Hookah use is on the rise among teens and young adults in the U.S. and the practice is commonly misperceived by youth as being both non-addictive and safer than smoking cigarettes, the American Heart Association (AHA) said in a scientific statement Friday.
The statement warned of mounting evidence linking chronic hookah smoke exposure to increased cardiovascular risk.
“The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use,” the scientific statement writing committee wrote.
“Hookah is often perceived as being less harmful than smoking cigarettes, but this is not a reduced harm product,” writing committee chairman Aruni Bhatnagar, PhD, of the University of Louisville, told MedPage Today.
“Hookah smoke contains harmful chemicals just like cigarettes, and there is also increasing evidence that hookah smoking may be acting as a catalyst for the initiation of cigarette smoking among youth, which is the last thing we want.”
Bhatnagar said that, unlike cigarettes, hookah products can be marketed in candy and fruit flavors, which appeal to younger users. And because many users smoke hookah pipes in dedicated lounges and bars, the activity is perceived as a social event.
The scientific statement is the first by the AHA to address the cardiovascular impact of water pipe tobacco smoking. Pipe designs vary, but the pipes typically consist of a bowl that holds tobacco, a body, a water base, and a hose or multiple hoses attached to mouthpieces.
Burning charcoal is placed on top of the tobacco-filled bowl and hookah tobacco typically includes a combination of dried fruit, flavored tobacco, and other substances.
Hookah smoking sessions typically last around 30 minutes or more, and during these sessions users can inhale numerous harmful substances.
The AHA scientific statement noted that:
- A meta-analysis of water pipe users from four countries found that, on average, daily hookah use produced a 24-hour urinary cotinine level of 0.783 mg/mL, the same as delivered by smoking 10 cigarettes. Just one hookah session in a 4-day period delivered the nicotine equivalent of smoking two cigarettes each day.
- Hookah pipes are significant sources of carbon monoxide exposure, with one session generating 35 times more CO than one cigarette, according to one study. “Side stream” CO emissions from a hookah session were about the same as would be expected from 10 cigarette smokers in the same space.
- Hookah pipes deliver particulate matter with diameters ranging from 0.01 to 0.2 microns, with a median of 0.04 to 0.05 microns.
“Given that a typical 1-hour session of water pipe consists of approximately 100 puffs compared with approximately 11 puffs of a (single) cigarette, a single session of water pipe use is likely to lead to at least a 10-fold greater exposure to tobacco particulate matter,” Bhatnagar and colleagues wrote.
In the 2016 National Youth Tobacco Survey, 4.8% of high-school students reported smoking tobacco using a hookah pipe during the past 30 days, with similar rates of use among boys and girls.
And in the 2016 Monitoring the Future survey, 13% of 12th graders reported water pipe use over the previous year.