The heavy smoke of hookah proves to be an alluring alternative to cigarettes. (Photo by John Moore/Getty Images)

One in five high school seniors in the United States has smoked hookah, according to a new study published in Pediatrics. These water pipes, used for centuries in the Middle East, have become an increasingly popular method of tobacco delivery across the country. Bars and restaurants offer pipes for tables to share (including in many states where smoking cigarettes indoors would be illegal). For those who grew up after cigarettes stopped being cool, it seems, hookah is slipping in as a smoking method with less stigma.

But according to another study also released this week, this one in Nursing Research, the majority of teens who smoke hookah are under the (false) impression that it’s a safe hobby. But don’t go smashing water pipes just yet: The FDA could soon place regulations on hookah to make it safer.

Hookah smoke isn’t great for you—that much is clear. It contains the same carcinogens and contaminants (like tar and carbon monoxide) as cigarette smoke, and still delivers nicotine. Mary Rezk-Hanna, a UCLA nursing doctoral student and lead author of one of these studies, said that 16 percent of hookah bar patrons she surveyed (all between 18 and 30 years old) thought that hookah smoke lacked nicotine, and wasn’t addictive. And 56 percent said that hookah wasn’t harmful to their health at all. Around half of those surveyed thought that the pipes, which generally have several feet of hose for the smoke to travel through, somehow “filtered out” the toxic components with air and water. Some even thought that the tasty flavors given to hookah smoke, which can be delightfully fruity, served to make them less toxic.

According to Joseph Palamar, an assistant professor of Population Health at NYU Langone Medical Center and lead author of the Pediatrics study, white, wealthier young men are more likely than other demographic groups to use hookah. But he acknowledges that it’s likely many teens use hookah quite infrequently. One session of hookah is certainly worse than a cigarette, with hookah taking up to two hours to smoke and involving much more inhalation. But it’s also more ritualistic, and allows for more “social” users—ones who truly save the practice for special occasions—than cigarettes do these days.

“It’s bad for you regardless,” he said, “but certainly not as bad as doing it every day.”

Palamar doesn’t think we should exaggerate the risks. “Saying, 'if you do this once with your friends, you’ll get addicted and get cancer',” he said, “is probably just going to alienate teens that use it.” Unfortunately, he said, anyone can buy a hookah pipe and tobacco to smoke in it on the Internet. It’s the lack of regulation that really troubles him, not teens who partake occasionally.

The FDA recently announced that it would create regulations for other methods of consuming nicotine, though it’s likely that the agency will focus on electronic cigarettes. Cheaper and more convenient than a water pipe, but with all the same fun flavors and misconceptions about health, these pose a more immediate threat to the health of U.S. teens. But Palamar and Rezk-Hanna are both eager to see the hookah question tackled.

“We really need more research on the effects of hookah smoking on health,” Rezk-Hanna said, “and the effects of the second hand smoke on other bar and restaurant patrons.”