Background Although cigarette smoking is decreasing in the U.S., hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposures. The purpose of this study was to assess how a representative sample of U.S. tobacco control policies may apply to HTS. Methods We examined municipal, county, and state legal texts that apply to the largest 100 cities in the U.S. We developed a summary policy variable that distinguishes cities without clean air legislation preventing cigarette or HTS in freestanding bars; with anti-smoking legislation exempting HTS by name; with anti-smoking legislation providing for a different exemption under which HTS may fall; and with anti-smoking legislation and no clear exemption governing HTS. We used multinomial logistic regression to determine associations between community-level socio-demographic variables and our policy outcome variable. Results Although 73 of the 100 largest cities in the U.S. have laws that disallow cigarette smoking in bars, HTS may be allowed due to exemptions in 69 of these 73 cities. While 4 of these cities have passed legislation specifically exempting HTS, 65 may permit HTS via generic tobacco retail establishment exemptions. Compared with cities without clean air legislation, the cities in which HTS may be exempted had denser populations. Conclusions Although three-fourths of the largest cities in the U.S. disallow cigarette smoking in bars, HTS may be permitted in nearly 90% of these cities via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.

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Disparities exist in local smoke-free law coverage. Identifying patterns in coverage can inform state efforts to address related disparities.

Background-Although cigarette smoking is decreasing in the U.S., hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposures. The purpose of this study was to assess how a representative sample of U.S. tobacco control policies may apply to HTS.