College students believe hookah safer alternative to cigarette smoking

Despite emerging evidence otherwise, many college students consider hookah smoking safer than smoking cigarettes, reports a University of South Florida (USF) College of Public Health study published this month by the Centers for Disease Control and Prevention (CDC).

The study, appearing online in the CDC journal Preventing Chronic Disease, examined the prevalence of hookah use and described social and behavioral factors associated with hookah smoking among students at USF, a large urban public university in Tampa, Fla. The research suggests that future public health campaigns address misunderstandings about the risks associated with hookah use as well as the regulation of such alternative nicotine-delivery devices.

"The biggest surprise was the misperception about the dangers of hookah smoking," said Jaime Corvin, PhD, USF assistant professor of global health and principal investigator for the study. "In general, the students we surveyed thought it was safer than cigarette smoking. They did not know the risks."

Hookahs are water pipes used to smoke specially made tobacco that comes in flavors ranging from mint and berries to chocolate. In recent years, while the prevalence of cigarette smoking has declined, the popularity of hookah and other alternative forms of tobacco use, including e-cigarettes, has increased among young adults.

Charcoal used to heat the tobacco in the hookah, which cools and filters the smoke through water, can raise health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals, according to the CDC.

While the science is still emerging, data accumulated so far indicates that using a water pipe to smoke tobacco poses serious health risks to smokers and others exposed to its secondhand smoke. Hookah smoking —- which delivers nicotine and can be just as addictive as cigarettes—has been linked to lung, stomach and oral cancers, reduced lung function, decreased fertility and heart disease.

"The World Health Organization estimates that one 45-minute session of smoking hookah is equivalent to smoking 100 cigarettes," Corvin said.

The 2012 cross-sectional USF study was initiated as a class project by graduate students enrolled in a Global Health Assessment Strategies course taught by Corvin. Shams Rahman, MD, MPH, now a doctoral student in epidemiology and biostatistics at USF, was lead author of the study.

The researchers interviewed 478 undergraduate and graduate students at USF to evaluate their lifetime and current hookah use. Among their findings:

- More than half of the students surveyed (54.4 percent) reported using hookah at some point in their lives. The current prevalence of hookah use among the USF students (within the last 30 days) was 16.3 percent - a finding consistent with other studies surveying college-aged students.

- Hookah smoking was significantly associated with cigarette smoking but not with alcohol use.

- While most respondents acknowledged that hookah smoking has harmful effects, more than half of the sample perceived hookah to be a safer alternative than cigarette smoking, and 13 percent thought hookah wasn't harmful at all.

- Regardless of their perception of harmfulness, 30 percent of those who never smoked hookah reported they would consider smoking it in the future.

The reasons why students significantly underestimate the potential hazards smoking hookah were unclear. Corvin suggests the lighter, softer smoke emitted from the water pipe and its fruity, pleasant smell may contribute to the perception that hookah is less risky than smoking cigarettes.

Add to that the highly social nature of the hookah use - often smoked in lounges or cafes while relaxing with friends and tea - and the activity presents an appeal that may be difficult for health education programs to overcome, she said.

As a result of USF's research findings, the university launched a public health education campaign with the message to students that hookah is as harmful as cigarette smoking, maybe even more so. (Corvin hopes to measure the effects of the campaign in a follow-up study). Still, nationally, hookah smoking has not been targeted with comprehensive health campaigns similar to those warning about the harmful effects of cigarette smoking.

The study authors recommend that future educational campaigns address misunderstandings about the risks associated with hookah smoking and include e-cigarettes, e-hookah and other emerging tobacco and nicotine delivery devices, as well as the regulation of the sales and marketing of these devices.