A recent report from the Centers for Disease Control and Prevention found that although tobacco use among teenagers in the US has declined in recent years, use of alternative tobacco products – such as hookahs – is on the rise. Now, a new study published in the journal Pediatrics reveals the prevalence of hookah use among adolescents and determines which teenagers are most likely to use them.

Hookahs, also known as water pipes, are tools used to smoke flavored tobacco. They consist of a head that is connected to a water bowl, a flexible hose and mouthpiece. The tobacco is mixed with a flavored solution and heated with charcoal. The tobacco smoke passes through water and is drawn through the hose to the mouthpiece, where it is inhaled by the user.

According to the Centers for Disease Control and Prevention (CDC), many users of hookahs believe they are much less harmful than conventional cigarettes, but this is not the case. Medical News Today recently reported on a study revealing that smoking hookahs is not as safe as commonly thought, as it exposes users to cancer-causing compounds.

To determine just how popular hookah use is among teenagers in the US, the researchers of this latest study – including Jospeh J. Palamar, an assistant professor of population health at NYU Langone Medical Center (NYULMC) in New York, NY – analyzed data from an ongoing annual study called Monitoring the Future, which looks at the values, behaviors and attitudes of around 15,000 American high school students.

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Researchers found that almost 1 in 5 adolescents – 18% – engage in hookah smoking.

The team included 5,540 study participants of an average age of 18 who were questioned about their hookah use between 2010 and 2012.

The researchers found that in the past 12 months, almost 1 in 5 adolescents had used hookahs. Furthermore, they were surprised to find that hookah use was more common among students who were of higher socioeconomic status.

“Surprisingly, students with more educated parents or higher personal income are at high risk for use,” says Palamar. “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.”

In addition, they found that students who smoked cigarettes and who had ever used alcohol, marijuana and other illegal substances were more likely to use hookahs.

The researchers say their findings raise concern, particularly since there is increasing evidence about the health risks associated with hookah smoking. Study co-author Dr. Michael Weitzman, a professor of pediatrics at NYULMC, says:

Tobacco use and exposure to secondhand smoke are the leading preventable causes of morbidity and mortality in the US. 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.”

Dr. Palamar notes, however, that unlike cigarette use, hookah use tends to be more “ritualistic.” But he believes this could change with the introduction of hookah pens.

Hookah pens are very similar to electronic cigarettes (e-cigarettes). They are battery operated devices that turn a liquid – consisting of water, fruit flavoring, vegetable glycerin, propylene glycol and possibly nicotine – into a vapor that is inhaled by the user.

Dr. Palamar notes that although not all hookah pens contain nicotine, the devices may “normalize” hookah use in everyday settings, particularly among adolescents.

“These nifty little devices are likely to attract curious consumers, possibly even non-cigarette smokers,” he adds. “And unlike cigarettes, hookahs come in a variety of flavors and are 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.”

The researchers stress that if hookah use becomes normalized among teenagers, the popularity of the devices could skyrocket, and increased and repeated use may lead to potentially severe consequences for health.

They conclude that public health officials and educators need to increase public understanding about the implications of hookah smoking.