Fewer young people in the US are smoking cigarettes, but more are turning to alternative tobacco products, such as hookahs and cigars that come in “fun” flavors and colors, research shows.
A new study uses data from Monitoring the Future (MTF), a nation-wide ongoing annual study of the behaviors, attitudes, and values of American secondary school students that takes place in approximately 130 public and private schools throughout 48 states in the US. Roughly 15,000 high school seniors are assessed annually.
Published in the journal Pediatrics, the study examined data from the 5,540 students (modal age = 18) who were asked about hookah use from 2010-2012. The annual prevalence (use in the last 12 months) of hookah use was nearly 1 in 5 high school seniors.
“What we find most interesting is that students of higher socioeconomic status appear to be more likely to use hookah,” says Joseph J. Palamar, assistant professor of population health at New York University Langone Medical Center.
“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.”
Alternative tobacco use up 123%
Hookah, an ancient form of smoking, in which charcoal-heated tobacco or non-tobacco based shisha smoke is passed through water before inhalation, is rapidly gaining popularity among adolescents in the US. Those students who smoked cigarettes, and those who had ever used alcohol, marijuana, or other illicit substances were more likely to use hookah.
“Tobacco use and exposure to secondhand smoke are the leading preventable causes of morbidity and mortality in the US,” says study coauthor Michael Weitzman, professor of pediatrics and of environmental medicine.
“Cigarette use has decreased by 33 percent in the past decade in the US, 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 that they are even more damaging to health than are cigarettes.”
While the US is experiencing an alarming increase in hookah use among adolescents, Palamar does point out that “Use tends to be much different from traditional cigarette smoking. Right now it appears that a lot of hookah use is more ritualistic, used occasionally—for example, in hookah bars, and not everyone inhales.
“However, times are beginning to change,” he says. “Now something called hookah pens, which are similar to e-cigarettes, are gaining popularity. While 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.”
Social stigma toward cigarette use appears to have played a large part in the recent decrease in rates of use, but researchers caution that it is doubtful the new hookah pens are frowned upon as much as cigarettes. Hookah pens also come in trendy designs and colors, which may be appealing to both adolescents and adults.
“These nifty little devices are likely to attract curious consumers, possibly even non-cigarette smokers,” Palamar says. “And 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.”
Increased normalization might lead to increases in use, and possibly adverse consequences associated with repeated use, the researchers say, stressing that it is crucial for educators and public health officials to fill in the gaps in public understanding about the harm of hookah smoking.
“This portends a potential epidemic of a lethal habit growing among upper and middle class adolescents, Weitzman says.
He and Palamar stress that it is crucial for educators and public health officials to fill in the gaps in public understanding about the harm of hookah smoking.