An Old Custom, a New Threat to Tobacco Control

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.