May 28, 2014
4 min read

Hookah smoking remains popular among college students despite known risks

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Two recent studies have highlighted the potential dangers and confusing messaging surrounding hookah pipe smoking, which appears to be particularly popular among college students and young adults.

One study, conducted at the University of Pittsburgh School of Medicine, found that college students are more likely to start smoking hookah tobacco if they perceive the behavior as “attractive and romantic.” When these perceptions are present, the study noted, students often initiate the habit despite knowledge of its risks.

A second study, published in Cancer Epidemiology, Biomarkers and Prevention, reported that after one evening of smoking a water pipe in a hookah bar, young adults had increased levels of nicotine, cotinine, tobacco-related carcinogens and volatile organic compounds in their urine.

These findings suggest a possible correlation between water pipe smoking and an increased risk for cancer and other diseases.

Despite these risks, said researcher Jaime Sidani, PhD, senior research specialist in the Program for Research on Media and Health at the University of Pittsburgh, young adults remain largely undeterred from initiating hookah smoking.

“Hookah tobacco smoking does not seem to be hampered by many of the negative social stigmas of cigarette smoking,” Sidani said in a press release. “If educational programs can help students to cut through the positive portrayals and marketing of hookah smoking, it may be possible to make hookah smoking less attractive and socially acceptable, resulting in less initiation.”

Exposure to carcinogens

The study published in Cancer Epidemiology, Biomarkers and Prevention, conducted by researchers at the University of California at San Francisco, sought to determine the levels of exposure to various harmful substances incurred from a single night of hookah smoking.

The researchers evaluated 55 experienced water pipe smokers aged between 18 and 48 years, who were considered to be in good health. They were instructed to discontinue all smoking for 1 week. At the end of this period, the participants provided a baseline urine sample. They then smoked water pipes at their preferred hookah bar in the San Francisco Bay area.

According to self-reported details of the smoking sessions, they spent an average of 74 minutes smoking water pipes, and smoked an average of 0.6 bowls of water pipe tobacco per participant. They provided urine samples shortly after the hookah bar visit, as well as a first-voided urine sample the next morning.

The researchers found that in the samples taken immediately after the evening of smoking, participants had a 73-fold increase in nicotine, a fourfold increase in cotinine, and twice their baseline levels of NNAL, a metabolite of a tobacco-specific nitrosamine that can lead to lung and pancreatic cancers. They also had between 14% and 91% increases in breakdown products of volatile organic compounds (VOCs), including benzene and acrolein, also known carcinogens and triggers of cardiovascular and respiratory diseases.

Nicotine, cotinine and NNAL were also elevated in the next-day samples vs. the baseline samples. Nicotine was 10.4-fold higher; cotinine was 3.2-fold higher and NNAL was 2.2-fold higher, according to a press release.


There was an association between the duration of water pipe smoking and the increase in urine nicotine levels. Additionally, the number of bowls smoked was significantly correlated with an increase in immediate post-exposure nicotine levels and next-morning cotinine levels. The average increase in nicotine levels was similar to those acquired after smoking at least one cigarette.

According to study investigator Gideon St. Helen, PhD, of the Division of Clinical Pharmacology and the Center for Tobacco Control Research and Education at the University of California at San Francisco, these findings challenge the misconception that hookah smoking is a “harmless” alternative to cigarettes.

“Our study provides evidence that water pipe smoking leads to significant intake of tobacco-related addictive and harmful substances, and is therefore not without risk, particularly among children and youths,” St. Helen said in a press release.

Undeterred by risk

In spite of these disturbing findings, findings from the University of Pittsburgh study suggest that the knowledge of potential harm is not enough to offset the appealing image of hookah smoking among young adults.

The study, which was supported by the National Cancer Institute, evaluated the circumstances surrounding initial use of a hookah by college students. The researchers sought to determine the motivating forces behind initiating this habit.

The investigators evaluated 569 first- and second-year students at the University of Florida. The students were surveyed twice over the course of 7 months regarding their knowledge, perceptions and practices pertaining to hookah smoking. Over the course of the study, 13% of the study participants began smoking hookahs.

The researchers found that the students had a greater likelihood of starting to smoke hookahs if they had a favorable perception of hookah smoking. Hookah smoking is frequently viewed among students as “relaxing, pleasurable, fun and sexual,” according to a press release. The students were additionally more likely to begin hookah use if it was considered socially acceptable in their peer group.

In an unexpected finding, the researchers reported that even when students were educated at baseline about the health risks of hookah smoking, they nevertheless began hookah smoking during the course of the study.

According to Sidani, a baseline negative perception toward hookah smoking appeared to be the only significant deterrent to initiating the practice. “This suggests that countering positive attitudes may be at least as effective as emphasizing harm in preventing initiation of hookah tobacco smoking,” she said in a press release.

Brian Primack, MD, PhD, director of the Program for Research on Media and Health at the University of Pittsburgh, noted that the positive perception of hookah smoking could also be a result of the relatively lax regulation of its use.

“Clear policy measures addressing the sale and marketing of hookah products and regulation of hookah bars and cafes may be another way to counteract the positive attitudes young adults hold toward hookah smoking,” Primack said in the press release.

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Disclosure: The researchers report no relevant financial disclosures.