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Centers for Disease Control & Prevention: Hookahs

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.1,2

Although many users think it is less harmful, hookah smoking has many of the same health risks as cigarette smoking.1,2

Hookah is also called narghile, argileh, shisha, hubble-bubble, and goza.1,2

Hookahs vary in size, shape, and style.2

A typical modern hookah has a head (with holes in the bottom), a metal body, a water bowl, and a flexible hose with a mouthpiece.3,4

Hookah smoking is typically done in groups, with the same mouthpiece passed from person to person.1,2,3,4

Hookah smoking is NOT a safe alternative to smoking cigarettes.1

Tobacco users should quit all tobacco products to reduce health risks.

Hookah Use

Hookah use began centuries ago in ancient Persia and India.1,2,3,4
Today, hookah cafés are gaining in popularity around the world, including Britain, France, Russia, the Middle East, and the United States.1
In 2018, the Monitoring the Future survey found that—5,6: Nearly 1 in every 13 (7.8%) high school students in the United States had used a hookah to smoke tobacco during the previous year; About 1 in every 8 (12.3%) young adults aged 19-30 years had used a hookah to smoke tobacco during the previous year.
Among 12th graders, annual hookah use increased from nearly 1 in 6 students (17.1%) in 2010 to about 1 in 4 students (22.9%) in 2014, but since that time has decreased sharply to nearly 1 in 13 students (7.8%) in 2018.5
Monitoring the Future also shows variations in hookah use by region and population density. In 2018, the highest prevalence of use were observed in the Northeast, where 1 in 6 (15.0%) young adults aged 19-30 years had used a hookah to smoke tobacco during the previous year, and in very large cities, where almost 1 in 5 (19.3%) young adults in this age group reported past year use .6
Other small studies of young adults have found high prevalence of hookah use among college students in the United States. These studies show past-year use ranging from 22% to 40%.7
New forms of electronic hookah products, including steam stones and hookah pens, have been introduced.These products are battery powered and turn liquid containing nicotine, flavorings, and other chemicals into an aerosol, which is inhaled.8 Limited information is currently available on the health risks of electronic tobacco products, including electronic hookahs.8,9

Health Effects

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.1,4
Even after it has passed through water, the smoke from a hookah has high levels of these toxic agents.4
Hookah tobacco and smoke contain several toxic agents known to cause lung, bladder, and oral cancers.1,4
Tobacco juices from hookahs irritate the mouth and increase the risk of developing oral cancers.4,10

Other Health Effects of Hookah Smoke

Hookah tobacco and smoke contain many toxic agents that can cause clogged arteries and heart disease.1,4
Infections may be passed to other smokers by sharing a hookah.2
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 nonsmokers.7,11
Babies born to hookah smokers are also at increased risk for respiratory diseases.10

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.1,2: Water pipe smoking delivers nicotine—the same highly addictive drug found in other tobacco products.2
The tobacco in hookahs is exposed to high heat from burning charcoal, and the smoke is at least as toxic as cigarette smoke.1,2

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.1,2: An hour-long hookah smoking session involves 200 puffs, while smoking an average cigarette involves 20 puffs.1,2 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.4

Hookah smokers may be at risk for some of the same diseases as cigarette smokers. These include:3,4 Oral cancer, Lung cancer, Stomach cancer, Cancer of the esophagus, Reduced lung function and decreased fertility.

Hookahs and Secondhand Smoke

Secondhand smoke from hookahs can be a health risk for nonsmokers. It contains smoke from the tobacco as well as smoke from the heat source (e.g., charcoal) used in the hookah.1,7,12

Nontobacco Hookah Products

Some sweetened and flavored nontobacco products are sold for use in hookahs.13
Labels and ads for these products often claim that users can enjoy the same taste without the harmful effects of tobacco.13
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.13,14

References

1. American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use.pdf iconexternal icon [PDF–222 KB] Washington: American Lung Association, 2007 [accessed 2019 Dec 30].
2. American Lung Association. Hookah Smoking: A Growing Threat to Public Health Issue Brief.pdf iconexternal icon [PDF–1.34 MB] Smokefree Communities Project, 2011 [accessed 2019 Dec 30].
3. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The Effects of Waterpipe Tobacco Smoking on Health Outcomes: A Systematic Review.external icon International Journal of Epidemiology 2010;39:834–57 [accessed 2019 Dec 30].
4. Cobb CO, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States.external icon American Journal of Health Behavior 2010;34(3):275–85 [accessed 2015 Sep 14].
5. Johnston DL, Miech RA, O’Malley PM et al. Monitoring the Future National Survey Results on Drug Use 1975-2018: Overview of Key Findings on Adolescents Drug Use.pdf iconexternal icon [PDF – 3.36 MB] Ann Arbor: Institute for Social Research, University of Michigan, 2019 [accessed 2019 Dec 13].
6. Shulenberg JE, Johnston DL, O’Malley PM et al. Monitoring the Future National Survey on Drug Use 1975-2018: Volume II, College Students and Adults Ages 19–60.pdf iconexternal icon [PDF – 10.7 MB] Ann Arbor: Institute for Social Research, The University of Michigan, 2019 [accessed 2019 Dec 16].
7. U.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 [accessed 2015 Sep 14].
8. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016 [accessed 2020 Jan 10].
9. National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes.external icon Washington, DC: The National Academies Press, 2018 [accessed 2020 Jan 10].
10. 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 [cited 2015 Sep 14].
11. Nuwayhid, I, Yamout, B., Ghassan, and Kambria, M. Narghile (Hubble-Bubble) Smoking, Low Birth Weight and Other Pregnancy Outcomes.external icon American Journal of Epidemiology 1998;148:375–83 [accessed 2019 Dec 30].
12. 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 [cited 2015 Sep 14].
13. 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.external icon Food and Chemical Toxicology 2012;50(5):1494–8 [accessed 2015 Sep 14].
14. 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 2011external icon;116(1–3):102–9 [cited 2015 Sep 14].