Hookah Use Among Youth And Young Adults In Florida
A hookah is a waterpipe that is used to smoke tobacco, mostly containing flavors such as apple, mint, and peach. The hookah has been in use for more than four centuries, and originated in Africa and Asia. A hookah resembles a water-filled vase. Tobacco is placed in a small bowl at the top with charcoal placed above it, usually separated by aluminum foil. A small flexible pipe extends from the side of the vase. As a hookah user inhales through that pipe, a vacuum pulls the heat from the charcoal through the tobacco, which is ignited, and creates smoke that then travels through a tube into the water, and back through the pipe into the smoker’s body.
The popularity of hookah in the United States has increased over the past two decades. It has an exotic allure. It is a social experience which may have additional appeal to teens and young adults who are looking to have “grown-up” experiences with their peers. Tobacco use is legal for those above 18, and as such hookah “bars” offer a legal venue for those under the drinking age to have a “nightlife”-type experience without breaking the law. Flavored tobacco, and the nature of water-diffused mechanism, may make the smoking sensation less harsh than cigarettes, offering an appealing gateway to other cigarette product use1.
Hookah Use In Florida
Hookah remains a concern in Florida as there has not been any significant decrease in the use of hookah among Florida’s high school students in recent years. In 2013, 8.2 percent of Florida high school students reported current hookah use, which is the same as 20102. In 2013, 16.7 percent of high school students had ever tried smoking hookah, compared to 16.6 percent in 2010 3. High school students were more likely than middle school students to perceive hookah as less harmful than cigarettes 4. In 2013, 42.1 percent of high school students said that, compared to cigarette smoking, water pipe/hookah smoking is less harmful5.
Growing Health Concerns
There are many misconceptions about hookah, chief among them that it is less harmful than cigarette smoking6. A 2009 study found the majority of hookah users (58.3%) believe hookah is less harmful than cigarette smoking7. Indeed its invention centuries ago was born out of the desire to find a less harmful way of smoking tobacco8. We’ve learned a lot about tobacco smoke since those days, and we now know that hookah smoking is damaging to health9. There is some evidence that hookah smoking causes chromosomal damage10. Levels of exhaled carbon monoxide (a toxin) from hookah users were twice as high as cigarette smokers11. Gum disease has been reported to be five times more common in hookah smokers than in cigarette smokers12. The tobacco used in hookah contains numerous toxic compounds known to cause lung cancer, heart disease and other diseases13.
The unique way hookah is used actually makes it more harmful in some ways. The heating element, typically wood cinders or charcoal, produce their own toxic chemicals in addition to those in the tobacco14,15. In fact, the concentration of cancer causing additive substances may be equivalent to that in cigarettes, but hookah smokers are additionally exposed to the carcinogenic effect of hydrocarbons and heavy metals in the charcoal16. The pipe used to inhale the smoke is also often passed around the group, exposing users to serious risk of transmission of communicable diseases like hepatitis and tuberculosis17. The tobacco used in hookah also contains nicotine, which is highly addictive, perhaps leading to greater receptivity to other tobacco products including cigarettes. In fact, hookah smoke contains 36 times the amount of nicotine compared with cigarettes18,19. Secondhand smoke from hookah is a mixture of tobacco smoke and smoke from the heating elements, typically wood chips or charcoal, and poses a risk for non-smokers 20.
Of particular concern is the length of a session. While a cigarette usually takes 5-7 minutes to smoke, hookah sessions last much longer. During a one hour long session, it is estimated that a hookah user can inhale the equivalent of 100 or more cigarettes21. During this time, hookah users and non-smokers inhaling the secondhand smoke are exposed to high levels of carbon monoxide, heavy metals and cancer causing chemicals22,23.
Hookah and the College Scene
Tracking hookah cafes and establishments in Florida is difficult because the use of hookah is not required to be reported to any government entity. As such, our information is limited to studies of limited geography, as well as advertising and monitoring efforts by advocates. What some of this monitoring is showing is a greater availability of hookah near college campuses24,25. In one large study aimed at comparing cigarette and hookah use among college intramural, club, and varsity athletes, 2,576 students (29.5%) reported ever trying hookah tobacco smoking and 631 (7.2%) reported hookah tobacco smoking in the past 30 days26. College students who had ever used hookah were significantly more likely to be aged 20–21 (34.2%), male (34.2%), and not black (87.8%)27. To broaden the research to include multiple institutions, one study sampled college students from eight universities in one U.S. state; 40.3% of the sample reported ever using hookah and 17.4% of the students reported current (past 30 day) hookah use28. Many hookah smokers also reported cigarette use29.
For example, a 2013 University of Florida survey found seven hookah venues in the community surrounding the college campus. Among the students hookah smoking was more prevalent than cigarette smoking for ever use (46.4% vs. 42.1%) and past year use (28.4% vs. 19.6%).30 According to this study, in Gainesville, the availability of hookah is high enough to provide the first known study in which ever use and past year use of hookah surpassed that of cigarette smoking in a U.S. university student population.
Hookah is clearly growing in popularity among all demographics, including youth and young adults. The Bureau of Tobacco Free Florida is monitoring the scale of the problem and working with community partners and stakeholders to limit initiation among youth. We are considering social marketing interventions aimed at parents to educate them on the dangers of hookah use and to alert them to the potential use of hookah among their children. A social marketing approach aimed at youth at this time is not recommended as it may have the unintended consequence of promoting hookah to those who may otherwise not be aware or interested.
The “transactional” nature of the hookah experience inherently encourages misinformation about the product. Hookah is typically ordered from a “menu” available at the location, customized to the venue, with little or no information about the health effects of the product. A server usually delivers and sets-up the hookah, and the users are not exposed to the product packaging and any warnings they may contain. The server is also unlikely to provide health information and may actually reinforce misinformation of misconceptions about use. As a first step, we might require health-related information to be provided or disclosed prior to the sale of hookah.
Additional measures should also be considered. Flavored tobacco, especially those with appeal to youth such as fruit and candy flavors, should be restricted. Misleading labels should be prohibited and a standard should be applied. Claims of reduced harm should be prohibited. Interventions that increase the price of hookah tobacco will deter use as youth and young adults are price sensitive. Campus health officials should be alerted to the trend, educated about hookah use and provided with the most effective messages to deter use. Businesses should also be required to disclose the sale of hookah and related products so this can be formally tracked and regulated.
The decline in cigarette use across all age and demographics is clear. However, the availability and increased usage of other tobacco products, including hookah, are eroding the progress in reducing tobacco use. It is vital that we remain vigilant about hookah, and address these concerning developments. For more information or to get involved, please visit www.tobaccofreeflorida.com