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Hookah Smoking: Healthy Option or Just as Harmful?

Brooke Ondov, Pharm. D. Intern & Jennifer Seltzer, Pharm. D.

January 21, 2011

Hookah is a waterpipe that has been used for smoking tobacco for hundreds of years in Africa and Asia. Recently, hookahs, also known as narghile, shisha, goza and hubble-bubble, are becoming increasingly popular worldwide, including Europe and the United States.1-6 In 2006, there were an estimated 300 hookah cafés operating in two-thirds of US states, and the trend shows no sign of slowing down. 2,3 This inexpensive, fashionable tobacco pipe is socially used, especially among urban youth, college students and young professionals, and its surge in popularity is partially due to the widespread perception that hookahs are less harmful than cigarettes.2,4,5

Though hookahs may vary in size, shape and composition, a typical hookah is made up of a head, metal body, water bowl and flexible hose with a mouthpiece. 3,5 Approximately 10 to 20 g of tobacco flavored with honey, molasses, fruits or oils is placed in the head of the hookah and is heated by lit charcoal placed atop the tobacco. As a smoker inhales through the hose, the smoke that is generated by the tobacco passes through the waterpipe body, bubbles through the water and is carried through the hose to the smoker.1,5 Hookah smoking is generally a social activity where the hose is passed around a group of participants for a typical session of 45 to 60 minutes or for several hours.5 Waterpipes and accessories can also be purchased from supply shops and internet vendors for home use.1

Contrary to popular belief, the water in the pipe "filters out" only a small amount of harmful substances. While the smoke may be cooler and less irritating to the throat, it contains significant amounts of carbon monoxide, nicotine, tar, heavy metals, arsenic, chromium and lead.1-6 Relative to a single cigarette, a hookah smoker inhales more than 40 times the smoke volume and 1.7 times the nicotine in a typical 45-minute smoking session due to the increased frequency of puffing, deeper inhalation and longer smoking session.6 Carboxyhemoglobin levels can be three times greater for hookah smokers than for cigarette smokers.5,6

While limited data exist on the health risks of waterpipe use, available evidence indicates that the risks may be very similar to cigarette smoking, including lung, oral and bladder cancer as well as cardiovascular disease.2,6-8 Hookah smoking may also carry the additional risk of transmitting communicable diseases such as tuberculosis and viruses due to the frequency of pipe sharing.1,5 Pregnant women who use hookahs are more likely to give birth to babies with low birthweights, low Apgar scores and respiratory distress syndrome.7,9 The addictive potential of hookahs is also surprisingly unresearched and likely depends on type of tobacco used, duration and frequency of use, volume of smoke inhaled and the contribution of charcoal.4

Currently, the content and packaging of waterpipe tobacco is not regulated by the FDA, thus allowing use in some clean air environments, access to minors, advertising with deceptive descriptors and lack of warning labels. While the media and café owners continue to exploit the scarcity of evidence about hookah health risks and minimize negative evidence, healthcare providers should be prepared to discuss the many potential health implications of this exploding trend with their patients.


  1. WHO Study Group on Tobacco Product Regulation. Tobacco regulation advisory note: Waterpipe tobacco smoking: health effects, research needs and recommended action by regulators. Geneva: World Health Organization, Tobacco Free Initiative, 2005. Available at:
    Waterpipe%20recommendation_Final.pdf . Accessed January 17, 2011.

  2. American Lung Association. An emerging deadly trend: Waterpipe tobacco use. Washington: American Lung Association, 2007. Available at: . Accessed January 17, 2011.

  3. Centers of Disease Control and Prevention. Hookahs. Available at: Accessed January 17,2011.

  4. Maziak W. The waterpipe: time for action. Addiction. 2008;103:1763-7.

  5. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics. 2005;116:113-9.

  6. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking direct comparison of toxicant exposure. Am J Prev Med. 2009;37(6):518-22.

  7. Chaouachi K. Hookah (shisha, narghile) smoking and environmental tobacco smoke (ETS). A critical review of the relevant literature and the public health consequences. Int J Environ Res Public Health. 2009;6(2):798-843.

  8. Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer: carcinoembryonic antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J. 2008;5:19. Available at: . Accessed January 17, 2011.

  9. Nuwayhid I, Yamout B, Ghassan, Kambria M. Narghile (hubble-bubble) smoking, low birth weight and other pregnancy outcomes. Am J Epidemiol. 1998;148:375-83.

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