Young Adult Hookah Smokers Perceive Lower Cardiovascular Harm from Hookah Smoking than Non-Smokers

Hookah (waterpipe) tobacco smoking remains common among young adults and is often perceived as less harmful than cigarettes, in part due to the misconception that water “filters” toxins. We examined the perceived short-term health effects of hookah versus cigarette smoking in a cross-sectional survey of 121 young adults (mean age 26 ± 5 years; 45% women) in Southern California, including 75 exclusive hookah smokers, 10 dual hookah and cigarette smokers, and 36 non-smokers. Participants rated perceived effects on general, cardiovascular, and respiratory health on a scale from −10 (extremely harmful) to +10 (extremely healthy). Multivariable linear regression adjusted for sex, ethnicity, and education assessed group differences. Compared with exclusive hookah smokers, non-smokers rated hookah as significantly more harmful to general (β = −2.49, p < 0.05), cardiovascular (β = −3.49, p < 0.01), and respiratory health (β = −2.52, p < 0.05). A pronounced perception difference was observed for cardiovascular health, where exclusive hookah smokers rated hookah’s cardiovascular impact near neutral (adjusted mean −1.70), whereas non-users rated it as substantially harmful (−4.91). Perceptions of cigarette harm were negative across groups. Hookah smokers reported relatively low perceived harm from hookah smoking, including cardiovascular harm, highlighting cardiovascular risk perceptions as a potential target for public health communication.