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What is Hookah and why is it making headlines?

Eastern hookah isolated on white backgroundOn July 7, 2014, a new study was published in the journal Pediatrics, published by the American Academy of Pediatrics, about the use of Hookah by US high-school seniors: Hookah Use among US High School Seniors.

The study examined the prevalence of hookah use which is significantly increasing among adolescents and aimed at delineating demographic and socioeconomic correlates of hookah use among high-school seniors in the United States.

Researchers evaluated data from 5,540 students who were asked about hookah use from 2010-2012. They found that nearly 1 in 5 high school seniors had smoked using a hookah at least once in the previous 12 months and that adolescents from higher socioeconomic status are at a particularly high risk of using hookah. Students who smoked cigarettes, and those who had ever used alcohol, marijuana or other illicit substances were more likely to use hookah.

Centers for Disease Control: the Health Effects of hookahs (Website)

Hookahs are water pipes that are used to smoke specially-made tobacco that comes in different flavors, such as apple, mint, cherry, chocolate, coconut, licorice, cappuccino, and watermelon. (1, 4)

Using a hookah to smoke tobacco poses serious health risks to smokers and others exposed to the smoke from the hookah.

Hookah Smoke and Cancer

  • The charcoal used to heat the tobacco can raise health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals. (1, 2)
  • Even after it has passed through water, the smoke from a hookah has high levels of these toxic agents. (2)
  • Hookah tobacco and smoke contain several toxic agents known to cause lung, bladder, and oral cancers. (1, 2)
  • Tobacco juices from hookahs irritate the mouth and increase the risk of developing oral cancers. (2, 3)

Other Health Effects of Hookah Smoke

  • Hookah tobacco and smoke contain many toxic agents that can cause clogged arteries and heart disease. (1, 2)
  • Infections may be passed to other smokers by sharing a hookah. (4)
  • Babies born to women who smoked water pipes every day while pregnant weigh less at birth (at least 3½ ounces less) than babies born to non-smokers. (5, 6)
  • Babies born to hookah smokers are also at increased risk for respiratory diseases. (6)

Hookah Smoking Compared With Cigarette Smoking

While many hookah smokers may think this practice is less harmful than smoking cigarettes, hookah smoking has many of the same health risks as cigarette smoking. (1, 4)

  • Water pipe smoking delivers nicotine—the same highly addictive drug found in other tobacco products. (4)
  • The tobacco in hookahs is burned (exposed to high heat) and the smoke is at least as toxic as cigarette smoke. (1,4)

Because of the way a hookah is used, smokers may absorb more of the toxic substances also found in cigarette smoke than cigarette smokers do. (1, 4)

  • An hour-long hookah smoking session involves 200 puffs, while smoking an average cigarette involves 20 puffs. (1, 4)
  • The amount of smoke inhaled during a typical hookah session is about 90,000 milliliters (ml), compared with 500–600 ml inhaled when smoking a cigarette. (2)

Hookah smokers may be at risk for some of the same diseases as cigarette smokers. These include: (7, 2)

  • Oral cancer
  • Lung cancer
  • Stomach cancer
  • Cancer of the esophagus
  • Reduced lung function
  • Decreased fertility

Hookahs and Second-hand Smoke

  • Second-hand smoke from hookahs can be a health risk for non-smokers. It contains smoke from the tobacco as well as smoke from the heat source (e.g., charcoal) used in the hookah. (1, 5, 8)

Non-tobacco Hookah Products

  • Some sweetened and flavored nontobacco products are sold for use in a hookah. (9)
  • Labels and ads for these products often claim that users can enjoy the same taste without the harmful effects of tobacco. (9)
  • Studies of tobacco-based shisha and “herbal” shisha show that smoke from both preparations contain carbon monoxide and other toxic agents known to increase the risks for smoking-related cancers, heart disease, and lung disease. (9, 10)


  1. American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use. Washington: American Lung Association, 2007.
  2. Cobb CO, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States. American Journal of Health Behavior 2010;34(3):275–85.
  3. El-Hakim Ibrahim E, Uthman Mirghani AE. Squamous Cell Carcinoma and Keratoacanthoma of the Lower Lips Associated with “Goza” and “Shisha” Smoking. International Journal of Dermatology 1999;38: 108–10.
  4. American Lung Association. Hookah Smoking: A Growing Threat to Public Health Issue Brief. Smoke-free Communities Project, 2011.
  5. S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health, 2012.
  6. Nuwayhid, I, Yamout, B., Ghassan, and Kambria, M. Narghile (Hubble-Bubble) Smoking, Low Birth Weight and Other Pregnancy Outcomes. American Journal of Epidemiology 1998;148:375–83.
  7. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The Effects of Waterpipe Tobacco Smoking on Health Outcomes: A Systematic Review. International Journal of Epidemiology 2010;39:834–57.
  8. Cobb CO, Vansickel AR, Blank MD, Jentink K, Travers MJ, Eissenberg T. Indoor Air Quality in Virginia Waterpipe Cafés. Tobacco Control 2012 Mar 24 doi:10.1136/tobaccocontrol-2011-050350.
  9. Shihadeh A, Salman R, Eissenberg T. 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 2012;50(5):1494–8.
  10. Blank MD, Cobb CO, Kilgalen B, Austin J, Weaver MF, Shihadeh A, Eissenberg T. Acute Effects of Waterpipe Tobacco Smoking: A Double-Blind, Placebo-Control Study. Drug and Alcohol Dependence 2011;116(1–3):102–9.

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