American youth are giving thumbs down to smoking cigarettes, but their use of smoking hookah is climbing, suggesting more education is needed to inform the public about the health dangers of this alternative form of smoking.

A recent Centers for Disease Prevention and Control (CDC) report found that teens are smoking fewer cigarettes and turning to alternative forms of smoking, including cigars and hookahs. Now a new study finds that 18 percent of teens have smoked hookah in the past year, and that hookah smoking rates are rising among middle- and upper-class youth.

A hookah is a type of pipe used to smoke tobacco. It is particularly common in the Middle East, and has been around for centuries. When the smoke is inhaled from the tobacco bowl, it is cooled in a water chamber before being inhaled.

The study, published in Pediatrics, was conducted by researchers from New York University’s Center for Drug Use and HIV Research (CDUHR).

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The researchers analyzed data from Monitoring the Future (MTF), a nationwide annual study of the behaviors, attitudes, and values of American secondary school students. The MTF survey is administered in approximately 130 public and private schools throughout 48 states in the U.S. Roughly 15,000 high school seniors are assessed annually. In this study, 5,540 students, who were an average age of 18, were asked about their hookah use from 2010 to 2012. The researchers found the annual prevalence of hookah use in the past 12 months was nearly one in five high school seniors.

Joseph J. Palamar, Ph.D., MPH, a CDUHR affiliated researcher and an assistant professor of Population Health at NYU Langone Medical Center (NYULMC), said in a press statement, “What we find most interesting is that students of higher socioeconomic status appear to be more likely to use hookah. Surprisingly, students with more educated parents or higher personal income are at high risk for use. We also found that hookah use is more common in cities, especially big cities. So hookah use is much different from cigarette use, which is more common in non-urban areas.”

Students who smoked cigarettes, and those who had ever used alcohol, marijuana or other illicit substances, were more likely to use hookah, according to the researchers.

Study co-author Dr. Michael Weitzman, a professor of Pediatrics and of Environmental Medicine at the NYULMC, said in the press statement, “Tobacco use and exposure to secondhand smoke are the leading preventable causes of morbidity and mortality in the U.S. Cigarette use has decreased by 33 percent in the past decade in the U.S., while the use of alternative tobacco products such as hookahs has increased an alarming 123 percent. This is especially worrisome given the public misperception that hookahs are a safe alternative to cigarettes, whereas evidence suggests they are even more damaging to health than are cigarettes.”

Speaking to Healthline, Dr. Andrew S. Ting, assistant professor of Pediatrics, Pulmonary and Critical Care at the Icahn School of Medicine at Mount Sinai in New York, said, “Pediatric lung specialists will always be worried when children and teenagers are inhaling substances of unknown provenance. Besides possibly triggering asthma attacks, the potential toxicity of these unregulated plant materials is of major concern.”

Dr. Ting went on to explain, “The inhalation of tobacco combustion products has been shown to be harmful in numerous studies. Whether or not inhaling the chemicals generated in hookah pipes turns out to be damaging is not a risk I would wish to take in the pediatric population.”

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Emphasizing that hookah use by adolescents tends to be much different from traditional cigarette smoking, Dr. Palamar did note that a lot of hookah use appears to be more ritualistic and used occasionally, for example, in hookah bars, and not everyone inhales.

Pointing out that times are changing, Dr. Palamar said that hookah pens, which are similar to e-cigarettes, are gaining popularity and, although not all hookah pens contain nicotine, this new delivery method might normalize hookah use in everyday settings and bring use to a whole new level.

Noting that while social stigma about cigarettes has contributed to the decline in cigarette smoking rates, the new hookah pens, which are available in catchy designs and colors, are not likely to be looked down upon as much as cigarettes, and may be attractive to adolescents and adults.

“These nifty little devices are likely to attract curious consumers, possibly even non-cigarette smokers,” said Dr. Palamar, adding, “Unlike cigarettes, hookah comes in a variety of flavors and is less likely to leave users smelling like cigarette smoke after use. This may allow some users to better conceal their use from their parents or peers.”

Lee Westmaas, Ph.D., director of Tobacco Control Research at the American Cancer Society told Healthline,”The rise in hookah use observed in the study is unfortunate because I think there’s a mistaken impression that it’s safer than cigarettes. The fact is that hookah, also called waterpipe, shisha, or Narghile, smoking also exposes users to the toxicants and carcinogens that regular cigarette smoking does.”

Westmaas went on to say, “A review published in the International Archives of Medicine of studies on hookah smoking even went so far as to say that it’s “at least as toxic as cigarette smoking” because of the concentration of tar, heavy metals, and other carcinogens associated with the activity. A user can be exposed to these in large amounts because of the way the hookah tobacco is smoked. The amounts of nicotine in hookah smoking also makes it a potentially addictive activity for the user.”

The researchers concluded that increased normalization might lead to increases in use and, possibly, adverse consequences associated with repeated use. Warning that there is a potential epidemic of a lethal habit growing among upper- and middle-class adolescents, Dr. Weitzman and the researchers recommended that educators and public health officials inform the public about the harm of hookah smoking.

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