A Harmful Trend: Increased Waterpipe Smoking

Waterpipe and other tobacco products displayed in a store window

Credit: John Stephen Dwyer

Waterpipe tobacco smoking (also known as hookah, narghile, shisha and other terms) has been used for centuries in parts of Asia, Africa, and the Middle East.  A part of the Arab culture, waterpipes are prominently used in social settings and are considered a status symbol in some parts of the world.  Since the 1990s, waterpipe smoking appears to be spreading to more diverse populations, and gaining popularity among young people and college students in the United States and some European countries, raising concerns among public health officials.

Diagram of a waterpipe

Credit: Smackware/Wikimedia Commons

The waterpipe consists of a head, body, waterbowl, and a hose with a mouthpiece, through which smoke is inhaled.  Tobacco, often sweetened or flavored, is burned with charcoal or wood in the head.  The combined tobacco and charcoal smoke passes through the waterbowl before being inhaled by the user.  Because the smoke passes through water before inhalation, waterpipe smokers commonly believe that the harmful substances in tobacco smoke are filtered out.  This misconception contributes to the popularity of waterpipe smoking, and the perception that it is less hazardous than cigarette smoking.  Adolescents and young adults may also be attracted by the flavors used in a waterpipe tobacco, for example: apple, melon, pineapple, strawberry, watermelon, grape, pear and orange.

Contrary to what many waterpipe users believe, waterpipe smoking presents significant potential health hazards. A session of waterpipe smoking can last from 20-80 minutes, and waterpipe puffs are often larger than puffs from a cigarette; the World Health Organization notes that waterpipe smokers may inhale as much smoke during one session as a cigarette smoker would get from smoking 100 or more cigarettes.  Waterpipe smoke contains many of the same toxic agents as cigarette smoke, including carbon monoxide, heavy metals, polycyclic aromatic hydrocarbons, and nicotine; because charcoal or wood are used to burn the tobacco, the waterpipe user also inhales toxic compounds from these substances.  While not well studied, secondhand smoke from waterpipe use (a mixture of tobacco smoke and smoking from burning charcoal or wood) poses a potential risk to exposed nonsmokers, especially infants and children. Although more research is needed, the evidence suggests that waterpipe smoking can increase the risk of lung cancer, oral cancer, bladder cancer, and respiratory diseases such as bronchitis, emphysema, and obstructive lung airways.

Only a few studies have been conducted on waterpipe use in the U.S.  A study conducted at the University of Pittsburgh found that approximately 40 percent of students surveyed reported having ever smoked a waterpipe, including 30.6 percent who reported smoking waterpipe in the past year, and 9.5 percent who reported smoking waterpipe in the past 30 days. Of those students who had tried waterpipe smoking, more than one-third (35.4%) had never smoked cigarettes.  Similarly, a study conducted in Montreal, Canada, published in the journal Pediatrics found that 23 percent of the young people (18-24 years old) surveyed had used a waterpipe in the previous year. The researchers attributed the popularity of waterpipe use, in part, to the belief that it is not as harmful or as addictive as cigarette use.

The World Health Organization and the American Lung Association (ALA) have called for more research to understand waterpipe smoking patterns, health risks and health effects, as well as the health effects of secondhand smoke from waterpipe use.  The ALA notes that as access to this “new” form of tobacco use continues to grow, especially among 18-to-24 year olds, waterpipes can become yet another inducement to tobacco smoking that appeal particularly to a younger audience.  Researchers argue for correcting common misperceptions about the health risks of waterpipe use, that smokefree air laws include waterpipe smoking, and that culturally appropriate products and services be provided to waterpipe smokers to help them quit.

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