Hookah or waterpipe smoking—also known as shisha or chica in other countries—is often considered a fun, harmless and lighter version of smoking without the dangers cigarettes pose. Add the inviting social element of going out with friends to charmingly decorated hookah lounges, filled with an array of sweet-smelling aromas, and it’s no surprise that hookah smoking has become a rising trend in the U.S., especially among adolescents and the college student population.

In the U.S., hookah typically involves a waterpipe system that uses wood charcoal to burn flavored tobacco on a piece of foil. As the charcoal burns, smoke passes through the tobacco mixture, then cools as it bubbles through the water before being inhaled through the mouthpiece. The earliest recording of waterpipe smoking is noted in India in 1616, intended to “purify” tobacco smoking, and regained popularity in the 1990s when maassel, or flavored tobacco, was introduced in the Middle East. In the U.S., it has gained more social acceptance as more people have become concerned about the health risks of cigarette smoking and seek alternatives. Many people are attracted to the light-headed high or headrush one may experience from hookah, and teens in particular may turn to hookah as a way to engage in what they perceive as a more mature and exotic experience.

But the perception that hookah is safer than cigarette smoking and virtually harmless is unfounded. Many marketers take advantage of the fact that the U.S. Food and Drug Administration does not regulate packaging descriptions, often misleadingly labeling products as having “0 mg tar.” This is deceptive because tar is not contained in any product, but is produced when something is burned. Other techniques include advertising a product as “100% natural,” which consumers associate with harmlessness. But hookah—or any type of smoking, for that matter—involves burning charcoal, which emits carbon monoxide and ultrafine particles (UFP) that carry the same carcinogens as cigarettes. Deposited in the body, along with the tar produced during the burning, they increase risk of lung and heart problems.

An increasing number of young consumers have become drawn to hookah and have been led to believe these misleading safety statements. While minors under 18 are prohibited from buying or smoking hookah, just like cigarettes, laws are not always heavily enforced. Some states like Florida have conducted statewide surveys that found that 11 percent of Floridian high school students have tried smoking at least once, as did 15.1 percent of high school seniors in Arizona. Numbers creep up for college kids; around 30 percent of 8,745 students from eight surveyed U.S. colleges have tried hookah at least once. This means that if you haven’t thought too much about it, you are still in the majority. In these aforementioned college and high school studies, the number of current users was less than 10 percent from each respective survey sample.

But beyond marketing techniques, why are more and more students engaging in this risky activity? It’s not because young people have a disregard for their health. Rather, many people make the common mistake of thinking that water filters out the harmful toxins produced in smoke—when in truth the water’s role is to humidify and cool the smoke to create a “smoother” sensation. Only about 5 percent of total nicotine content is actually trapped in water, and one actually inhales more nicotine, UFP, and carbon monoxide from smoking hookah than from smoking cigarettes. One study showed that in a single waterpipe smoking session, which typically starts from 15g of tobacco for 45 minutes, smokers were exposed to 3-9 times more carbon monoxide (CO) and 1.7 times more nicotine than in cigarette smoking. Another meta-analysis compared six different studies from Lebanon, Jordan, Kuwait, and India, all of which have a more established tradition of hookah. It showed that daily use of waterpipe smoking, of an average of 20g of tobacco per pipe at least once a day, produced a nicotine absorption rate of about 10 cigarettes a day. People who smoked hookah occasionally (i.e. average of 20g of tobacco per pipe in a 4-day period), absorbed a nicotine level of about two cigarettes a day.

It should be noted that waterpipe smoking studies have generated controversy because of the differing methodologies used and of factors like puff frequency and types or sizes of waterpipes that can confound data. But this doesn’t mean that hookah studies are altogether unreliable. Despite a variation in numbers, it’s universally agreed that inhaling any type of smoke will at the very least cause adverse lung effects.

As far as deciding between hookah and cigarette smoking, here’s an extreme example: think of cocaine and ecstasy (MDMA) and the simplest effects they have on your body’s physiological health. Both are stimulants, but cocaine has more addictive potential, while ecstasy causes more neurological damage. It’s a moot argument to say which is “better” for you, and the same goes with hookah smoking versus cigarette smoking. If you are going to smoke hookah, you might not know exactly how much more toxic it is for you compared to cigarettes, but it is definitely not as harmless as most people might think.

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