ASHES, Vol. 7(8) – Smoking tobacco with a hookah: Replacing the cigarette as high schoolers’ smoke of choice?


Cigarette use among high school students has been on a steady decline during recent years (SAMHSA, 2010). Media and regulatory campaigns have targeted and attempted to reduce cigarette smoking, but more exotic forms of tobacco smoking, such as hookah, have received relatively little attention (Smith, Novotny, Edland, Hofstetter, Lindsay & Al-Dalaimy, 2011). Because Hookah smoking can involve the use of many substances (e.g., opium, marijuana, or tobacco), we want to note that for the remainder of this article, ‘hookah use’ will refer to specifically and only to smoking tobacco. Previously, the BASIS published a history and introduction to hookah, as well as a study about hookah use among college students. Today’s ASHES explores hookah use and attitudes towards hookah smoking among high school students (Smith, et al., 2011).

Figure. A typical hookah. Click image to enlarge.


  • Researchers surveyed junior (11th grade) and senior (12th grade) students from three high schools in San Diego. Six hundred and eighty-nine students participated in the study, out 691 potential students (99.7%).
  • Students answered a questionnaire assessing hookah use and cigarette use, as well as perceived danger and social acceptability of hookah, chewing tobacco, cigar, and cigarette use.


  • Eighty-three percent of students had “heard of a tobacco-smoking device called a hookah or waterpipe”.  
  • More than a quarter (26.1%) of students reported ever smoking a hookah and 10.9% reported past-month hookah use.  
    • Thirty-eight percent reported ever smoking a cigarette and 11% reported past-month cigarette smoking.
    • Hookah users were significantly more likely than non-users to have tried cigarettes or be current cigarette smokers [1] (p < .001).
    • Almost sixty percent (59.5%) of students thought hookah use was more socially acceptable than cigarette, cigar, and chewing tobacco use. Nearly half (46.3%) thought hookah use was safer than any other tobacco product.


  • The study only uses self-report and cross-sectional (i.e., only includes data from one time point) data.
  • The study population is from a limited geographical area, which potentially limits the generalizability of the data to the general high school population.


These results show that many students know about hookah and a good percentage have tried hookah. Also, many students perceive hookah smoking as a safer, more socially acceptable alternative to cigarettes. Previous research has shown that hookah smoking is more harmful than cigarette smoking, given the greater amount of smoke inhaled (Jacob, Abu Raddaha, Dempsey, Havel, Peng, Yi & Benowitz, 2011) during comparatively longer smoking sessions (hookah sessions averaged 47.5 minutes in this study; Smith, et al., 2011). Furthermore, studies have shown that hookah use is predictive of future regular cigarette use among Danish youth (Jensen, Cortes, Engholm, Kremers & Gislum, 2010). For American high school students, hookah is a non-traditional nicotine delivery method, one that has not received much attention in the media or literature. Hookah use is harmful and predictive of future cigarette smoking, suggesting that closer parental, societal, and regulatory attention should be afforded to high school hookah use.

–Daniel Tao


Jacob, P. III, Abu Raddah, A.H., Dempsey, D., Havel, C., Peng, M., Yu, L., Benowitz, N.L. (2011). Nicotine, carbon monoxide and carcinogen exposure after a single use of a waterpipe. Cancer Epidemiology, Biomarkers & Prevention, online first.

Jensen, P.D., Cortes, R., Engholm, G., Kremers, S., Gislum, M. (2010). Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Substance Use and Misuse, 45, 1245-1261.

Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

Smith, J.R., Novotny, T.E., Edland, S.D., Hofstetter, C.R., Lindsay, S.P., Al-Delaimy, W.K. (2011). Determinants of hookah use among High School students. Nicotine & Tobacco Research, 13(7), 565-572.

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[1] No t statistics provided.

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