Hookah, Shisha and Waterpipe Tobacco: Consequences for Health and Future Research Directions
Although California has made great strides in curbing the sale of flavored tobacco products, one exception has been shisha, flavored tobacco smoked in a hookah or waterpipe. Through public misinformation about the nature of its current use and even its history, the hookah industry has successfully managed to avoid the regulations placed on most other flavored tobacco products.
“Flavors were only introduced in the 90s, and this led to an exponential increase of hookah use among youth within [the Middle East], not only among males, but also females,” says Sarah Alnahari, who spoke at a TRDRP webinar held in November 2022. Ms. Alnahari is a doctoral student in Public Health at the University of California Merced and studies tobacco use, including hookah, in first and second-generation Arab American immigrants. Hookah refers to a waterpipe used to heat and smoke shisha, or mu’assel in Arabic, which means “honeyed.” Though sweeter than cigarette tobacco, shisha tobacco was traditionally not flavored. In the Middle East and North Africa, it was traditionally a social practice used by males, though that is shifting. After the introduction of flavors, its use rapidly spread to Arab American immigrant communities in the U.S., including women and youth, and has since become popular in other communities, such as among college students and in bars.
Of note, hookah use has skyrocketed among college students and young adults, leading to what some have called an epidemic.[i] “An increase of hookah smoking has even been documented among middle and high school students, according to the National Youth Tobacco Survey,” says Alnahari. Studies have shown that flavors are an important factor in why youth and young adults use hookah,[ii] yet despite this, hookah was excluded from California’s law banning sales on flavored tobacco products (SB793), which went into effect in December of 2022. “The exclusion of hookah from flavored tobacco products that are regulated, like e-cigarettes, [will] only increase hookah smoking among youth, because users normally shift their use [to] easily accessible flavored tobacco products.”
When Alnahari started researching flavored tobacco in her doctoral studies, she noticed the parallel between the tactics the tobacco industry used for menthol cigarettes and flavored shisha. “I was doing research on a toolkit for flavored tobacco control and one thing stood out: All flavors were being regulated except for menthol,” she says. “We were told that it was racist to [ban] menthol since it was predominantly used by the African American community,” but when her research team spoke with the African American community and tobacco researchers, they explained that this a spurious argument from the tobacco industry when, in fact, menthol cigarettes account for the tobacco-related health disparities seen among the African American community.
Now she sees that same strategy being used—successfully—by the hookah industry with flavored shisha, even as all other flavored tobacco is banned in California with the passing of SB793. “Today, hookah is excluded from flavored tobacco laws citing bias against Arab and Middle Eastern communities with cultural practices,” adds Alnahari.
“Hookah lounge owners have become a real political force in winning exemptions from flavored tobacco laws in California and throughout the nation, and they make the case that this is a cherished cultural tradition, and no doubt in many circumstances it is, particularly at home,” says Mr. Jim Knox, managing director of the American Society Cancer Action Network. However, search ‘hookah lounge near me,’ or go to a hookah lounge, and “you’ll find establishments that look like night clubs for college-age kids, with menus of shisha flavors like red gummy bear, passion kiss, queen of sex. I'm pretty sure these are not honoring cultural traditions.”
In addition to naming flavors in ways that appeal to young people, “[hookah] is heavily advertised and marketed, particularly towards young men and women as a safer alternative to cigarettes,” says Dr. Mary Rezk-Hanna, Assistant Professor in the School of Nursing at UCLA. Her research team has published multiple studies[iii], [iv] providing evidence to counter such claims.
In her studies, smoking tobacco with a waterpipe impaired cardiovascular endothelial function just as cigarette smoking did. “The endothelium is the innermost cell layer lining our blood vessels, and it performs a key number of functions that are critical to keep our arteries in proper homeostatic balance,” explains Rezk-Hanna. “Endothelial dysfunction plays a key role in the initiation and also the progression of cardiovascular disease events.”
Hookah smoke contains similar chemicals found in cigarette smoke, sometimes at even higher concentrations. “Numerous studies have shown that several harmful or potentially harmful substances present in cigarette smoke are also present in waterpipe smoke, but the quantity differs. Some [levels] may exceed those found in cigarettes,” Rezk-Hanna explains. “For example, carbon monoxide that has been shown to exceedingly increase in waterpipe [smoke] versus cigarettes [smoke] because of the charcoal combustion.”
Many people have a misconception that the water filters out harmful substances and smoke, but in reality, the vapor facilitates the embedding of fine particles into the lungs,[v] says Alnahari. “[This] is very dangerous, as these [fine particles] are directly linked to cardiovascular effects, such as cardiac arrhythmias and heart attacks and respiratory effects, such as asthma attacks and bronchitis.” In addition, hookah pipes create clouds of “lateral smoke,” creating an issue with secondary smoke exposure in environments where it’s used.[vi]
“There's a lot of like (sic) misinformation around the myth that shisha use is safer than [other] tobacco,” says Gamila Abdelhalim, Executive Director of Communities Upward, a nonprofit organization that partnered with Prevention Research Center at PIRE (Pacific Institute for Research & Evaluation) to develop “Commit to Quit,” a culturally, linguistically, and gender-appropriate tobacco cessation program focused on Arab American women.
Communities Upward brought Arab American women together and helped them understand research on the health and safety of hookah use, and to provide support for quitting. “In one 30-minute session of hookah smoking, [a person] can smoke an equivalent of like 100 cigarettes,” Abdelhalim explains. This is just one example of the scientifically based information they shared with the participating women.
Similar to other culturally tailored cessation programs, such as Project Sun for Native American youth, Communities Upward proved highly effective. “Eighty percent of people who smoked reported changing their smoking habits,” said Lee, Director of PIRE. Women reported outcomes such as quitting smoking shisha, cutting down on smoking from every day to once a week, and stopping smoking in the presence of children or at friends’ homes, among other outcomes. Prior to the creation of this program, there were no free cessation services in this area of California, and all the available programs targeted cigarette smokers. “There were no particular programs addressing women's lives and concerns, women’s bodies and women’s health, and we found this was true when we looked at the published [scientific] literature as well.”
Many questions remain to be answered about hookah, from use patterns to health impacts. For example, how many people use hookah and how much, particularly youth and vulnerable populations? “I've seen some studies say that 4.3% of people 18 to 24 [years of age] use hookah; Others have it as high as 12%,” says Knox. Other questions that researchers can address include whether hookah is a gateway for other tobacco use, and whether SB793, which tightened language around the use of hookah, will result in greater enforcement of laws regulating hookah lounges. These laws and policies can make a huge difference in affecting smoking habits and ultimately, health.
“Growing up in the Middle East, it was normal for tobacco smoke to be found almost everywhere. It was on public transportation, inside restaurants, and even the doctor’s office. Parties and gatherings were ultimately smoking chambers,” says Alnahari. “As I immigrated to the U.S. and started my career in public health, I learned how policies such as banning smoking in indoor public spaces, having an age limit for purchase, banning flavored cigarettes, taxation and warnings make a difference not only reducing smoking rates but also preventing young people from starting smoking altogether.”
Another concern surrounding hookah is the regulation of shisha. “Because many of these products are not manufactured in the United States, it's sort of a ‘buyer beware’ situation where it cannot be necessarily determined how safe these products are,” says TRDRP Director Dr. Tracy Richmond McKnight. Tobacco products manufactured in the United States for hookah use are regulated by the Food and Drug Administration (FDA) under the Family Protection Act[vii]. While shisha that is manufactured abroad and imported to the U.S. must also comply with applicable FDA requirements, products sold through illegal markets evade regulation.
The webinar helped shed light on what research and information on hookah use is available, common misconceptions around hookah use and health impacts, and areas where additional research is needed. What is clear is that targeted cessation programs like Commit to Quit can have an enormous impact on bringing awareness of research findings to communities, reducing hookah use and providing cessation support to underserved communities.
Hookah, Shisha and Waterpipe Tobacco (One Pager)
Written by Wendee Nicole Holtcamp
MEDIA CONTACT
trdrp@ucop.edu
[i] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int J Environ Res Public Health. 2009;6(2):98–843. doi:10.3390/ijerph6020798.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672364/.
[ii]Owens VL, Ha T, and Soulakova JN. Widespread Use of Flavored E-cigarettes and Hookah Tobacco in the United States. Prev Med Rep. 2019; 14: 100854. doi: 10.1016/j.pmedr.2019.100854. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441788/.
[iii]Rezk-Hanna M, Mosenifar Z, Benowitz NL. High Carbon Monoxide Levels from Charcoal Combustion Mask Acute Endothelial Dysfunction Induced by Hookah (Waterpipe) Smoking in Young Adults. Circulation. 2019;139(19):2215–2224. doi:10.1161/CIRCULATIONAHA.118.037375. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.037375.
[iv]Rezk-Hanna M, Seals DR, Rossmanet MJ al. Ascorbic Acid Prevents Vascular Endothelial Dysfunction Induced by Electronic Hookah (Waterpipe) Vaping. J Am Heart Assoc. 2021;10(5):e019271. doi:10.1161/JAHA.120.019271.
https://www.ahajournals.org/doi/10.1161/JAHA.120.019271.
[v] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int J Environ Res Public Health. 2009;6(2):98–843. doi:10.3390/ijerph6020798.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672364/.
[vi] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int J Environ Res Public Health. 2009;6(2):98–843. doi:10.3390/ijerph6020798.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672364/.
[vii] Hookah Tobacco (Shisha or Waterpipe Tobacco). U.S. Food and Drug Administration, 3 Jan. 2020, https://www.fda.gov/tobacco-products/products-ingredients-components/hookah-tobacco-shisha-or-waterpipe-tobacco#regulation.
