Higher socioeconomic status associated with higher rates of hookah use

While cigarette use is declining precipitously among youth, evidence indicates that American adolescents are turning to ethnically-linked alternative tobacco products, such as hookahs, cigars, and various smokeless tobacco products, according to a recent report from the Centers for Disease Control and Prevention (CDC).

Now a new study by researchers affiliated with New York University's Center for Drug Use and HIV Research (CDUHR), in the August 2014 edition of Pediatrics identifies how prevalent Hookah use is and which teens are most likely to be using it.

The study, "Hookah Use Among U.S. High School Seniors," published online July 7, used data from Monitoring the Future (MTF), a nation-wide ongoing annual study of the behaviors, attitudes, and values of American secondary school students. The MTF survey is administered in approximately 130 public and private schools throughout 48 states in the US. Roughly 15,000 high school seniors are assessed annually. This study examined data from the 5,540 students (modal age = 18) who were asked about Hookah use from 2010-2012. The researchers found the annual prevalence (use in the last 12 months) of hookah use was nearly 1 in 5 high school seniors.

"What we find most interesting is that students of higher socioeconomic status appear to be more likely to use hookah," said Joseph J. Palamar, PhD, MPH, a CDUHR affiliated researcher and an assistant professor of Population Health at NYU Langone Medical Center (NYULMC). "Surprisingly, students with more educated parents or higher personal income are at high risk for use. We also found that hookah use is more common in cities, especially big cities. So hookah use is much different from cigarette use, which is more common in non-urban areas."

Hookah, an ancient form of smoking, in which charcoal-heated tobacco or non-tobacco based shisha smoke is passed through water before inhalation, is rapidly gaining popularity among adolescents in the US. The researchers found those students who smoked cigarettes, and those who had ever used alcohol, marijuana or other illicit substances were more likely to use hookah.

"Tobacco use and exposure to secondhand smoke are the leading preventable causes of morbidity and mortality in the US," said a study co-author Michael Weitzman, MD, a professor of Pediatrics and of Environmental Medicine at the NYULMC. "Cigarette use has decreased by 33% in the past decade in the US, while the use of alternative tobacco products such as hookahs has increased an alarming 123%. This is especially worrisome given the public misperception that hookahs are a safe alternative to cigarettes whereas evidence suggests that they are even more damaging to health than are cigarettes."

While the US is experiencing an alarming increase in hookah use among adolescents, Dr. Palamar does point out that "Use tends to be much different from traditional cigarette smoking. Right now it appears that a lot of hookah use is more ritualistic, used occasionally--for example, in hookah bars, and not everyone inhales."

"However, times are beginning to change," notes Dr. Palamar. "Now something called hookah pens, which are similar to e-cigarettes, are gaining popularity. While not all hookah pens contain nicotine, this new delivery method might normalize hookah use in everyday settings and bring use to a whole new level."

Researchers note that social stigma toward cigarette use appears to have played a large part in the recent decrease in rates of use, but they caution that it is doubtful these new hookah pens are frowned upon as much as cigarettes. Hookah pens also come in trendy designs and colors, which may be appealing to both adolescents and adults.

"These nifty little devices are likely to attract curious consumers, possibly even non-cigarette smokers," said Dr. Palamar. "And unlike cigarettes, hookah comes in a variety of flavors and is less likely to leave users smelling like cigarette smoke after use. This may allow some users to better conceal their use from their parents or peers."

Researchers conclude increased normalization might lead to increases in use, and possibly adverse consequences associated with repeated use. "This portends a potential epidemic of a lethal habit growing among upper and middle class adolescents," said Dr. Weitzman. They stress that it is crucial for educators and public health officials to fill in the gaps in public understanding about the harm of hookah smoking.