The Under-Recognized Burgeoning Cardiovascular Risks of Water Pipe or Hookah Smoking

Tobacco use in its various forms remain one of the leading causes of morbidity and mortality worldwide with the World Health Organization (WHO) estimating that tobacco use accounts for ~ 9% of deaths globally¹. In 2015, smoking caused more than one in ten deaths worldwide, killing more than 6 million people with a global loss of a staggering 150 million disability-adjusted life-years². Tobacco use is a particularly important and modifiable cardiovascular risk factor associated with premature atherosclerosis and the need for coronary revascularization in young adult patients’ ≤40 year’s old, thus affecting people in their prime³. It is disconcerting that while cigarette smoking declined among middle and high school students in recent years, use of electronic cigarettes and water pipe (hookahs) increased among middle school students between 2011 and 2017, with data that current Water pipe use was more than twice as common as cigarette smoking⁴. Furthermore, in a recent survey a significant proportion of students reported current use of two or more tobacco products in the past 30 days suggesting that use of Water pipe may also lead to cigarette smoking4. In fact, if tobacco abuse continues at the current rate among youth in this country, 5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness⁵. That’s about 1 of every 13 Americans aged 17 years or younger alive today⁵.

While the reasons for increase in water pipe (Hookah) use are not completely understood there are several factors in play. One of the factors is that hookah smoking is a social behavior and most commonly occurs at the respondent’s own house, a friend’s house, or at another relative’s house⁶. Compared to other forms of tobacco, social pressure may be greater because the behavior is immediately observable in a social group setting and abstaining from hookah smoking may require a higher degree of refusal skills⁷. Another major factor leading to increase in water pipe smoking is misperceptions about harms that hookah smoking is a harmless hobby rather than a dangerous addiction. Actual data suggest otherwise. First, water pipe smoking delivers nicotine, the same highly addictive drug found in other tobacco products. Secondly, the amount of smoke inhaled during a typical hookah session is about 90,000 milliliters (ml), which is several-fold higher compared with 500–600 ml inhaled when smoking a cigarette⁸. Finally, the constituents of hookah smoke contains similar chemicals compared to cigarette smoke, many of which are known to be harmful to cardiovascular health and mediated by similar pathophysiologic processes⁹. One prospective study reported that a single hookah smoking session causes an acute increase in arterial stiffness of comparable magnitude to what has been previously reported for cigarettes¹⁰. Another study quantified the mainstream smoke of a single cigarette and/or single water pipe session for smoke volume, nicotine, tar, and carbon monoxide and reported that compared with a single cigarette, one hookah session delivers approximately 125 times the smoke, 25 times the tar, 2.5 times the nicotine and 10 times the carbon monoxide¹¹. A meta-analysis of 15 studies reported that water pipe (Hookah) exposure is associated with statistically significant and potentially clinically relevant short term increases in hemodynamic parameters of cardiopulmonary function, including increases in systolic and diastolic blood pressure, mean arterial blood pressure, heart rate, and the amount of expired carbon monoxide similar to the acute effects seen with smoking cigarettes¹². Thus, there is overwhelming evidence of the detrimental effects of water pipe smoking and that it is definitely no safer or less addictive than cigarette smoking.

A recent Scientific Statement from the American Heart Association authored by Bhatnagar et al¹³ eloquently highlight the perils of the increasing use of water pipe (Hookah) smoking and the attendant adverse cardiovascular effects. The authors make some practical suggestions to mitigate this escalating phenomenon, including healthcare providers asking about water pipe use and frequency explicitly, using a variety of terms if necessary, as well as use of other tobacco products, as part of every routine clinical encounter. They also suggest that healthcare providers advise current users to quit water pipe and other tobacco product usage at each visit, and assist water pipe smokers to quit by providing cessation counseling, including setting a quit date and providing social support and coping assistance. It is also important to refer water pipe smokers to credible evidence-based sources such as the Centers for Disease Control and Prevention (CDC), WHO and the recent AHA Scientific Statement¹³, for information regarding potential addictiveness and adverse health consequences of water pipe use. These helpful suggestions will go a long way in mitigating and reducing this escalating hazard.

Mass media and programs that educate youth and their parents, caregivers, and health providers on the risks of water pipe (hookah) smoking and encourage the adoption of smoke-free home would further help disrupt hookah use among our youth. There is also a need to test both behavioral and pharmacological methods to promote water pipe (Hookah) cessation in adequately powered, randomized, controlled trials using standardized outcome criteria, including adequate follow-up durations, and biochemical verification of abstinence. Such studies would help policy makers develop appropriate strategies to reduce water pipe smoking and help reduce cardiovascular risk associated with its use.