A recent report from the Centers for Disease Control and Prevention (CDC) found that use of alternative tobacco products such as hookah
is on the rise among teenagers although cigarette smoking among United States high school students has slowed.
Additionally, a study published online in July’s Pediatrics focused on which teenagers seem to gravitate toward hookah smoking.
“Hookah use began centuries ago in ancient Persia and India,” according to a CDC factsheet. “Today, hookah cafés are gaining in popularity around the world, including Britain, France, Russia, the Middle East, and the United States."
But hookah smoking has many of the same health risks as smoking cigarettes, despite myths of its safety, according to Brooke Rosman Bokor, MD, MPH, a physician in the Division of Adolescent and Young Adult Medicine at Children’s National Health System.
We spoke with Dr. Bokor about this practice and its health implications.
What do children and adults like about hookah use?
Motivations for use include socializing, relaxation, pleasure, and entertainment. Hookah use is increasingly popular on college campuses and among high school seniors, particularly those of higher socioeconomic status.
Why do users of hookah believe it is much less harmful than conventional cigarettes? Is this the case?
Hookah is also known as shisha, narghile, or waterpipe. Users and non-users believe that smoking tobacco through a water filter makes it less harmful and non-addictive. This is a myth. The current lack of regulation against hookah lounges and the cheaper price of hookah tobacco (shisha) facilitate the false impression that hookah smoking is safer.
What are the health risks associated with hookah smoking?
Because cigarettes and hookah share some of the same ingredients, they likely share the same health risks. Specific studies on hookah are limited at this time. What we know for sure is that the smoke from one hookah session (which may be 60 minutes or more) contains up to 40 times the tar, 30-50 times the carcinogenic polycyclic aromatic hydrocarbons, two times the nicotine, and 10 times the carbon monoxide as the smoke from a single cigarette. The burning charcoal that heats the tobacco is the source of carbon monoxide.
Is there a link to smoking cigarettes, using alcohol, smoking marijuana, or other illegal substances and using hookahs?
Most children begin smoking cigarettes prior to age 18. The current increasing trend of hookah use is predominantly based among high school seniors, college students, and other young adults. Since current and former cigarette users are those most likely to use hookah, the link may simply be tobacco in an alternative form that is perceived to be less harmful and part of a more mature social setting. The link also may relate to the neurobiologic role of “reward” in the brain, to which the adolescent brain is very sensitized. This may account for increased hookah use among users of alcohol and marijuana.
What is otherwise fueling the initiation and use of hookah?
Hookah bars have popped up in cities and near college campuses around the U.S. since smoke-free laws have not been extended to hookah lounges. Hookah use increases in communities with an increased number of hookah lounges. Hookah tobacco also appeals to young people due to its lower cost and fruity or candy flavoring. Since shisha is considered pipe, rather than cigarette, tobacco per the Food and Drug Administration, it has escaped the 2009 ban against flavored cigarettes as well as the higher taxation of cigarette tobacco.
What should parents do?
Remember that initiation and early patterns of tobacco use are strongly influenced by family and social factors, said Dr. Bokor.
- Set a good example. Don’t personally use hookah or any other form of tobacco, as that sends a message of acceptability to children and teenagers. Parental effort to cut down and quit any form of tobacco (and the challenges incurred) sends another powerful message that helps keep minors from tobacco initiation or use.
- Correct myths. Using tobacco via hookah exposes them to more addictive nicotine and toxic smoke than cigarettes, despite use of water filtration or flavoring.
- Communicate early and often. Open communication with children and teenagers about the risks of all forms of tobacco is the best prevention strategy against tobacco addiction.
Since hookah use increases with age, make sure to talk with high school seniors prior to attending college.
If a child or teenager makes it to age 21 without ever using tobacco, they have very little likelihood of becoming addicted.
Dr. Bokor said hookah produces 40 times the amount of smoke for equal time spent smoking hookah or cigarettes.
“Patrons of hookah bars are exposed to a very high level of secondhand smoke (containing carbon monoxide and toxicants) and third-hand smoke, for example, soot on the walls that contributes to poor air quality,” she said. “The air quality in hookah bars, per one study, regularly reached ‘hazardous’ Environmental Protection Agency levels. This impacts smoking and non-smoking patrons alike, especially those with asthma or other respiratory limitations."
D. Camenga. “The New Cigs on the Block”: An Update on Conventional and Novel Tobacco Products.” Adolescent Medicine: State of the Art Reviews. 2014; 25:33-49.