With a barrage of anti-cigarette commercials, warnings on cigarette packs, and scientific data highlighting the dangers of cigarette smoking, the tobacco industry has taken a hard hit in recent years. Adults have begun to pivot toward what they believe is a “safe alternative” to cigarettes: water pipe smoking, commonly known as hookah — an industry that has profited from the downfall of cigarettes. However, a recent study published in the journal Cancer Epidemiology, Biomarkers & Prevention, found smoking hookah can lead to significantly higher levels of nicotine and carcinogens in the body equivalent to at least one cigarette.

“I have seen entire families, including young children, smoking water pipes. I have even been offered a smoke by my friend who thought water pipe smoking was 'totally safe,'" said Gideon St. Helen, lead author of the study and postdoctoral fellow in the Division of Clinical Pharmacology and the Center for Tobacco Control Research and Education at the University of California, San Francisco, in the press release. This is of particular concern since studies have found several regions, including the U.S., Europe, and the eastern Mediterranean, have seen a significant increase in hookah smoking, especially among youth. St. Helen and his colleagues, aware of the potential addictiveness of hookah and its possible effects on the developing brains of children and older youth, sought to challenge the perception of hookah smoking as “safe.”

The study, funded by the National Institutes of Health and the California Tobacco-related Disease Research Program, aimed to breakdown how much nicotine and carcinogens are present in the body after one hookah smoking session. A total of 55 healthy, experienced hookah smokers between the ages of 18 and 48 were recruited for the study. The participants were instructed to refrain from any type of smoking for a week.

The small cohort had to provide a urine sample before smoking water pipes at a hookah bar of their choice in the San Francisco Bay area. They also gave the researchers a urine sample immediately after smoking hookah, and another one the morning after. The smokers then received questionnaires asking details on the total time spent smoking, the number of bowls smoked, and the number of shared users. On average, the participants spent 74 minutes smoking water pipes and smoked an average of 0.6 bowls of water pipe tobacco per person.

The findings revealed there were elevated levels of nicotine, cotinine, and NNA — a breakdown product of a tobacco-specific nitrosamine, NNK — linked to causing lung and pancreatic cancers. In comparison to the urine samples collected after a week of not smoking, these urine samples had 73 times higher nicotine levels, four times higher levels of cotinine, two times higher levels of NNAL, and four percent to 91 percent higher levels of breakdown products of volatile organic compounds (VOC) — such as benzene and acrolein — known to cause cancer, heart, and lung diseases.

The significant increase in nicotine levels raises concerns about the potential of becoming addicted to smoking hookah and the health effects this may bring. The number of bowls smoked per person was significantly linked to the increase in post-exposure and next-day urine cotinine levels, respectively. Nicotine levels after smoking were comparable to the levels obtained by at least one cigarette, explained St. Helen.

The researchers hope their findings can help steer policies regarding public health. "One public health concern is the use of water pipes among adolescents and young adults and whether it leads to nicotine dependence. This is an area that warrants further research, as the answer is not clear. However, our study showed substantial intake of nicotine in users of water pipes in the hookah bar setting,” St. Helen told Medical News Today. Moreover, the researchers suggest the average increase in nicotine levels measured in these hookah users were high enough to cause physiological changes in the brain that can tolerate nicotine addiction, based on previous studies.

St. Helen’s study did not assess cancer risk from water pipe smoking, but they believe depending on the frequency of use and lifetime smoking duration, it may increase smokers’ cancer risk. The presence of cancer-causing substances like benzene and acrolein in hookah smoking and its effect on the consumers' body does warrant further research but remains a cause for concern, especially in youth.

While many hookah smokers may consider this practice less harmful than smoking cigarettes, the Centers for Disease Control and Prevention (CDC) says it carries many of the same health risks as cigarettes.

Source: American Association for Cancer Research (AACR). Water pipe smoking causes significant exposure to nicotine, cancer-causing agents. Cancer Epidemiology, Biomarkers & Prevention. 2014.