Health: Hooked on Hookah

Megan Gardner sits with a group of friends, socializing in a smoke-filled room around a Middle Eastern water pipe. Mellow music plays in the background. Authentic artwork adorns the hookah café's walls. As a junior at the University of Miami, Gardner smokes hookah once a week and considers it a great way to relax and unwind and to bring people together.

The modern fad of smoking hookah derives from a 500-year-old Arabian tradition based on smoking flavored tobacco heated by coals and filtered through water. Today, hookah smoking is a growing phenomenon among American college students, with hundreds of hookah cafés, bars and lounges popping up near major universities, including Arizona State University and Boston University, in the last few years. In Pittsburgh, Penn, four hookah bars have opened since 2003, all within five miles of Carnegie Mellon University and the University of Pittsburgh.

Like many college students, Gardner believes shisha, the flavored tobacco smoked from a hookah, lacks the same nicotine potency and addictive puff as cigarettes. But a recent study labels the popular college pastime a dangerous one.

Surprised by the popularity of the smoking ritual and the lack of thorough study of its effects, Christopher Loffredo, director of the cancer genetics and epidemiology department at Georgetown University, led a study in which he and his colleagues compared the cheek cells of hookah and cigarette smokers to non-smokers. The results were startling. Loffredo found that both sets of smokers exhibited four times the mouth damage (including gum disease) as the non-smokers and that hookah, like cigarettes, could lead to more addictive behavior. Loffredo also found that the quick-lighting charcoal used by many hookah smokers may pose an additional hazard: it may produce greater levels of carbon monoxide than standard charcoal.

Loffredo compares a typical hookah session to inhaling a pack of cigarettes and argues that though the water absorbs some soot, turning the water murky, the smoker still inhales nicotine, carbon monoxide and tar. Countering the claim that shisha doesn't have nicotine, Loffredo, who has been studying the health effects of hookah smoking for the past five years, says that the raw material of tobacco matches that of shisha. "It's the same tobacco," he maintains. Other health experts fear that shisha is also a gateway to nicotine addiction. Teens and young adults who smoke hookah "almost certainly" enjoy the physical and psychological effects that nicotine produces when inhaled, says Thomas Eissenberg, Virginia Commonwealth University professor and director of the Clinical Behavioral Pharmacology Laboratory.

The comparison of cigarettes to hookah, though, may overlook some major differences, according to hookah enthusiasts. Smoking hookah is definitely better healthier than smoking cigarettes, claims Aleena Schlotzhauer, assistant manager at Hunky Dory Pipe and Tobacco, a hookah lounge and retailer in Eugene, Ore. Students at the University of Oregon-the store's biggest customer base-can purchase shisha in dozens of flavors, including vanilla, apple, strawberry and piña colada. On a busy evening, the shop can sometimes sell out of its hookah pipes. "There's only five percent tar and no nicotine," Schlotzhauer maintains. "That's very, very little." Most other tobaccos, she explains, are dry in cigarettes, whereas shisha has a molasses or honey base. "It's almost like vaporizing when you're using coals to burn it."

Yet Loffredo says he has witnessed people's dependency on hookah smoking and is currently examining the shift from casual hookah habits to cigarettes. "A few puffs now and again is not going to endanger anyone," he says. "The question is: Is this going to lead to dangerous nicotine addictions similar to cigarettes?" The appeal of hookahs, Loffredo admits, often lies precisely in its differentiation from cigarettes. "It doesn't look like a cigarette, it doesn't smell like a cigarette, it doesn't taste or burn like a cigarette," he says. This, he says, may be why even students who avoid cigarettes are sometimes drawn to hookah.

Wasim Mazaik, research professor at the University of Memphis department of health and sports sciences, agrees. He says that the "fallacious harm-reduced perception of water pipe hazards" combined with the "bad image attached to cigarettes" contributes to college students' infatuation with the social custom. Eissenberg also suggests that the aromatic flavors and smooth smoke make hookah easier on the user's throat than cigarettes and may account for hookah's rise in popularity. "Water pipe tobacco smoke is easy to inhale, being cooled by the water, and tastes and smells flavorful," he explains. His study of 744 students at VCU revealed that more than 20 percent of students had smoked from a hookah within the last 30 days. He credits the popularity to hookah's "social mystique."

Retailers have taken note of the fad, and the hookah industry is booming. "In the past five years it's just skyrocketed in the U.S.," says Brennan Appel, director of, a website that helps users find local hookah bars, purchase hookah paraphernalia and even learn a weekly hookah tip. Appel says the site's sales have increased 33 percent each year since 2003. Students under the age of 21 for whom bars are not an option now have the hookah bar, he says. He relates hookah lounges to coffeehouse bastion Starbucks, where people congregate as much for the company as for the frappuccinos. "It's not necessarily about smoking a product. The hookah itself brings people together," Appel explains.

Like Gardner and Appel, University of Oregon junior Shayna Brown views the social appeal of hookah as its biggest draw. "I look at smoking hookah from a social aspect," says Brown, who first experimented with smoking hookah while visiting Israel a few years ago. "I don't really have a reason to smoke hookah unless I'm around friends."

Though Loffredo discourages hookah smoking regardless of the motivation, others are questioning whether we should find hookah so alarming in the first place. "I'm a little skeptical," says Bryan Page, University of Miami anthropology chair. "It took a major overall increase in life expectancy to pin the current array of health risks on tobacco. Going to a hookah bar a couple times a week just doesn't measure up."

In the hope of contributing to the debate, two studies specifically dealing with hookah smoking and college students in the U.S. are currently underway. Hookah researchers hope to fill the gaps of medical knowledge soon. In the meantime, students will continue lighting up, meeting at hookah bars to share conversations and memories while sharing a smoke.