Are teens turning from cigarettes to hookahs? Study raises red flag.

The prevalence of cigarette smoking among teens may be on the decline, but a significant portion of American high school students are smoking hookahs, and they’re not the usual suspects, a new study found.

As many as 1 in 5 adolescents have tried smoking from a hookah before high school graduation, according to new data analysis conducted by researchers at New York University and published Monday in the medical journal Pediatrics.

A hookah is an ancient water pipe that is used to smoke “shisha,” an herbal mixture that may contain tobacco and comes in a variety of flavors, including fruits, mints, and spices. Hookahs originated in the Middle East and India but in recent years have gained popularity in Europe and the United States.

Surveys of young adults in multiple countries, including the United States, suggest that young people believe smoking from a hookah is less harmful and addictive than smoking cigarettes.

While there has been little research into the specific health effects associated with hookah use, “research has shown that hookahs deliver tar, nicotine, and carbon monoxide in even higher doses than cigarettes,” the paper’s authors wrote. The Centers for Disease Control and Prevention website cautions that "hookah smoking is NOT a safe alternative to smoking cigarettes" and that "secondhand smoke from hookahs can be a health risk for nonsmokers."

Going into the study, the New York University researchers had hypothesized that prevalence of hookah use would be highest among low-income students and minorities, following the trend line for cigarette smoking. However, analysis of data collected during 2010-2012 Monitoring the Future surveys of high school students showed that white teens from higher socioeconomic backgrounds are the more likely hookah smokers.

That finding came as a surprise to Dan Romer, the director of the Adolescent Communication Institute at the University of Pennsylvania’s Annenberg School of Public Policy in Philadelphia, who was not affiliated with the study.

“I’m kind of shocked because it's usually people from poorer neighborhoods and with less money who smoke nowadays,” Professor Romer says. “Somehow the allure of this idea of smoking through this water pipe has overcome some of the concerns about the health effects.”

Smoking from a shisha pipe is frequently seen as a social activity. Some hookahs have multiple mouth pieces for several smokers to use at the same time. In recent years, hookah bars, cafes, and lounges have popped up in several major US cities, many of which have managed to survive city-wide smoking bans.

Romer suggests that young people may perceive hookah smoking as a sophisticated, worldly activity. He does caution that the Monitoring the Future survey could be presenting a distorted snapshot of high schoolers’ habits.

“One of the problems with the Monitoring the Future survey is that it collapses having ever used with frequent use,” he says. “It’s most likely that many have done it once or twice. That could mean that this is just a flash in the pan.”

Further, the survey relies on teens, who may be trying to appear cool in the eyes of their peers, to self-report their behavior. That could lead to a higher reporting rate than actual rate of use, he says.

“It’s still kind of concerning that we are getting these numbers,” Romer says. “Health educators and people worried about population health are going to have to start paying attention."