Lots of college students hugely underestimate the risk of smoking hookah, a new federal report shows.



The Centers for Disease Control and Prevention published new data about 500 undergrad and graduate students at the University of South Florida, on their views on and uses of the increasingly popular waterpipe.



They discovered that more than half of the students (54.4 percent) had smoked hookah — also known as shisha — at some point in their lives, and 16 percent had used hookah recently, in the past 30 days. This squares with a broader trend the CDC has documented: that young people in this country are increasingly using hookah along with other non-cigarette tobacco products, like e-cigarettes.



But the most unsettling part of the study was the utter lack of awareness about harms related to hookah: more than half of the students thought smoking from a waterpipe is less dangerous than cigarette smoking and 13 percent thought hookah wasn’t harmful at all.

What is hookah?

Before we get into the harms, let's look at how hookah works: it is essentially a tobacco delivery device that cools and filters smoke through water.



Researchers in the British Medical Journal described smoking through a waterpipe this way: "Tobacco or molasses are placed in a bowl at the top of the apparatus, which is connected to the water filled base by a pipe. This bowl is then covered with perforated material, such as kitchen foil. Burning charcoal is then placed on top of the foil."



When you inhale, you pull smoke from the charcoal through the tobacco, down the pipe, and towards the water. The smoke then bubbles through the water, cools, and comes back up the hose into your mouth.





The practice originated centuries ago, in ancient Persia and India, but has spread around the world with hookah cafés popping up in Europe, the Middle East, and the US. In the US alone, between 2,000 and 3,000 new hookah cafes opened in the last decade. An estimated 100 million people now smoke hookah every day, and the number of users keeps rising — to the chagrin of anti-smoking campaigners.

Hookah smoking is just as harmful as cigarette smoking — if not more so

Research on hookah suggests it’s actually just as harmful as cigarette smoking — if not more so.



"Contrary to ancient lore and popular belief," the World Health Organization reported, "the smoke that emerges from a waterpipe contains numerous toxicants known to cause lung cancer, heart disease, and other diseases."



When compared with cigarette smoking, according to the Mayo Clinic, "The tobacco is no less toxic in a hookah pipe, and the water in the hookah does not filter out the toxic ingredients in the tobacco smoke."



There's reason, they continue, to think it might actually be more dangerous.



"Hookah smokers may actually inhale more tobacco smoke than cigarette smokers do because of the large volume of smoke they inhale in one smoking session," the Mayo Clinic's report says, "which can last as long as 60 minutes."



The WHO estimated that, in one session, a waterpipe user inhales as much smoke as a cigarette user would by puffing through 100 or more cigarettes.



One hour of hookah smoking, the CDC reported, delivers "three- to six-fold higher levels of carbon monoxide and 46-fold higher levels of tar than from a single cigarette." The WHO concluded, "Even after it has been passed through water, the smoke produced by a waterpipe contains high levels of toxic compounds, including carbon monoxide, heavy metals and cancer-causing chemicals." Other studies have shown that, in addition to increasing one's carbon monoxide levels, hookah smoking caused people's heart rates and blood pressure to rise significantly.

hookah smoking is linked with lung, stomach and oral cancers, Decreased fertility, and heart disease Hookah can also be addictive; it delivers nicotine, just like cigarettes. Just like cigarettes, there are well-documented dangers of secondhand smoke. Unlike cigarettes, though, hookah pipes are passed around among users, which can spread infectious diseases.



All this adds up to a clear and problematic health hazard: hookah smoking is linked with lung, stomach and oral cancers, reduced lung function, decreased fertility, and heart disease. One study showed that hookah smoke is a source of benzene exposure — a risk factor for leukemia.

Why is it that these public-health harms aren't getting through?

There's a reason for hookah's popularity: it's social. People gather around the pipe to talk and drink alcohol or tea. In many parts of the world, hookah is considered a bonding ritual, more common among men. But hookah-manufacturers are increasingly marketing their wares to women, adding feminine flourishes and decorations to the pipes, so they too are taking up the practice.



The smoke from a hookah is more palatable than cigarette smoke. The tobacco is often flavored (with everything from apples or berries to chocolate), and the smoke passes through water before it’s inhaled so it feels cool when it hits the mouth.



Hookah smoking also hasn't been the subject of the same kinds of health campaigns that have been launched about cigarettes.



But, public-health campaigners are saying hookah is just as harmful, maybe more so. This is a message you need to spread among your friends, preferably not over a waterpipe.