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Through a cloud of smoke: Navigating a new trend in tobacco usage in hookahs

Dec. 24, 2015
While there are other names, I will use the term "hookahs" because it seems to be the most recognized in the United States. Most commonly a glass-based, single- or multi-stemmed apparatus for smoking a variety of fruity- and sweet-flavored tobaccos, hookahs have a water base to cool the tobacco smoke.

By Wendi K. Sparks, RDH, BS

As a dental hygienist for 20 years and as a clinical instructor in a local community college's dental hygiene program, I regard myself as an oral health and prevention advocate. While researching ways to incorporate a tobacco cessation protocol into my private practice, I uncovered surprising information about the newest threats and trends in tobacco products.

As I questioned my dental hygiene peers about their knowledge of these new fads, many (as I was) were completely unaware of the tobacco products on the market and available on the Internet that are not approved by the Food and Drug Administration (FDA). Times are changing fast, and the tobacco industry is aggressive in its approach to entice young people to get hooked on its products. They are cleverly disguising tobacco in different packaging and flavoring delivery systems, including electronic and vapor devices.

"Hookah" is one of the many names around the world to describe a tobacco pipe that uses water as a filter. While there are other names, I will use the term "hookah" because it seems to be the most recognized in the United States. Most commonly a glass-based, single- or multi-stemmed apparatus for smoking a variety of fruity- and sweet-flavored tobaccos, a hookah has a water base to cool the tobacco smoke. A hookah also has a small clay bowl in which the tobacco is heated by burning charcoal. When the smoker inhales through the hose, the smoke passes from the heated tobacco into the water. It makes a bubbly sound, and goes through the hose into the smoker's mouth and lungs.

Like electronic vapor devices, hookahs are not FDA-regulated. There are also many myths surrounding hookah use; therefore, more adolescents are experimenting with these new products that offer zero odor, pleasant flavorings, and a social outlet. This trend has been around for centuries and has emerged into Europe and the United States. Today, hookah lounges and personal hookah apparatuses are gaining popularity among U.S. teenagers and college students.

Hookahs and teens

As hygienists, we often educate elementary-aged children during National Children's Dental Health Month. We usually arrive armed with an animated cartoon movie, some brushing and flossing demonstrations, discuss healthy nutrition habits, and incorporate fun activities. However, I set out to conquer a different territory: the adolescent teen and hookah smoking. I wanted to investigate whether they believed the myths about smoking from hookahs.

I gained permission to present a short educational session about hookah usage to a high school in my community. The purpose was to evaluate whether discussing these myths and facts about hookah usage would change their positions on smoking from hookahs in the future. On the day of my presentation, I was surprised to learn that 50% of the students responded that they had previously smoked tobacco through hookahs. Here's what else I learned:

• More than half of the students stated that they believed that smoking tobacco through a hookah was safer than smoking cigarettes.

• More than half of the students stated that they believed smoking tobacco through a hookah was not as addictive as smoking cigarettes.

• Only 43% of the students believed that smoking tobacco through a hookah could contribute to the spread of diseases.

• Fortunately, 85% of the students assumed that whether they smoked cigarettes or hookahs, it could affect their teeth and gums.

Before the presentation, I was unsure about whether I would make an impact on the teenagers. But the results of this short presentation were impressive. After my presentation and discussion, 90% of the students responded that they were more knowledgeable about the risks of smoking hookahs and, more importantly, that they would be more confident in saying "no" to hookah usage in the future.

Oral health promoters

Dental professionals can and should take the lead in educating our youth and encouraging tobacco abstinence in school settings and/or from the dental chair.

When asking patients about tobacco usage, we also need to include hookahs and other forms of tobacco products. I am convinced that we, as hygienists, are essential to education about tobacco abstinence. The World Health Organization has stated that the "education of health professionals, regulators, and the public at large is urgently needed about the risks of [hookah] smoking, including high potential levels of secondhand exposure among children, pregnant women, and others."1

I encourage my dental hygiene peers to seek education regarding various tobacco products and devices, including hookahs. It is also important to support our local components in state and city governments as they try to win the war on tobacco. Promotion of ongoing studies and further research is necessary to understand the full implications of hookah smoking.

My hope is that you may also be inspired to look beyond the scope of the clinical dental hygienist and be empowered to impact the health and wellness of future generations. As Mahatma Gandhi said, "Be the change you wish to see in the world." RDH

Myths and facts about hookahs

Through my research leading up to the presentation to adolescent teens, I began to understand how the myths and misconceptions surrounding hookah usage could entice our vulnerable youth to become addicted to yet another nicotine source.

The myths

1. Smoking tobacco through a hookah is safer than smoking cigarettes because impurities and nicotine are filtered through water.

2. Smoking tobacco through a hookah is less addictive than smoking cigarettes.

3. Smoking tobacco through a hookah does not impose a public or personal health threat.

4. Smoking tobacco through a hookah does not impact the oral cavity in a negative way.

The facts

1. The water in the pipe cools the smoke, but it does not filter any chemicals or nicotine from the smoke. Actually, because the water cools the smoke, the hookah smoker will inhale more deeply than a cigarette smoker, causing chemicals and elements (nicotine, tar, and carbon monoxide) to penetrate deeper into the lungs. The hookah smoker may therefore inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 or more cigarettes.1

2. Hookah smoking, even on occasion, can lead to addiction. The FDA does not yet control labeling of herbal tobacco, which is purchased for usage in hookahs and which may mislead young consumers. The nicotine content of hookah tobacco has been reported to be 2% to 4%, in comparison with 1% to 3% for cigarettes.2

3. Hookahs are often shared in groups, which may sometimes involve the sharing of one mouthpiece. There is no guarantee that the hoses on hookahs in hookah lounges are cleaned or disinfected; therefore, the potential for spreading diseases such as tuberculosis, colds, herpes, oral bacterial infections, hepatitis, and respiratory infections exists.2

4. In a cross-sectional study published in the Journal of Periodontology, among 262 participants aged 17-60 years in Saudi Arabia, periodontal disease measured in terms of probing depth was found associated with both water pipe and cigarette smoking. The prevalence of periodontal disease defined as a minimum of 10 sites with a probing depth of 5 mm was 19.5% in the total population, 30% in water pipe smokers, 24% in cigarette smokers, and 8% in nonsmokers. The relative risk for periodontal disease was 5.1 and 3.8-fold higher in water pipe and cigarette smokers respectively, compared to nonsmokers (P < 0.001 and P < 0.05 respectively).3,4

Wendi K. Sparks, RDH, BS, is an adjunct clinical and radiography lab instructor at Oakland Community College. She has taught radiography, clinical instrumentation, and patient care on all clinical levels since 2012. Her career in dental and dental hygiene has spanned more than 35 years. She has extensively studied and researched hookah tobacco. She has also collaborated with and is an active member of the Detroit-Wayne County Tobacco-Free Coalition, which promotes awareness of tobacco-use prevention, cessation, and regulation. Outside of her professional career, she enjoys spending time with her family and being a new grandma. Wendi can be reached at [email protected].


1. Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. World Health Organization. http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf?ua=1. Accessed July 14, 2015.
2. Knishkowy B. Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics. 2005;116(1):113-119.
3. Natto S, Baljoon M, Bergström J. Tobacco Smoking and Periodontal Health in a Saudi Arabian Population. J Perio. 2005;76(11):1919-1926.
4. Ray C. The hookah - the Indian waterpipe. Current Science. 2009;96(10):1319-1323. http://www.indiaenvironmentportal.org.in/files/The%20hookah.pdf.