23, 24 Studies measuring the indoor air quality of hookah bars have shown PM 2.5 and carbon monoxide (CO) concentrations ranging from ‘unhealthy’ to ‘hazardous’ according to Environmental Protection Agency (EPA) standards for outdoor air pollution, but these studies have focused on commercial hookah bars, despite widespread home use of these devices. 20– 22 Moreover, a number of studies have found that SHS from hookah use contains high concentrations of particulate matter (PM 2.5). Hookah use is widely perceived to be a safer alternative to cigarettes because the smoke is filtered through water, 18, 19 but growing evidence indicates that actively smoking hookahs may be as or more harmful than smoking cigarettes. 11 To date, SHS has largely been investigated and thought to arise mainly from cigarette smoke, and there is very limited research on hookah smoking as a source of SHS, even though hookah smoking has already been associated with an increased risk of lung cancer, 12 periodontal disease, 13 respiratory disease, 14 and low birthweight in infants 15 and the sharing of hookahs can spread infectious diseases, such as hepatitis C, tuberculosis and herpes. 2 Among non-smoking adults, more than 20% reported SHS exposure in their workplace. –2012 National Health and Nutrition Examination Survey found that 41% of children aged 3–11 years were exposed to SHS. 9 WHO estimates that 700 million or half of the world’s children may be exposed to SHS, especially in homes. 8 In addition to the adult mortality and morbidity that is widely recognised, it is well known that SHS is responsible for causing an increased risk of ear infections, respiratory infections, asthma attacks and sudden infant death syndrome, as well as a myriad of other health problems among children, such as increased risks of attention deficit hyperactivity disorder and the metabolic syndrome. Secondhand smoke (SHS) from cigarettes includes more than 7000 toxic chemicals that kill more than 600 000 non-smokers globally each year. 6 Among young adults, almost one in four have used hookah. 5 In 2015, 25% of male and 22% of female college students in the USA reported ever used hookah. 4 The National Youth Tobacco Survey reported that in 2011, 8% of male and 5% of female middle school and high school students in the USA ever used hookah, but by 2014, these rates had more than doubled to 14% for boys and almost tripled to 15% for girls. 2, 3 A recent review suggests that hookah (also called water pipe, hubble-bubble or narghile) use may be the ‘second global tobacco epidemic since the cigarette’. 1 From 2000 to 2011, cigarette consumption in the USA has declined 33%, but the drop in cigarette use is being offset by the marked increase in the consumption of alternative tobacco products, including cigars, cigarillos, smokeless tobacco and hookah. Although cigarette use has dramatically declined globally, there has been a recent, rapid upturn in the use of other forms of tobacco.
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