Up in Smoke: The Myth of the Healthy Hookah

by Michael Grisafe on October 19, 2012

“Narghile.” “Hubble-bubble.” “Shisha.” All names for what is commonly known in the United States as “Hookah.” A hookah is a type of water pipe in which users inhale flavored tobacco smoke through a long, hose-like stem after it passes through a basin of water. Hookah smoking has been around in the Middle East for over 400 years; however it’s seen a surge in popularity among college age adults in the United States over the past ten years.1

If you don’t know what hookah is, I guarantee that you’ve seen a pipe advertised in a shop window or a new “hookah lounge” opening up in your hometown.

I first heard about hookah when my little sister called me from college one day: “It’s awesome! They have these little water pipes you smoke with fruity flavors.”

“Wait, you smoke now?” I asked.

This surprised me because my sister never drank, let alone smoked, and was a pretty solid vegetarian.

“Oh yeah, well, it’s ‘smoke’ but not really  ‘smoke.’ Not like a cigarette. The water filters out all of the bad stuff.”


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This reminded me of an explanation I’d heard years before of another “water-assisted-smoking-filtration-device” given to me by an undergraduate engineer. “You see,” he said after eating his fourth bag of Doritos, second bag of M&M’s, and third Twinkie, “the smoke passes through the water and takes out all the bad stuff. The bad stuff in the smoke is made of ‘polarized molecules,’ and the water has ‘polar molecules.’ You dig? So it sucks out all the bad stuff. Kinda like a magnet. Ohhhh yeahhh.” The veracity of this claim was then verified by a solid belch, a belly pat, and a complacent look of satisfaction.

So, with all of this outstanding empirical evidence behind me from “trusted experts,” why wouldn’t I try hookah when I came across it in restaurants across the Lower East Side in New York? For a couple bucks you could smoke a pipe, talk to your friends, and enjoy the evening while lounging on pillows. It seemed like a great way to unwind, and I was entranced by the allure of what seemed like an exotic and esoteric practice (please remember, I came from a small town in which “Indian food” was sometimes seen as a daring culinary adventure).

Thus, it wasn’t long before I became a hookah regular. It just never seemed like a health risk. I mean, the “real organic tobacco” was flavored by “real organic” apples, watermelon, or pears. And “organic” stuff is always healthy. After all, it’s from “nature.”

Around this “hookah-experimental-phase,” I also started to develop my super-sensitive-public-health-reflexive-interviewing-strategies which I deftly used on my smoker friends anytime they stepped out to light-up: “You schmucks know you’re going to get cancer, right? You cool with that?”

“You are too,” they’d shoot back (and here I might be omitting a playfully procreative moniker). “You smoke hookah like two hours every weekend.”

“Yeah, but that’s ‘pure’ stuff,” I’d tell them. “The tobacco smoke is cleaned by water.”

Which was true, right? Because smoking a hookah isn’t anything like smoking cigarettes? Right?


Well, it turns out that hookah smoke contains many of the same dangerous chemicals in cigarettes- sometimes in even higher concentrations.

A Pack in 30 Minutes2

One of the first things that got my attention when researching hookah smoking was the rapid exposure that users get to many hazardous chemicals. Several studies have found that an average 30-60 minute hookah session is about equivalent to smoking a whole pack of cigarettes.3 This really made me think, because most of the people I know that smoke hookah (myself included) sat around smoking for at least an hour. That means that we were smoking the equivalent of 1-2 packs of cigarettes each time we went out. Not good.

Carbon Monoxide Poisoning


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One risk of hookah use is the high levels of carbon monoxide that a person is exposed to when smoking (even higher than cigarette smokers).4 High levels of carbon monoxide in your body prevent oxygen from being effectively delivered to your cells. This results in a condition known as “hypoxia,” which means inadequate oxygen supply. When a person is hypoxic from having too much carbon monoxide in their body, they get headaches, feel dizzy, and may be slightly short of breath. These effects gradually diminish as a person is exposed to normal, clean air, but in the mean time they can feel a bit sick. Think of it as a “hookah hangover.”

Trust me. I’ve been there, it’s no fun.

Driving Under the Influence….of Smoking?

Because of the carbon monoxide effects described above, a person’s motor skills can be affected enough to impair their driving. This was shown in a controlled study in which individuals who smoked hookah fared significantly worse on a driving simulator than those that didn’t smoke (measured by participants’ inability to avoid crossing over a center line while driving).5

Hooked on Hookah

Nicotine is one of the major addictive substances in cigarettes. Research indicates that hookah smoke contains about as much nicotine as cigarette smoke, meaning that hookah is potentially as addictive as cigarettes.6

At Least as Toxic as a Cigarette


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The Centers for Disease Control and Prevention (CDC) warns that hookah use is at least as toxic as cigarette smoke.7 Researchers state that hookah users are exposed to carbon monoxide, heavy metals, nicotine, and a variety of cancer-causing chemicals. So much for being “all-natural.”

In addition, studies have shown that hookah use can impair cardiac function8, and lead to cancers of the esophagus9, mouth, lung10, stomach, and decreased fertility.11 So basically all of the “pleasant things” we have come to associate with cigarette smoking are at least as prevalent for hookah smokers.

Filtering Through a Water Pipe Doesn’t Decrease Toxins

As you’ve probably guessed from all of the writing up until now, smoking tobacco through a water filter really doesn’t do anything to decrease the type of toxins that would be normally delivered by smoking cigarettes.12 I’m sad to say that my engineering friend was wrong (he’s now working in the biomedical field, so let’s hope his knowledge has improved!).

Switching to Coffee

I have to admit, I’m new to the field of public health, and I was hoping a little bit that hookah smoking wasn’t quite a bad as I thought it was. Visiting hookah lounges was always a way to socialize with my friends in a way that wasn’t as debaucherous as drinking or as socially passive as watching TV; kinda like a coffee shop with cushions on the floor.


Image courtesy of healingdream / FreeDigitalPhotos.net

I think deep down I knew it wasn’t the best health-wise, but I just wanted to believe it was little bit better than smoking cigarettes.

So I can understand how people like my sister would reject cigarettes but embrace hookah. Until you have the facts, it doesn’t seem so bad. Cigarette smoking is widely known to cause cancer and other detrimental health effects while hookah is relatively new and unknown to many people in the West. Because of this, it’s no surprise to see that cigarette smoking often decreases during college years, while hookah use is showing a rapid increase.13

Hookah just seems “hip” and “trendy,” and the popular media often touts it as being somehow “more pure and natural” than cigarette smoking. Which is true in a way: hookah does use “all-natural” tobacco and flavors.

The only problem is that cancer is “all-natural” too.

What do you think? How hazardous to your health is smoking hookah?

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After reading this article, did your views on hookah smoking change?

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1Ashurst, J. V., Urquhart, M., & Cook, M. D. (2012). Carbon monoxide poisoning secondary to hookah smoking. The Journal of the American Osteopathic Association, 112(10), 686–8.
2Serota, J. A. (2007). A Pack in 30 Minutes. Journal of Pediatric Health Care, 21(3), 209–210.
3Cobb, C. O., Sahmarani, K., Eissenberg, T., & Shihadeh, A. (2012). Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a “healthy” tobacco-free alternative. Toxicology letters, 1–6. doi:10.1016/j.toxlet.2012.09.026
4Ashurst, J. V., Urquhart, M., & Cook, M. D. (2012). Carbon monoxide poisoning secondary to hookah smoking. The Journal of the American Osteopathic Association, 112(10), 686–8.
5Elias, W., Assy, N., Elias, I., Toledo, T., Yassin, M., Armaly, Z., & Bowirrat, A. (2012). The detrimental danger of water-pipe (Hookah) transcends the hazardous consequences of general health to the driving behavior. Journal of translational medicine, 10(1), 126.
6Dale, L.  (n.d.). Is hookah smoking safer than smoking cigarettes? Retrieved from http://www.mayoclinic.com/health/hookah/AN01265
7Centers for Disease Control and Prevention.  (2011, August 22).  Smoking and Tobacco Use:  Hookahs. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/
8Cobb, C. O., Sahmarani, K., Eissenberg, T., & Shihadeh, A. (2012). Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a “healthy” tobacco-free alternative. Toxicology letters, 1–6.
9Dar, N.A., Bhat, G.A., Shah, I.A., et al. (2012). Hookah smoking, nass chewing, and oesophageal squamous cell carcinoma in Kashmir, India. British Journal of Cancer. doi: 10.1038/bjc.2012.449
10Koul, P. a, Hajni, M. R., Sheikh, M. a, Khan, U. H., Shah, A., Khan, Y., Ahangar, a G., et al. (2011). Hookah smoking and lung cancer in the Kashmir valley of the Indian subcontinent. Asian Pacific journal of cancer prevention : APJCP, 12(2), 519–24.
11Centers for Disease Control and Prevention. (2011, August 22).  Smoking and Tobacco Use:  Hookahs.  Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/
12Shihadeh, A., Salman, R., Jaroudi, E., Saliba, N., Sepetdjian, E., Blank, M. D., Cobb, C. O., et al. (2012). Does switching to a tobacco-free waterpipe product reduce toxicant intake? A crossover study comparing CO, NO, PAH, volatile aldehydes, “tar” and nicotine yields. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association, 50(5), 1494–8.
13Nuzzo, E., Shensa, A., Kim, K. H., Fine, M. J., Barnett, T. E., Cook, R., & Primack, B. a. (2012). Associations between hookah tobacco smoking knowledge and hookah smoking behavior among US college students. Health education research, 1–9. doi:10.1093/her/cys095

[10/19/2012 Article Update:  A big thanks to Margaret and “number1monkeyfan” for pointing out that my last section title, “Switching to Tea,” didn’t really go with the ending of the article- due to the fact that I cut an alternate ending that mentioned “tea.”  I forgot to update the title to “coffee,” which still only marginally ties in…Sigh…  I’ll try to keep my edits and section titles straight next time!]