Use of hookah pipes and the tobacco product snus predicts cigarette smoking among teenagers and young adults, according to a study published in JAMA Pediatrics.
Cigarettes, loose tobacco and smokeless tobacco products are all regulated by the Food and Drug Administration (FDA), although hookah pipe tobacco and other tobacco products are outside of the FDA’s current jurisdiction.
In the mid-2000s, when public cigarette smoking was severely limited by clean indoor air laws, tobacco companies introduced smokeless tobacco products such as snus to the US market. Aggressive marketing of these products ensured that smokeless tobacco remains popular among some subgroups, particularly rural young men.
The popularity of smoking hookah pipes has also risen among adolescents and young adults in the US, possibly due to the variety of flavored hookah products.
Although users of these products often believe them to be a safer alternative to smoking cigarettes, studies have shown that in a single 60-minute session of hookah smoking, the smokers inhale 100 times the volume of smoke compared with the smoke from a single cigarette.
One previous study found that hookah pipe smoking is predictive of cigarette smoking among young college-attending women in the US, and another study found a link between snus use and risk of cigarette smoking. However, there have not been many other studies investigating this association.
The new study involved 2,541 participants between the ages of 15 and 23, whose smoking habits were initially assessed between October 2010 and June 2011, and then followed up between October 2012 and March 2013.
At the start of the study:
- 38.7% of all participants had tried cigarettes
- 15% were current smokers
- 20.1% had smoked hookah
- 9.4% used snus.
Of the 1,596 study participants who contributed to the follow-up, 65.7% had never smoked cigarettes at the start of the study, and among that group, 6.8% had smoked hookah and 1.9% had used snus.
At follow-up, 39% of the participants who were not cigarette smokers at the start of the study – but who had used hookah – had since started smoking cigarettes, compared with 4.9% of the participants who had not smoked hookah.
Of the participants who did not smoke cigarettes at baseline but who had used snus, 55% had started smoking cigarettes, compared with 20.5% of the participants who had not used snus.
In terms of current cigarette smokers (people who had smoked cigarettes in the past 30 days), 11% of the hookah users who had taken up smoking cigarettes since the start of the study were current cigarette smokers, compared with 4.9% of those who had not smoked hookah. And 25% of the snus users who had begun smoking cigarettes since the start of the study were now current smokers, compared with 5% of those who had not used snus.
The authors report that the odds of beginning smoking or smoking more often were higher for people who had used hookah or snus at the start of the study than those who were not. However, the study cannot prove conclusively that hookah smoking and snus use caused subsequent cigarette smoking – the study can only report that there is an association.
The authors write:
“In conclusion, our study demonstrates that WTS [water pipe tobacco smoking] and snus use among noncigarette smoking adolescents and young adults were longitudinally associated with subsequent cigarette smoking. Yet, water pipe tobacco remains largely unregulated by the FDA, and snus is less regulated than other smokeless tobacco.”
“The success of FDA tobacco regulatory control policies will depend, in part, on their ability to reduce the use of alternative tobacco products that may lead to subsequent cigarette smoking,” they add.