Hookah Smoking Linked to Cigarette Use Within Two Years
Risks of Hookah Use
A hookah is a water pipe in which flavored tobacco is heated using coals and inhaled (after the smoke passes through a bowl of water) using a long hose emanating from the pipe. Hookahs contain nicotine and can thereby lead to addiction in the same way as traditional cigarettes. There is also a misconception that allowing the smoke to travel through water prior to inhalation decreases users’ exposure to toxic chemicals, but this isn’t the case. High levels of toxic chemicals—including carbon monoxide, metals and various carcinogens like formaldehyde—are produced as the tobacco is heated, and the passage through water appears to make little difference.
Broadly speaking, the fact that a hookah session typically involves 200 puffs (compared to 20 to smoke a cigarette) and that both the tobacco and the charcoal produce dangerous chemicals means there is more than enough reason to expect significant risk from hookah smoking. Lung cancer, oral cancer, reduced lung function and decreased fertility are expected risks for hookah smokers.
To investigate the relationship between hookah use and smoking, the researchers recruited 2,541 participants between the ages of 15 and 23, who were asked about their cigarette, hookah and snus (a form of chewing tobacco) use at their first meeting. Two years later, the participants were followed up to see how many of the nonsmokers had become regular smokers or had tried cigarettes, with particular emphasis on the previous nonsmokers. Only 1,596 participants were successfully contacted after two years, though, so the final sample was over a third smaller than the original sample.
Hookah or Snus Use Linked to Increased Odds of Smoking
Of the 1,048 nonsmokers who were queried, 71 had used hookahs and 20 had tried snus at the baseline reading. After adjusting for known risk factors, the researchers found that both hookah and snus use at baseline were associated with taking up smoking, currently being a smoker and a greater intensity of smoking two years later in comparison to the nonsmokers who hadn’t tried the products at the start of the study. The adjusted odds for all of these were around two-and-a-half times greater for those who had used a hookah at the start of the study.
However, the fact that someone had even tried a hookah indicates that he or she may have an interest in smoking cigarettes. Simply put, a nonsmoker who tries a hookah is probably more open to smoking cigarettes than one who doesn’t, so the finding shouldn’t be interpreted as meaning that using a hookah definitely caused the increased risk of smoking: using a hookah could just signify a greater existing risk of becoming a smoker within a couple of years.
Lead author of the study, Samir Soneji, Ph.D., commented on this issue: “We definitely can’t say that hookah use is necessary and sufficient for an adolescent to transition from a never smoker to a cigarette smoker. But I’m not certain that this precise causal relationship is needed for regulation. We ought to regulate other tobacco products to the level that they regulate cigarettes.”
Legal Loopholes With Snus and Hookahs
The regulatory actions Soneji suggests relate to loopholes that benefit hookah and snus sellers. Specifically, hookah tobacco (known as shisha) comes in a wide range of flavors, which are not allowed in traditional cigarettes. In combination with the (misguided) perception that hookahs are safer, the flavors might lead more youths into trying hookahs. For snus, the weight of the product means that companies can legally distribute free samples, which may lead more nonsmokers into trying them.
Even if it isn’t necessarily fair to say that hookah use causes increased odds of smoking, the survey finds that for nonsmokers, trying a hookah is a significant risk factor for taking up the habit. Since hookah use itself is dangerous and addictive, the study offers even more reason to close the legal loopholes that allow hookah smoking to proliferate. If we’re going to stamp out nicotine addiction for good, it’s no use focusing only on traditional cigarettes—nicotine comes in many forms.