Study: Hookah, snus associated with the onset of cigarette smoking
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* Kim Krisberg

Hookah and snus use may put youth who have never smoked cigarettes at increased risk for picking up the deadly habit, according to a recent study.

Published online Dec. 8 in *JAMA Pediatrics*, the study found that water pipe tobacco smoking from hookahs and the use of snus — a smokeless type of tobacco that often comes in a teabag-like pouch and is placed inside a person’s lip — was associated with the initiation of cigarette smoking as well as current smoking among adolescents and young adults. Researchers conducted a national longitudinal study among more than 2,500 people ages 15 to 23, gathering baseline data at the start of the study and follow-up data two years later.

Research showed that 39 percent of participants who did not smoke cigarettes at baseline but who had smoked water pipe tobacco had begun smoking cigarettes at follow-up, compared to about 20 percent of those who had not smoked water pipe tobacco. Also, 11 percent of baseline noncigarette smokers who smoked hookah tobacco had smoked cigarettes in the previous 30 days at follow-up, compared to about 5 percent who had not smoked hookah tobacco. In addition, 55 percent of baseline noncigarette smokers who had used snus had started smoking at follow-up, compared to 20.5 percent who had not used snus at baseline. And 25 percent of baseline noncigarette smokers who used snus had smoked in the previous 30 days at follow-up, compared with only 5 percent who had not used snus.

Overall, the probability of starting to smoke cigarettes was 19.7 percentage points higher for those who smoked water pipe tobacco at the beginning of the study and nearly 30 percentage points higher for those who used snus.

Study co-author Samir Soneji, PhD, an assistant professor of health policy at the Geisel School of Medicine at Dartmouth College, said he and his colleagues wanted to examine the influence of hookah and snus use, as both are subject to less stringent regulations than other tobacco products. He noted that water pipe tobacco is largely unregulated even though its use is increasing among youth; and snus products are less regulated than other smokeless tobacco products — in fact, companies can still distribute free samples of snus.

“There are so many loopholes that continue to make hookah and snus use easier and more appealing for youth,” Soneji told *The Nation’s Health*. “For parents, it may be time to have a new round of talks about tobacco with their kids. There are many tobacco products available now that never existed before — it’s no longer just cigarettes.”

Soneji also said he hopes tobacco control advocates can use his findings to call on the U.S. Food and Drug Administration to close regulatory loopholes and restrict the flavoring, marketing and packaging of novel tobacco products that appeal to young people. He also cautioned that while snus products are largely an import, more U.S. companies are beginning to manufacture the tobacco product, which could serve as a gateway to cigarette smoking.

In 2009, the historic federal Family Smoking Prevention and Tobacco Control Act gave FDA new regulatory authority to oversee the manufacturing, distribution and marketing of tobacco products, though many novel tobacco products are not held to the same standards as cigarettes. Recently, a Swedish snus company applied to FDA asking that snus be classified as less harmful. Comments on the application are being accepted through Feb. 23 and can be submitted at [www.regulations.gov/#!documentDetail%3BD=FDA-2014-N-1051-0001](http://www.regulations.gov/#!documentDetail%3BD=FDA-2014-N-1051-0001).

For more on the hookah and snus study, visit [http://archpedi.jamanetwork.com/article.aspx?articleid=2020785](http://archpedi.jamanetwork.com/article.aspx?articleid=2020785).

*   Copyright The Nation’s Health, American Public Health Association