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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2006.090381
LETTER |
Brian A. Primack is with the Center for Research on Health Care, Division of General Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa. Jay D. Aronson is with the Department of History, Carnegie Mellon University, Pittsburgh, Pa. Aaron A. Agarwal is an undergraduate at the University of Pittsburgh, Pittsburgh, Pa.
Correspondence: Requests for reprints should be sent to Brian A. Primack, MD, EdM, Center for Research on Health Care, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Room 4, Pittsburgh, PA 15213 (e-mail: bprimack{at}pitt.edu).
We applaud Lewis and Wackowski’s review of the tobacco industry’s trend toward more aggressive marketing of flavored cigarette brands.1 This article’s appearance in the same issue that highlighted the value of history to public health is timely, because flavored tobacco is becoming popular among young people by way of a very old smoking device: the hookah. Originally from the Indian subcontinent, hookahs have been common in the Arab world for almost 400 years. Recently the hookah has become popular in restaurants and nightclubs in major US cities. In Pittsburgh, 4 hookah bars have opened since 2003, each no more than 5 miles from the campuses of Carnegie Mellon University and the University of Pittsburgh. Hookahs have become commonplace at fraternity parties at these universities.
Until recently, most hookah tobacco was made by mixing shredded tobacco leaf with honey, molasses, or semidried fruit. In the late 1980s, Egyptian tobacco companies began replacing the honey and molasses with glycerin, enhancing the sweetness and flavor of the tobacco, and adding an array of flavorings to make the product more appealing to less seasoned palates.2 Today, hookah tobacco can be found in varieties including sweet melon, strawberry, grape, cola, mango, vanilla, mixed fruit, and mint. These innovations have captivated the youth market around the world.3 At Carnegie Mellon University, fruit- and candy-flavored tobacco is even available in the on-campus convenience store.
The earlier in age people begin smoking, the more likely they are to become strongly addicted to nicotine,4 and physical addiction to nicotine can develop extremely rapidly.5 These facts are likely true whether the nicotine is delivered via cigarette or hookah.6 Cigarette smoking in the United States is at its lowest level in 55 years,7 with proportionate decreases among adolescents.8 The increased popularity of hookah smoking may therefore represent a way for the tobacco industry to addict young people to nicotine and then transition them to cigarette smoking later in their lives.
We therefore urge that attention be given to hookah smoking among adolescents. It will be necessary not only to increase research efforts in this area but to act on the preliminary concerns we outline here. The tobacco industry has ensured its survival to this point by skillfully adjusting to social and policy changes9; it would behoove us to endeavor to stay one step ahead.
References
1. Lewis MJ, Wackowski O. Dealing with an innovative industry: a look at flavored cigarettes promoted by mainstream brands. Am J Public Health. 2006;96: 244–251.
2. Chaouachi K. Narghile (Hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode. Paris, France: Université Paris X; 2000.
3. Rastam S, Ward KD, Eissenberg T, Maziak W.Estimating the beginning of the waterpipe epidemic in Syria. BMC Public Health. 2004;4:32.[CrossRef][Medline]
4. Centers for Disease Control and Prevention. Preventing tobacco use among young people: a report of the surgeon general. Executive summary. MMWR Morb Mortal Wkly Rep. 1994;43:1–10.[Medline]
5. Stolerman IP, Jarvis MJ. The scientific case that nicotine is addictive. Psychopharmacology (Berl). 1995; 117:2–10; discussion 4–20.[CrossRef][Medline]
6. Maziak W, Eissenberg T, Ward KD. Patterns of waterpipe use and dependence: implications for intervention development. Pharmacol Biochem Behav. 2005;80:173–179.[CrossRef][Web of Science][Medline]
7. National Association of Attorneys General. Cigarette sales in US reach historic 55-year low. March 9, 2006. Available at: http://www.tobacco.org/news/218950.html. Accessed May 20, 2006.
8. Johnston LD, O’Malley PM, Backman JG, Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings 2005. Available at: http://www.monitoringthefuture.org/pubs/monographs/overview2005.pdf. Accessed May 23, 2006.
9. Wakefield MA, Terry-McElrath YM, Chaloupka FJ, et al. Tobacco industry marketing at point of purchase after the 1998 MSA billboard advertising ban. Am J Public Health. 2002;92:937–940.
This article has been cited by other articles:
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  B. A. Primack, M. Walsh, C. Bryce, and T. Eissenberg Water-Pipe Tobacco Smoking Among Middle and High School Students in Arizona Pediatrics, February 1, 2009; 123(2): e282 - e288. [Abstract] [Full Text] [PDF]
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