Smoking water pipe tobacco, or hookahs, more than doubles the odds that a non–cigarette smoker will begin smoking within 2 years, according to a recent study. Using snus increases the risk of starting smoking by more than sixfold.

“Our study demonstrates that [water pipe tobacco] and snus use among non–cigarette smoking adolescents and young adults were longitudinally associated with subsequent cigarette smoking,” Samir S. Soneji, Ph.D., of Dartmouth University, Lebanon, N.H., and his associates reported online [JAMA Pediatr. 2014 Dec. 8 [ doi:10.1001/jamapediatrics.2014.2697 ]).

“Yet, water pipe tobacco remains largely unregulated by the [Food and Drug Administration], and snus is less regulated than other smokeless tobacco,” Dr. Soneji and colleagues wrote. “The success of FDA tobacco regulatory control policies will depend, in part, on their ability to reduce the use of alternative tobacco products that may lead to subsequent cigarette smoking.”

The researchers interviewed 2,541 respondents between October 2010 and June 2011 and then gathered follow-up data 2 years later from 1,596 respondents. Of the original sample, 39% had never tried smoking cigarettes, and 15% were current smokers. Two thirds of follow-up respondents (1,048 of 1,596) were non–cigarette smokers at baseline: 20 of these individuals had used snus, and 71 had smoked water pipe tobacco.

At follow-up, among those who did not smoke cigarettes at baseline, 39% of hookah users had begun smoking, compared with 20% of those who had not used water pipes. Similarly, among baseline nonsmokers, 55% of snus users had begun smoking at follow-up, compared with 21% of those who did not use snus.

After accounting for sociodemographic and behavioral risk factors, those who used hookahs at baseline, compared with non–hookah users, were 2.6 times more likely to start smoking 2 years later; snus users were 3.7 times more likely than non–snus users. Similarly, hookah users were 2.5 times more likely to be current smokers and 2.6 times more likely to be higher-intensity cigarette smokers at follow-up. Snus users were 6.2 times more likely to be current smokers and 4.5 times more likely to be higher-intensity cigarette smokers.

The sociodemographic factors controlled for included age, sex, race/ethnicity, region, urbanicity, and socioeconomic status as based on maternal educational level and annual household income. Behavioral risk factors considered included smoking status of friends and parents, and respondents’ answers to questions about risk taking, sensation seeking, and binge drinking.

The research was funded by the National Cancer Institute and the National Center for Advancing Translational Sciences. The authors reported no disclosures.


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