title: Waterpipe Promotion and Use on Instagram: #Hookah.
abstract: BACKGROUND
  Waterpipe (hookah) use is becoming more prevalent in the United States and abroad with potential implications for public health. As waterpipe use rapidly grows in popularity, novel data streams are needed that can help capture and document the social and environmental context in which individuals use, and are marketed, this emerging tobacco product. This study characterized waterpipe-related posts on Instagram in order to inform regulatory and policy activities in the United States.
  
  
  METHODS
  Data were collected from Instagram, an image-based social media site. Inclusion criteria for this study comprised an Instagram post with the hashtag "#hookah" that was accompanied by geo-location metadata demonstrating that the post was inside the contiguous United States. Rules were established for coding themes of images (n = 1705).
  
  
  RESULTS
  Seven percent of images depicted a single person using a waterpipe and/or blowing smoke, 25% depicted two or more persons lounging and/or using a waterpipe, 6% depicted waterpipes, coals or flavored tobacco without people, 18% of images were promotional material for hookah lounges and restaurant/bars/nightclubs referencing hookah in the text or depicting a waterpipe, 25% were non-waterpipe-related promotional material, 1% were sexually explicit material, and 18% other. 31% of all images depicted or referenced alcohol. 30% of posts provided geo-location from a hookah lounge, 56% from a restaurant/bar/nightclub, and 14% from other types of locations.
  
  
  CONCLUSIONS
  The cross promotion of waterpipe and alcohol use by hookah lounges, and restaurants/bars/nightclubs suggests that poly-substance use is regularly depicted, and promoted, in nightlife entertainment as well as normalized on Instagram in the United States.
  
  
  CONCLUSIONS
  In the US Instagram posts with the hashtag #hookah regularly depicted waterpipe use in conjunction with alcohol use. Instagram's focus on images facilitates picture-based advertising where hookah lounges promote drink specials at the same time nightclubs promote waterpipe specials. Instagram users often document the variety of shapes, sizes, and styles, of waterpipes, suggesting users take pride in their purchases and like to show their customized, and often times elaborate, waterpipes to their followers. Instagram has been underutilized in understanding tobacco related-behaviors and identifying tobacco-related promotional material.
authors.affiliation: Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Jon-Patrick
authors.initials: JP
authors.lastname: Allem
authors.affiliation: Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Kar-Hai
authors.initials: KH
authors.lastname: Chu
authors.affiliation: Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Tess Boley
authors.initials: TB
authors.lastname: Cruz
authors.affiliation: Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Jennifer B
authors.initials: JB
authors.lastname: Unger
mesh_terms: D006801:Humans; D012147:Restaurants; D012309:Risk-Taking; D000075387:Smoking Water Pipes / Q000706:statistics & numerical data*; D061108:Social Media; D014481:United States