Darrell Hulisz, PharmD


September 03, 2010


Many clinicians have been getting questions about the health effects of hookah, a type of pipe. Is this method of inhaling smoke less harmful than cigarette smoking?

Response from Darrell Hulisz, PharmD
Associate Professor, Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio; Clinical Pharmacist, University Hospitals, Case Medical Center, Cleveland, Ohio

Hookah is a waterpipe used for smoking tobacco. Hookah smoking, also known as narghile, shisha, and goza, originated in ancient Persia and India and has been used for over 4 centuries. Hookah tobacco is often flavored with molasses, mint, chocolate, honey, or fruit, such as cherry or apple. Relative to cigarettes, hookah has a sweeter smell and a more appealing taste.[1,2,3,4,5,6,7,8] Hookah bars are becoming increasingly popular, especially with older teens and the college crowd. There is a general perception among these young people that tobacco inhaled via a hookah pipe is relatively safe, or at least safer than cigarettes.[1,2]

In a typical hookah bar, patrons can purchase flavored tobacco and rent a waterpipe to smoke it. Hookah smoking is a social event, allowing users to visit with each other as they pass the pipe around. Many hookahs bars or cafes also serve food and drinks; some serve alcohol too. Hookah smoke is generated by burning charcoal on top of the flavored tobacco. When the smoker inhales through the hookah pipe, a pressure gradient forces air past the heating source and heats the tobacco, giving off smoke. The smoke is then pulled away from the tobacco and passes through the water and into the smoke chamber, where it is inhaled by the user.[9]

The demographic characteristics of waterpipe smokers were obtained via mailed self-reported questionnaires. The questionnaires were completed by 871 adults, 18-24 years of age, in Montreal, Canada.[1] In this study, 23% of participants reported using a waterpipe in the previous year. Independent factors increasing the odds of waterpipe use included younger age, male gender, English language, not living with parents, and higher household income. Waterpipe use was significantly higher in those who had smoked cigarettes, used other tobacco products, consumed alcohol, or abused other illicit drugs in the previous year.

In a survey of 235 hookah users, 58.3% believed that hookah is less harmful than cigarette smoking.[2] However, numerous publications have documented the harmful effects of hookah.[3,4,5,6,7,8,9] For example, a single session of waterpipe smoking (which may last about an hour) may deliver as much tar as an entire pack of cigarettes.[3] As with cigarette smoking, the user inhales nicotine, carbon monoxide, benzene, toluene, arsenic, lead, formaldehyde, and other carcinogens.[3,4] Concern has been raised over a lack of warning labels of waterpipe tobacco products and accessories.[3,4]

Scholarly reviews have found similar adverse health consequences with waterpipe and cigarette smoking.[9] Pregnant women who use waterpipes are more likely than abstainers to give birth to babies with low birthweights, low Apgar scores, and respiratory distress syndrome. Studies have shown that hookah smoking increases the chances of periodontal disease, and may be associated with adverse cardiovascular effects, such as tachycardia and increased blood pressure.[9]

Debate is ongoing about the addictive nature of hookah relative to cigarettes. This is an area with little research to support firm conclusions. With regard to hookah, the addictive potential is influenced by the properties of smoke emitted, duration and frequency of use, type of tobacco used, volume of smoke inhaled, and the contribution of charcoal.[5] As with cigarette smoking, it is plausible that hookah might act as a gateway to nicotine addiction. Earlier experimentation with waterpipes may lead to addiction in minors and complicate long-term nicotine abstinence. Surprisingly, one Florida survey found that 4% of middle school and 11% of high school students reported some use of a waterpipe.[6]

Some researchers have suggested that the public health implications of hookah smoking have not been fully addressed. Clinician advocates of tobacco control must address the specific issue of waterpipe smoking and integrate both the prevention and the cessation messages into current anti-tobacco initiatives.[7,8]

The World Health Organization[10] and the American Lung Association[11] have released advisory statements indicating that many of the long-term adverse consequences of hookah smoking, including increased risk for cancer, mimic those of cigarette smoking.

The content and packaging of waterpipe tobacco are not currently regulated by the US Food and Drug Administration. Hookah use is increasing in the United States, especially among young people. This same group erroneously believes that waterpipe smoking is considerably safer than cigarette smoking. Multiple factors contribute to the addictive potential of hookah. As with cigarettes, the quantity, frequency, and longevity of smoking determine the development of nicotine dependence. Thus, health professionals should send an unequivocal message about the harmful effects of hookah and especially discourage its use in minors.


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