Hookah Smoking: Assessing College Students' Behaviors, Attitudes, and Knowledge

Introduction

Hookah smoking, commonly known as waterpipe smoking, has become a popular trend in recent years, especially among high school and college students.^1-4 While many students find hookah smoking to be socially acceptable, they may not understand the negative impact it can have on general and oral health.⁵ Hookah smoking has recently been deemed a growing threat to public health due to its popularity and associated negative health effects.^{6, 7} An estimated 9,750 people in the United States (U.S.) will die from oropharyngeal cancer annually; many due to various forms of tobacco use, including hookah.⁸ Even with the harmful effects of hookah smoking coming to the attention of health experts, little research has been conducted on public knowledge about hookah smoking. Dental hygienists often spend 45-75 minutes with patients, placing them in a prime position to educate patients, particularly young people, about the dangers of hookah smoking.⁹

Hookah, or waterpipe smoking, is thought to have originated in the Middle East. It also has links to India and North Africa and is believed to have begun as a social tradition dating over 500 years ago.^{1, 6, 10, 11} Hookah smoking is also known as narghile, argileh, hubble-bubble, shisha, and goza, depending on the culture and country.¹² Hookah continues to be common in the Middle East, while it is increasing in popularity in countries such as Britain, France, Russia, and the United States.^1-4

The basic hookah waterpipe consists of four main parts: the head, body, water bowl, and hose connected to a mouthpiece. (Figure 1)^1,12 Tobacco is placed in the head, which is often covered with perforated aluminum foil. Charcoal or burning embers are placed on top of the perforated foil to heat the tobacco. The user inhales through the hose that is connected to the mouthpiece, which in turn, draws air over the lit charcoal. The heated air then passes through the tobacco and produces the smoke which is drawn through the body of the waterpipe and is cooled as it passes through the water in the water bowl.^11,13

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Figure 1.

Basic Hookah Waterpipe

Tobacco used in hookahs is frequently moist and sticky and often contains molasses, honey, and other sweeteners and flavorings. Frequently used flavors include strawberry, cappuccino, toffee, cotton candy, orange, white grape, and chocolate mint.^{6, 14} The aromatic nature of the flavored smoke appeals to younger users and tends to mask the harshness of the tobacco.^{6, 11, 12} Hookahs have also been reported to be used for smoking other substances besides tobacco, including marijuana.¹⁵

Hookah tobacco smoke contains many of the same hazardous chemicals found in cigarette smoking including: nicotine, tar, and carbon monoxide (CO). In addition, hookah smoking produces the carcinogenic polycyclic aromatic hydrocarbons released from the burning of tobacco as well as from the coal used to heat the tobacco.^16-18 The emissions produced from charcoal combustion create health concerns for both the users and bystanders.¹⁹ Volatile aldehydes (formaldehyde, acetaldehyde, acrolein propionaldehyde, and methacrolein) are toxicants known to cause pulmonary disease. Additional hazardous exposures include phenols and heavy metals, such as cobalt, arsenic, chromium, and lead.^16-18

Studies have shown that hookah smoking contains 1.7 times higher concentration of metals, 6.5 times the amount of CO, and 46.4 times the amount of tar when compared to the equivalent nicotine dose found in cigarettes.^{7, 11} Because a hookah smoking session may last roughly 60 minutes, a hookah smoker may consume approximately 200 times more smoke during a hookah session as compared to a single cigarette.^{7, 12} In terms of inhalation of smoke volume, one 60-minute hookah session is considered the equivalent of smoking 60 to 100 cigarettes.^{18, 24} Additionally, the literature indicates that hookah use may serve as a gateway to other tobacco products such as cigarette smoking.^{3, 20} In light of these significant health risks, questions regarding hookah use should be part of the tobacco cessation and prevention conversations dental hygienists have with their patients on a regular basis.

Cigarette smoking has been linked to 480,000 deaths per year in the United States, including 42,000 deaths due to secondhand smoke exposure.²¹ A limited number of studies have been conducted on the health risks of hookah use, although existing research suggests that the health risks are similar to those of cigarette smoking including the noteworthy risk of tobacco addiction.^{6, 22} Hookah smokers inhale more smoke (including nicotine), in a single session compared to cigarette smokers, which increases their risk of addiction.^{2, 11} Other health consequences of long-term tobacco use include: esophageal squamous cell carcinoma, nasopharyngeal cancer, lip carcinoma, cardiovascular disease, lung cancer, bladder cancer, pancreatic cancer, respiratory disease (chronic bronchitis and air inflammation), elevated heart rate and blood pressure, elevated carboxyhemoglobin levels, infertility, and changes in voice and pitch.^{5, 16, 23, 24} Infectious diseases, acquired from sharing the hookah mouthpiece, include Mycobacterium tuberculosis, Hepatitis C, Helicobacter pylori, influenza, Epstein-Barr virus, herpes simplex virus and a variety of respiratory viruses.^{6, 23} In addition to oropharyngeal cancers, specific oral health effects of hookah smoking include increased risk of periodontal disease, acute osteitis, oral candidiasis, and stained teeth and restorations.^{7, 16}

Although firsthand smoke inhaled by the smoker poses significant health risks, it is important to note that the inhalation of secondhand smoke poses similar health risks.²³ Secondhand smoke from a hookah session is of particular concern since it contains smoke from the tobacco as well as the toxicants from the charcoal.¹² Hookah smoke contributes to a higher level of indoor particulate matter as compared to cigarette smoke and it common for people to smoke hookah indoors.¹⁹ Over the last twenty years, approximately 200-300 hookah bars have opened in the United States, many are in university towns.¹⁹ Patrons frequenting these establishments are not always aware of the dangers of the particulate matter or secondhand smoke related to hookah use. Additionally, statewide smoke-free air laws vary and hookah bars or cafes, cigar bars, and smoke shops may be exempt or fall into loopholes that are not fully addressed by city and state ordinances.^{6, 22, 25}

There are many misconceptions among youth who are either smoking hookah or exposed to hookah via secondhand smoke. Hookah smokers may have the perception that because these products are aromatic and sweet smelling, that they are less harmful than other forms of tobacco use.² In addition, because smoke is cooled as it passes through water, it produces a less irritating experience making inhalation more enjoyable.^{22, 26} Other users have reported the erroneous belief that the water filters the toxins as the smoking session continues. Some hookah tobacco is marketed as “herbal tobacco,” which may lead consumers to believe that this is a healthier product than traditional tobacco. However, herbal and sweetened tobaccos, nonetheless, contain tar and carcinogens.¹⁰

Hookah use in the United States is a growing public health concern particularly in regards to college students, although differences have been reported in student gender, ethnicity as well as in the location and size of the university. A national survey completed over the fall of 2008 to the spring of 2009 (N=82,155) showed that 23% of college students reported smoking hookah.⁴ Several other studies demonstrate that males are more likely than females to smoke hookah,^{5, 27, 28} with students of Arab decent being more likely than non-Arab students to participate in hookah smoking.²⁸ Jarrett et al. reported that the prevalence of hookah smoking was significantly higher in university towns with populations greater than 500,000, particularly in Northeastern or Western states;⁴ Midwestern states have been shown to have lower rates of hookah use.^{4, 5, 26, 27, 29}

Despite increasing trends of hookah use and recognized oral health risks, little research has been published on hookah or waterpipe smoking in dental journals.²⁴ The purpose of this study was to assess college students' behaviors, attitudes, and knowledge regarding hookah smoking and to examine the differences in knowledge between health care professional students and those in other disciplines as well as between those who engage in hookah smoking and those who do not.