It's risen in popularity among young people, in particular, who are drawn to tobacco sold in colorful packaging and in fruit and candy flavors.
But a new scientific statement released this week by a group of medical researchers debunks that misconception, saying that smoking tobacco in windpipes, water pipes or hookahs results in inhaling toxic chemicals, often at even greater levels than cigarette smoke.
The statement, published in the American Heart Association's journal Circulation, says that hookah smokers, during sessions that typically last 30 minutes, tend to inhale liters of smoke filled with large quantities of hazardous matter at higher levels than cigarettes.
Aruni Bhatnagar, professor of medicine and director of the University of Louisville Diabetes and Obesity Center in Kentucky, said in a statement that hookah smoke contains harmful substances and that the American Heart Association "strongly recommends" avoiding the use of tobacco in any form.
Bhatnagar helped write the statement on behalf of 10 other health experts who are co-authors. The main features of hookahs — which have entire bars devoted to the popular practice across the U.S. — include a head or a bowl to hold the tobacco, a water base and a hose that connects to a mouthpiece.
The statement says that direct comparisons between hookah smoking and cigarettes have limitations, but that a hookah session has greater carbon monoxide exposure than a single cigarette. Hookah users on average take three to five sessions a day, studies have shown.
"Comparing a single cigarette with a single water pipe session shows that water pipe use exposes smokers to significantly higher levels of heavier and more toxic (PAHs) polycyclic aromatic hydrocarbons than cigarette smoking," the statement says.
But it isn't just the length of a hookah session that makes it harmful, the researchers say.
Short-term exposure to carbon monoxide in hookahs is toxic as well. They argue it "acutely impacts heart rate and blood pressure" and that chronic use is associated with increased long-term risk for coronary artery disease.
The medical statement says that hookah smoke contains other potentially harmful chemicals as well that can affect the cardiovascular system: nicotine, air pollutants, particulate matter, volatile organic chemicals, polycyclic aromatic hydrocarbons, acrolein, lead, cadmium and arsenic.
"Most of these toxins are higher in hookah than cigarette smoke," the American Heart Association warns.
Helping fuel the popularity of hookahs, health experts say, is a misconception that smoking from a hookah is not addictive. In reality, they argue, people who smoke hookahs are in greater risk to start smoking cigarettes than people who don't smoke.
In the United States, hookah smoking is most popular among young adults between 18 and 24, which accounts for 55 percent of hookah smokers, according to studies cited by the American Heart Association.
Hookah tobacco smoking is used by 13.8 percent of young adults and 4.8 percent of high school students. That's on the rise, reflecting greater hookah usage among young people in the United Kingdom and the Middle East.
The group of health care professionals say that more research is needed to more effectively communicate the negative health impacts of hookah smoking.