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Research Article Research Article

What’s the harm in hookah? How risk misperceptions relate to rising use

Many people think hookah is safer than cigarettes, when in fact, a typical one-hour hookah session can be equivalent to smoking 100 cigarettes. With hookah use rising in the U.S.—use among high school and middle school students rose by more than 50 percent from 2011 to 2015—is the perception that hookah is less harmful than cigarettes driving the increase?

Truth Initiative® researchers surveyed more than 7,500 young people, ages 15 to 21 years old, over two years to examine the role hookah harm perceptions and other factors have in increasing hookah use over time. Participants answered questions about hookah use, perception of harm, age, sex, region, family financial situation, parental education, race and smoking status.


32.03% of youth and young adults believe hookah is less harmful than cigarettes

The results, published in the American Journal of Health Behavior, found nearly one-third of youth and young adults believe hookah is less harmful than cigarettes. Yet, research shows “hookah tobacco smokers are exposed to toxicants that are at least comparable to cigarettes, including both carbon monoxide and tar,” said Elizabeth Hair, vice president of Evaluation Science and Research at Truth Initiative.

Researchers also found that perceiving hookah as less harmful than cigarettes increased the likelihood of both current and future hookah use. Other factors linked with hookah use? People who are current smokers, female, African-American or Hispanic and have parents who went to college are more likely to use hookah. The connection between parents’ educational attainment and hookah use could mean that those who are more likely to go to college could have more “exposure to the popularity of this campus-centric activity.”

Public health educators can help raise awareness about the harms of hookah. “Peer-reviewed intervention research shows that brief education messages about hookah can increase young adult harm perception and increase desire to quit,” Hair said.

Hookah use is higher for young adults than youth, and researchers raised a question about whether hookah is used to substitute cigarettes in otherwise smoke-free environments. This would undermine smoke- and tobacco-free policies in college and university settings. Currently, 1,827 college and university campuses have adopted smoke-free policies, while only 701 explicitly prohibit hookah use, according to the Americans for Nonsmokers’ Rights Foundation.

Learn more about hookah with our fact sheet.

Key takeaways


32.03% of youth and young adults believe hookah is less harmful than cigarettes


For those who believe hookah is less harmful than cigarettes, the odds of trying hookah are 15 times greater than those who perceive hookah and cigarettes as equally harmful


The odds of trying hookah are 1,000 times greater for current cigarette smokers