Our study suggests there is a widespread perception among hookah users that it is less harmful than cigarette smoking and it is independent of gender, ethnicity, age or smoking status of users. Our population-based study of hookah-bar patrons in San Diego included all hookah bars in the downtown area and surveyed patrons from different ethnic groups and both genders. Hookah users were mostly young men and women below the age of 25 years.
The percentage of smokers in our study population of hookah users was 28.4%, which is higher than the 13-16% smoking prevalence in the general California population for those aged 18-44 years [34
]. However, smoking prevalence among hookah users in our study was very comparable to that in the general California population as represented by the California Tobacco Survey; which is a State-wide survey of a representative population from California that found that 30.6% of hookah users were current smokers in 2008, which is the same year the current study was conducted. Therefore, our study sample of hookah users resembles the larger California population in terms of smoking prevalence.
It therefore appears that hookah smokers are more likely to be cigarettes smokers. This was also found in other studies from US cities, although the cigarette smoking rates for hookah users varied widely, from 63% in Richmond, VA [33
] to 58% in Pittsburg, PA [20
] and 35% in Memphis, TN [33
]. This may reflect the difference in sampling from web-based and volunteer study subjects to random university sample compared to hookah café users in our study. This could also be explained by the difference in the population of hookah users between regions in the US. This difference is important to document and understand for the purpose of determining future hookah control programs and initiatives.
A study from the United Kingdom found cigarette smoking was the most important predictor among those who ever tried hookahs to become regular hookah users [21
]. In our study, smoking cigarettes did not significantly influence the belief that hookah is less harmful than cigarettes; a majority of hookah users believed it was less harmful than cigarette smoking. Recent smaller studies from different US populations confirm this misperception [17
]. A qualitative analyses of attitudes among 12 hookah users in the UK and Canada also support the perception among users that hookah use is less harmful than cigarettes [35
Perception that the hookah smoke is filtered in the water seems to be one the main beliefs justifying the less harmful influence of hookahs [22
]. However, it is well known that passing air bubbles through water does not change their contents, and since the volatile carcinogens for tobacco smoke and other particles will stay within the air bubble during its passage through the water, the water will not filter the smoke in the bubbles. Some hookah users report hookah smoke being less irritating than cigarette smoking, noting it has a 'smooth texture' that allows them to smoke it for hours [35
]. More importantly, the negative social norm against cigarette smoking is not applied to hookah because of its more recent trend and use. This may be contributing to the wide and dramatic spread of this type of tobacco use.
It is a public health concern that non-cigarette smokers believe that hookahs are less harmful than cigarette use because those who did not smoke until becoming adults passed the period of adolescence and early adulthood when they are most vulnerable to cigarette smoking. This group may be reintroduced to the habit of cigarette smoking through hookah use or continue to be regular hookah users and get exposed to the harms of tobacco use. In conducting this study, there were several friends of hookah users who were sitting at the same table in the hookah café but reported never smoking a hookah. Given that previous studies show most of the hookah users started with friends in café restaurants [17
] and since this has mostly become a group socializing activity, we believe those nonsmokers will eventually try a hookah and become users along with their friends.
Higher frequency of hookah use was positively related to the belief that it is less harmful than cigarettes; 70% of every-day hookah users believe it is less harmful than cigarettes while only 50% of those who use it every six months believe it is less harmful than cigarettes. This did not reach statistical significance. This suggests that there is a risk that irregular users will gradually become regular more frequent users based on their belief this will not be as harmful to their health.
Our ethnic distribution of Latinos, Asians and African Americans were demographically comparable to that for California, but there were less Whites and a much higher Middle Eastern ethnic group in our study sample. Middle Eastern ethnicity is usually categorized as White in the general census. The much higher use by the Middle Eastern ethnic group was also found in a study in the UK, where they were twice as likely to use hookah than other ethnic groups [21
Another observation we noted during data collection was a tendency for similar ethnicities to frequent the same hookah bars. This is part of the appeal of hookah use, as a social group activity for people with similar backgrounds. In addition, the exotic relaxed atmosphere, the nice sweetened scents from the flavored hookah tobacco smoke, and the relatively cheap costs of smoking a hookah contribute to its use among mostly young adults [26
]. Asians in our sample were significantly more likely to believe a hookah is more harmful than cigarettes. However, this was not significant in the multivariate analyses and may be due to the small number of subjects in this group. Further exploration of this finding is needed from future studies. Other comparable studies in the US mostly included White ethnic groups.
There was no influence of gender on the perceptions and use of hookah from our study. The hookah originated in Asia and its use for many decades in recent history was dominated by males. However, re-birth of this habit in modern age among young adults in the Middle East is spreading among females [11
] due to social acceptability even in traditionally conservative societies like Saudi Arabia. Previous studies in the US show a large variation in participation of hookah users according to gender [17
Mint flavor is the highest single hookah tobacco flavor preferred by users in our study. This flavor has also been popular in the US by smokeless tobacco and cigarette users Outside the US, it is not known which flavors predominate. The numerous varieties of flavors and the fact the most users used or preferred all flavors suggest a risk for continued use and exploration by users of the different flavors of tobacco.
Our study is one of the larger studies in the United States that addresses characteristics of hookah users by targeting them in the general population as café patrons. Previous studies recruited volunteers who were provided incentives for volunteering. Although our study is not a random representative sample of hookah users, the fact that all major hookah cafes were included gives some confidence about the representativeness of such users. Some San Diego cafes that do not have a web address or are not listed on the Internet might have been missed, but this is unlikely, since the majority of businesses are on the Internet and list web sites for the hookah bars. We are not able to comment on users who exclusively smoke at home; those users may be underage teens. The short questionnaire prevented in-depth exploration of attitudes and behaviors about hookah use. However, this was not a qualitative analyses and the aim was to assess the characteristics and perceptions of hookah café patrons.
In conclusion, we found a concerning trend of emerging use of hookah and the belief that it is less harmful than cigarette use. Most of the hookah users were non-cigarette smokers. Both current smokers and nonsmokers had comparable views and therefore there is a risk that this will become a new tobacco use trend for never smokers. The exotic, social, and group nature of this habit is appealing to young adults, regardless of gender or ethnicity. Middle Eastern ethnicity seems to be the most vulnerable group for hookah use. Culturally-targeted public health campaigns to educate and disseminate to the younger population about the harmful effects of hookah are urgently needed. Health policy initiatives should be formulated to prevent marketing and licensing of hookah tobacco products and paraphernalia in local markets and shops. Further studies on the spread of hookah use among underage teens who are unlikely to frequent the hookah bars are needed. We also believe future studies should directly quantify the harmfulness of hookah smoking by determining pulmonary and other vital functions among users.