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Despite a growing number of cities instituting smoking bans across the country, hookah bars are continuing to crop up everywhere and gaining a loyal customer base in young adults.

Hookahs, for those who are unfamiliar, are smoking instruments that use charcoal to heat flavored tobacco. The smoke from the heated tobacco is then sucked through a hose into the mouth.  Hookah cafés often offer a wide variety of flavorings on their menu, from mango to rose petals.  People often share hookahs in groups.

Wake Forest University researchers have found that 40.3 percent of students in North Carolina reported trying hookah at least once – just barely lower than the percentage of students who reported smoking at least one cigarette (46.6).  Moreover, 17.4 percent said they actively use hookahs.

“The popularity of hookah smoking among young adults is quite alarming given the potential for negative health effects,” said Erin Sutfin, Ph.D., an assistant professor in the Department of Social Sciences and Health Policy and lead author on the study. “Unfortunately, many young adults are misinformed about the safety of hookah smoking and some mistakenly believe it to be safer than cigarette smoking.”

The results also indicated that freshmen and males were more likely to use hookahs, and that there was an association between individuals who used hookahs and those who smoked cigarettes, smoked marijuana, had a history of other illegal drug use and had drank alcohol in the 30 days prior to the survey.

Hookah users who participated in the study seemed to share a mistaken perception that smoking from a hookah was less harmful than smoking a cigarette.

“The smoke produced by hookahs is a very mild smoke that may be appealing to non-cigarette smokers as a starter product,” Sutfin said.

According to Sutfin, 22 percent of hookah users in the study had never tried a cigarette, suggesting that hookahs may be their first tobacco product.

“Likely because of the pleasant aroma and taste, users may inhale more deeply over a longer period of time,” she said. “This results in hookah smokers actually inhaling a larger volume of tobacco smoke than cigarette smokers do.”

The dangers associated with smoking hookah are two-fold.  First, there is a concern about the cleanliness of the hookah cafes.  Because hookahs are shared and re-used, if cafes do not clean them properly, there is a risk of spreading infectious diseases.

Second, the hookah smoke itself contains high levels of toxic compounds, including tar, carbon monoxide, heavy metals and cancer-causing chemicals. Smoking from a hookah actually exposes an individual to more carbon monoxide and smoke than a cigarette, and delivers the same amount of nicotine, which can lead to dependence.

Health risks of smoking hookah include lung cancer, respiratory illness, low birth-weight (among infants whose mothers smoked hookah during pregnancy) and periodontal disease.

“This study highlights hookah smoking as a considerable public health concern, especially among young adults,” Sutfin said. “Going forward, we need to develop interventions to address this risky behavior.”

The study was published in Drug and Alcohol Dependence.