Hookah smoking has become more popular in the U.S. among young people and college students, because of the belief that it is somehow safer than smoking cigarettes.

But another study has emerged warning of the potentially harmful effects of smoking hookah, which has commonly been considered less dangerous than tobacco smoke. Though hookah is a water pipe, it still has nearly as many toxins as cigarette smoke and nicotine, the addictive drug in cigarettes.

Smoking tobacco through water doesn’t necessarily filter out any of these toxins that can damage the lungs and heart. “The cooled and sweetened flavor of hookah tobacco makes it more enticing to kids and they falsely believe it’s less harmful,” Tracey E. Barnett of the University of Florida in Gainesville told Reuters. “One-time use can lead to carbon monoxide poisoning or other diseases, including but not limited to tuberculosis, herpes, respiratory illnesses including the flu, and long-term use can lead to heart disease and many cancers.”

Smoking hookah, or “shisha,” dates back to the 15th century, where it was common among Hindus in India. The practice spread throughout the Ottoman Empire, and has recently become far more popular in Europe and the West.

In a study completed in 2012, the Centers for Disease Control and Prevention (CDC) discovered that many hookah smokers believe it’s less risky than cigarette smoking. “However, hookah smoke contains many of the same harmful toxins as cigarette smoke,” the CDC writes on its website, “and has been associated with lung cancer, respiratory illness, low birth weight, and periodontal disease.” The World Health Organization (WHO), meanwhile, states that hookah smoking sessions last much longer than a typical cigarette break. They can last from 20 to 80 minutes, with the smoker inhaling the same amount of smoke that would be produced by 100 cigarettes. A typical one-hour long hookah session involves about 200 puffs, compared to an average of 20 puffs per cigarette.

There’s also the nicotine aspect. Smoking enough hookah could easily trigger addiction, ultimately leading more easily into other tobacco products like cigarettes.

Despite the increasing number of studies pointing to hookah’s risks, people continue to be unaware and assume it’s safer than cigarettes. “In casual conversations with friends and patients, folks often appreciate that smoking anything comes with risks,” Adrienne J. Heinz, who researches alcohol and drug use patterns at the Stanford University School of Medicine, told Reuters. “However, hookah is certainly viewed as more benign, and when you share general facts about toxin exposure in one hookah session, it often shocks and surprises them.” Heinz also points out that there hasn’t been a strong public health campaign to raise awareness about the dangers of hookah smoke, the way there is for cigarettes. “There is also the misconception that because hookah sessions tend to be less frequent than smoking a cigarette, and because hookah is smoked through a water chamber, that the practice is safer,” Heinz told Reuters.

Source: Blachman-Braun R, Lira Del Mazo-Rodriguez R, López-Sámano G, Buendía-Roldán I. “Hookah, is it really harmless?” Respiratory Medicine, 2014.