Smoke volumes are larger and levels of tobacco toxicants are higher in a single hookah smoking session compared with a single cigarette. These findings were published in Public Health Reports (2016; 131:76-85).

Hookahs are communal pipes that allow users to draw tobacco smoke through water. They are also known as waterpipe tobacco smoking. Past 30-day use of hookah tobacco among US high school students was higher than past 30-day use of cigarettes, according to the Centers for Disease Control and Prevention (CDC). In addition, hookah use is reported by approximately one-third of US college students, with many of these hookah users not having previously used other forms of tobacco.

This study, from the University of Pittsburgh School of Medicine in Pittsburgh, involved the review of 542 scientific articles that were narrowed down to 17 studies with sufficient data to be included in this meta-analysis.

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When the researchers compared 1 hookah session with 1 cigarette, the hookah session delivered approximately 125 times more smoke, 2.5 times more nicotine, and 10 times more carbon monoxide.

“Our results show that hookah tobacco smoking poses real health concerns and that it should be monitored more closely than it is currently,” said Brian A. Primack, MD, PhD, assistant vice chancellor for health and society in Pitt’s Schools of the Health Sciences, and lead author of the study.

“For example, hookah smoking was not included in the 2015 Youth Risk Behavior Surveillance Survey System questionnaire, which assesses cigarette smoking, chewing tobacco, electronic cigarettes, and many other forms of substance abuse.”

Primack noted that it is complex to compare a single hookah smoking session to a single cigarette because smoking patterns differ. While a frequent smoker may smoke 20 cigarettes each day, a frequent hookah smoker may only have a few hookah sessions each day.

“It’s not a perfect comparison because people smoke cigarettes and hookahs in very different ways,” said Primack. “We had to conduct the analysis this way, comparing a single hookah session to a single cigarette, because that’s the way the underlying studies tend to report findings. So, the estimates we found cannot tell us exactly what is ‘worse.’”

Primack explained that the study’s findings suggest that hookah smokers are exposed to a lot more toxicants than they probably realize.