Michelle Healy

USA TODAY

Cigarette use is declining among young people at the same time that hookah smoking is gaining in popularity, says a new study that finds nearly 1 out 5 high school seniors used the water pipe device sometime in the last year.

The study's findings confirm earlier research showing that students from families of higher socioeconomic status are more likely to use hookahs, as are males, white students, those who already smoke cigarettes, and those who had previously used alcohol, marijuana or other illicit substances, says the study published online today in Pediatrics.

But the analysis of data collected from a nationally representative sample of 5,540 high-school seniors between 2010 and 2012 also finds that living in a big city, having more highly educated parents, and having a higher weekly income from a job or other source also increases the odds of hookah use.

"When it comes to cigarette smoking, at least now, we tend to think of it as more associated with lower socioeconomic status and lower parental education," says lead study author Joseph Palamar, an assistant professor of population health at NYU Langone Medical Center. That was the exact opposite for students most likely to engage in using hookahs, he says.

According to the study, "Given the cost of frequenting hookah bars, it is not surprising that wealthier students, as indicated by higher weekly income, are more regular visitors, although it remains unknown what proportion of hookah use occurs in hookah bars versus in homes or other noncommercial settings."

Data for the study came from the University of Michigan's Monitoring the Future survey, which recently reported that hookah smoking among high-school seniors in the past year rose to 21%. (The 2013 data was not yet available when the analysis in Pediatrics was conducted.)

The percentage of seniors who reported that they had ever smoked cigarettes declined from 40% in 2012 to 38% in 2013, according to MTF data.

Although many users think that hookah smoking is less harmful than cigarette smoking, "extensively documented" research shows "that's a total and complete misconception," says Harold Farber, a pediatric pulmonologist at Texas Children's Hospital and associate professor at Baylor College of Medicine, who studies tobacco use and adolescents. He was not involved in the new study.

"I've even encountered some younger physicians who thought it was true," Farber says.

According to the CDC, hookah smoking has "many of the same health risks" as cigarette smoking. Other research shows hookahs — which use specially made tobacco known as shisha, available in a variety of fruit and candy flavors — deliver tar, nicotine, and carbon monoxide in even higher doses than cigarettes.

A 2005 World Health Organization report said that a water-pipe smoker may inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 or more cigarettes.

Although some non-tobacco hookah products carry labels claiming that they can be used without the harmful effects of tobacco, CDC says studies of tobacco-based and herbal versions of shisha show that smoke from both types "contain carbon monoxide and other toxic agents known to increase the risks for smoking-related cancers, heart disease, and lung disease."

The notion that the water used in a water pipe or hookah filters out harmful ingredients has also been proven false, Farber says. "It in no way, shape, or form removes the toxins."

Myths about hookah safety help build the image that this is an acceptable, trendy way to have fun with friends, Palamar says. And colorful and brightly designed electronic smoking devices known as hookah pens, hookah sticks and e-hookahs that have recently come on the market may be the next step in "normalizing" hookah use and making it seem like the cool thing to try, he says.

In fact, Palamar says, these devices make it even more important for educators, health providers and policy makers to collaborate and fill in the gaps in public understanding about the risks of hookah smoking.