Harmless Hookah? Hardly

While many view water pipes as safer tobacco enjoyment, evidence says otherwise.

Feb. 12, 2008 — -- The sweet-smelling tobacco smoke wafts dreamily into the relaxed atmosphere of the hookah bar. Customers draw heavily from the water pipes in front of them, calm expressions on their faces, making easy conversation with friends.

Sound romantic?

It's anything but.

In the most recent issue of the medical journal Nicotine and Tobacco Research, a study led by Dr. Stephanie Smith-Simone and colleagues at Virginia Commonwealth University in Richmond documents attitudes and behaviors of water pipe users — and makes some disturbing findings.

Water pipe use, also known as hookah or hukka, is becoming increasingly popular among American youth, particularly college students. Smoking in this way involves heating the tobacco to form smoke that then bubbles through water and into tubes from which one inhales the smoke.

It is estimated that more than 100 million people worldwide smoke tobacco using a water pipe, with use most common in the Middle East.

While the exact number of users of water pipe tobacco is not known in the United States, dozens of water pipe bars have opened in college towns and large metropolitan areas nationally. Most tobacco experts believe that this phenomenon is on the increase, but no national surveys have been done.

Like a Cigarette on Steroids

Water pipe tobacco comes in many varieties, with fruit flavors among the most popular. Unlike other forms of tobacco use, it appears that women are equally as likely to smoke hookah as men.

Water pipe smoking is by no means safe. Use of this product exposes the smoker to twice the amount of poisonous gas, carbon monoxide, and three times the amount of nicotine compared with one cigarette.

Water pipe smoke also contains more tar — the component of tobacco smoke that contains the cancer-causing chemicals — than cigarette smoke, although some experts argue that hookah smoke tar is less harmful than cigarette tar because it is not heated to the same degree.

There is no disagreement, however, that the worst cancer-causing chemicals — the so-called tobacco specific nitrosamines — are present in water pipe smoke. In addition, particles within the smoke irritate the lungs, causing inflammation that in turn can lead to bronchitis and emphysema. In fact, some evidence suggests that airflow rates among regular hookah smokers are reduced more frequently than among cigarette smokers.

And that is not the end of the story. According to the Centers of Disease Control and Prevention, the length of hookah smoking sessions combined with the depth of inhalation expose smokers to 100 to 200 times the volume of a single cigarette. Moreover, hookah smokers can develop the same diseases as cigarette smokers, including heart disease and cancers of the mouth, lung and bladder.

Cancer development is not surprising because water pipe smoking causes DNA changes in the cells of these smokers compared to nonsmokers.

Safe Smoke? A Dangerous Misconception

Despite these scary risks, Smith-Simone and colleagues document relatively favorable attitudes toward water pipe smoking compared with cigarette smoking.

Their study surveyed customers from a water pipe café in Richmond as well as Internet users who logged on to HookahForum.com.

Sixty percent of participants reported first-time water pipe use at or before age 18. About one-fifth of those surveyed reported daily use, and more than half of the users stated that they owned their own water pipe, usually ordered via the Internet. More than 40 percent of users smoked 60 minutes or more at one session.

Most users were confident that they could quit easily.

More ominously, the majority of users felt that water pipe use was safer than cigarettes because the smoke passes through water before being inhaled.

But neither belief has been proven.

In fact, because water pipe use involves a greater exposure to nicotine than cigarette smoking, the likelihood of regular hookah smokers to become addicted is higher.

Furthermore, prolonged exposure to water pipe smoke increases the likelihood of health effects that have been documented in scientific studies.

There is no safe exposure to tobacco smoke. Even secondhand smoke — such as sitting in a hookah bar without smoking — increases health risks.

The most famous example of the harm of secondhand smoke comes from the "natural experiment" that occurred in Helena, Mont., after that city passed an ordinance outlawing smoking in public places. Within six months of passage of this law, heart attack rates were cut in half in this community — and rebounded to pre-ordinance rates when the law was repealed.

Not to mention the bad breath, smelly clothes, tooth staining and premature wrinkles that go along with any tobacco smoke exposure.

Harmless hookah? Romantic smoking?


Dr. John Spangler is director of tobacco-intervention programs and a professor of family medicine at Wake Forest University School of Medicine.