In the JournalsPerspective

Social hookah smoking prevalent among adolescents

Photo of Israel Agaku
Israel Agaku

Although cigarette use has been on a steady decline, hookah smoking has increased in certain populations specifically young adults or college students and adolescents. According to researchers, social hookah smoking most commonly takes places in the home.

“The popularity of hookah smoking in social settings and the health risks it poses make it an important public health issue, particularly among young people,” Israel Agaku, DMD, MPH, PhD, senior scientist for the office on smoking and health at the CDC, told Infectious Diseases in Children. “In the United States, hookah smoking is most common among youth and young adults. The issue is complicated by the fact that many young people are unaware of the health risks of hookah smoking. But research shows that youth use of tobacco products in any form is unsafe, including hookah smoking.”

Agaku and colleagues used the 2016 National Youth Tobacco Survey data collected from a nationally representative sample of 20,675 adolescents from sixth to twelfth grade. According to the study, frequency of hookah smoking could be rated as never, former, current occasional and current frequent. Agaku and colleagues also assessed the places youths chose to smoke in the past 30-days and identified student perception of the prevalence of hookah smoking among their peers.

According to the study, 10.5% of the surveyed population reported smoking hookah one or more times in their life. Of that group, 65.8% were former hookah smokers, 26.3% were current occasional hookah smokers and 7.9% were current frequent hookah smokers. When researchers analyzed typical patterns of behavior related to perceived hookah smoking frequency within a respondent’s grade, 59.3% overestimated its prevalence. Additionally, Agaku and colleagues observed that adolescents who overestimated how much their peers smoked were more likely to be current occasional hookah smokers (adjusted OR = 9.30).

Photo of hookah
Source: Adobe Stock

The study results also showed that boys were more likely than girls to be current frequent hookah smokers (aOR = 1.54), whereas girls more frequently reported being current occasional hookah smokers (aOR = 0.65) and former hookah smokers (aOR = 1.12). Furthermore, adolescents who spoke a second language other than English (aOR = 2.17), used mentholated cigarettes (aOR = 19.94) or other flavored noncigarette tobacco products (aOR = 17.59) and lived with someone who smoked hookah (aOR = 20.56) showed a greater prevalence of current frequent hookah smoking.

Agaku and colleagues also aimed to determine where youths were most likely to smoke and found that the home, whether it was the respondent’s own home (aOR = 31.8%), a friend’s home (aOR = 47.7%%) or a family member’s house (20.8%), was the most common environment for social hookah smoking.

The study suggests social youth hookah smoking is more prevalent among boys, bilingual speakers, cigarette or other noncigarette tobacco product users and adolescents who live in a household with a member who smokes hookah. Hookah smoking should be denormalized, and the researchers suggest home-tailored interventions, such as voluntarily instituting smoke-free rules. They also said that warning about the dangers of social smoking may help to decrease its prevalence among the adolescent population.

“At the population level, mass media campaigns and programs can educate youth and their parents, caregivers, and other adult relatives about the risks of all forms of tobacco product use, including hookah smoking, and encourage voluntary smoke-free home rules that include hookah,” Agaku said. “Health care professionals, including pediatricians, can help prevent and reduce hookah smoking among youth by advising parents and youth about the dangers of hookah smoking and discouraging all forms of tobacco product use among youth, including hookah.” – by Marley Ghizzone

Disclosures: Agaku reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Photo of Israel Agaku
Israel Agaku

Although cigarette use has been on a steady decline, hookah smoking has increased in certain populations specifically young adults or college students and adolescents. According to researchers, social hookah smoking most commonly takes places in the home.

“The popularity of hookah smoking in social settings and the health risks it poses make it an important public health issue, particularly among young people,” Israel Agaku, DMD, MPH, PhD, senior scientist for the office on smoking and health at the CDC, told Infectious Diseases in Children. “In the United States, hookah smoking is most common among youth and young adults. The issue is complicated by the fact that many young people are unaware of the health risks of hookah smoking. But research shows that youth use of tobacco products in any form is unsafe, including hookah smoking.”

Agaku and colleagues used the 2016 National Youth Tobacco Survey data collected from a nationally representative sample of 20,675 adolescents from sixth to twelfth grade. According to the study, frequency of hookah smoking could be rated as never, former, current occasional and current frequent. Agaku and colleagues also assessed the places youths chose to smoke in the past 30-days and identified student perception of the prevalence of hookah smoking among their peers.

According to the study, 10.5% of the surveyed population reported smoking hookah one or more times in their life. Of that group, 65.8% were former hookah smokers, 26.3% were current occasional hookah smokers and 7.9% were current frequent hookah smokers. When researchers analyzed typical patterns of behavior related to perceived hookah smoking frequency within a respondent’s grade, 59.3% overestimated its prevalence. Additionally, Agaku and colleagues observed that adolescents who overestimated how much their peers smoked were more likely to be current occasional hookah smokers (adjusted OR = 9.30).

Photo of hookah
Source: Adobe Stock

The study results also showed that boys were more likely than girls to be current frequent hookah smokers (aOR = 1.54), whereas girls more frequently reported being current occasional hookah smokers (aOR = 0.65) and former hookah smokers (aOR = 1.12). Furthermore, adolescents who spoke a second language other than English (aOR = 2.17), used mentholated cigarettes (aOR = 19.94) or other flavored noncigarette tobacco products (aOR = 17.59) and lived with someone who smoked hookah (aOR = 20.56) showed a greater prevalence of current frequent hookah smoking.

Agaku and colleagues also aimed to determine where youths were most likely to smoke and found that the home, whether it was the respondent’s own home (aOR = 31.8%), a friend’s home (aOR = 47.7%%) or a family member’s house (20.8%), was the most common environment for social hookah smoking.

The study suggests social youth hookah smoking is more prevalent among boys, bilingual speakers, cigarette or other noncigarette tobacco product users and adolescents who live in a household with a member who smokes hookah. Hookah smoking should be denormalized, and the researchers suggest home-tailored interventions, such as voluntarily instituting smoke-free rules. They also said that warning about the dangers of social smoking may help to decrease its prevalence among the adolescent population.

“At the population level, mass media campaigns and programs can educate youth and their parents, caregivers, and other adult relatives about the risks of all forms of tobacco product use, including hookah smoking, and encourage voluntary smoke-free home rules that include hookah,” Agaku said. “Health care professionals, including pediatricians, can help prevent and reduce hookah smoking among youth by advising parents and youth about the dangers of hookah smoking and discouraging all forms of tobacco product use among youth, including hookah.” – by Marley Ghizzone

Disclosures: Agaku reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Harold J. Farber

    Harold J. Farber

    Hookah: yet another tobacco product being promoted to our youth.

    It is not just your parents' cigarettes; hookah, cigars, vapes (electronic nicotine delivery systems), and Juul (a type of electronic nicotine delivery system shaped like a flash drive) are becoming very popular with youth. What these products have in common is a false perception of safety, candy and fruit flavors that appeal to youth and a 'cool' factor.  Product design, promotion and flavoring often specifically appeal to youth.

    Hookah is a water pipe. Many people think that because hookah smoking is 'traditional' and is bubbled through water that it is somehow safer. That is not true. Hookah smoke is not just tobacco, but also charcoal and flavoring agents.  The smoker has to inhale deeper to get the smoke through the water and usually will hold the smoke in their lungs. Sharing the mouthpiece and hookah bowl increases risk for transmission of diseases such as herpes, hepatitis and tuberculosis. Hookah exposes the user to more toxic chemicals and more carbon monoxide, an odorless poison that interferes with oxygen delivery in the blood, than cigarette smoking. The amount of smoke inhaled during a typical hookah session is about 90,000 ml, which is much greater than the 500–600 ml inhaled when smoking a cigarette.

    That hookah use was more common among those with other household smokers is not surprising.  That hookah smokers more commonly perceived this as normative and underestimated the harms is concerning. That by 12th grade, close to 23% of youth report hookah smoking is very concerning.

    What can be done to protect our youth? As flavors increase the appeal of tobacco products, and as fruit and candy flavors become common in hookah and other non-cigarette tobacco products where they are permitted, flavors should be banned from all tobacco products, including hookah. Because false perceptions about the popularity and safety of hookah are common among youth, education and counter-promotion campaigns will be important.  Just because it is not a cigarette does not mean we should sacrifice another generation to the ravages of tobacco.

    • Harold J. Farber, MD, MSPH
    • Pediatric pulmonologist, Texas Children’s Hospital

    Disclosures: Farber is the Chair of the American Thoracic Society Tobacco Action Committee and associate medical director for Texas Children’s Health. Previously, he was an executive committee member and policy chair for the AAP Section on Tobacco Control.