Colorectal cancer knowledge and perceptions among individuals below the age of 50.

BACKGROUND: Colorectal cancer (CRC) rates are increasing in individuals below the age of 50 and this trend has been projected to continue for the foreseeable future. Health officials are calling for increased awareness of rising rates in affected populations to promote discussion and early detection. METHODS: In May 2018, we surveyed an online purposive sample of adults below the age of 50 (N = 624). We conducted an exploratory analysis examining knowledge of current CRC screening guidelines, knowledge of available CRC screening methods, perceived risk of CRC, and perceived importance of screening for CRC by gender, race, and previous CRC screening activity. RESULTS: The sample was 56% female, averaged 36 years of age, largely identified as Caucasian (84%), married (48%), and well educated (70% with some college or a college degree). 36% correctly identified the current age of recommended CRC screening initiation. Few (8%) correctly identified all CRC screening options presented. Genetics was thought to be the most relevant determinant of CRC. African American or black participants perceived themselves to be at lower risk of CRC, while women rated the importance of screening significantly lower than men. CONCLUSION: We identified a lack of CRC knowledge in individuals below the age of 50. Interventions should correct perceptions of risk of CRC and highlight the importance of screening. Complete knowledge of the range of screening options may reduce barriers to screening while a greater knowledge of modifiable risk factors of CRC can promote healthy behaviors.

Evaluating preferences for colorectal cancer screening in individuals under age 50 using the Analytic Hierarchy Process.

BACKGROUND: In 2021, the United States Preventive Services Task Force updated their recommendation, stating that individuals ages 45-49 should initiate screening for colorectal cancer. Since several screening strategies are recommended, making a shared decision involves including an individual's preferences. Few studies have included individuals under age 50. In this study, we use a multicriteria decision analysis technique called the Analytic Hierarchy Process to explore preferences for screening strategies and evaluate whether preferences vary by age. METHODS: Participants evaluated a hierarchy with 3 decision alternatives (colonoscopy, fecal immunochemical test, and computed tomography colonography), 3 criteria (test effectiveness, the screening plan, and features of the test) and 7 sub-criteria. We used the linear fit method to calculate consistency ratios and the eigenvector method for group preferences. We conducted sensitivity analysis to assess whether results are robust to change and tested differences in preferences by participant variables using chi-square and analysis of variance. RESULTS: Of the 579 individuals surveyed, 556 (96%) provided complete responses to the AHP portion of the survey. Of these, 247 participants gave responses consistent enough (CR < 0.18) to be included in the final analysis. Participants that were either white or have lower health literacy were more likely to be excluded due to inconsistency. Colonoscopy was the preferred strategy in those < 50 and fecal immunochemical test was preferred by those over age 50 (p = 0.002). These results were consistent when we restricted analysis to individuals ages 45-55 (p = 0.011). Participants rated test effectiveness as the most important criteria for making their decision (weight = 0.555). Sensitivity analysis showed our results were robust to shifts in criteria and sub-criteria weights. CONCLUSIONS: We reveal potential differences in preferences for screening strategies by age that could influence the adoption of screening programs to include individuals under age 50. Researchers and practitioners should consider at-home interventions using the Analytic Hierarchy Process to assist with the formulation of preferences that are key to shared decision-making. The costs associated with different preferences for screening strategies should be explored further if limited resources must be allocated to screen individuals ages 45-49.

Providers' Perceptions of Barriers to Optimal Communication With Patients During the Postcolonoscopy Experience.

INTRODUCTION: Colonoscopy screening is an effective method of detecting and preventing colorectal cancer. Standard procedure for most colonoscopies (98%) is to use conscious sedation, which can cause short-term cognitive impairment postprocedure, including communication difficulties. In this study, we explored providers' (gastroenterology doctors and nurses) perceptions of the barriers to optimal communication with patients immediately following colonoscopy. METHODS: We conducted interviews with 61 providers across 5 clinical configurations. Interviews were transcribed and coded with NVivo version 11 software. RESULTS: Themes emerged regarding barriers to optimal provider-patient communication postcolonoscopy: patient barriers (sedation and patient characteristics), caregiver barriers, and system characteristics. CONCLUSIONS: Providers' perceived barriers to communication are an important topic to study. They endorsed, in particular, interventions that target the postcolonoscopy time frame when patients may still be sedated, but providers must convey important discharge and follow-up instructions.

Barriers and facilitators associated with colonoscopy completion in individuals with multiple chronic conditions: a qualitative study.

BACKGROUND: A recommendation to undergo a colonoscopy, an invasive procedure that requires commitment and motivation, planning (scheduling and finding a driver) and preparation (diet restriction and laxative consumption), may be uniquely challenging for individuals with multiple chronic conditions (MCCs). This qualitative study aimed to describe the barriers and facilitators to colonoscopy experienced by such patients. MATERIALS AND METHODS: Semistructured focus groups were conducted with male Veterans who were scheduled for outpatient colonoscopy and either failed to complete the procedure or completed the examination. Focus group recordings were transcribed and analyzed by an inductive grounded approach using constant comparative analysis. RESULTS: Forty-four individuals aged 51-83 years participated in this study (23 adherent and 21 nonadherent). Participants had an average of 7.4 chronic conditions (range 2-14). The five most common chronic conditions were hypertension (75%), hyperlipidemia (75%), osteoarthritis/degenerative joint disease (59%), atherosclerotic heart disease (48%), and diabetes mellitus (36%). We identified four unique themes that influenced motivation to undergo a colonoscopy: competing medical priorities, low perceived benefit, a prior negative colonoscopy experience, and pre-existing medical conditions. Additionally, we identified four themes that influenced individuals' ability to complete the examination: difficulty with bowel cleansing, difficulty with travel, worry about exacerbation of pre-existing conditions, and heightened concerns about potential complications. CONCLUSION: MCCs are common in individuals referred for colonoscopy and generate unique barriers to colonoscopy completion related to medication, dietary changes, transportation, preparation processes, symptoms exacerbation, and complication concerns. Future research should examine whether tailored interventions that include education and support in addressing the unique barriers can enhance colonoscopy completion.

Influential factors on treatment decision making among patients with colorectal cancer: A scoping review.

PURPOSE: In recent years, a greater emphasis has been placed on shared decision-making (SDM) techniques between providers and patients with the goal of helping patients make informed decisions about their care and subsequently to improve patient health outcomes. Previous research has shown variability in treatment decision-making among patients with colorectal cancer (CRC), and there is little comprehensive information available to help explain this variability. Thus, the purpose of this study was to evaluate the current state of the literature on factors that are influential in treatment decision-making among patients with CRC. METHOD: A priori search terms using Boolean connectors were used to examine PubMed, PsycINFO, Web of Science, CINAHL, and MEDLINE for relevant studies. Eligibility criteria for inclusion in the study included patients with CRC and examination of influences on CRC treatment decision-making. All relevant data were extracted including, author, title and year, study methodology, and study results. RESULTS: Findings (n = 13) yielded influences in four areas: informational, patient treatment goals, patient role preferences, and relationship with provider. Quality of life and trust in physician were rated a high priority among patients when making decisions between different therapeutic options. Several studies found that patients wanted to be informed and involved but did not necessarily want to make autonomous treatment choices, with many preferring a more passive role. CONCLUSIONS: Providers who initiate a dialog to better understand their patients' treatment goals can establish rapport, increase patient understanding of treatment options, and help patients assume their desired role in their decision-making. Overall, there were a small number of studies that met all inclusion criteria with most used a cross-sectional design.

A Prospective Biopsychosocial Investigation Into Head and Neck Cancer Caregiving.

PURPOSE: Head and neck cancer (HNC) patients suffer from significant morbidity, which may introduce challenging care demands and subsequent stress-induced mind-body interactions for informal caregivers. This prospective study evaluated patient and caregiver predictors of diurnal cortisol rhythm among HNC caregivers during radiation treatment. METHOD: Patient-caregiver dyads completed measures at radiation treatment start (T1; n = 32) and 5 weeks into treatment (T2; n = 29). Measures included the Functional Assessment of Cancer Therapy-Head and Neck, the Caregiver Quality of Life (QOL) Index-Cancer, the Caregiver Reaction Assessment, the Medical Outcomes Social Support Survey, and the Eating Assessment tool. Patients also received a clinical swallowing evaluation using the Functional Assessment of Oral Intake Scale. Caregiver cortisol concentrations were assessed from salivary samples at T1 and T2. RESULTS: Caregiver cortisol slope became significantly flatter during radiation treatment. Greater caregiver schedule burden was associated with a flatter cortisol slope (ß = .35, p = .05) in caregivers at T1. Lower patient functional QOL (ß = -.41, p = .05) and lower overall caregiver QOL at T1 (ß = -.39, p = .04) were each separately associated with a flatter cortisol slope in caregivers over treatment. CONCLUSIONS: Results suggest the presence of a mind-body interaction in HNC caregivers. Dysregulation in diurnal cortisol rhythm in caregivers was significantly associated with increased caregiver schedule burden and lower patient and caregiver QOL. Targeted interventions developed for HNC caregivers may help to prevent negative health outcomes associated with dysregulated cortisol.

Income differences in social control of eating behaviors and food choice priorities among southern rural women in the US: A qualitative study.

The role of social influences on rural women's food choice is not well understood. Rural adults experience high rates of obesity and poor diet quality prompting exploration of how social factors influence food choice in this population. Semi-structured qualitative interviews were conducted with 20 women in rural North Central Florida. Women were purposively sampled and stratified by race and income. Lower income was defined as household income at or below 185% of the federal poverty level (FPL). Women at or below 185% poverty level (BPL) experienced direct social control of their eating behaviors, which occurred when social network members explicitly regulated or otherwise sanctioned eating behaviors or food choices. Women above 185% of the federal poverty level (APL) internalized social norms and self-regulated their eating behaviors to maintain healthy habits. APL women described choosing foods for health reasons whereas BPL women offered a variety of reasons including taste, convenience, family history, price, health, and routine. Findings suggest that women in different income groups have different social influences working to help them regulate eating behaviors as well as diverse priorities influencing their food choices. Future interventions to promote healthy eating may be more effective by incorporating social network members and framing intervention messages so they are consistent with priorities.

Construct Validity of the eHealth Literacy Scale (eHEALS) Among Two Adult Populations: A Rasch Analysis.

BACKGROUND: The Internet has become a ubiquitous venue for information seeking, especially for health information. Public health practitioners have noticed the promise and potential of the Internet, however, little is known about individuals' skills of their eHealth literacy. The eHealth Literacy Scale, eHEALS, was designed to measure perceptions of individuals' eHealth literacy skills. OBJECTIVE: The objective of the study was to examine the psychometric validity and reliability of the eHEALS with two adult populations using the Rasch Model. METHODS: A college-aged sample and an Internet-based sample (Amazon's MTurk) were recruited to complete the eHEALS, demographic questions, and a health literacy scale. Using WINSTEPS and SPSS, unidimensionality, item fit, rating scale, item hierarchy, person ability-item match, and reliability were analyzed, compared, and contrasted against each sample and to other samples found in the literature. RESULTS: An exploratory factor analysis supported unidimensionality in both samples. More than 90% of respondents from both samples fit the model. No items were outright misfitting. Both samples separated into three distinct groups. CONCLUSIONS: Based on the results, the eHEALS is a reliable and consistent measurement tool for a college sample and an Internet-based sample. As these individuals are most likely to use the Internet as a health resource, it is necessary to learn and know their skills versus perceiving that they can critically and successfully navigate the Internet. Further analyses are necessary to ensure that the eHEALS can serve as a standard eHealth literacy measure for public health.

Burden, quality of life, and social support in caregivers of patients undergoing radiotherapy for head and neck cancer: A pilot study.

OBJECTIVE: The purpose of this pilot study was to (1) obtain preliminary data on changes in burden and quality of life in head and neck cancer caregivers during and shortly following patient radiotherapy, (2) assess the relationship between perceived social support and burden as well as perceived social support and quality of life in caregivers during radiotherapy, and (3) identify preferences for sources of support among caregivers during radiotherapy. METHODS: Caregivers completed burden and quality of life instruments at the start of patient radiotherapy (T1), 5 weeks into radiotherapy (T2), and 1 month post-radiotherapy (T3) and instruments for perceived social support and support preferences at T2 only. RESULTS: Caregivers showed a trend toward increased burden and worsened quality of life for the majority of subscales at T2 or T3 than at T1. Caregivers reported significantly lower esteem and significantly greater disruption at T2 than at T1 and significantly worse health at T3 than at T2. Higher perceived social support was typically associated with lower burden and higher quality of life at T2. Spouses/partners were the most commonly preferred source of support. DISCUSSION: These pilot findings suggest that caregivers experience psychosocial impairments during and shortly after patient radiotherapy, but more research using larger samples is warranted.

"It is just another test they want to do": Patient and caregiver understanding of the colonoscopy procedure.

OBJECTIVE: Colonoscopy is a complex procedure that requires bowel preparation, sedation, and has the potential for substantial risk. Given this, we investigated colonoscopy patients' perceived and actual understanding of the procedure. METHODS: Consecutive colonoscopy patients were enrolled and surveyed, with their caregivers, immediately prior to their procedure. Demographics, health literacy, socioeconomic status and perceived risks/benefits were assessed. Thematic analysis was conducted on open-ended responses and a 3-level outcome variable was created to categorize correctness of patients' and caregivers' understanding. Multinomial logistic regression was used to determine predictors of response level. RESULTS: Patients (N=1821) were 77% White, 60% female, and averaged 54 years old; caregivers were demographically similar. Among patients, bivariate analysis revealed that younger age, minority race, and low income, education, and health literacy were associated with incomplete understanding. Multinomial regression revealed that age, education, health literacy, first-time colonoscopy, and perceived risk-benefit difference discriminated among groups. Bivariate and multinomial results for caregivers were similar. CONCLUSION: Patients and caregivers varied on information, understanding and misconceptions about colonoscopy. Implications are discussed for inadequate: 1. informed consent, 2. bowel preparation, and 3. emotional preparation for cancer detection or adverse events. PRACTICE IMPLICATIONS: Attention should be paid to patients' understanding of the purpose, anatomy, and logistics of colonoscopy, preferably prior to bowel preparation.

Hookah and Alcohol Use among Young Adult Hookah Smokers: A Mixed Methods Study.

OBJECTIVES: Hookah tobacco smoking has grown steadily in popularity among young adults in the United States. Little attention has been given to the relationship between hookah smoking and another behavior that is common among young adults - alcohol use. The purpose of this study was to examine hookah and alcohol use among young adults. METHODS: Forty young adult hookah smokers (55% female) participated in focus group sessions on hookah use beliefs and a brief survey examining hookah and alcohol use including drinking alcohol before, during, or after smoking hookah. RESULTS: Quotes from the focus groups indicated that alcohol use may promote hookah use among individuals who have little or no hookah smoking experience. Alcohol use, binge drinking, and alcohol use before, during, and after hookah use were common among the participants regardless of legal drinking age status. Nearly half of the participants preferred to drink alcohol while smoking hookah due to the improved physical and social effects they associated with combining the 2 behaviors. CONCLUSIONS: For some young adult hookah smokers, alcohol appears to enhance the hookah smoking experience and may play a role in hookah smoking initiation. Future research and interventions should address the association between hookah and alcohol use.

Pathways to colonoscopy in the South: seeds of health disparities.

OBJECTIVES: We aimed to highlight sociodemographic differences in how patients access colonoscopy. METHODS: We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011-October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card. RESULTS: We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure. CONCLUSIONS: Patients' facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population.

Un análisis cuantitativo del uso de Plaguicidas en los campesinoscolombianos: percepción del control y la confianza en este uso / A quantitative analysis of Colombian campesinosÆ use of pesticides: perceived control and confidence in this use

Objetivo: Este estudio pretende explorar como los campesinosno usuarios de plaguicidas difieren en su conocimiento, actitudesy creencias y percepciones de control y confianza en torno aluso de plaguicidas comparado con usuarios de plaguicidas.Metodología: Colectamos 79 cuestionarios con hombresy mujeres adultas que son campesinos agricultores en SanCristóbal, Antioquia, Colombia. Examinamos las percepcionesde estos campesinos sobre el daño de los plaguicidas sobrela salud humana y el medio ambiente. También se exploraronsus creencias, actitudes, percepciones de control y confianzarelacionadas con el uso de los plaguicidas. Resultados:Los hallazgos difieren entre los dos grupos de campesinosmuestreados: usuarios y no usuarios de plaguicidas. Losusuarios de pesticidas experimentaron menores percepcionesdel daño de los plaguicidas sobre la salud humana y el medioambiente, menor percepción del control acerca de parar eluso de plaguicidas (el incremento de una unidad en controldisminuyó el logit de usar pesticidas en un 74%), y menor confianza acerca de parar el uso de pesticidas comparadocon los no usuarios de plaguicidas (el aumento de una unidaden la confianza, disminuyó el logit de usar pesticidas en un64%). Discusión: Varios factores individuales influencian lasalud ocupacional y la salud de los campesinos incluyendola percepción del control y la confianza. Recomendamos quefuturas intervenciones educativas en salud pública aumenten elentrenamiento sobre prácticas seguras y la confianza. Así loscampesinos pueden ganar control en el proceso de implementarcambios en su comportamiento relacionado con la reduccióndel uso de pesticidas...

Objective: this study aims to explore how campesino nonpesticide users differ in their knowledge, attitudes and beliefs,and perceptions of control and confidence surroundingpesticide use compared to pesticide users. Methodology:we collected 79 questionnaires with adult (male and female)rural agricultural campesinos in San Cristobal, Antioquia,Colombia. We examined the campesinosÆ perceptions onpesticidesÆ harm for human health and the environment, aswell as their beliefs, attitudes, perceived control, and perceivedconfidence related to pesticide use. Results: The findingsdiffered between two campesino groups sampled: pesticideusers and agroecological adherents. Pesticide users showedlower perceptions of pesticide harm for human health and theenvironment, lower perceived control about stopping pesticideuse (an increase of one unit in control decreases the logit ofusing pesticides by 74%), and lower confidence about stoppingpesticide use than agroecological adherents (an increase ofone unit in confidence decreases the logit of using pesticidesby 64%). Discussion: Several individual factors influencethe occupational safety and health of campesinos, includingperceived control and confidence. We recommend that futurepublic health and educational interventions should improvesafety training and confidence so campesinos can gain controlof the process for implementing behavioral change related topesticide use reduction...

A multiyear assessment of hookah use prevalence among Florida high school students.

INTRODUCTION: The purpose of this study was to assess the prevalence of hookah use among Florida high school students over time. Alternative tobacco products, including hookah, pose a public health threat to tobacco prevention efforts, especially among adolescents. METHODS: Florida Youth Tobacco Survey data, representing all public high school students in the state, were analyzed to assess the prevalence of lifetime and current hookah use and were compared by demographic groups. Multiple years of data (2007-2012) were examined to assess changes over time. RESULTS: During the past 6 years, there was an increase in lifetime hookah use among Florida high school students. While males remained at a higher rate overall, female adolescents increased at a faster rate. Hispanic and non-Hispanic White respondents reported increased trends as well. Current use trends did not change over 4 years, remaining at about 8%. CONCLUSIONS: Hookah is a new tobacco product in the United States that appears attractive to youth, with dramatic increases among the state population. While cigarette use among youth is declining in Florida, the increasing uptake of alternative tobacco products may lessen the overall public health gains for tobacco use. There is a need for continued monitoring of hookah use among the adolescent population, for both prevention and cessation efforts as well as policy interventions to address this emerging trend.

Health effects of air pollution on length of respiratory cancer survival.

BACKGROUND: Air pollution has been extensively and consistently linked with mortality. However, no study has investigated the health effects of air pollution on length of survival among diagnosed respiratory cancer patients. METHODS: In this study, we conducted a population-based study to investigate if air pollution exposure has adverse effects on survival time of respiratory cancer cases in Los Angeles (LA), CA and Honolulu, HI. We selected all White respiratory cancer patients in the two study areas from the 1992-2008 Surveillance Epidemiology and End Results cancer data. Death from respiratory cancer and length of survival were the main outcomes. RESULTS: Kaplan-Meier survival analysis shows that all respiratory cancer cases exposed to high air pollution referring to the individuals from LA had a significantly shorter survival time than the low pollution exposure group referring to those from Honolulu without adjusting for other covariates (p <0.0001). Moreover, the results from the Cox Proportional-Hazards models suggest that exposure to particles less than 10 micrometers in diameter (PM10) was associated with an increased risk of cancer death (HR = 1.48, 95% CI: 1.44-1.52 per 10 µg/m3 increase in PM10) after adjusting for demographic factors and cancer characteristics. Similar results were observed for particles less than 2.5 micrometers in diameter and ozone. CONCLUSION: Our study indicates that air pollution may have deleterious effects on the length of survival among White respiratory cancer patients. This study calls for attention to preventive effort from air pollution for this susceptible population in standard cancer patient care. The findings from this study warrant further investigation.

Evidence of emerging hookah use among university students: a cross-sectional comparison between hookah and cigarette use.

BACKGROUND: The emergence of hookah is being noted on college campuses and in large U.S. cities and evidence points to an increasing trend for college students. The purpose of this study was to assess hookah use and identify associations with cigarette smoking and demographic factors. METHODS: An intercept sampling method was used at various locations on a large university campus in the southeastern United States, yielding a high participation rate (52%). A total of 1,203 participants completed a computer-aided survey that assessed the use of tobacco products. The sample characteristics were then weighted to match the University population of students enrolled during the same semester. Bivariate (chi-square and t-test) and multivariate (logistic regression) tests of association were conducted to assess differences between cigarette and hookah users. RESULTS: Hookah smoking exceeded cigarette smoking for both ever use (46.4% vs 42.1%) and past year use (28.4% vs 19.6%). Females and males used hookah at similar rates. Hispanic respondents had the highest prevalence of current use of hookah (18.9%) and cigarettes (16.4%). CONCLUSIONS: As hookah surpasses cigarette use, efforts need to be made to slow the increase in new tobacco products that are attractive to young adults and that pose many of the same health risks as those related to traditional tobacco products. Prevalence of all emerging tobacco products, including hookah, and the relationship with cigarette use needs to be monitored on an ongoing basis.

Area-level socioeconomic position and repeat mammography screening use: results from the 2005 National Health Interview Survey.

BACKGROUND: Despite a considerable number of studies describing the relationship between area-level socioeconomic conditions and mammography screening, definitive conclusions have yet to be drawn. The aim of this study was to examine the relationship between area-level socioeconomic position (SEP) and repeat mammography screening, using nationwide U.S. census SEP data linked to a nationally representative sample of women who participated in the 2005 National Health Interview Survey (NHIS). METHODS: An area-level SEP index using 2000 U.S. census tract data was constructed and categorized into quartiles, including information on unemployment, poverty, housing values, annual family income, education, and occupation. Repeat mammography utilization (dichotomous variable) was defined as having three mammograms over the course of 6 years (24-month interval), which must have included a recent mammogram (in past 2 years). Results were obtained by ordinary multivariable logistic regression for survey data. Women ages 46 to 79 years (n = 7,352) were included in the analysis. RESULTS: In a model adjusted for sociodemographics, health care factors, and known correlates of mammography screening, women living in more disadvantaged areas had lower odds of engaging in repeat mammography than women living in the most advantaged areas [OR comparing quartile 4 (most disadvantaged) to quartile 1 (most advantaged) = 0.63; 95% confidence interval, 0.50-0.80]. CONCLUSION: The results of this nationwide study support the hypothesis that area-level SEP is independently associated with mammography utilization. IMPACT: These findings underscore the importance of addressing area-level social inequalities, if uptake of mammography screening guidelines is to be realized across all social strata.

Carbon monoxide levels among patrons of hookah cafes.

BACKGROUND: Individuals who use a hookah (water pipe) as a method of tobacco smoking are exposed to high levels of carbon monoxide (CO). Assessing hookah use in one of the venues of its use (hookah bars) will aid the understanding of the toxins and exposure for the user. In Florida, smoking is prohibited in public places under the Florida Clean Indoor Act but permitted in establishments that have less than 10% gross revenue from food. PURPOSE: To assess the CO level of hookah cafe patrons, using traditional bar patrons as a comparison. METHODS: After IRB approval, a nighttime field study of patrons (aged >18 years) exiting hookah cafes and traditional bars in 2009 was conducted, using sidewalk locations immediately outside these establishments in a campus community. As hookah cafes and bars are typically entered and exited in groups, every other group of people exiting the establishment was approached. For comparison purposes, the sample collected was similar in number, 173 hookah cafe and 198 traditional bar participants. RESULTS: Results from analysis conducted in 2010 indicate that patrons of hookah cafes had significantly higher CO levels (mean=30.8 parts per million [ppm]) compared to patrons of traditional bars (mean=8.9 ppm). Respondents who indicate no cigarette use in the past month but had visited a hookah cafe still demonstrated significantly higher CO values (mean=28.5 ppm) compared to those exiting traditional bars (mean=8.0 ppm). Current cigarette smokers also produced significantly more CO if exiting a hookah cafe (mean=34.7 ppm) compared to a traditional bar (mean=13.3 ppm). CONCLUSIONS: CO levels are higher for patrons of hookah cafes, for both current and non-cigarette smokers. Although users report that they perceive hookah to be less harmful than cigarettes, the greater CO exposure for hookah users that was observed in this study is not consistent with that perception.