title: Use of a water pipe is not an alternative to other tobacco or substance use among adolescents: results from a national survey in Sweden.
abstract: BACKGROUND
  Studies of social characteristics and substance use patterns among young users of water pipe are rare in Western countries, and no such study has been conducted in Sweden.
  
  
  METHODS
  Cross-sectional study based on a national survey conducted in 2011, including 4,710 primary school students (15 years of age) and 3,624 high school students (17 years of age). Prevalence of lifetime and current water pipe use was compared among subgroups defined by other substance use, that is, cigarettes, snus, alcohol, and illicit drugs. Logistic regression was employed to calculate odds ratios (OR) of water pipe use and corresponding 95% confidence intervals (CI), conditionally on sociodemographic characteristics.
  
  
  RESULTS
  Use of water pipe was associated with the use of other substances in both age groups. In particular, current use of water pipe at the age of 15 years was strongly associated with current cigarette smoking (OR = 6.46; CI = 5.13-8.14); use of snus (OR = 5.62; CI = 3.94-7.96); binge drinking (OR = 7.39; CI = 5.88-9.31); drunkenness (OR = 7.05; CI = 5.60-8.88); and recent use of illicit drugs (OR = 14.20; CI = 9.18-22.19). Annual alcohol consumption predicted water pipe use in a dose-response fashion. Cigarette smokers willing to quit used water pipe to a lower extent than smokers who did not intend to quit. Being an exclusive smoker of water pipe was associated with substance use when compared with a nonsmoker of tobacco, but not when compared with an exclusive smoker of cigarettes.
  
  
  CONCLUSIONS
  Water pipe use among adolescents in Sweden is not a recreational tobacco use alternative to cigarettes and should be regarded as a marker of multiple substance use.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Centre for Epidemiology and Community Medicine, Stockholm Health Care District, Stockholm, Sweden rosaria.galanti@ki.se.
authors.forename: Maria Rosaria
authors.initials: MR
authors.lastname: Galanti
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden;
authors.forename: Maissa
authors.initials: M
authors.lastname: Al-Adhami
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior; D016497:Adolescent Health Services; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D015995:Prevalence; D012907:Smoking / Q000453:epidemiology*; D016540:Smoking Cessation / Q000379:methods*; D000074606:Smoking Prevention; D019966:Substance-Related Disorders / Q000453:epidemiology / Q000517:prevention & control; D013548:Sweden / Q000453:epidemiology