There’s no questioning the stigma cigarette smoking has developed over the past couple of decades. The health risks associated with smoking has led to large  declines in the amount of smokers in the U.S. since the 1970s, dropping from around 40 percent to about 18 percent of adults. But as always, as one popular vice fades away, another one gains steam — or in this case, smoke. Now, a new study from New York University has determined how popular hookah smoking has become among high school seniors.

Traditionally from the Middle East, hookah involves smoking flavored tobacco from a large water pipe. It’s become increasingly popular in North America and other parts of the world, in part, because it’s believed to be less harmful to the body — the tobacco is considered to be milder. However, that’s not entirely the case because hookah smokers tend to take more puffs in one session, resulting in similar, if not worse effects than smoking.

The NYU researchers’ study involved data from the Monitoring the Future nationwide study, which follows teens’ behaviors, values, and attitudes. Of the almost 15,000 kids aged 18 involved in the study, 5,540 were questioned about their hookah use between 2010 and 2012. They discovered that 18 percent, or almost one in five high school seniors, had smoked hookah within the 12 months prior to being surveyed.

Interestingly, they also found that “students of higher socioeconomic status appear to be more  likely to use hookah,” said Dr. Joseph Palamar, assistant professor of population health at NYU Langone Medical Center, in a press release. “Surprisingly, students with more educated parents or higher personal income are at high risk for use. We also found that hookah use is more common in cities, especially big cities. So hookah use is much different from cigarette use, which is more common in non-urban areas.”

In NYC, hookahs have become very  popular, appearing in clubs, increasingly numerous hookah bars, and pretty much wherever someone with a hookah pipe wants to bring it, from the beach to their stoop. Among the general population, hookah use has increased by as much as 123 percent, co-author of the study Dr. Michael Weitzman said. But although they come with similar health risks — respiratory illness, herpes, heart disease, and some cancers — consistent use isn’t such an issue. “Use tends to be much different from traditional cigarette smoking,” Palamar said in the release. “Right now it appears that a lot of hookah use is more ritualistic, used occasionally — for example, in hookah bars, and not everyone inhales.”

The researchers dampened that glimmer of hope, however, warning that people who begin using hookah may eventually turn to vape pens or e-cigarettes, which also sport a wide range of flavors while remaining mysterious in terms of health effects. But increased scrutiny directed toward the e-cigarette industry may deter these possible transitionaries. Educating the public, and especially the youth, about how smoking hookah isn’t completely harmless may be the experts’ best bet.

Source: Palamar J, Weitzman M, Zhou S, Sherman S. Hookah Use Among U.S. High School Seniors. Pediatrics. 2014.