title: Reigniting tobacco ritual: waterpipe tobacco smoking establishment culture in the United States.
abstract: BACKGROUND
  Waterpipe tobacco smoking (WTS) is an increasingly prevalent form of tobacco use in the United States. Its appeal may stem from its social, ritualistic, and aesthetic nature. Our aim in this study was to understand WTS as a social ritual with the goal of informing prevention efforts.
  
  
  METHODS
  We conducted a covert observational study consisting of 38 observation sessions in 11 WTS establishments in 3 U.S. cities. Data collection was based on an established conceptual framework describing ritualistic elements of tobacco use. Iterative codebook development and qualitative thematic synthesis were used to analyze data.
  
  
  RESULTS
  Atmospheres ranged from quiet coffee shop to boisterous bar party environments. While some children and older adults were present, the majority of clientele were young adults. Men and women were evenly represented. However, there were 19 occurrences of a male smoking by himself, but no women smoked alone. The vast majority (94%) of the clientele were actively smoking waterpipes. All 83 observed groups manifested at least 1 of the ritual elements of our conceptual framework, while 41 of the 83 observed groups (49%) demonstrated all 4 ritual elements.
  
  
  CONCLUSIONS
  Despite its heterogeneity, WTS is often characterized by 1 or more established elements of a tobacco-related social ritual. It may be valuable for clinical and public health interventions to acknowledge and address the ritualistic elements and social function of WTS.
authors: Program for Research on Media and Health, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA;
authors: Mary V
authors: MV
authors: Carroll
authors: Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA;
authors: Judy
authors: J
authors: Chang
authors: Program for Research on Media and Health, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA;
authors: Jaime E
authors: JE
authors: Sidani
authors: Department of Behavioral Science and Community Health, University of Florida College of Public Health and Health Professions, Gainesville, FL;
authors: Tracey E
authors: TE
authors: Barnett
authors: Department of Behavioral Science and Community Health, University of Florida College of Public Health and Health Professions, Gainesville, FL;
authors: Eric
authors: E
authors: Soule
authors: Community Health Program, School of Arts and Sciences, Tufts University, Medford, MA;
authors: Edith
authors: E
authors: Balbach
authors: Program for Research on Media and Health, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA bprimack@pitt.edu.
authors: Brian A
authors: BA
authors: Primack
mesh_terms: D000328:Adult; D002562:Ceremonial Behavior; D003469:Culture; D005260:Female; D006801:Humans; D008297:Male; D015995:Prevalence; D012907:Smoking / Q000208:ethnology* / Q000523:psychology / Q000639:trends*; D014481:United States / Q000208:ethnology; D055815:Young Adult