Hookah use could make it easier for young people who have never smoked to start smoking

A meta-analysis highlights the influence of shisha on the susceptibility of adolescents and young adults who have never smoked to becoming smokers, and suggests some ways to address this.

The explanation of the factors contributing to the establishment of smoking remains a broad field of study. Among these factors, the gateway effect between different tobacco and nicotine products is notably studied, but little data is available on the uses of shisha (water pipe or hookah). Based on the results of six studies, a meta-analysis by a team of Chinese researchers explored the relationships between hookah and cigarette use among adolescents and young adults who had never smoked.[1].

Hookah experimenters are twice as likely to become smokers

This meta-analysis was based on a total of 59,710 participants, 3,559 of whom had at least experienced hookah smoking. Of the six studies considered, two were conducted in Arab countries, three in the United States, and one in China. Four of these studies involved adolescents, while two focused on young adults, with participants' ages ultimately ranging from 13 to 29 years. All six studies included prospective questions exploring the susceptibility of becoming a smoker.

The results indicate that the susceptibility of becoming a smoker would be twice as high among non-smokers who had tried hookah than among those who had never tried it. The authors here hypothesize that exposure and dependence on nicotine, resulting from the first hookah experiments, would facilitate the transition to conventional cigarettes. Nicotine concentrations, most important in hookah smoke than in that of conventional cigarettes, and the higher reactivity to nicotine of young brains could further reinforce the mechanisms of addiction. Exposure to passive smoking, known to be a factor in the initiation and dependence on nicotine, is also, more substantial with shisha and could explain this greater tendency to become a smoker.

Cultural and social factors may also come into play.

While this susceptibility to becoming a smoker is higher among regular shisha users and in studies on Arab countries, the authors nevertheless admit that other factors, particularly related to the mode of use and the cultural context, could also be involved. Although it seems obvious, this last avenue is often neglected in scientific work, while social influence and identification with peers are also well-known factors in smoking initiation.[2].

The major limitation of this meta-analysis is that it focuses on the susceptibility of becoming a cigarette smoker and not on actual smokers, although there are strong correlations between these two situations. The authors call for further studies among people who have never smoked to corroborate these results and suggest better integrating shisha into public health policies.

Keywords: hookah, youth, gateway effect

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