-mile buffer radius placed around the center of
each public 4-year university in the sample.................................................................................... 9
Figure 2: A Sample Reduction Model for Open Hookah Bars in the US …….............................. 7
Figure 3: Geocoded Public 4-Year Universities and Hookah Bars Verified to be Open via Recent
Business Reviews on Yelp or Google Reviews……………………………………….……....... 10
Table 2: Proportion of selected public US universities (N=596) with at least one open hookah bar
within 5 miles of the center of their campus..................................................................................11
Table 3: Demographics of public 4-year universities in the US (N=748) that collected
information on university enrollment size, university urbanicity, student poverty rates, and
student ethnicities……………………………………………….................................................. 12
Table 4: Open US hookah bars (N=1653) verified using recent reviews on Yelp and Google
Reviews..........................................................................................................................................13
Table 5: Multivariable regression results for nearby open hookah bars within a 1-5-mile buffer of
the center of each selected public 4-year university. Buffer increments from 1-5 miles were
placed starting at the center of each university in the sample. Predictors considered were total
campus enrollment, university urbanicity, proportion of students living under the poverty line,
and student ethnicities………………………………………………............................................15
viACKNOWLEDGEMENTS
I would like to acknowledge Professors Yuyan Shi, PhD, Jesse Nodora, DrPH, and Shu-
Hong Zhu, PhD for their support as chair and co-chairs of my committee. Through multiple
ideas, drafts, and much teamwork, their guidance has proven to be invaluable.
I would also like to acknowledge Yiwen Cao, PhD, for her tireless dedication and
patience as I learned how to conduct research over the last two years. Her guidance in teaching
me how to conduct statistical and geospatial analysis has helped me immensely and will continue
to help me in my career.
Lastly, I would like to express my sincerest appreciation to the Tobacco-Related Disease
Research Program, who granted me a Student Supplement Award that funded the research I did
for my thesis. I am so humbled to have had this opportunity to do tobacco related research and
put my research into practice as a public health professional.
viiABSTRACT OF THE THESIS
A Geospatial Analysis of Public
4-Year Universities and Open Hookah Bars
in the United States
by
Angelina Carrillo
Master of Public Health
University of California San Diego, 2020
Professor Yuyan Shi, Chair
Online and in person, hookah use is promoted as a safer alternative to traditional methods
of tobacco consumption. Hookah bars promote themselves as businesses with novel flavors and
opportunities for social connection. Young people are particularly likely to be enticed by
continual exposure to hookah bars. In a sample of all the public 4-year universities in the United
States, open hookah bars most commonly settled near campuses that had a high proportion of
students living under the poverty line or students of color. Additionally, open hookah bars near
universities were more likely to promote lower prices, making their business accessible to young
viiipeople. The ways in which hookah bars are promoting themselves near universities is
particularly concerning.
ixBackground
In the United States (US) novel tobacco devices have remained popular among young
adults, despite their general knowledge of the hazardous effects of tobacco use (Primack et al.,
2013). Smoking hookah has remained novel to young people in the US despite its historic and
cultural popularity in countries in the Middle East that dates as far back as the 15th century
(Blachman-Braun, Del Mazo-Rodríguez, López-Sámano, & Buendía-Roldán, 2014). This is
perhaps because of the unique, and perhaps sophisticated appearance of hookah smoking
devices, which typically contain a water bowl at the base, an elongated body for smoke to filter
through water from the base, a head where heated coals and flavors are placed, and an extendable
hose with a mouthpiece that is shared between individuals participating in the same hookah
session (Figure 1).
Figure 1: A model of the typical device used to consume hookah. Retrieved from CDC
1In an assessment of US university students, about 1/3 of students reported that they have
used hookah before, making hookah use the second most popular method of tobacco
consumption besides cigarettes (Primack et al., 2013). Although the FDA has banned other types
of flavored tobacco in the past, this has not been the case with hookah (Quinn, 2009). In a
national survey of college students, 95% of those who identified as hookah smokers were
undergraduate students (Kassem et al., 2015). Another survey showed that young adults’
perception of harm regarding hookah is very misconstrued (Akl et al., 2015; Creamer et al.,
2016)- with about 30% of students believing hookah does not contain tobacco or nicotine
(Creamer et al., 2016). Lax age restrictions may also contribute to the popularity of hookah bars
among young adults (Primack et al., 2012), indicating that more surveillance may be needed at
hookah establishments.
Despite the perception of hookah as a safer alternative than tobacco products, research
has shown that smoking hookah can result in the uptake of 50-100 times more smoke and
carcinogens than cigarettes would (Primack et al., 2012). Hookah use can lead to a myriad of
health problems including pulmonary injuries, cancer, communicable diseases, and even
dependence (Knishkowy & Amitai, 2005). Despite the inherent riskiness of hookah use, it
continues to be promoted as less harmful than cigarettes (Asfar et al., 2019; Colditz, Chu,
Switzer, Pelechrinis, & Primack, 2018; Grant & O’Mahoney, 2016; Frederick R. Kates et al.,
2016; Frederick Richard Kates, Salloum, & Byrd, 2015; Primack et al., 2012). This façade
continues because of the way in which hookah bars promote themselves. For instance, it is not
uncommon for hookah establishments to neglect to include the word tobacco (Asfar et al., 2019;
Primack et al., 2012) in their menus and websites. They also offer supposedly natural, appealing
flavors (Asfar et al., 2019; Primack et al., 2012) and opportunities for social connection (Allem,
2Chu, Cruz, & Unger, 2017; Chen, Zhu, & Conway, 2015; Frederick Richard Kates et al., 2015;
Primack et al., 2012), which further entices young adults.
Just like how cigarette companies are always targeting younger users, it seems that
hookah establishments are using similar tactics. Hookah bars in the US strategically settle near
locations where young people congregate- like universities. They seem to settle in these areas to
become a social outlet and stress reliever for young adults (Frederick R. Kates et al., 2016;
Frederick Richard Kates et al., 2015). The literature shows that campuses with characteristics
such as a high rate of full time student enrollees are more likely to have hookah bars near their
campuses (Frederick R. Kates et al., 2016). Some research shows that campuses with smoke free
policies were less likely to have hookah bars within their proximity (Frederick R. Kates et al.,
2016), indicating that social norms against hookah may have an impact on whether new hookah
businesses open near universities. Allowing for hookah establishments to continue their
deceptive marketing toward young adults will lead to serious public health implications. To curb
the incidence of tobacco related disease in young people, it is clear that a public policy
intervention like graphic warning labels are needed.
To date, geospatial analyses pertaining to the proximity of hookah bars to public 4-year
universities in the US has not included the ethnic composition, poverty rates, or urbanicity of
campuses as predictors of nearby hookah bars. The primary aim of this thesis project is to
conduct geospatial analyses to understand the multivariable factors that make hookah
establishments more likely to settle near US universities. In my analyses, I considered university
student demographics such as ethnicity and poverty level, campus urbanicity, and campus
enrollment size. I hypothesized that all of these variables will be significant predictors of nearby
open hookah bars, with highly diverse and urbanized campuses having an even stronger
3likelihood of nearby open hookah bars. This project contributes to existing literature by
analyzing whether social determinants of health like student ethnicity and socioeconomic status
are factors that hookah establishments consider when choosing where they will get the most
business.
4Methods
Data Sources
In September 2018, crowdsourcing was used to collect data on all US businesses on Yelp
that mentioned the word hookah. Variables in the dataset included: business name, business type
(hookah caterer, hookah bar/lounge, bar, restaurant, or smoke shop), operation status, price range
(less than $10– greater than $62), number of Yelp reviews, and business ratings on a scale of one
to five stars. Among these data, the average number of Yelp reviews was 70, and the average
Yelp rating was four out of five stars. This dataset contained N=5244 entries. After data cleaning
to verify that hookah bars in the dataset were truly open hookah businesses, 1653 open hookah
samples remained in the sample. In this project, hookah bars were defined as any business with a
location specifically allocated for the consumption of hookah (also known as shisha, narghile, or
waterpipe tobacco smoking). National College Education Statistics on public US universities
were also collected and filtered, resulting in a final university sample of 748 universities.
Data cleaning of hookah bar data was done in two rounds- first by hand, and then again
in the Statistical Analysis Software R Version 3.6.0. 5151 businesses were listed as hookah bars
before data cleaning. Further cleaning was done to determine whether each business labeled as a
hookah bar was truly an open hookah business.
To determine whether a location was truly a hookah bar, I navigated each Yelp business
link in the dataset verify whether there were for reviews about smoking hookah at the business.
If at least one review in the last three months expressed sentiment about hookah, the business
was determined to be an open hookah bar. If there were no recent reviews on Yelp, the business
address was used to conduct a search on Google Maps Reviews. If the search showed that the
business was still functioning either through the presence of reviews or the business being
5marked as open, the business was deemed a true, open hookah bar. If business type could not be
verified over Yelp or Google Maps, phone calls were utilized to verify the operation status of the
business. If the phone call was answered, the business was verified as an open hookah bar.
By these methods, 2509 businesses were excluded for being other business types. Of the
remaining 2642 hookah bars, 774 were excluded because they were no longer in operation. The
final hand coded sample consisted of 1917 hookah bars in the United States. To further refine the
sample cleaned by hand, I conducted data cleaning using the statistical analysis software,
R Version 3.6.0. This process determined that there were 1653 open hookah bars in the US.
67
Figure 2: A Sample Reduction Model for Open Hookah Bars in the USMeasures
As a means to identify hookah establishments near universities, I used the Compare
Institutions Tool in the National Center for Education Statistics (NCES) website. To create a
more generalizable dataset, I filtered only for institutions that met a specific criterion. The first
criterion was that campuses identified as 4-year public universities in 2018. This created an
output of 2693 institutions. I chose public universities because they are a more racially/ethnically
diverse and affordable alternative to private universities. Generally private universities charge
higher tuition and may have religious restrictions. Data were also filtered to include campuses
that collected percentages of different student ethnicities. This resulted in a dataset with 789
entries. When I included a filter for universities with documentation of campus enrollment size
and urbanicity, the sample was reduced to 748 entries. I then filtered by student poverty level,
and the sample remained at 748 data entries. This list was geocoded into the geospatial analysis
software ArcGIS, along with the list of open hookah bars mentioned above.
8Table 1: Demographics of public 4-year universities in the US (N=748) that collected
information on university enrollment size, university urbanicity, student poverty rates, and
student ethnicities
Full Sample (%)
University Size
≥20,000 19.65
10,000-19,999 21.26
5,000-9,999 22.46
1,000-4,999 31.68
≤1,000 4.95
University Characteristics
Institution Type
Public, 4-year 100
Urbanicity
City 47.19
Suburb 20.86
Town 24.87
Rural 7.09
910
Figure 3: Geocoded Public 4-Year Universities and Hookah Bars Verified to be Open via Recent Business
Reviews on Yelp or Google ReviewsTo make proximity analyses possible, 1-5-mile increment buffers were placed around
each university in the dataset. By using the spatial join tool in ArcMap, I was able to get the
specific number of open hookah bars within a five-mile radius of public 4-year universities.
Table 2: The number of hookah bars within a 1-5-mile buffer radius placed around the center
of each public 4-year university in the sample
Counts
Buffer 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 636 70 26 9 NA 3 1 1 NA 2 NA NA NA NA NA NA NA NA NA
2 557 97 40 22 6 12 2 4 2 NA 1 NA NA 1 NA NA NA 2 NA
3 511 104 48 25 12 13 8 5 6 2 3 1 NA NA NA 3 1 1 1
4 482 106 57 30 10 12 1 4 7 4 2 4 2 1 2 1 2 1 NA
1
5 463 95 67 33 18 14 8 4 4 7 5 1 NA 4 NA 3 2 4 1
Counts
Buffer 19 21 22 23 24 27 28 30 31 32 33 35 39 41 43 51 68
1 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
2 NA 1 NA NA NA NA 1 NA NA NA NA NA NA NA NA NA NA
3 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
4 1 NA 2 2 2 NA NA 1 1 1 NA NA NA NA NA 1 NA
5 NA 3 2 1 1 2 NA NA NA NA 1 1 1 1 NA NA NA
Entries marked as NA are instances where the specific number of hookah bars within said buffer
was not applicable.
Statistical Analysis
The hookah bar counts within in each buffer (1-5-mile radius around the center of each
campus) was tracked and saved as an outcome measure in multivariable regression analyses.
Because the number of open hookah bars in the different buffers had such a large range (from
zero-51), I converted hookah bar counts into a binary variable (Table 2).
11Table 3: Proportion of selected public US universities (N=596) with at least one open hookah
bar within a buffer distance of 5 miles from the center of their campus
Universities with an
Buffer Distance Open Hookah Bar in its
(in miles) Buffer Zone (N, %)
1 112 (15.0%)
2 185 (24.9%)
3 223 (30.4%)
4 241 (33.3%)
5 250 (35.1%)
The variable for university urbanization level was also recoded from the four original
categories (with three sublevels each) into four umbrella categories: city, suburb, rural, and
remote. Descriptive statistics were conducted to understand the characteristics of the NCES
dataset and the open hookah bar dataset.
The binary hookah count variable was used as an outcome measure in multivariable
regression analyses. The following university characteristics were considered as predictors: total
university enrollment, urbanicity, proportion of students in poverty, and proportion of ethnic
minority identities. All analyses were conducted in R Version 3.6.0 with the data cleaning
package “dplyr,” as well as with base R.
12Results
Descriptive Statistics
Among these data, a majority of university campuses were of large enrollment and in
highly urbanized areas. Among the sample of open hookah bars near these universities, prices on
average were very low. Descriptive statistics for the proportion of universities with at least one
hookah bar within a one to five-mile buffer showed that 35% of public, 4-year universities in the
US have at least one hookah bar in their proximity. A majority of campuses with an open hookah
bar within the proximity were in urbanized areas such as cities or suburbs (32.8%). In addition,
hookah bars within proximity of universities in the sample had an average price range of $11-30
(Table 4).
Table 4: Open US hookah bars (N=1653) verified using recent reviews on Yelp and Google
Reviews
Full Sample (%)
Business Type
Hookah Bar 100
Operation Status
Open 100
Price Range
$≤10 21.6
$11-30 75.5
$31-60 1.9
$≥61 0.6
13Ninety-six percent of universities within five miles of an open hookah bar had Pell Grant
recipients. The percentages of student ethnicities varied by each campus. Upon geocoding all
open hookah bars in the US and the sample of public four-year universities, a clear pattern was
visible. Hookah bars were clustered around universities across the US, especially near
universities in highly urbanized locations like Los Angeles, San Francisco, and San Diego.
Multivariable Regression Analyses
In multivariable regression analyses for each buffer around universities in the sample, all
models showed that university enrollment of 1,000–9,999 (p < 0.01) or ≥ 20,000 students (p <
0.05) were significant predictors of open hookah bars within the 1-5-mile buffer proximity
(Table 4). The degree of urbanization of each university was also a significant predictor of
nearby open hookah bars; especially in suburbs (p < 0.001) or towns (p < 0.05). The percentage
of students at each university receiving the Pell Grant, a marker of student poverty level, was
also a predictor of nearby, open hookah bars (pTable 5: Multivariable regression results for nearby open hookah bars within a 1-5-mile
buffer of the center of each selected public 4-year university. Buffer increments from 1-5
miles were placed starting at the center of each university in the sample. Predictors considered
were total campus enrollment, university urbanicity, proportion of students living under the
poverty line, and student ethnicities.
Open Hookah Bar Counts ~ Institution Size (ref: 10,000 students) + Urbanization Level (ref:
City)+ Percent of students in poverty + Percent American Indian or Alaska Native Students +
Percent Native Hawaiian or Pacific Islander Students + Percent Asian +
Percent Black or African American Students + Percent Hispanic or Latino Students +
Percent White Students, family = binomial, data = buffer model (1, 2, 3, 4, or 5 mile)
Model 1 Model 2 Model 3 Model 4 Model 5
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Total Enrollment
10,000-19,999 (reference)
≤1,000 0.91 (0.22-3.04) 0.71 (0.23- 0.84 (0.29- 0.56 (0.19- 0.60 (0.22-
1.98) 2.23) 1.51) 1.58)
1,000 - 4,999 0.20 (0.08- 0.38 (0.20- 0.42 (0.24- 0.39 (0.22- 0.43 (0.25-
0.47)** 0.68)* 0.74)* 0.68)** 0.73)*
5,000 - 9,999 0.44 (0.20- 0.48 (0.26- 0.58 (0.33- 0.56 (0.33- 0.54 (0.32-
0.90) . 0.84). 0.98). 0.96). 0.91).
≥20,000 2.23 (1.26- 2.03 (1.22- 2.37 (1.42- 1.98 (1.17- 1.78 (1.05-
4.01)* 3.40)* 4.00)** 3.37). 3.05).
Locale
City (reference)
Suburb 0.25 (0.12- 0.37 (0.22- 0.37 (0.23- 0.39 (0.25- 0.47 (0.30-
0.47)** 0.60)** 0.57)** 0.60)** 0.72)**
Town 0.38 (0.17- 0.20 (0.10- 0.14 (0.07- 0.11 (0.06- 0.10 (0.05-
0.81). 0.37)** 0.26)** 0.21)** 0.18)**
Rural 0.00 (0.00- 0.00 (0.00- 0.00 (0.00- 0.07 (0.01- 0.06 (0.01-
4.26x104) 0.00) 0.00) 0.27)** 0.23)**
Poverty Rate
Percent Pell 0.97 (0.95- 0.98 (0.96- 0.98 (0.96- 0.97 (0.95- 0.97 (0.96-
Grant Recipients 0.99)** 0.99)** 0.99)* 0.98)** 0.99)**
Student Population
Ethnicity
Hispanic/ Latino 1.00 (0.97- 1.01 (0.98- 1.01 (0.99- 1.01 (0.99- 1.01 (0.99-
1.03) 1.03) 1.03) 1.04) 1.04)
Hawaiian Native 0.59 (0.23- 1.00 (0.75- 0.99 (0.72- 1.00 (NA- 0.99 (0.70-
or Pacific 1.00) 1.07) 1.07) 1.08) 1.07)
Islander
Asian 1.02 (0.97- 1.01 (0.97- 1.02 (0.97- 0.99 (0.95- 1.00 (0.96-
1.07) 1.06) 1.06) 1.04) 1.05)
Black or African 1.02 (1.00-1.05) 1.02 (1.00- 1.03 (1.00- 1.03 (1.01- 1.03 (1.01-
American 1.05) 1.05) 1.06)* 1.06)*
White 0.99 (0.97- 1.00 (0.98- 1.00 (0.98- 1.00 (0.98- 1.00 (0.98-
1.02) 1.02) 1.02) 1.02) 1.02)
Significance Codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1
15Discussion
Conducting geospatial analyses regarding the proximity of hookah establishments near
US universities is vital in helping the public health sector understand the factors contributing to
novel tobacco use. In this study, I found that campus urbanicity, enrollment size, and the
proportion of students from low income or minority families were all significant predictors of
open hookah bars within a 5-mile radius of universities. My geospatial analyses show that more
than 1/3 of public 4-year universities in the sample have at least one open hookah bar within a
five-mile buffer of their campus. From the literature, I know that tobacco outlets have a history
of settling in areas where they can entice young people to become new users (Abdel Magid et al.,
2020). There is minimal literature focused on the strategic location of hookah bars within the
proximity of where young adults congregate. However, it is likely that the increased interest in
novel tobacco products among young adults is likely to contribute to the growing number of
open hookah bars near college campuses (Abdel Magid et al., 2020).
Multivariable analyses confirmed that campuses with a higher proportion of students
living in poverty are more likely to have open hookah bars within a 5-mile radius of their
campus. This may indicate that hookah bars are purposely establishing themselves near
populations of low income brackets (Ribisl, Luke, Bohannon, Sorg, & Moreland-Russell, 2017),
which often pertains to university students. A low price range may make hookah bars more
accessible and appealing to their target audience (Fakunle et al., 2016), and could therefore
contribute to an increase in hookah use among young adults.
The proportion of students of color at public 4-year universities also proved to be a
significant predictor of nearby open hookah bars. This is consistent with past patterns of tobacco
related businesses settling in areas with a high composition of ethnic minorities (Lee et al., 2017;
16Ribisl et al., 2017). This is concerning because close proximity may lead to increased exposure
to hookah related marketing and an increased hookah consumption. This is of particular concern
in the US, where people of color who are diagnosed with tobacco related cancers have a much
higher mortality rate than whites (Singh & Jemal, 2017). Results from my multivariable analyses
also show that campuses in areas of higher urbanicity (i.e. suburban or town) were more likely to
have an open hookah bar within a five-mile proximity. This may be because urbanized areas
often are home to young people who embrace novel, social experiences.
These findings indicate that overall, campuses where the student population is highly
diverse, of low income, or in urbanized areas are more likely to have open hookah bar(s) within a
five-mile radius of their university. Like other novel tobacco devices (e-cigarettes), hookah
smoking is perceived to have a lower potential of causing harm. This can put young people at a
greater risk of different tobacco related cancers and even an increased risk of communicable
disease (Cohn, Ehlke, Cobb, & Soule, 2017). Future research can establish if increased exposure
to hookah advertising without public health counter-marketing results in more young people
becoming hookah users.
This study has several limitations. First, this was a cross-sectional study, so the results
may not reflect the state of the hookah business at the time this thesis is submitted. Also,
causality cannot be inferred because of the inherent limitations of the study design. Because
information on hookah bars was gathered from a public source, Yelp, it is possible that not all
open hookah bars were included in my analyses. Lastly, because I focused on only a sample of
US universities, the strength of the associations found in this study may actually underestimates.
Finally, my results cannot be generalized to private 4-year universities or universities outside of
the US.
17It is important to acknowledge that the demographic and geographic variables determined
to be significant predictors at the university level in this study (minority ethnicity and low
income) were not consistent with similar literature. For instance, in studies of hookah
consumption among college students, high income and white students were almost three times
more likely than low income or minority students to be hookah users (Montgomery et al., 2015,
De Borba-Silva et al., 2013), indicating that the proportion of minority and low income students
at the group level are not typical predictors of nearby hookah establishments. Since the results of
my study are not reflective of the current literature, it is important to consider the possibility that
an ecological fallacy is present. Since the dataset I used from NCES was aggregated at the
university level, it is highly possible that information about many individuals is missing,
resulting in trends at the university level that is not necessarily reflective of campuses in their
entirety. So, although my university level results state that campuses with a high proportion of
low income and minority students are more likely to have hookah bars nearby, this may not
actually be the case because of an ecological fallacy. This is important for readers to consider as
they review this manuscript.
18Conclusion
This study supports my hypothesis that hookah bars are settling in areas where young
people congregate, such as near universities. The fact that these businesses are strategically
settling in close proximity to young and vulnerable populations is a significant public health
concern. Increased exposure to deceptive health claims associated with hookah is likely to entice
young adults at universities to experiment with the drug. Continual hookah use exposes users to
carcinogens and may lead to nicotine dependence and cancers, yet studies have shown that most
hookah menus still don’t include a disclaimer about the inherent risks of hookah use. Further
scrutiny and regulation of where hookah establishments are located is needed.
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