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Young adults who smoke tobacco from a water pipe, or hookah, are more likely to use illicit drugs, a cross-sectional Canadian study showed.

Among Montreal residents ages 18 to 24, one-third of those who reported water-pipe smoking also said they used illegal drugs other than marijuana, whereas 11% of those who said they didn't smoke from a water pipe reported such activity (P<0.0001), found Jennifer O'Loughlin, PhD, of the University of Montreal, and colleagues.

Water-pipe smokers were also more likely to smoke cigarettes, use other tobacco products, drink alcohol, binge drink, and smoke marijuana, cannabis, or hashish (P<0.0001), the researchers reported in the June issue of Pediatrics.

Not living with one's parents and having a household income of $100,000 or more both increased the chances of water-pipe use by 80% (HR 1.8, P<0.0001 for both).

"Water-pipe users may represent an advantaged group of young people with the leisure time, resources, and opportunity to use water pipes," O'Loughlin and her colleagues wrote.

Smoking tobacco, sometimes sweetened or flavored, from hookahs has been growing in popularity in North America and Europe, especially among the younger population, according to the researchers.

Such a pipe, which includes an upright device where tobacco is burned, a metal body, a base half filled with water, and a hose with a mouthpiece for inhaling, has been used for centuries in Arabic societies.

Although there is a perception that smoking tobacco from a hookah is less harmful than cigarette smoking, there is little information about its health effects.

It is known, however, that water-pipe smoke also contains harmful components, such as nicotine, carbon monoxide, and carcinogens, and may contain a greater quantity of tar and heavy metals than cigarette smoke.

Studies have linked water-pipe smoke to lung cancer, heart disease, infectious diseases, and pregnancy-related complications, the researchers wrote.

To examine the characteristics of individuals who use a water pipe for tobacco, O'Loughlin and her colleagues mailed surveys to participants in the Nicotine Dependence in Teens Study, a longitudinal investigation of the natural history of nicotine dependence among adolescents in Montreal, starting in the seventh grade.

In the current study, 871 of the participants -- now ages 18 to 24 -- completed the surveys.

Nearly a quarter (23%) reported smoking tobacco from a water pipe in the past year; of those, the majority (78%) said they used a hookah less than once a month and 3% said they used one at least once a week.

A multivariable analysis revealed that younger individuals, men, English-speakers, those not living with their parents, and those with high household incomes were more likely to use a water pipe.

The use of other psychoactive substances was high in the overall sample, with a greater mean number of other substances used by hookah users (3.2 versus 1.9).

Almost all of the water-pipe users drank alcohol (98%) and 92% reported binge drinking.

Nearly three-quarters of hookah smokers also puffed marijuana (74%), compared with 35% of the nonusers.

There were no patterns of water-pipe use according to racial, ethnic, or cultural background.

O'Loughlin and her colleagues concluded, "Research is needed to increase understanding of the health effects, natural history, and determinants of water-pipe smoking, as well as the reasons for the high levels of concurrent psychoactive substance use."

They acknowledged some limitations, including the fact that self-reported data may be subject to recall bias, that the use of a convenience sample may limit the generalizability of the findings, that the study had low power to detect use in racial or ethnic groups aside from whites, and that causal relationships could not be established using cross-sectional data.