Hookah Smoking Is on the Rise as Teens Seek Cigarette Alternatives

Chalanda Jones, MD

While the number of children and adolescents smoking cigarettes has steeply declined in the United States in recent years,1,2 hookah use is growing in popularity in this country and the across the rest of the Western world.3 The Monitoring the Future (MTF) study, an annual cross-sectional survey of high school seniors in approximately 130 public and private schools throughout the United States, found that the number of seniors reporting hookah use in the previous 12 months increased significantly from 18.3% in 2012 to 21.4% in 2013.4

Hookah is a centuries-old form of smoking that originated in the Middle East and India. A hookah is a water pipe in which the smoke of shisha, an herbal material that often is tobacco-based, is passed through water before being inhaled.5 Shisha is available in flavors such as apple, mint, cherry, chocolate, and watermelon.5

A commonly held misconception is that hookah smoking is less addictive and less harmful than smoking cigarettes. However, hookah smoke contains toxic agents known to cause lung, bladder, and oral cancers and is at least as toxic as tobacco smoke, and hookah smokers absorb more of the toxic substances that also are found in cigarette smoke than cigarette smokers do.5

In their recent study,6 Joseph J. Palamar, PhD, MPH, and colleagues at New York University Langone Medical Center set out to delineate demographic and socioeconomic characteristics in correlation with hookah use among U.S. high school seniors. They note that while the spread of hookah use among U.S. adolescents has led to a growing body of epidemiologic data about hookah use, most of the studies have relied on small, nonrepresentative samples.

Using data on a large representative sample of more than 5,500 high school seniors aggregated from the 2010–2012 MTF study, the researchers surveyed for hookah use in the last 12 months. Gender, race, age or ethnicity, parental education level, metropolitan residency status, religious attendance, and financial sources (including job earnings) were used to classify the adolescents.

They found that high school seniors who were male, who lived in homes with higher socioeconomic status, and who were current cigarette smokers were at the highest risk for hookah use. Identifying as male, nonblack, or nonreligious was associated with increased hookah use. Seniors with a higher weekly income and whose parents had higher levels of education were more likely to smoke hookah, as were past and current tobacco or marijuana smokers or alcohol users and those living in urban areas (counties or groups of counties with one or more cities with at least 50,000 inhabitants).

The authors note that widely recognized risk factors for cigarette use among adolescents, such as lower socioeconomic status and lower parental education level, unexpectedly were associated with lower rates of hookah use, which “supports the hypothesis that hookah smoking, unlike cigarette smoking, is a social activity often occurring among those of higher socioeconomic status.”

Why is this important? As we campaign to educate our patients about the adverse health effects associated with nicotine use, it is important to recognize that cigarette substitutes are available that pose just as significant a health risk to our young patients as smoking cigarettes does. n

Chalanda Jones, MD, is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware. 

Charles A. Pohl, MD—Series Editor, is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson College in Philadelphia, Pennsylvania.


1. Centers for Disease Control and Prevention (CDC). Tobacco product use among middle and high school students—United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):893-897.

2. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. NSDUH Series H-46. HHS publication 13-4795.

3. Amrock SM, Gordon T, Zelikoff JT, Weitzman M. Hookah use among adolescents in the United States: results of a national survey. Nicotine Tob Res. 2014;16(2):231-237.

4. Johnston LD, OMalley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use 1975-–2013: Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2014.

5. Centers for Disease Control and Prevention (CDC). CDC fact sheet: hookahs. Updated December 17, 2013. Accessed August 1, 2014.

6. Palamar JJ, Zhou S, Sherman S, Weitzman M. Hookah use among US high school seniors. Pediatrics. 2014;134(2):227-234.