Hookah smoking ain’t that cool after all!

In a recent scientific statement published in the journal Circulation by the American Heart Association, a group of cardiologists, epidemiologists and public health experts have summarized data available for adverse effects of hookah smoking or water pipe use and have come out strongly against it. Hookah use is on the rise among teens and young adults in the US and the practice is commonly misperceived by youth as being both non-addictive and safer than smoking cigarettes. Unlike cigarettes, hookah products can be marketed in candy and fruit flavors, which appeal to younger users. And because many users smoke hookah pipes in dedicated lounges and bars, the activity is perceived as a social event. Hookah flavors such as cherry, chocolate, and coffee appeal to young consumers. There is mounting evidence, however, linking this social activity with increased cardiovascular risk.

The objective of this scientific statement was to focus on the design and operation of the water pipes and their use patterns as well as to identify harmful ingredients in water pipe smoke and document cardiovascular risks in water pipe use. The researchers also sought to identify water pipe smoking cessation and health care treatment for water pipe tobacco smokers.

Bhatnagar and colleagues analyzed data from the 2016 National Youth Tobacco Survey (NYTS), the 2016 Monitoring the Future (MTF) survey and the Population Assessment of Health (PATH) study to determine water pipe use among youths. In the NYTS study, nonlinear increases in past-30-day water pipe tobacco use among high school students (4.1% to 4.8%) were observed between 2011 and 2016, the researchers wrote. There was a steady increase in annual water pipe increase among 12th graders from 2010 (17.1%) to 2014 (22.9%), but a decrease in both 2015 (19.8%) and 2016 (13%), according to the MTF study, the researchers wrote. In data from wave 1 of the PATH study, authors identified 89% of youth (aged 12 to 17 years) who used a water pipe reported their first use involved flavored tobacco. In 2014, the more than 12,000 water pipe-related tweets were sent daily, mostly from users with high influence, with many of the tweets being pro water pipe.

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Potential constituents of water pipe tobacco smoke and their associated cardiovascular effects. Source: AHA Scientific Statement on water pipes, Circulation 2019

Findings from the National Adult Tobacco Survey showed an increase as well, from 1.5% during 2009-2010 to 3.2% during 2013-2014. Adults cite cultural and social influences, as well as psychological benefits of reduced stress and anger and improved concentration, which may be attributable to nicotine, as noted in the statement. Water pipe smoking involves placing charcoal briquettes on top of a tobacco-filled bowl with a stem immersed in water such that the smoke is pulled through and bubbles up through the water into a mouthpiece. The harmful or potentially harmful constituents (HPHCs) involved in water pipe are similar to those in standard cigarettes and include tar, phenanthrene, carbon monoxide, heavy metals, and arsenic, as well as nicotine. Data on the long-term effects of water pipe smoking on cardiovascular health are limited, but “lifetime exposures exceeding 40 water pipe–years (2 water pipes per day for a total of 20 years or 1 water pipe for 40 years) are associated with a threefold increase in the odds of angiographically diagnosed coronary artery stenosis,” according to the statement.

Meanwhile, e-cigarettes, another alternative to smoking cigarettes that has gained immense popularity, has also been linked with heart attacks and strokes in a recent study American Stroke Association’s International Stroke Conference in Honolulu on Feb 6th, 2019. E-cigarette use among high school students increased by 900 percent between 2011 and 2015. In 2018, more than 3.6 million young people in the U.S., including 1 in 5 high school students, were users of e-cigarettes, according to the Centers for Disease Control and Prevention. The researchers used data collected by the 2016 Behavioral Risk Factor Surveillance System, a phone survey sponsored by several federal agencies, including the CDC. The survey includes people in all 50 states, asking about risky health-related behaviors, like smoking, and whether respondents have been diagnosed with any health problems. Of the more than 400,000 respondents in 2016, 66,795 reported having used e-cigarettes at least once, and compared with nonusers, e-cigarette users had a 71 percent higher risk of stroke, 59 percent higher risk of heart attack and 40 percent higher risk of heart disease. The risk is way higher for dual-users of regular and e-cigarettes.

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