Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States Caroline Cobb, MS; Kenneth D. Ward, PhD; Wasim Maziak, MD, PhD; Alan L. Shihadeh, ScD; Thomas Eissenberg, PhD Objective: To examine the preva- waterpipe session produces the lence and potential health risks equivalent of at least 1 and as of waterpipe tobacco smoking. many as 50 cigarettes. Miscon- Methods: A literature review was ceptions about waterpipe smoke performed to compile information content may lead users to under- relating to waterpipe tobacco estimate health risks. Conclusion: smoking. Results: Waterpipe to- Inclusion of waterpipe tobacco bacco smoking is increasing in smoking in tobacco control ac- prevalence worldwide; in the tivities may help reduce its spread. United States, 10-20% of some Key words: waterpipe tobacco young adult populations are cur- smoking, prevention, adolescent rent waterpipe users. Depending behavior on the toxicant measured, a single Am J Health Behav. 2010;34(3):275-285 obacco use causes many of the ing the tobacco epidemic over the past 20 world’s leading lethal ailments, in- years.2 This success is threatened by cluding cardiovascular disease, alternative methods of tobacco use, in- T 3,4 chronic obstructive pulmonary disease, cluding waterpipe tobacco smoking. and lung cancer.1 In the United States, Waterpipe tobacco smoking is a centu- tobacco smoking remains the leading pre- ries-old tobacco use method with an am- ventable cause of death, even as consid- biguous origin5 and links to the countries erable success has been achieved in curb- of southwest Asia and north Africa. Al- though known by many different names (eg, hookah, narghile, shisha), the term waterpipe has been used for the last 2 Caroline Cobb, Graduate Student, Department decades in the English language scien- of Psychology, Virginia Commonwealth University, tific literature6-10 to refer to any of a vari- Richmond, VA. Kenneth D. Ward and Wasim Maziak, Associate Professors, Department of Health ety of instruments that involve passing and Sport Sciences and Center for Community tobacco smoke through water before in- Health The University of Memphis, Syrian Center halation. Contrary to popular belief that for Tobacco Studies, Aleppo, Syria, Memphis, TN. waterpipe tobacco smoking is less lethal Alan L. Shihadeh, Associate Professor, Department than cigarette smoking,9,11 emerging re- of Mechanical Engineering, American University of search indicates that both involve com- Beirut, Lebanon. Thomas Eissenberg, Professor, parable health risks3,4,12 including nico- Department of Psychology and Institute for Drug tine/tobacco dependence.13,14 In addition, and Alcohol Studies, Virginia Commonwealth Uni- waterpipe tobacco smoking may be, for versity, Syrian Center for Tobacco Studies, Aleppo, some individuals, a precursor to cigarette Syria, Richmond, VA. 15-17 Address correspondence to Dr Eissenberg, De- smoking. All of these issues are rel- partment of Psychology and Institute for Drug evant to the United States, where and Alcohol Studies, Virginia Commonwealth waterpipe tobacco smoking appears to be University, Box 980205, Richmond, VA 23298. increasing in popularity. Thus, this re- E-mail: [email protected] view addresses this emerging tobacco Am J Health Behav.™ 2010;34(3):275-285 275 Waterpipe Tobacco Smoking Figure 1 A Waterpipe Prepared for Tobacco Smoking, Including Perforated Foil Separating the Charcoal from the Tobacco That Has Been Placed in the Head use method in the United States by high- What Are Waterpipes and How Are lighting current data regarding its preva- They Used to Smoke Tobacco? lence and potential health effects, as well Although composition details may dif- as the knowledge, beliefs, and attitudes fer by culture, tobacco waterpipes most associated with, and potentially fueling, often seen in the United States have a the spread of this tobacco use method. fired-clay head, metal body, glass or acrylic Our goals include increasing awareness, water bowl, and leather or plastic hose stimulating research, influencing policy, (Figure 1). The bowl is partially filled with and developing effective prevention and water and the head is filled with moist- treatment interventions. ened tobacco upon which a lit piece of 276 Cobb et al Table 1 Mean Puff Topography for Waterpipe Users and Cigarette Smokers Waterpipe Cigarette Topography variable N = 2024 N =5222 N = 3025 N = 5626 Puff number 178 171 10.0 12.7 Puff volume (ml) 590 530 51.0 48.6 Puff duration (s) 2.8 2.6 1.4 1.5 Interpuff interval (s) 15.2 15.5 30.7 21.3 charcoal is placed (tobacco and charcoal Waterpipe Tobacco Smoking in the are often separated by perforated alumi- United States num foil). The smoker inhales through Waterpipe tobacco smoking is often as- the hose, thus drawing air over the burn- sociated with southwest Asia and north ing charcoal, heating the tobacco, and Africa but, in recent years, has spread producing smoke that travels through the across the globe and to the United States. body of the waterpipe, the water, and the In this country, several lines of evidence hose to the user.18 The most popular type suggest that waterpipe tobacco smoking is of waterpipe tobacco is called maassel becoming more common, especially on (also known as shisha tobacco), a wet college campuses. First, in April 2004, mixture of tobacco, sweetener, and flavor- Smokeshop magazine (a 30- year-old trade ings. Maassel comes in many flavors, journal serving the tobacco industry) re- including fruit and candy, and it produces ported that 200-300 new waterpipe cafés an aromatic smoke that may be particu- had opened in the United States since larly appealing to youth.19 Waterpipe char- 1999 and that these cafés were “often near coal products range from traditional college campuses.”27 Second, recent press earthen kiln charcoal to quick-lighting reports support the idea that the United products that are particularly common in States is in the early stages of a waterpipe the United States.20 epidemic among its college-age popula- Relative to a single cigarette, com- tion: waterpipe use has been reported in at pleted in about 5 minutes,21 a single least 33 states, with most reports coming waterpipe use episode typically lasts for from cities with a large university.28-35 As about 1 hour.18 Recent technical innova- one recent letter in the American Journal of tions22-24 confirm this duration and also Public Health noted: “In Pittsburgh, 4 hoo- provide a more detailed analysis of kah bars have opened since 2003, each no waterpipe tobacco smoking episodes. As more than 5 miles from the campuses of seen in Table 1, data collected from actual Carnegie Mellon University and the Uni- waterpipe tobacco smokers in natural versity of Pittsburgh. Hookahs have be- settings show that a waterpipe use epi- come commonplace at fraternity parties at sode typically involves almost 200 puffs, these universities. .”36 with an average puff volume exceeding These anecdotal reports are beginning 500 ml.22,24 Thus, compared to a cigarette, to be corroborated by survey data from which involves inhalation of approximately individual universities across the coun- 500-600 ml of smoke (ie, 10-13 puffs of try (Figure 2, Panel B). For example, in a about 50 ml, on average25,26), a single convenience sample survey of 411 Johns waterpipe use episode involves inhala- Hopkins University freshmen (100% <age tion of approximately 90,000 ml of 23, 48% women, 58% white, 93% US citi- smoke.22,24 Although these detailed puff zen), 15.3% reported past 30-day waterpipe topography data are based on waterpipe tobacco smoking.11 In another conve- tobacco smokers in Lebanon, the dura- nience sample survey of 744 Virginia tion of waterpipe use episodes has been Commonwealth University students (93% explored (via self-report) in surveys of US <age 23, 65% women, 43% nonwhite, 92% waterpipe tobacco smokers, with as many US citizen), 20.3% reported past 30-day as 44% reporting episodes of 60 minutes waterpipe use.38 In the only study of a US or longer.20 college population to use random sam- Am J Health Behav.™ 2010;34(3):275-285 277 Waterpipe Tobacco Smoking Figure 2 Percent of Respondents from Locations in Southwest Asia19,37 and North America11,38,39 Reporting Lifetime and Past 30-day Waterpipe (WP) Tobacco Smoking 100 AB100 Southwest Asia North America 80 80 Lifetime WP use 60 Past 30-day WP use 60 40 40 Percent (%) Percent (%) 20 20 0 0 Aleppo, Syria Beirut, Lebanon Baltimore, MD Richmond, VA Pittsburgh, PA N = 58719 N = 41637 N = 41111 N = 74438 N = 64739 pling procedures, 40.5% of 647 students rettes (23% vs 15%, respectively).43 Many who responded to an e-mail survey re- waterpipe users in this survey reported ported ever using a waterpipe to smoke that they first used the waterpipe before tobacco, with 9.5% reporting waterpipe the age of 10.43 In a study of a convenience tobacco smoking in the past 30 days.39,40 sample of 1872 14- to 18-year-olds in the Thus, especially among university stu- US Midwest, 16.7% Arab American youth, dents, waterpipe tobacco smoking has and 11.3% non-Arab youth reported past- become remarkably common in the month waterpipe use.44 Clearly, cultural United States. The spread of waterpipe factors may be important in understand- tobacco smoking may be attributable, at ing waterpipe use among these Arab least in part, to the ready commercial American populations, and more work availability of flavored tobacco and quick- addressing this issue is necessary. lighting charcoal.9 In the United States, Waterpipe tobacco smoking is also sur- these and other waterpipe-related prod- prisingly common in more diverse popu- ucts commonly are purchased via the lations:, among 6594 Arizona students Internet.20 (grades 6 thru 12) who responded to the Recent work in Southwest Asia and the Youth Tobacco Survey, 7.3% of 12th grad- United States suggests that some indi- ers and 3.5% of all students reported past viduals begin smoking tobacco using a 30-day waterpipe use.45 All of these data waterpipe at a young age.