Hookah smoking, a practice that originated in the Middle East, now has roots all over the globe.

In the United States, using a water pipe to smoke tobacco has found growing popularity among urban youths, college students, and young professionals, according to the American Lung Association (ALA). Studies suggest that the trend is also attracting high-school students.

One of the biggest draws of hookah smoking is that it brings people together. They meet up in places, such as hookah bars or hookah cafes, so that they can smoke in groups. People pass the hookah around among them during a session.

A hookah, which is another name for a water pipe, was developed centuries ago, specifically in Persia and India. The name itself refers to the pipe, not the contents that users smoke. It is known as a shisha (also spelled as sheesha). Shisa can also refer to the flavored tobacco mix that is smoked. Hubble-bubble, narghile, and goza are other names for a hookah. These devices come in different sizes, shapes, and styles.

Hookah smoking is often perceived as less dangerous than smoking traditional cigarettes. This perception is especially common among young people who partake in the activity. Part of the reason the practice is thought to be safe is because of the flavored tobacco mixtures smoked, which also contain sugars and fruits.

Flavors, such as apple, mint, cherry, and watermelon, among many others, make hookah smoking appealing and something people want to try. As a result, many think they’ll get the benefits of smoking without dealing with the health effects, which include smoke that irritates the nose and lungs.

This is not true, but we’ll explain more about that later.

Does Hookah Smoking Lead to Marijuana Use?

There is concern among some in the medical community that hookah smoking can lead to the use of stronger substances, such as marijuana.

Healthline writes that a hookah isn’t designed for marijuana use or other kinds of drugs. However, comments on several internet forums indicate that there are people who use their hookah to smoke marijuana.  They add it to their shisha before they smoke it.

While it is challenging to find research that addresses the link between hookah use and marijuana use, some sources have studied whether there is a connection between the two.

A 2018 study, published in The Journal Pediatrics, reported that teens who use electronic cigarettes (e-cigarettes for short) and hookahs are more inclined to pick up marijuana use later. The research, conducted by the University of Pennsylvania and the University of Southern California, surveyed 2,600-plus students at 10 public high schools in Los Angeles.

At the time of the survey, the students were 14 years old and in the ninth grade when they were asked if they had ever used hookahs or e-cigarettes. A follow-up survey with the students in 2015, when they were 16-year-old 11th-graders, found that those who tried e-cigarettes when they were 14 were three times more likely to have tried marijuana than those who did not try e-cigarettes.

CNN’s report on the study highlighted that researchers who conducted the study “controlled for factors that could be associated with an increased risk of marijuana use, including family history of both tobacco and marijuana use, peer use, depression, and impulsivity.”

A hookah pipe with hot coalsDr. Ana Navas-Acien, a Columbia University professor who was not involved with the study, told CNN that care must be taken when interpreting relationships between these factors.

“But it seems that the use of these tobacco products, including combustible cigarettes and e-cigarettes, seems to precede the use of marijuana somehow,” she said.

Navas-Acien, who studies e-cigarette and hookah use, also told the cable news network that there might be a strong link between hookah and marijuana use because hookahs allow users to mix more than one combustible product that could be used with marijuana itself.

In another study published in 2013, researchers attempted to examine the relationship between hookah smoking and cigarette smoking and marijuana use. They studied hookah, cigarette, and marijuana use among women who were in their first year of college. They concluded that hookah use among college women is common. They also wrote that their findings were mixed in supporting the idea that hookah tobacco use leads youths to start abusing other substances.

They wrote, “ In this sample of college women, pre-college hookah smoking increased risk for initiating or resuming cigarette smoking, but not for initiating marijuana use, during the first year of college. In addition, pre-college marijuana use increased risk for initiating hookah tobacco use.”

The researchers also said their findings show a need to educate young people about how hookah use can lead to cigarette smoking.

Why Hookah Smoking is Dangerous

Despite limited data that tracks hookah smoking as well as its possible link to marijuana use, a troubling trend is emerging, according to the ALA. The health risks that come with smoking are emphasized across sources in the medical community.

The smoke produced from hookah use is one of several reasons why the ALA and the Centers for Disease Control and Prevention (CDC) both report that the practice comes with the same health risks as cigarette smoking.

The CDC highlights research findings in its report that:

Smoking from a water pipe delivers the same nicotine found in tobacco products. Hookah smoke can be highly toxic, even to those who are not smoking directly from the device. The tobacco that is exposed to high heat from the burning charcoal makes it just poisonous as cigarette smoke is, the CDC writes. And, inhaling it secondhand is also harmful.

Medical News Today highlights that carbon monoxide is among the harmful components found in tobacco smoke. “The water in the hookah does not filter out these components,” it notes.

Hookah users also are at risk of absorbing more toxic smoke than cigarette smokers do. “An hourlong hookah smoking session involves 200 puffs, while smoking an average cigarette involves 20 puffs,” the CDC writes.

Other potential health risks of hookah smoking, according to Medical News Today,  include:

  • Lung complications (e.g., chronic obstructive pulmonary disease (COPD) and bronchitis)
  • Heart disease and heart attack
  • Cancer of the lungs, throat, and mouth
  • Aging of the skin
  • Higher risks of infectious diseases
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