Wayne State University School of Medicine researchers have published the findings of a pilot study that shows hookah smoking is on the rise among white Americans of non-Arab descent. The team believes the hookah trend could hold dangerous health implications, including serving as a gateway to cigarette smoking and other drug use.

While the hookah - a water pipe used to burn and ingest flavored and scented tobacco - conjures up images of middle-aged and older men of Arabic descent sharing a smoke in dark cafes, Bengt Arnetz, M.D., Ph.D., M.P.H., and Hikmet Jamil, M.D., Ph.D., professors in the Department of Family Medicine and Public Health Sciences, believe the practice is insidiously working its way into a health hazard for Americans.

"I am very concerned [that the trend appears to be rising with younger age groups]," said Dr. Arnetz, who also is director of the Division of Occupational and Environmental Medicine. "Hookah use is now spreading rapidly in the U.S. as well as across the globe among those of non-Arab descendent. The moassel [tobacco and various added flavors] makes the smoking very smooth and appealing, which makes it possible to smoke for longer times. The hookah smoke smells sweet and attractive. Thus, a combination of low cost, social gatherings, peer pressure and perception of less risk makes hookah smoking very attractive."

A number of hookah cafes have been operating in metropolitan Detroit. The state's May 1 ban on smoking in public places may extinguish smoking in some of those establishments, but a provision in the law could allow them to continue. And a quick scan of the Internet finds a number of sites offering hookahs and related flavored tobaccos readily for sale to home users.

For their study, "Sociodemographic risk indicators of hookah smoking among White Americans: A pilot study," published in the March 2010 online edition of the Nicotine & Tobacco Research journal, the doctors surveyed 240 adults of non-Arab descent in Southeast Michigan. They found that 19 percent of those surveyed were involved in hookah smoking. Ten percent said they smoked only using a hookah, and 9 percent smoked both cigarettes and a hookah.

Surprisingly, 19 percent of the respondents said they believed smoking via a hookah was less harmful than smoking cigarettes. Hookah smoking, Dr. Arnetz said, is likely more dangerous than cigarette smoking. Hookah smokers are exposed to and inhale greater amounts of carbon dioxide, nicotine and other carcinogens during a session with the water pipe.

Dr. Arnetz said researchers do not yet know whether the health risks for second-hand smoke from hookahs are similar to secondhand smoke from cigarettes. The exposure dose and time that nonsmokers spend when visiting hookah bars will determine long-term risks. However, hookah smoking has been shown to increase the risk for lung cancer, respiratory illness, low birth weight and periodontal disease, he said. And there are investigations into whether the practice increases the risks for communicable diseases such as tuberculosis and hepatitis C.

Those most likely to use a hookah, according to the survey results, were 22 and younger and lived with a family member who used tobacco. The study found no difference in the prevalence of hookah use between men and women. Hookah use was more prevalent among students and those who exercised regularly, lending credence to the hypothesis that smokers mistakenly believe the hookah offers fewer health hazards than cigarettes.

"We believe in general the hookah venue attracts both genders," Dr. Arnetz said. "You do it in groups, and there is a perception of less danger but also more social peer pressure to use it."

Dr. Arnetz and Dr. Jamil have submitted a grant request to the National Institutes of Health seeking $450,000 a year for five years to expand their pilot study. They propose following a random sample of adolescent students from ninth grade through high school. This would be the first random sample study of hookah use among students in general.

"We want to study the prevalence of hookah use among different groups of students, especially youth from underserved families; how hookah use might change during the high school career and what factors determine the uptake of hookah, including peer pressure," Dr. Arnetz said. "Finally, we want to study whether hookah acts as a gateway drug for cigarettes, marijuana and heavier drugs, and poor lifestyle choices in general."

Wayne State University is a premier urban research university offering more than 350 academic programs through 13 schools and colleges to nearly 32,000 students.