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. Author manuscript; available in PMC: 2024 Feb 14.
Published in final edited form as: Subst Use Misuse. 2023 Feb 14;58(5):657–665. doi: 10.1080/10826084.2023.2177966

High on hookah: Smoking marijuana from a hookah among adults in the United States, Population Assessment of Tobacco and Health Study, 2015-2019

Mohammad Ebrahimi Kalan 1, Rime Jebai 2, Wei Li 3, Prem Gautam 2, Olatokunbo Osibogun 2, Mohammed M Alqahtani 4, Kenneth D Ward 5, Raed Behaleh 6, Zoran Bursac 7, Ziyad Ben Taleb 8
PMCID: PMC10069405  NIHMSID: NIHMS1875450  PMID: 36786640

Abstract

Objective:

This study aimed to examine the trend and factors associated with smoking marijuana from a hookah device among US adults.

Methods:

Data were drawn from the Population Assessment of Tobacco and Health (PATH) Study, an ongoing nationally representative, longitudinal cohort study of the US population. Adult respondents who self-reported ever smoking marijuana from a hookah at Wave 5 (2018-19, N=34,279 US adults) were included in the multivariable analysis. Trend analysis also was conducted using National Cancer Institute JoinPoint software from 2015 to 2019.

Results:

In 2018-19, an estimated 23.6 million (9.7%) US adults reported ever smoking marijuana from a hookah. Trend analysis showed the increasing prevalence of using marijuana from a hookah device from Wave 3 (8.9%) to Wave 5 (9.7%; time trend p=.007). Adults aged 25-44 years old (vs.18-24;13%, vs. 9%), whites (vs. Black;11%vs.9%), and lesbian, gay, or bisexual (LGB vs. straight;17% vs. 9%) were more likely to report ever smoking marijuana from a hookah (ps<.05). Former and current users (vs. never users) of e-cigarettes (19% and 25% vs. 5%), cigarettes (11% and 21% vs. 2%), cigars (17% and 27% vs. 3%), and pipes(21% and 33% vs. 7%) and past 30-day blunt users (vs.non-users;39% vs. 9%) were more likely to ever smoke marijuana from a hookah (ps<.05). Pregnant women (vs non-pregnant;12.8% vs. 8.6%; p=0.03) were more likely to smoke marijuana from a hookah.

Conclusions:

Smoking marijuana from a hookah device is prevalent among young adults in the US, especially among vulnerable populations, and has increased significantly from 2015-2019.

Keywords: Marijuana, Hookah, Tobacco, Smoking, Adults, United States

INTRODUCTION

Cannabis—colloquially known as marijuana, weed, pot, or dope—is the most commonly used federally illegal drug in the United States (US) (SAMHSA, 2021). In 2020, an estimated 32.8 million Americans aged 12 or older reported using marijuana in the past month, with 14.2 million people having a marijuana use disorder in the past year (SAMHSA, 2021). Marijuana use is gaining higher public health significance due to its legalization for medicinal and recreational purposes in different US states. Moreover, marijuana use has adverse health consequences, including cognitive impairment (e.g., short-term memory impairment and slowness of learning) (Dellazizzo et al., 2022; Meier et al., 2012; NASEM, 2017), addiction (Lopez-Quintero et al., 2011), mental health problems (NASEM, 2017; Volkow et al., 2016), impaired immune response (Maggirwar and Khalsa, 2021), impaired driving (Hollenbeck and Uetake, 2021), possible adverse effects on heart function (NASEM, 2017; Rumalla et al., 2016), adverse neonatal outcomes (Crume et al., 2018), and respiratory damages (NASEM, 2017; Tan et al., 2009).

Although marijuana use is federally prohibited, medical marijuana is legal in some form in 37 states, the District of Columbia (DC), Guam, Puerto Rico, and the US Virgin Islands. Out of the 37 states,19 states including DC and Guam legalized recreational marijuana for adults as of May 27, 2022 (NCSL, 2021; ProCon.org, 2021). The growing decriminalization of marijuana has led to a burgeoning industry that is producing an expanding variety of marijuana products, making it accessible for use in numerous ways (NASEM, 2017; Peters and Chien, 2018; Cohn et al., 2017; Peters and Chien, 2018). For example, joints (rolling it into a cigarette), blunts (rolled into a cigar wrap), spliffs (marijuana mixed with tobacco), and vaping tetrahydrocannabinol (THC) are different routes of consuming marijuana (Peters and Chien, 2018; Ben Taleb et al., 2020; Loflin and Earleywine, 2014). The relaxed regulatory environment in the US, coupled with the industry’s enormous investments in marketing (Hollenbeck and Uetake, 2021), may entice users to experiment with new routes of consuming marijuana. One of the ways that is not fully captured in the literature is using hookah to smoke marijuana. Hookah is a waterpipe device typically used to smoke sweetened and flavored tobacco (Ben Taleb et al., 2019; Maziak et al., 2015). Over the past few decades, hookah smoking gained popularity among youth and adults in the US despite its well-established harmful effects on human health (Qasim et al., 2019; El-Zaatari et al., 2015; Ali and Jawad, 2017). According to the Monitoring the Future survey, in 2018, nearly 1 in every 13 (7.8%) high school students (Johnston et al., 2019) and about 1 in every 8 (12.3%) young adults aged 19-30 in the US had used a hookah to smoke tobacco during the previous year (Schulenberg et al., 2019).

Many hookah users misperceive hookah as a less harmful product compared to cigarette smoking, which may pave the way to use this device to inhale other substances, including marijuana (Sutfin et al., 2014). Smoking marijuana from a hookah device with a group of friends with long smoking sessions - typical for traditional hookah tobacco use (Maziak et al., 2015)- can likely increase the risk of addiction to marijuana and higher exposure to both toxicants emitted from hookah smoking by other users in the social gathering and marijuana smoke itself. Evidence shows that some hookah users smoke marijuana out of the same device they use for tobacco (Sutfin et al., 2014; Smith-Simone et al., 2008). Additionally, anecdotal reports show that smoking hookah loaded with marijuana is growing in popularity (EMJAY, 2022) and has been widely circulated on social media platforms like Reddit (Reddit, 2022). Therefore, smoking marijuana from a hookah device has the potential to grow in popularity, especially in countries with legalized marijuana–such as the US and Canada–which may pose a threat to public health. Most importantly, the combined toxicant exposure of smoking marijuana and tobacco using a hookah device poses an increased risk of developing diseases. Evidence regarding the co-use of marijuana and other tobacco products reveals a higher concentration of combustion-related toxicants among co-users compared with exclusive tobacco users (Smith et al., 2020). Specifically, the use of charcoal as a source of combustion in hookah has been associated with an elevated concentration of heavy metals and carbon monoxide that are detrimental to health and linked with developing chronic diseases and malignancies (Qasim et al., 2019; Lopez et al., 2017; Rostami et al., 2021; Schubert et al., 2015; Ali and Jawad, 2017). Yet, to the best of our knowledge, the rates of smoking marijuana from a hookah and the factors associated with this route of consumption have never been investigated. This study examines the prevalence of smoking marijuana from a hookah and its correlates using a nationally representative sample of US adults. We also examined the temporal trend in using a hookah device to smoke marijuana.

METHODS

Design and sample

Using the Population Assessment of Tobacco and Health (PATH) cohort study, cross-sectional analyses (Wave 5, December 2018-November 2019; with a response rate of 69.4% at Wave 5, N=34,309) and longitudinal analyses (Waves 3-5, from October 2015 to November 2019) were conducted. PATH survey collected data on using marijuana through hookah starting wave 2. The response rate for associated questions (Have you ever smoked marijuana from a hookah?) in Wave 2 was 11.7% (N= 3,325). However, the response rate for the same question was 99.9% for Wave 3 (N=28,111), 97.2% for wave 4 (N= 32,869), and 99.9% (N= 34,279) for Wave 5. The PATH Study is an ongoing large-scale and nationally representative cohort study in the US. It uses a four-stage stratified area probability sample design, varying sampling rates for adults by age, race, and tobacco use status. Adults (≥18 years of age) were screened in person, and African Americans, 18–24 year olds, and tobacco users were oversampled (Hyland et al., 2017). Details about the study design and methodology can be found elsewhere (Hyland et al., 2017; USDHHS, 2021). The Westat research firm collected PATH study data and obtained written informed consent from all adult participants. The PATH study was approved by the Westat Institutional Review Board. We used publicly available deidentified data; hence, this study was deemed exempt from institutional review board oversight. The current study followed the reporting guideline of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (Von Elm et al., 2007).

Measures

Outcome variable

The outcome variable was ever smoking marijuana from a hookah. All respondents were asked “Have you ever smoked marijuana from a hookah?” with response options “yes” (coded as 1) or “no” (coded as 0). The information for the past 30 days use of marijuana from a hookah was not collected in the PATH study.

Independent variables

Demographic variables included sex (male and female), age (18-24, 25-44, 45-64, and ≥65 years), race and ethnicity (non-Hispanic/Latinx White [herein: White], non-Hispanic/Latinx Black or African American [herein: Black], Hispanic/Latino/a/x [herein: Hispanic], and other race/multiracial non-Hispanic/Latinx [herein: other/multiracial], or not reported, level of education [high school or less vs. more than high school], and annual household income [less than $50,000 vs. $50,000+]). Sexual orientation was assessed by the question “Do you consider yourself to be…,” with response options of “straight,” “lesbian or gay,” “bisexual,” and “something else.” Respondents who identified as lesbian or gay, bisexual, or something else were coded as LGBs vs. straight (Wheldon et al., 2018). We also included the pregnancy status in the past 12 months. Female participants aged 18-50 were asked “In the past 12 months, have you been pregnant? Please include a current pregnancy, live births, miscarriages, abortions, ectopic or tubal pregnancies, and stillbirths” with response items as “yes” or “no.”

Self-perception of mental health was measured by asking how participants would rate their mental health, including stress, depression, and emotional problems. The response options were excellent, very good, good, fair, or poor. We dichotomized response options as good (excellent, very good, or good) vs. poor (fair or poor).

Tobacco use measures are defined in Supplementary e-Table 1. We measured the use of cigarettes, electronic nicotine delivery systems (ENDS), hookah (smoked tobacco in a hookah), cigars (including traditional cigars, filtered cigars, and cigarillos), pipe filled with tobacco, snus pouches, and smokeless tobacco. Three categories were defined to measure product use status (never, former, or current use). Those who never used [product], even once, were defined as “never users.” Those who were defined in PATH Study as former established or experimental users were categorized as “former users.”Those who were defined as current established, experimental, or past 30-day users were categorized as “current users.” Never use was coded as 0, former use as 1, and current use as 2, with 0 as the reference group (see definitions of tobacco use status in Supplementary e-Table 1). We measured current blunt use (yes vs. no) in the past 30 days preceding the survey.

Hookah tobacco use-specific characteristics were measured using several items collected from adult respondents (n=1,920) who were current established, current experimental, or past 30-day hookah (tobacco) smokers. Participants were asked, “Where [do/did] you usually smoke hookah?” and responded to “your home,” “someone else's home,” “a hookah bar or café,” “a dance club or lounge,” and “in somewhere else.” Each response option was categorized as “yes” vs “no”. Participants also provided information about sharing their hookah, whether it contained tobacco, and whether they ever used liquid besides water in the hookah bowl. Lastly, we included an item to explore which hookah tobacco flavors were usually/last smoked (e.g., menthol, or fruit).

Data analysis

Using survey procedures in SAS/STATv15.2, all reported percentages were weighted employing wave 5 single-wave sampling weights to account for the complex survey design and generate nationally representative and unbiased estimates. Unweighted and weighted frequencies with 95% confidence interval (95% CI) were reported. As suggested by PATH study guideline (McCarthy, 1969; USDHHS, 2021), variances were estimated using a balanced repeated replication method with Fay adjustment (e.g., Fay = 0.3). Bivariate associations between outcome and each independent variable were estimated, and Rao-Scott p-values were reported. Weighted multivariable logistic regression models were applied to examine associations between outcome and independent variables (i.e., demographics, mental health, tobacco product use, and blunt use). Adjusted odds ratio (AOR) and corresponding 95% CI were reported. Only a few variables had missing values for more than 1%of the cases (i.e., sexual orientation, race/ethnicity, and annual income) due to participants not knowing the answer or refusing to respond; we considered these values as “Not reported” for each variable in our regression model to account for any unknown association (Table 1).

Table 1.

Characteristics of the Study Population, Wave 5 PATH Study (n = 34,279)

Variables Unweighted n Weighted % (95 % CI)
Age group (years)
 18–24 11,919 11.74 (11.38-12.12)
 25–44 11,732 33.05 (32.43-33.67)
 45+ 7,407 33.30 (32.48-34.13)
 65+ 3,221 21.91 (21.35-22.48)
Sex
 Female 17,491 51.91 (51.33-52.49)
 Male 16,744 48.09 (47.51-48.67)
Sexual Orientation
 Straight 30,337 91.96 (91.49-92.40)
 LGB 3,572 6.58 (6.18-7.00)
 Not reported a 370 1.46 (1.24-1.71)
Race/ethnicity
 Black 5,080 11.19 (10.83-11.56)
 White 18,692 63.85 (63.29-64.40)
 Hispanic 6,172 13.54 (13.15-13.94)
 other/multiracial 2,691 7.52 (7.22-7.83)
 Not reported b 1,644 3.88 (7.22-4.28)
Education
 High school or less 14,645 37.91 (37.35-38.47)
 More than high school 19,491 62.09 (61.52-62.64)
Income
 Less than $50,000 18,926 46.68 (45.70-47.68)
 $50,000 or more 13,214 46.76 (45.81-47.72)
 Not reportedc 2,139 6.55 (6.07-7.05)
Self-reported mental health
 Good 27,133 84.75 (84.07-85.40)
 Poor 7,036 15.25 (14.60-15.93)
Pregnancy in the past 12 months d
 No 9706 90.5 (89.58-91.32)
 Yes 1214 9.5 (8.68-10.41)
ENDS use
 Never 16,713 70.05 (69.30-70.78)
 Former 14,299 25.17 (24.50-25.85)
 Current 3,172 4.79 (4.53-5.06)
Cigarettes use
 Never 10,987 33.15 (32.03-34.29)
 Former 14,664 50.44 (49.41-51.46)
 Current 8,579 16.42 (15.85-17.00)
Used tobacco in hookah
 Never 22556 79.54 (78.77-80.30)
 Former 11226 19.79 (19.06-20.54)
 Current 412 0.65 (0.57-0.76)
Cigars use
 Never 16,069 56.16 (55.03-56.15)
 Former 15,942 41.97 (42.35-44.60)
 Current 1,627 0.36 (0.29-0.45)
Pipe use (filled with tobacco)
 Never 27,581 81.15 (80.40-81.89)
 Former 6,401 18.48 (17.75-19.23)
 Current 196 0.37 (0.30-0.45)
Snus pouch use
 Never 30,212 92.55 (92.17-92.92)
 Former 3,511 7.01 (6.65-7.39)
 Current 240 0.44 (0.37-0.53)
Smokeless tobacco use
 Never 27,400 83.30 (82.49-84.08)
 Former 5,546 14.52 (13.78-15.29)
 Current 1,053 2.18 (1.98-2.39)
Blunt use (past 30 days)
 No 2,817 97.05 (96.82-97.27)
 Yes 7,325 2.95 (2.73-3.18)
Ever used marijuana from a hookah
 No 29758 90.3 (89.77-90.85)
 Yes 4521 9.67 (9.14-10.23)
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LGB, Lesbian, gay or bisexual, or something else. ENDS, electronic nicotine delivery systems.

Note. Some variables may not add up to the total number because there were <1% missing in variables gender, education, mental health, tobacco products, and blunt use.

a

In wave 5 PATH study codebook, n= 371 participants either answered “Don’t know” (n= 61) or “refused” to respond (n= 310) to the sexual orientation question. We included information from n=370 participants in our analysis to account for these responses instead of excluding or imputing them since they were not missing at random.

b

n= 1,670 participants either answered “Don’t know” (n= 1,022) or “refused” to respond (n= 648) to race and ethnicity questions. We included information from n=1,644 participants in our analysis.

c

n= 2,147 participants either answered “Don’t know” (n= 1087) or “refused” to respond (n= 1059) for the income question. We included information from n=2,139 participants in our analysis.

d

Female participants aged 18-50 responded to the pregnancy status item.

We examined the regression models for any potential multicollinearity by tolerance <0.1, VIF >10, and eigenvalues close to zero (Kim, 2019; Vatcheva et al., 2016) and found no evidence of multicollinearity among the covariates except for variable “Used tobacco in hookah.” Hence, this variable was removed from the multivariable regression model. Further, we performed several multivariable regression models to explore the association between hookah tobacco use-specific characteristics and smoking marijuana from a hookah accounting for age, gender, sexual orientation, race/ethnicity, education, annual income, and mental health. There was no evidence of multicollinearity in these models. To explore the association between a pregnancy in the past 12 months and smoking marijuana from a hookah device, an additional multivariable regression model (accounting for all other variables) was performed restricting the sample to only female participants (N=10,920). The statistical significance level was set at α=0.05, along with consideration of other evidence, such as the magnitude of association and variability.

Trend analysis

Based on the reviewer’s suggestion, we conducted a time series trend analysis using National Institue of Health JoinPoint software Version 4.9.1.0 (https://surveillance.cancer.gov/joinpoint/) to explore temporal change in the prevalence of using marijuana from a hookah between Waves 3 and 5. Each wave’s single-wave sampling weights were used to account for the complex survey design and generate nationally representative and unbiased estimates.

RESULTS

The main characteristics of the study sample are summarized in Table 1. In 2018-2019, 23.6 million (9.7%) US adults reported ever smoking marijuana from a hookah. Of these 23.6 million, about 11 million (5.7%) never smoked tobacco in a hookah, 12 million (24.8%) were former smokers, and about half a million (34.5%) were current smokers (Supplementary e-Table 2). The trend analysis of PATH data showed that the prevalence of using marijuana from a hookah increased significantly from 2015-16/wave 3 (8.9%,) to 2018-19/wave 5 (9.7%; time trend p=.007) (Figure 1).

Figure1.

Figure1.

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Temporal trend in smoking marijuana from a hookah device (2015-2019), United States Adults.

Adults who were 25-44 years old (vs. 18-24; AOR=1.4: 95%CI=1.2-1.6) were more likely to smoke marijuana from a hookah device (Table 2). Also, smoking marijuana from hookah was more likely to occur among people who were white (vs. Black; AOR=1.2: 1.1-1.5), LGBs (vs. straight; AOR=1.5: 1.3-1.8), had more than a high school education (vs. less than high school; AOR=1.3:1.2-1.5) or reported poor mental health (vs. good; AOR=1.2: 1.0-1.3). Adults with an annual income of $50,000 or more (vs. <$50,000; AOR= 0.9: 0.8-1.0) were less likely to report ever smoking marijuana from a hookah (all ps<0.05). Our additional multivariable regression model among female participants (data not shown) revealed that women who were pregnant in the past 12 months were more likely to ever smoke cannabis from a hookah device (AOR=1.3: 1.1-1.8, p=0.03).

Table 2.

Multivariable regression model of ever using a hookah to smoke marijuana (n=4521) compared to never users (n= 29,758), PATH Wave 5

Variables No. who used hookah to smoke marijuana/No. in category Multivariable
Unweighted n Weighted % (95 %
CI)		 Estimated
Population		 Rao-Scott
p-value		 aOR (95 %CI), p-value
Overall 4521 9.7 (9.1-10.2) 23,559,415
Age group (years) <.0001
 18–24 1066 9.4 (8.7-10.2) 2,685,834 Ref
 25–44 2235 13.2 (12.5-14.0) 10,661,599 1.4 (1.2-1.6), <.0001
 45–64 911 8.6 (7.7- 9.6) 6,974,416 1.1 (1.0-1.4), 0.1308
 65+ 309 6.1 (5.1- 7.2) 3,237,566 1.0 (0.8-1.2), 0.9263
Sex <.0001
 Female 1964 7.2 (6.7-7.8) 9,092,337 Ref
 Male 2552 12.3 (11.5-13.3) 14,441,949 1.1 (0.9-1.2), 0.2543
Sexual Orientation <.0001
 Straight 3768 9.2 (8.7- 9.8) 20,637,285 Ref
 LGB 720 17.2 (15.3- 19.2) 2,748,685 1.5 (1.3-1.8), <.0001
 Not reported 33 4.9 (2.8- 8.2) 173,445 0.7 (0.3-1.4), 0.2641
Race/ethnicity <.0001
 Black 611 8.5 (7.7- 9.4) 2,317,272 Ref
 White 2740 10.6 (9.9- 11.4) 16,537,112 1.2 (1.1-1.5), 0.004
 Hispanic 664 7.7 (6.9- 8.6) 2,937,279 1.1 (0.9-1.3), 0.4969
 other/multiracial 363 7.9 (6.6- 9.5) 1,451,405 1.1 (0.8-1.4), 0.6707
 Not reported 143 6.6 (5.1-8.4) 621,783 1.0 (0.7-1.3), 0.8066
Education <.0001
 High school or less 1854 8.9 (8.4- 9.6) 8,264,183 Ref
 More than high school 2656 10.1 (9.5- 10.8) 15,240,397 1.3 (1.2-1.5), <.0001
Income <.0001
 Less than $50,000 1763 10.7 (10.2- 11.3) 12,224,022 Ref
 $50,000 or more 984 9.1 (8.3- 10.0) 10,396,613 0.9 (0.8-1.0), 0.0167
 Not reported 183 5.9 (4.7-7.3) 938,780 0.8 (0.6-1.1), 0.2293
Self-reported mental health <.0001
 Good 3318 9.0 (8.4- 9.5) 18,426,418 Ref
 Poor 1191 13.7 (12.6- 15.0) 5,085,392 1.2 (1.0-1.3), 0.0127
ENDS use <.0001
 Never 1066 5.2 (4.7- 5.8) 8,809,280 Ref
 Former 2706 19.3 (18.3- 20.4) 11,816,758 1.9 (1.7-2.2), <.0001
 Current 744 25.0 (23.0- 27.1) 2,907,528 2.1 (1.8-2.5), <.0001
Cigarettes use <.0001
 Never 388 1.8 (1.6- 2.2) 1,480,984 Ref
 Former 2246 11.2 (10.4- 12.1) 13,785,155 3.3 (1.6-4.1), <.0001
 Current 1883 20.7 (19.5-22.0) 8,277,462 3.8 (1.0-4.7), <.0001
Cigars use <.0001
 Never 804 3.3 (2.9-3.7) 4,526,055 Ref
 Former 3673 17.2 (16.2-18.3) 17,095,052 2.2 (1.9-2.6), <.0001
 Current 34 26.9 (24.2- 29.8) 1,900,900 1.1 (1.5-4.6), 0.0008
Pipe use (filled with tobacco) <.0001
 Never 2705 6.9 (6.5- 7.4) 13,658,283 Ref
 Former 1743 21.4 (19.8- 23.0) 18,786,462 1.7 (1.5-2.0), <.0001
 Current 69 33.0 (24.9-42.2) 294,210 2.0 (1.3-3.0), 0.0017
Snus pouch use <.0001
 Never 3468 8.4 (7.9- 8.9) 18,789,340 Ref
 Former 930 25.0 (23.0- 27.2) 4,244,787 1.1 (1.0-1.3), 0.0932
 Current 81 30.8 (23.9-38.6) 327,738 1.8 (1.2-2.6), 0.0021
Smokeless tobacco use <.0001
 Never 2962 7.6 (7.1- 8.1) 15,336,780 Ref
 Former 1317 20.5 (18.7- 22.3) 7,202,489 1.2 (1.0-1.3), 0.0648
 Current 209 17.1 (14.2-20.5) 905,293 0.9 (0.7-1.1), 0.3173
Blunt use (past 30 days) <.0001
 No 3704 8.7 (8.2- 9.3) 20,613,270 Ref
 Yes 786 39.3 (36.5- 42.1) 2,810,811 3.4 (1.8-4.0), <.0001
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LGB, Lesbian, gay or bisexual, or something else. ENDS, electronic nicotine delivery systems. Some variables may not add up to the total number because there were <1% missing in variables gender, education, mental health, all tobacco products, and blunt use. The reference group for the multivariable model was “never users” of marijuana from a hookah device.

Compared to never ENDS users, former (AOR=1.9: 1.7-2.2) and current users (AOR= 2.1: 1.8-2.5) were more likely to smoke marijuana from a hookah. Similarly, compared to never cigarette smokers, former (AOR=3.3: 1.6-4.1) and current users (AOR=3.8: 1.0-4.7) were more likely to smoke marijuana from a hookah. Compared to never cigar smokers, former (AOR= 2.2: 1.9-2.6) and current users (AOR=1.1: 1.5-4.6) were more likely to smoke marijuana from a hookah (all ps<0.05). Former pipe users (vs. never users; AOR=1.7: 1.5-2.0) and current pipe users (vs. never users; AOR=2.0: 1.3-3.0) were more likely to smoke marijuana from a hookah. Only current (vs. never; AOR=1.8: 1.2-2.6) snus pouches users were more likely to smoke marijuana from a hookah (all ps<0.05). Finally, past 30-day blunt users were more likely to smoke marijuana from a hookah (AOR=3.4: 1.8-4.0; p<0.0001) compared to non-users.

Table 3 illustrates the association between hookah tobacco use-specific characteristics and ever smoking marijuana from a hookah. Adult hookah tobacco users who smoked hookah in someone else home (AOR=1.6: 1.2-2.1), ever used another liquid besides water in the bowl of the hookah (AOR=3.2: 2.3-4.7), and used an alcoholic drink flavor in their hookah (AOR=2.6: 1.6-4.3) were more likely to smoke marijuana from a hookah compared to those who did not smoke marijuana from a hookah. On the other hand, adults who usually smoked hookah tobacco at bars or cafés (AOR=0.6: 0.4-0.9), usually used hookah that contained tobacco (AOR=0.6: 0.4-0.9) or reported menthol or mint as their favorite flavor (AOR=0.6: 0.4-0.9) were less likely to smoke marijuana from a hookah.

Table 3.

Hookah tobacco use-specific characteristics and ever smoked marijuana from a hookah, wave 5 PATH Study (n= 1,920) *

Characteristics Ever smoked marijuana; yes vs no
Adjusted OR (95%CI) P
Where [do/did] you usually smoke hookah tobacco? yes vs no
 In your home 1.3 (0.96-1.7) 0.0968
 In someone else's home 1.6 (1.2-2.1) 0.0007
 In a hookah bar or café? 0.6 (0.4-0.9) 0.0039
 In a dance club or lounge 0.8 (0.6-1.2) 0.3327
 In somewhere else 0.9 (0.3-2.8) 0.7896
Usually share hookah with others, yes vs no 1.5 (0.9-2.3) 0.0517
When smoked hookah whether shisha usually contain tobacco, yes vs no 0.6 (0.4-0.9) 0.0394
Ever used another liquid besides water in the bowl of the hookah, yes vs no 3.2 (2.3-4.7) <.0001
Hookah tobacco flavor usually/last smoked,, yes vs no
 Menthol or min 0.6 (0.4-0.9) 0.0263
 Clove or spice 0.8 (0.4-1.8) 0.7164
 Fruit 1.1 (0.7-1.6) 0.7192
 Chocolate 1.1 (0.6-2.0) 0.7238
 An alcoholic drink 2.6 (1.6-4.3) 0.0002
 Candy or other sweets 0.9 (0.6-1.4) 0.9583
 Some other flavor 1.8 (0.3-10.0) 0.4757
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Note. Each multivariable model was adjusted for age, gender, sexual orientation, race/ethnicity, education, annual income, and mental health.

*

The sample for this analysis was adult respondents who were current established, current experimental, recent former established, or past 30-day hookah (tobacco) smokers who provided information about using tobacco in hookah.

DISCUSSION

While hookah is traditionally used to smoke shisha tobacco—tobacco leaves that are treated with a combination of molasses, glycerin, and honey—it can be adapted for other substances such as marijuana (High desert, 2022; Sutfin et al., 2014). This nationally representative study among a sample of US adults is the first to document that nearly 24 million US adults are estimated to have ever smoked marijuana from a hookah device, with a worrisome increasing trend. This is a novel finding that has not been reported in previous nationwide studies, which mainly focused on other routes of consuming marijuana, such as cigars (blunt) or ENDS (Ebrahimi Kalan et al., 2021; Knopf and Letter, 2020; Morean et al., 2015; Peters and Chien, 2018; Ben Taleb et al., 2020). In our study, smoking marijuana from a hookah device was more prevalent among middle-aged adults, whites, LGBs individuals, more educated but lower-income, and those with self-reported poor mental health. In addition, former and current users of different tobacco products had greater odds of smoking marijuana from hookah than never users.

Based on our results, the popularity of smoking marijuana from a hookah among former and current hookah tobacco users raises an important public health concern. Since marijuana is typically mixed with shisha tobacco when smoked through hookah (High desert, 2022; Hookah Forum, 2004), the combined toxicant exposure of marijuana and tobacco may represent an increased health burden and an additional risk for developing diseases. Combustion-related toxicants such as acrylonitrile and acrylamide metabolites have been detected among marijuana smokers (Lorenz et al., 2021). In fact, evidence regarding the co-use of marijuana and various tobacco products indicates a higher concentration of toxicants among co-users compared with exclusive tobacco users (Smith et al., 2020). Moreover, analyses of hookah tobacco–the tobacco used in hookah—and charcoal revealed substantial amounts of heavy metals, including nickel, cadmium, lead and chromium (Rostami et al., 2021; Schubert et al., 2015). This is in addition to the elevated concentration of carbon monoxide that is inhaled during hookah smoking (Lopez et al., 2017). Therefore, there is an urgent need to accurately characterize the combined toxicant exposure profile of smoking marijuana from hookah to better understand the collective health risks associated with this method of marijuana smoking and to protect public health, especially among vulnerable populations, including LGBs individuals, lower-income, and those with poor mental health.

Our finding that smoking marijuana from a hookah is associated with use of several tobacco products (cigarette, ENDS, hookah tobacco, cigar, pipe, and snus) has important implications for tobacco control. implications were the characterizing of the relationship between the use of tobacco products among US adults and smoking marijuana from a hookah. Specifically, our data revealed a significant association between ever and current use of tobacco products and smoking marijuana from a hookah. Our results suggest that adults with prior or existing experience using tobacco products are more likely to utilize hookah to consume marijuana. A previous study (Sutfin et al., 2014) of students from 8 colleges in North Carolina reported a high prevalence of smoking marijuana from a hookah among current cigarette smokers. This pattern was also identified in previous studies among youth who vape marijuana using ENDS and found a positive correlation with ever and current use of tobacco products (Ben Taleb et al., 2020; Dai et al., 2018). Emerging evidence also shows that marijuana use appears to be associated with poorer smoking cessation (Goodwin et al., 2022). Taken together, these findings call for the need to integrate educational elements into preventive interventions and tobacco control campaigns regarding the use of tobacco products such as hookah to consume marijuana and the potential impact on health and advancing cessation of tobacco products.

In our study, adults who usually smoked hookah tobacco in someone else’s home (apparently a friend’s place) were more likely to smoke marijuana through hookah, while those who smoked hookah tobacco in a bar or café were less likely to try marijuana from a hookah. In addition, two potentially risky characteristics of regular hookah tobacco smokers (who smoked marijuana from the device) were using another liquid besides water in the bowl of the hookah and using an alcoholic drink flavor (but not menthol) in a hookah. These findings signal the importance of further investigations among this unique population of marijuana smokers through hookah at the national level, which could have both regulatory and clinical implications.

Our previous report (Kondracki et al., 2021) from the PATH survey showed an increasing trend in using marijuana among reproductive-age women in the US. This study adds to the literature a new mode of marijuana consumption-hookah device-that is popular among this vulnerable age group of women compared to their counterparts. Although potential dire health consequences of using marijuana during pregnancy (e.g., lower birth weight) have been documented (NASEM, 2017), it is crucial to continuously monitor the current use of marijuana among this population, along with collecting data on the mode of consumption (e.g., hookah, ENDS, and cigars).

This study has some limitations. First, we only measured ever use of marijuana through a hookah. The PATH Study is the only nationally representative study (to our knowledge) providing this question; future national surveys, especially among youth, should explore current use (past 30 days) of marijuana from a hookah. Second, the cross-sectional nature of the multivariable analyses in our study precludes any causal relationship between the outcome and independent variables. Since our longitudinal trend analysis showed an increasing trend in smoking marijuana through hookah, future longitudinal studies are needed to assess the bidirectional causal association between regular smoking marijuana in hookah and the use of other tobacco products. Furthermore, this study used self-reported data, which may introduce recall bias and social desirability bias. Nonetheless, self-reporting of smoking habits is generally reliable and has been consistently used in previous studies assessing smoking behaviors (Patrick et al., 1994).

CONCLUSIONS

This nationally representative study showed that many adults in the US have smoked marijuana from a hookah, and the trends of using this mode of consumption are rising. Additionally, the concurrent use of marijuana and tobacco products, especially from a hookah, is an emerging public health challenge requiring educational and regulatory actions to prevent cumulative dire health consequences (e.g., lung damage) instigated by smoking these substances. Although we reported ever use of marijuana in hookah among US adults and explored some important risk factors, additional research lies ahead to better understand this contemporary route of consuming marijuana. In the era of the legalization of marijuana in the US and the growing concurrent use of tobacco products and marijuana (Smith et al., 2021), consistent monitoring of use—including routes to consume this drug—is crucial to inform tailored preventive intervention programs (e.g., integrating educational elements and tobacco control campaigns regarding hookah use to consume marijuana) and related regulatory actions. Such actions are crucial to curb the exclusive and co-use of marijuana and tobacco products, especially among vulnerable populations including pregnant women, LGBTs, and people with poor mental health conditions.

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Funding

Dr.Ben Taleb is supported by National Institute on Drug Abuse of the National Institute of Health (1R03DA054417)

Footnotes

Declarations of competing interest: None

The authors report no conflicts of interest.

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