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Background Determinants of waterpipe use in adolescents are believed to differ from those for other tobacco products, but there is a lack of studies of possible social, cultural, or psychological aspects of waterpipe use in this population. This study applied a socioecological model to explore waterpipe use, and its relationship to other tobacco use in Swedish adolescents. Methods A total of 106 adolescents who attended an urban high-school in northern Sweden responded to an anonymous questionnaire. Prevalence rates for waterpipe use were examined in relation to socio-demographics, peer pressure, sensation seeking behavior, harm perception, environmental factors, and depression. Results Thirty-three percent reported ever having smoked waterpipe (ever use), with 30æ% having done so during the last 30ædays (current use). Among waterpipe ever users, 60æ% had ever smoked cigarettes in comparison to 32æ% of non-waterpipe smokers (95æ% confidence interval 1.4?7.9). The odds of having ever smoked waterpipe were three times higher among male high school seniors as well as students with lower grades. Waterpipe ever users had three times higher odds of having higher levels of sensation-seeking (95æ% confidence interval 1.2?9.5) and scored high on the depression scales (95æ% confidence interval 1.6?6.8) than non-users. The odds of waterpipe ever use were four times higher for those who perceived waterpipe products to have pleasant smell compared to cigarettes (95æ% confidence interval 1.7?9.8). Waterpipe ever users were twice as likely to have seen waterpipe use on television compared to non-users (95æ% confidence interval 1.1?5.7). The odds of having friends who smoked regularly was eight times higher for waterpipe ever users than non-users (95æ% confidence interval 2.1?31.2). Conclusion The current study reports a high use of waterpipe in a select group of students in northern Sweden. The study adds the importance of looking at socioecological determinants of use, including peer pressure and exposure to media marketing, as well as mental health among users.

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