While it is widely known that exposure to cigarette smoke is the leading preventable cause of death worldwide, current trends reveal that cigarette smoking rates among the youth are at their lowest in 22 years. The Centers for Disease Control and Prevention warns that this drop is being offset by increases in other forms of tobacco usage such as hookah, otherwise known as a water pipe. Hookah smoking is an explosive, unregulated and understudied recent worldwide epidemic affecting more than 100 million people, particularly young adults. Until recently, hookah smoking was endemic only to Middle Eastern culture – specifically to men – providing an attractive opportunity for socialization and cultural identity. However, hookah “went viral” starting in the early 1990s when tobacco companies added molasses, glycerin and fruit flavors to the traditionally unflavored tobacco product and heavily targeted youth – including women – of all ethnic groups.
The results are striking – California became the epicenter of this epidemic and is one of the top three states where hookah is most prevalent. Recent epidemiological studies show that up to one in five high school seniors and half of college students report smoking hookah. Hookah is said to have been invented by the Indian physician Hakim Abul Fath who introduced the widespread popular belief that “smoke should be first passed through a small receptacle of water so that it would be rendered harmless.” This belief has been shown to be the most common reason for the upsurge of hookah smoking. However, while studies have demonstrated nicotine as water soluble, research findings do not support that water filters out toxins, including nicotine, found in the fruit-flavored hookah paste.
Though nicotine is one of the well-studied addictive components of tobacco smoke, studies have also explored effects of other prevalent toxins. Fine particulate matter less than 2.5 microns, (PM2.5) – small enough to enter the lung – plays a crucial role in increasing the risk of morbidity and reduced life expectancy. Air pollution studies indicate that even low levels of particulate exposure is associated with a significantly increased risk of morbidity and mortality. These findings become of great concern in light of current data revealing that, compared to cigarettes, exposure to particulate matter can be 250-fold higher in hookah smoke. The burning charcoal – which distinguishes hookah from all other forms of smoking – increases the concentration of carcinogens, carbon monoxide and other toxins far beyond the levels found in cigarette smoke.
Contrary to the widespread popular belief that hookah is a healthier, nonaddictive alternative to cigarettes, emerging data show that hookah smoking as well as the secondhand smoke from the water pipe is associated with many deleterious health outcomes including cardiovascular and respiratory illnesses, low birth weight, lung, esophageal and pancreatic cancer. Alarming reports reveal that one hour of hookah smoking is equivalent to inhaling up to 100 cigarettes. In addition, there are suspected links to infectious diseases such as tuberculosis, hepatitis C, Epstein-Barr virus and herpes simplex that could be transmitted by sharing the hookah mouthpiece and not properly cleaning the water pipe in hookah cafes.
Despite this alarming data and while most U.S. cities ban other forms of tobacco use in bars, hookah cafes are exempt from clean air legislation in 90 percent of those cities, allowing their unchecked expansion. In 2013, an online search estimated that California has 2,242 stores that sell water pipes, hookah tobacco and related products in addition to 175 hookah cafes. A disproportionate majority of these are located in Los Angeles near college campuses, providing 18- to 20-year-old youth the chance to enjoy the “bar scene” before reaching the legal alcohol drinking age of 21. In fact, two of Los Angeles’ busiest hookah lounges are located only one mile away from our university.
Every year on May 31, the World Health Organization calls for all countries to draw attention to tobacco use. While aggressive marketing claims hookah to be a safer alternative to cigarettes, hookah does indeed contain nicotine, which is known to be one of the most addicting substances, and numerous toxins known to cause detrimental health effects. In this challenging new global context, it is important to support the call for more hookah research as well as control measures to limit its spread globally and protect public health.
More information about hookah is available at UCLA’s Tobacco-Free Initiative Webpage, including the CDC fact sheet: http://www.cdc.gov/tobacco/
Rezk-Hanna is a nurse practitioner and doctoral candidate at at the School of Nursing. Ong is an associate professor in residence at the David Geffen School of Medicine and co-chair of UCLA’s Tobacco-Free Task Force. Sarna is the interim dean, professor and Lulu Wolf Hassenplug endowed chair at the School of Nursing and chair of UCLA’s Tobacco-Free Task Force.