Reigniting Tobacco Ritual: Waterpipe Tobacco Smoking Establishment Culture in the United States.

INTRODUCTION: 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.\ud \ud 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.\ud \ud 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 one of the ritual elements of our conceptual framework, while 41 of the 83 observed groups (49%) demonstrated all 4 ritual elements.\ud \ud CONCLUSIONS: Despite its heterogeneity, WTS is often characterized by one 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.\ud \u