Spotlight
Cigarette smoking has substantially decreased in American teenagers and young adults (aged 18–24 years) since 1991; however, hookah smoking is increasing in popularity as an alternative form of tobacco use in this age group. Individuals between the ages of 18 and 24 years seem to be the most prolific users, although some data suggest those of middle and high school age might also smoke hookah. A concerning perception is that smoking hookah is safer than smoking cigarettes, and that it is less of a health risk. Hookah smoking originated in ancient Persia and India and is a highly social activity in which aromatic tobacco, or shisha, is smoked through a waterpipe that is generally shared by several people. The shisha is burnt using charcoal, passed through a vessel containing water, and then inhaled through a hose. Most tobacco-related research and tobacco control efforts have focused primarily on cigarettes. But even though many states in the USA have curtailed indoor smoking, exemptions in these regulations have allowed tobacco smoking in hookah lounges to proliferate. Thus, smoking bans that affect restaurants and bars allow loop holes for establishments dedicated exclusively to tobacco use. Alternative tobacco products are increasing in popularity, remain largely unregulated, and can also pose health risks. “Because it is so publically accessible, and hookahs can be used almost anywhere, it gives a perception of safety”, said Judy Zelikoff, professor in the Department of Environmental Medicine at New York University (NY, USA). “As compared to cigarettes, hookah has a sweeter smell and a more appealing taste, which helps give the impression that its use is less harmful.” Several studies show that hookah smoking is often perceived as a less harmful method of smoking tobacco. For example, a survey done in university students in the state of Florida identified that although most did believe that smoking hookah could be harmful to their health (74·6%), more than half (54·4%) considered it a safer alternative to cigarette smoking. However, Zelikoff explained, there are significant health risks of hookah smoking. Similar to cigarettes, hookah smoking seems to be associated with lung cancer, other respiratory diseases, and low birth weight in babies. “There is also the risk of infectious disease transmission from sharing a mouthpiece”, she said, “and hookahs use charcoal, so that may have its own set of health risks.” Unlike cigarettes, which are smoked as a solitary activity and relatively quickly, a hookah is smoked slowly www.thelancet.com/respiratory Vol 3 April 2015
and leisurely, with sessions lasting half an hour or more, which can result in high levels of nicotine exposure. One pooled analysis that looked at cotinine, a nicotine by-product excreted in urine, estimated that smoking hookah daily was equivalent to smoking ten cigarettes a day. As most state and local agencies do not track hookah smoking, estimates about use must be gauged from studies that have assessed usage, especially in teenagers. Data about hookah use in the university age group vary substantially, from 9·5% to 20·4% for the past month, to 41% and 48% for lifetime use. Variation in hookah smoking exists between younger adolescents (13–17 years) as well. In one study, Zelikoff and colleagues used data from the National Youth Tobacco Survey, a cross-sectional, school-based, self-administered survey given to US middle school (aged 11–13 years) and high school (aged 14–16 years) students. From a 2011 sample of 18 866 young adults (from 17 years old), 7·3% reported ever trying hookah and 2·6% reported using it within the past month. In the Monitoring the Future study (years 2010–12), an annual nationally representative survey of high school students in the USA, 18% of 5540 students reported hookah use in the past year. Students who were most likely to smoke hookah tended to be of higher socioeconomic status, be male, and live in an urban environment. However, Joseph Palomar, assistant professor in the Department of Population Health at NYU Langone Medical Center (NY, USA) believes that it is too complicated to compare hookah with cigarettes. “Many people say that hookah is much worse than cigarettes because it is unfiltered and a lot of tobacco tends to be smoked in one session”, he said. “However, hookah use is a different animal than cigarette smoking. True cigarette smokers are addicted and must smoke numerous times per day. Hookah use tends to be much more infrequent—weekly, monthly, yearly, if at all.” Although there are exceptions, generally hookah isn’t used very frequently, “so in many respects it is safer, because most people don’t use it very often”, Palomar comments. “On a session by session basis, hookah is much, much worse. But in general, cigarette smoking tends to be worse because it is most often a habit. I highly doubt, though, that cigarette smokers are moving to hookah to quit. My worry is that people will move onto cigarettes from hookah.”
Jason Florio/Corbis
Features Hookah smoking seduces US young adults
For perception of hookah as less harmful than smoking see http://www.cdc.gov/pcd/ issues/2014/14_0099.htm and http://stage-nursingcenter.wkhmr.com/JournalArticle?Article_ ID=2507472&Journal_ ID=54027&Issue_ID=2506776 For the Florida survey see http:// www.cdc.gov/pcd/ issues/2014/14_0099.htm For the pooled analysis on cotinine see Nicotine Tob Res 2007; 9: 987–94 For the study by Zelikoff and colleagues see http://ntr. oxfordjournals.org/ content/16/2/231 For the National Youth Tobacco Survey see http://www.fda.gov/ TobaccoProducts/ ProtectingKidsfromTobacco/ ucm405173.htm For the Monitoring the Future study see http://www. monitoringthefuture.org/
Roxanne Nelson 277
Cigarette smoking has substantially decreased in American teenagers and young adults (aged 18–24 years) since 1991; however, hookah smoking is increasing in popularity as an alternative form of tobacco use in this age group. Individuals between the ages of 18 and 24 years seem to be the most prolific users, although some data suggest those of middle and high school age might also smoke hookah. A concerning perception is that smoking hookah is safer than smoking cigarettes, and that it is less of a health risk. Hookah smoking originated in ancient Persia and India and is a highly social activity in which aromatic tobacco, or shisha, is smoked through a waterpipe that is generally shared by several people. The shisha is burnt using charcoal, passed through a vessel containing water, and then inhaled through a hose. Most tobacco-related research and tobacco control efforts have focused primarily on cigarettes. But even though many states in the USA have curtailed indoor smoking, exemptions in these regulations have allowed tobacco smoking in hookah lounges to proliferate. Thus, smoking bans that affect restaurants and bars allow loop holes for establishments dedicated exclusively to tobacco use. Alternative tobacco products are increasing in popularity, remain largely unregulated, and can also pose health risks. “Because it is so publically accessible, and hookahs can be used almost anywhere, it gives a perception of safety”, said Judy Zelikoff, professor in the Department of Environmental Medicine at New York University (NY, USA). “As compared to cigarettes, hookah has a sweeter smell and a more appealing taste, which helps give the impression that its use is less harmful.” Several studies show that hookah smoking is often perceived as a less harmful method of smoking tobacco. For example, a survey done in university students in the state of Florida identified that although most did believe that smoking hookah could be harmful to their health (74·6%), more than half (54·4%) considered it a safer alternative to cigarette smoking. However, Zelikoff explained, there are significant health risks of hookah smoking. Similar to cigarettes, hookah smoking seems to be associated with lung cancer, other respiratory diseases, and low birth weight in babies. “There is also the risk of infectious disease transmission from sharing a mouthpiece”, she said, “and hookahs use charcoal, so that may have its own set of health risks.” Unlike cigarettes, which are smoked as a solitary activity and relatively quickly, a hookah is smoked slowly www.thelancet.com/respiratory Vol 3 April 2015
and leisurely, with sessions lasting half an hour or more, which can result in high levels of nicotine exposure. One pooled analysis that looked at cotinine, a nicotine by-product excreted in urine, estimated that smoking hookah daily was equivalent to smoking ten cigarettes a day. As most state and local agencies do not track hookah smoking, estimates about use must be gauged from studies that have assessed usage, especially in teenagers. Data about hookah use in the university age group vary substantially, from 9·5% to 20·4% for the past month, to 41% and 48% for lifetime use. Variation in hookah smoking exists between younger adolescents (13–17 years) as well. In one study, Zelikoff and colleagues used data from the National Youth Tobacco Survey, a cross-sectional, school-based, self-administered survey given to US middle school (aged 11–13 years) and high school (aged 14–16 years) students. From a 2011 sample of 18 866 young adults (from 17 years old), 7·3% reported ever trying hookah and 2·6% reported using it within the past month. In the Monitoring the Future study (years 2010–12), an annual nationally representative survey of high school students in the USA, 18% of 5540 students reported hookah use in the past year. Students who were most likely to smoke hookah tended to be of higher socioeconomic status, be male, and live in an urban environment. However, Joseph Palomar, assistant professor in the Department of Population Health at NYU Langone Medical Center (NY, USA) believes that it is too complicated to compare hookah with cigarettes. “Many people say that hookah is much worse than cigarettes because it is unfiltered and a lot of tobacco tends to be smoked in one session”, he said. “However, hookah use is a different animal than cigarette smoking. True cigarette smokers are addicted and must smoke numerous times per day. Hookah use tends to be much more infrequent—weekly, monthly, yearly, if at all.” Although there are exceptions, generally hookah isn’t used very frequently, “so in many respects it is safer, because most people don’t use it very often”, Palomar comments. “On a session by session basis, hookah is much, much worse. But in general, cigarette smoking tends to be worse because it is most often a habit. I highly doubt, though, that cigarette smokers are moving to hookah to quit. My worry is that people will move onto cigarettes from hookah.”
Jason Florio/Corbis
Features Hookah smoking seduces US young adults
For perception of hookah as less harmful than smoking see http://www.cdc.gov/pcd/ issues/2014/14_0099.htm and http://stage-nursingcenter.wkhmr.com/JournalArticle?Article_ ID=2507472&Journal_ ID=54027&Issue_ID=2506776 For the Florida survey see http:// www.cdc.gov/pcd/ issues/2014/14_0099.htm For the pooled analysis on cotinine see Nicotine Tob Res 2007; 9: 987–94 For the study by Zelikoff and colleagues see http://ntr. oxfordjournals.org/ content/16/2/231 For the National Youth Tobacco Survey see http://www.fda.gov/ TobaccoProducts/ ProtectingKidsfromTobacco/ ucm405173.htm For the Monitoring the Future study see http://www. monitoringthefuture.org/
Roxanne Nelson 277
