Waterpipe (Hookah) Tobacco Smoking Among Youth

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Waterpipe tobacco smoking is a centuries old practice, influenced by cultural tradition in Eastern Mediterranean countries, the Middle East, and parts of Asia. It historically has been an activity enjoyed primarily by men. In the past 2 decades, however, this method of tobacco smoking has increased in popularity in other parts of the world, including the USA. Growing interest in this form of smoking can be traced, in part, to the advent of a flavored tobacco, called maassel. The combination of flavoring agents and the paraphernalia itself used in the smoking process, along with its mystic appeal, novelty, affordability, and the social atmosphere in which smoking often occurs, has made waterpipe smoking attractive to women as well as men, cigarette smokers and nonsmokers alike, and particular groups, including persons of college age and younger adolescents. Although waterpipe smoking is perceived by its new generation of users to be less addictive and hazardous to health than cigarette smoking, researchers draw diametrically opposed conclusions. Research demonstrates that numerous toxic agents, including carcinogens, heavy metals, other particulate matter, and high levels of nicotine, are efficiently delivered through waterpipes. Moreover, sidestream smoke exposes others in the vicinity of waterpipe smokers to the risk of respiratory diseases and other conditions. In addition, persons sharing waterpipe mouthpieces may share infectious agents as well. Waterpipe tobacco smoking has been declared a public health problem by the World Health Organization and other authorities. Recognition of the deleterious effects of waterpipe smoking has led to initial attempts to expand regulatory control. Because waterpipe tobacco is not directly burned in the smoking process, many existing control measures do not apply. Public health authorities should monitor waterpipe tobacco use carefully. Finally, pediatricians and other healthcare providers should discourage experimentation and continued use among their adolescent patients.

Section snippets

Overview of Hookah Smoking

The prevalence of waterpipe tobacco smoking has increased worldwide, in part, because of misconceptions about its safety. Waterpipe tobacco smoking has become popular among youth and young adults owing to its social acceptance, its novelty, its availability in numerous appealing flavors, and its relatively low cost. Although both the chronic and the acute health consequences of waterpipe smoking are beginning to surface in the literature, information about the negative short-term and long-term

Incidence and Prevalence: An International Assessment

Waterpipe tobacco smoking has been around for centuries with 1 of the earliest recordings of its use in 1616 in India.12 Identifying the actual country in which waterpipes were invented is less clear; however, there seems to be consensus on India for invention and the Muslims for the growth of its popularity.12 The Middle East experienced a resurgence of waterpipe smoking in the 1990s with the introduction of maassel.4, 13 Although customary among men, the practice of waterpipe tobacco smoking

Misconceptions About Waterpipe Tobacco Smoking

Several studies have looked at misconceptions related to waterpipe smoking—ones ranging from the way the smoke enters the lungs to the water filtering capability of the device. Roskin and colleagues44 found that British university students perceived waterpipe tobacco smoke as entering the lungs in a different pathway than cigarette smoke, thus rendering it less harmful. The smoothness of the fruit-flavored tobacco smoke was equated with less harm as well. Students also thought that because

Increased Popularity of Waterpipe Tobacco Smoking

Increased marketing no doubt has contributed to the growing popularity of waterpipe smoking, higher overall sales, particularly through Internet sites, sponsorship at events, distribution of free samples, and direct advertisements.27, 41 Marketing techniques conceal potential dangers associated with waterpipes. For example, in the Eastern Mediterranean Region, the package is labeled as being “100% natural,” making the product seem more acceptable and perhaps even a healthy behavior to consider.5

Overview of Youth Smoking

The WHO66 has declared tobacco smoking as the single most preventable cause of death and disability in the USA.1 Despite global warnings about the health consequences of smoking, every day another 80,000-100,000 children worldwide begin smoking cigarettes.66 Nearly half of the adolescents who start smoking cigarettes continue to smoke for another 15-20 years, an indicator of tobacco's addictiveness.66 The overwhelming relationship between tobacco and youth has prompted the FDA47 to declare

Health Effects

Tobacco smoking is responsible for 440,000 deaths and 5.6 million years of potential life lost in the USA each year.62, 71 Although smoking is causally related to coronary artery disease, stroke, and lung disease, many people continue to smoke because of nicotine's addictive nature.44, 72 Although waterpipe smoking is perceived as being less harmful than cigarettes, evidence suggests that it contains similar harmful agents and has similar addictive potential as cigarettes.8, 10, 53, 73 Unlike

Regulatory Efforts

Policies related to tobacco control include efforts, such as establishment of smoke-free environments, regulation of the sale of tobacco products, including excise taxes and restrictions on sales to minors, regulation of advertising, and control of the content of tobacco products. Efforts at tobacco control occur nationally in the USA as well as worldwide.

The WHO FCTC was adopted by the World Health Assembly in May 2003. It was the first treaty of its kind established under the auspices of the

Conclusions

Waterpipe smoking has had a long and culturally strong tradition in the Middle East, Eastern Mediterranean, parts of Asia, and elsewhere, particularly among men. Since the 1990s its use has migrated to other parts of the world, including the USA, and has given rise to hookah bars and lounges that attract college students and other young adults who enjoy the novelty, social atmosphere, and bonding that they perceive it provides. The introduction of flavored and sweetened tobacco has contributed

References (117)

  • H. Fromme et al.

    Indoor air contamination during a waterpipe (narghile) smoking session

    Food Chem Toxicol

    (2009)
  • G. Kiter et al.

    Water-pipe smoking and pulmonary functions

    Respir Med

    (2000)
  • B. Monzer et al.

    Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke

    Food Chem Toxicol

    (2008)
  • N. Daher et al.

    Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: sidestream smoke measurements and assessment of second-hand smoke emission factors

    Atmos Environ

    (2010)
  • R. Saleh et al.

    Elevated toxicant yields with narghile waterpipes smoked using a plastic hose

    Food Chem Toxicol

    (2008)
  • E. Sepetdjian et al.

    Measurement of 16 polycyclic aromatic hydrocarbons in narghile waterpipe tobacco smoke

    Food Chem Toxicol

    (2008)
  • Youth and tobacco, 2010 [cited 2010]

  • Advisory Note: Waterpipe tobacco smoking: Health Effects, Research Needs and Recommended Actions by Regulators

    (2005)
  • S. Rastam et al.

    Estimating the beginning of the waterpipe epidemic in Syria

    Biomed Centr Publ Health

    (2004)
  • J. Khalil et al.

    The tobacco health nexus? Health messages in narghile advertisements

    Tob Control

    (2009)
  • Y. Shafagoj et al.

    Hubblie bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine

    Int J Clin Pharmacol Ther

    (2002)
  • T. Eissenberg et al.

    Waterpipe tobacco and cigarette smoking

    Am J Prevent Med

    (2009)
  • Tobacco use among students aged 13-15 years—Baghdad, Iraq 2008

    Morb Mortal Wkly Rep

    (2009)
  • Z.A. Bacha et al.

    Saliva cotinine and exhaled carbon monoxide levels in natural environment waterpipe smokers

    Inhal Toxicol

    (2007)
  • E. Pautler

    Hookah Device

    (2010)
  • J. Goodman

    Tobacco in history: The cultures of dependence

    (1993)
  • W. Maziak

    The waterpipe: time for action

    Addiction

    (2008)
  • P. Salameh et al.

    Waterpipe smoking: construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11)

    Nicotine Tob Res

    (2008)
  • T. Asfar et al.

    Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers

    Biomed Centr Publ Health

    (2005)
  • K.D. Ward et al.

    Are waterpipe users interested in quitting?

    Nicotine Tob Res

    (2005)
  • Global Youth Tobacco Survey (GYTS), 2010 [cited: July 24, 2010]

  • F. El-Awa et al.

    Changes in tobacco use among 13-15-year-olds between 1999 and 2007: findings from the Eastern Mediterranean region

    East Mediterr Health J

    (2010)
  • Health behavior in School-aged children (HBSC), 2010 [cited 2010

  • National Youth Tobacco Survey (NYTS), 2010 [cited: July 24, 2010]

  • Tobacco use, 2010 [cited: July 24, 2010]

  • E. Drimly et al.

    Hamas forbids Gaza women from smoking in public places. Englishnewscn Gaza 2010

  • R.A. Afifi et al.

    Neighbourhood influences on narghile smoking among youth in Beirut

    Eur J Public Health

    (2009)
  • H. Tamim et al.

    Cigarette and nargileh smoking practices among school students in Beirut, Lebanon

    Am J Health Behav

    (2007)
  • K. Parna et al.

    Cigarette and waterpipe smoking among adolescents in Estonia: HBSC survey results, 1994-2006

    Biomed Centr Publ Health

    (2008)
  • P.D. Jensen et al.

    Waterpipe use predicts progression to regular cigarette smoking among Danish youth

    Subst Use Misuse

    (2010)
  • Tobacco Use Among Students Aged 13-15 Years—Baghdad, Iraq, 2008

    Morb Mort Wkly Rep

    (2009)
  • S. Gadalla et al.

    Prevalence of smoking among rural secondar school students in Qualyobia governate

    J Egypt Soc Parasitol

    (2003)
  • A. Combrink et al.

    High prevalence of hookah smoking among secondary school students in a disadvantaged community in Johannesburg

    S Afr Med J

    (2010)
  • I. Harrabi et al.

    Comparison of cigarette and waterpipe smoking among pupils in the urban area of Sousse, Tunisia

    Tunis Med

    (2010)
  • S. Stafström

    SkolungdomarsDrogvanor 2007 in Skåne (School Youth Drug Habits 2007 in Skåne)

    (2007)
  • B. Orth et al.

    Bei Jugendlichen (Smoking among youth 2007)

  • O.G. Baker et al.

    Predictors of narghile (water-pipe) smoking in a sample of American Arab Yemeni adolescents

    J Transcult Nurs

    (2008)
  • Tobacco useStatistics 2010 [cited 2010]

  • T. Barnett et al.

    Water pipe smoking among middle and high school students

    Am J Public Health

    (2009)
  • B.A. Primack et al.

    Water-pipe tobacco smoking among middle and high school students in Arizona

    Pediatrics

    (2009)
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