Waterpipes (also know as hookahs) are the first new tobacco trend in the 21st century, giving new popularity to an old form of tobacco use. Waterpipe use continues to grow in 18-to-24-year olds; however, misperceptions about the safety of waterpipe use are widespread and need to be addressed.

Background/ History of Waterpipe Tobacco Use

The waterpipe is used to smoke specially made tobacco by indirectly heating the tobacco with burning embers or charcoal which then filters the smoke through a bowl of water. The smoke is then drawn through a rubber hose to a mouthpiece, where it is inhaled by the user. Waterpipes are commonly referred to as hookah, but other names include narghile or narghila, and shisha or sheesha.

Hookahs generally consist of four main parts:

1. The bowl where the tobacco is heated;
2. The base filled with water or other liquids;
3. The pipe, which connects the bowl to the base; and
4. The hose and mouthpiece through which smoke is drawn.

Hookah smoking originated in ancient Persia and India, and spread throughout the Middle East and Asia during the 15th century. In the late 20th century, sweeter additives and more flavors were developed to make the hookah more appealing to women. As people emigrated to Europe and the United States from the Middle East and Africa, hookah cafes began appearing in European cities and are now growing in popularity in the United States.

Hookahs have become fashionably popular among the urban youth, young professionals, and college students

Health Effects of Hookah Smoking

The existing evidence on hookah use indicates that smoking through a hookah carries the same or similar health risks as cigarette smoking. These adverse health effects include increased risk of lung, oral, and bladder cancer and heart disease.

While studies of mainstream smoke from hookahs found that it contains similar amounts of nicotine, tar and heavy metals as other tobacco products, some experts believe that hookah smoking increases exposure to toxic substances over other products. This is due in part to the way hookah smoking occurs in contrast to cigarette smoking. Hookah smokers use a waterpipe over a much longer period of time, often 40 to 45 minutes, rather than the 5 or 10 minutes it takes to smoke a cigarette. Because the inhalation and exposure to smoke occurs over a longer and more sustained period of time, a hookah smoker could potentially inhale as much smoke in a single session as consuming 100 or more cigarettes.

Another problem with hookah smoking is the commonly used heat sources that are applied to burn the tobacco, such as wood cinders or charcoal. These substances, when burned, release high levels of potentially dangerous chemicals, including carbon monoxide and metals. Some research suggests that hookah smoke is therefore more dangerous, as it contains smoke from the tobacco itself as well as the smoke from the heat source used to burn the tobacco.

Although more research needs to be done to determine long-term health effects of hookah smoking, available research strongly indicates that it presents many of the same risks as cigarette smoking and should not be viewed as a safe alternative to smoking.

Perception and Awareness

Hookahs are often considered more pleasant for smokers, because the smell, taste and smoothness of the sweetened tobacco provide a much less irritating smoking experience than traditional cigarette smoking. Experienced smokers sometimes add other liquids, such as fruit juice or wine, to change the taste and effect of the smoke. Hookah smoking also offers a more affordable method of smoking than cigarette smoking, which creates another incentive for its use.

Current Estimate of Hookah Use in the U.S.

There is little data on the number of people who use hookahs in the United States. However, some studies of Arab-American teens have shown that hookah use is a strong predictor of cigarette smoking. Researchers found that the odds were two times greater that teens who use hookahs would also be cigarette smokers and the odds of a teen experimenting with cigarettes were more than eight times greater if they had "ever smoked" a hookah. Internationally, hookah use is on the rise and trends in the United States tend to resemble these patterns.

Hookah Bars and Cafes

The rise in hookah smoking in the United States may be the result of marketing for hookah cafes done in and around colleges and universities, targeting 18- to 24-year olds. Hookah bars and cafes have sprung up in urban areas and cities and towns near large colleges or universities, despite states with strong smoke free air laws. Based on US business listings, an estimated 200 to 300 hookah bars or cafes currently operate in the United States, in more than two-thirds of the states.

State Regulations, Legislation, and Policies

Although many states now have laws prohibiting smoking in almost all public places and workplaces, hookah establishments have been exempted from these requirements in many states in a number of different ways. Hookah bars can sometimes qualify for exemptions either as "retail tobacco establishments” or “tobacco bars or cigar lounges" or businesses that primarily engage in the retail sale of tobacco products, whether for consumption on premises or elsewhere. Smoke free air laws, in many cases, have seemed to have a positive effect on hookah establishments, actually bolstering their status as one of the few exempt establishments.

Source: American Lung Association, Tobacco Policy Trend Alert. "An Emerging Deadly Trend: Waterpipe Tobacco Use," February 2007.