Hookah (aka shisha, argileh, nargile, hubble-bubble, water pipe, hooka, goza, meassel, sheesha) is an Arabic water-pipe in which fruit-scented tobacco is burnt using coal and becomes smoke, then passes through an ornate water vessel and is inhaled through a hose.
Unfortunately, people mistakenly assume Hookah smoking is safer and less addictive than cigarettes. Read or listen to a 101.5 radio interview with our Executive Director, Karen Blumenfeld, which discusses the worrisome trend of youth hookah smoking in our nation. Read an April 18, 2013 press release from the American Association for Cancer Research which studied the difference between smoking cigarettes and smoking hookah and found that hookah smoking led to a different pattern of toxic exposure which may cause cardiovascular diseases and leukemia.
The smoking of hookahs presents particular public health hazards including secondhand smoke exposure and transmission of infectious disease.
- Read GASP's presentation on the health concerns of hookah smoking given at the 2009 American Public Health Association conference.
- Read GASP's easy-to-ready tri-fold brochure, Hazards of Hookah Smoke.
- Read a GASP poster summarizing the health concerns with hookah smoking and youth hookah smoking prevalence rates.
Learn more at our webpage about the December 2010 U.S. Surgeon General's Report which concludes:
"There is no safe level of exposure to tobacco smoke. Any exposure to tobacco smoke - even an occasional cigarette or exposure to secondhand smoke - is harmful... and that damage from tobacco smoke is immediate."
In 2012, the Journal of Environmental and Public Health published the research article, Use of Emerging Tobacco Products in the United States. Mississippi State University researchers conducted a national survey of 2400 adults to determine emerging tobacco product use. 13.6% tried at least one of these products (hookah, snus, electronic cigarettes, dissolvables), with hookah smoking taking the lead at 8.8%. Nondaily smokers smoked hookah 25% more than daily cigarette smokers or nonsmokers. The authors concluded that “Polytobacco use among these nondaily smokers may also increase levels of nicotine exposure and risk of persistent tobacco dependence relative to the exclusive use of cigarettes.”
Below are more details on concerns with the spread of infection, disease through hookah use, hookah smoking and exposure to secondhand hookah smoke.
Smoking and Secondhand Smoke Consequences of Hookah
The US Centers for Disease Control fact sheet on waterpipe smoking emphasizes that it is as dangerous as cigarette smoking. "Hookah smokers are at risk for the same kinds of diseases as are caused by cigarette smoking, including oral cancer, lung cancer, stomach cancer, cancer of the esophagus, reduced lung function, and decreased fertility. A fact sheet from The American Cancer Society also points out that "smoking waterpipes as well as breathing secondhand smoke from waterpipes can be presumed to have similar effects as exposure to cigarette smoke." The state of New Jersey issued an Advisory Note in October 2011 regarding hookah establishments. In February 2007, The American Lung Association published a Tobacco Policy Trend Alert Paper on the rise of hookah establishments in the U.S. targeting 18-24 year olds.
A March 2012 study published in The Canadian Journal of Emergency Medicine (CJEM) focused on carbon monoxide poisoning from hookah smoking. CJEM published a case report entitled Carbon monoxide poisoning in narghile (water pipe) tobacco smokers, and an editorial entitled Inhaling smoke causes smoke inhalation: put that in your hookah pipe! The opinion shared key information, citing to studies:
- "Hookah smoking has the potential for acute, single-session toxicity from ... carbon monoxide .... [M]ost of the carbon monoxide found in hookah fumes originates from the charcoal rather than the shisha."
- "Even under optimal conditions, it far exceeds the carbon monoxide in the exhaust of the 2000 Toyota 4-Runner truck one of us drives."
- "Smoking outdoors does not make the hookah safer. The session described by La Fauci and colleagues was on an open beach, not a tiny, smoke-filled room."
A study published in the March 2013 edition of the journal Cancer Epidemiology, Biomarkers & Prevention found that hookah smokers may increase their risk for leukemia, due to high levels of benzene exposure from using a hookah water pipe. An April 23, 2013 Huffington Post story reported that University of California (San Francisco) researchers found that after the study participants smoked a hookah water pipe, the participants had twice higher urine levels of benzene byproduct linked with higher leukemia risk, and twice higher breath levels of carbon monoxide levels, which are particularly bad for people with heart risks, compared with smoking cigarettes. The researchers also found that the hookah smoking participants inhaled acrylamide (linked with damage to the nervous system), acrolein (which can irritate the eye, throat and nose), benzene, carbon monoxide and naphthalene (which can damage red blood cells). "In addition to delivering toxic substances from the charcoal and tobacco, the heat causes chemical reactions in the mixture, which produce toxic volatile organic compounds (VOCs) and polycyclic aromatic hydrocarbons (PAHs),” Researcher Peyton Jacob III, said in the statement. "Some PAHs are highly carcinogenic and can cause lung cancer.” Researchers analyzed toxins inhaled by eight men and five women, who had all smoked cigarettes and hookah before. For the study, the participants smoked an average of 11 cigarettes a day or three water pipe sessions a day.
Read a March 5, 2013 study abstract from the journal Cancer Epidemiology Biomarkers & Prevention which found water pipe use showed greater exposure of carbon monoxide, and a different pattern of carcinogen exposure compared to cigarette smoking, with greater exposure benzene and high molecular weight PAHs, but less exposure to tobacco-specific nitrosamines.
Read an August 3, 2012 news article which points out that hookah smoking puts young people at risk for oral cancers. This 2011 study published in the Asian Pacific Journal of Cancer Prevention studied lung cancer in the Kashmir Valley and concluded "Hookah smoking is associated with a significantly higher risk for lung cancer in Kashmiri population, with about 6 fold elevated risk as compared to non-smoking controls."
A July 29, 2011 study published online by the American Association of Chest Physicians entitled "The Effects of Water-pipe Smoking on Lung Function, a Systematic Review and Meta-analysis" concluded that "Water-pipe smoking negatively affects lung function and may be as harmful as cigarette smoking. Water-pipe smoking, therefore, is likely to be a cause of COPD."
The New York Times' May 30, 2011 cover story on the health hazards of hookah smoking, reported that state lawmakers in California, Connecticut and Oregon have introduced bills that would ban or limit hookah bars, similar steps have been taken in cities in California and New York. Boston and Maine have already ended hookah bar exemptions in their smokefree air laws. New York City Councilman Vincent J. Gentile, a Brooklyn Democrat, has introduced a bill that would prevent new hookah bars from opening next year and beyond.
On May 16, 2011 New Jersey's Bergen Record newspaper published an investigative story on smoking in northern New Jersey hookah lounges. The story discusses increased use of hookah smoking by teens and young adults, the hazards of hookah smoking, and hookah lounges that are either in compliance or noncompliant with the 2006 New Jersey Smokefree Air Act.
New York state banned the sale of shisha and of paraphernalia used to smoke tobacco, including hookahs and vaporizers, to minors. Governor Cuomo signed SO4269A in June 2011, taking effect in January 2012.
The Southern Nevada Health District's campaign about the dangers of hookah smoking and secondhand hookah smoke shares that "hookah smoke contains 36 times more tar than cigarette smoke" and "the sidestream smoke (smoke that comes out of a pipe, not the smoker's mouth) from a single waterpipe use session emits 30 times more carbon monoxide than a single cigarette." Read more about these facts at their campaign's website www.smokefreevegas.com/hookah.
The World Health Organization Advisory Note issued in 2005 cites:
"Waterpipe smoke contains numerous toxicants known to cause lung cancer, heart disease and other diseases, adverse effects on pregnancy. Same secondhand smoke disease risks caused by cigarette smoking. In one waterpipe smoking session, waterpipe smoker may inhale up to equivalent of 100 cigarettes."
Secondhand smoke exposure in hookah lounges can be worse than smoking-permitted bars. An air testing study conducted by Wake Forest University School of Medicine and Roswell Park Cancer Institute found high levels of secondhand smoke in five hookah lounges located in five North Carolina college towns. Measured secondhand smoke levels were, on average, more than twice those found in nearby smoking-permitted bars in North Carolina. The study will be presented at the American Public Health Association's Annual Meeting in November 2011.
In November, 2010 a study published in the American Journal of Preventative Medicine measured the toxicant exposure associated with waterpipe tobacco and cigarette smoking, and concluded "Relative to cigarette smoking, waterpipe use is associated with greater CO, similar nicotine, and dramatically more smoke exposure. Physicians should consider advising their patients that waterpipe tobacco smoking exposes them to some of the same toxicants as cigarette...". Read the published study.
An August 2009 study by the UK Department of Health and Tobacco Control Collaborating Centre found that one session of smoking shisha resulted in carbon monoxide levels at least four to five times higher than the amount produced by one cigarette. High levels of carbon monoxide can lead to brain damage and unconsciousness. Shisha smokers had 40-70 ppm of CO in their breath, affecting 8-12% of their blood. Click here to read a news article about the study. A case study published in the International Journal of Emergency Medicine documents a 19 year old healthy man sufferering from carbon monoxide poisoning from hookah smoking.
Pesticide and sugar/glycerine levels are not tested in hookah tobacco or sheesha, according to the United Arab Emirates' Ministry of Health in June 2011 news story. "The absence of testing makes them even more harmful for people." Because of increased tobacco use among youth in the UAE, that Office states that there is an urgent need to introduce standards on the sale of products like sheesha tobacco and loose tobacco for the midwakh (pipe), including the testing of contents before the tobacco products are put on sale.
This study by the National Institute of Health from October 2007 showed a single session of waterpipe use by non-daily users produced a urinary cotinine level that was equivalent to smoking two cigarettes in one day. Daily use of waterpipes produces nicotine absorption of a magnitude similar to that produced by daily cigarette use.
Infectious Disease Concerns
State, county and local governments may need to consider restricting the use of hookahs in public places because the hookah apparatus is not 100% sterilized before being used by another person, and separate mouthpieces and disposable hoses do not eliminate the risk of spreading infectious disease through the hookah. Nuisance codes may be applicable.
Public health agencies such as the U.S. Centers for Disease Control (CDC) and World Health Organization (WHO) are deeply concerned about the increased risk of contracting infectious diseases via shared hookah usage, and non-sterilization of the hookah apparatus.
- "Over recent years, there has been a resurgence of use around the world, most notably among youth.... Sharing a hookah may increase the risk of transmission of tuberculosis, viruses such as herpes or hepatitis, and other illnesses." U.S. Centers for Disease Control: Fact sheet on hookahs, updated April 2007.
- "...Sheesha pipes are an ideal tool for users to catch the [H1N1] virus since they are often passed from person to person." The warning was recently added to the Bahrain Health Ministry's swine flu awareness campaign
According to the March 24, 2008 newsclip from IRIN, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs:
- "The World Health Organization regional office in Cairo estimates that 17 percent of TB cases in the eastern Mediterranean are attributable to the smoking of water pipes."
"...water pipe smoking (WPS) and the sharing of the pipe with someone with pulmonary TB led to a great risk of TB transmission... You still have water in the container where the bacteria resides.."
Periodontal Disease Concerns
Hookah smoking negatively affects periodontal health. A 2005 Swedish study assessed and compared oral hygiene, gingival inflammation, and probing depth of nonsmokers, to cigarette and hookah smokers. The researchers found that the relative risk for periodontal disease increased by 5.1- and 3.8-fold in water pipe and cigarette smokers, respectively, compared to non-smokers. They also observed an association between water pipe smoking and periodontal disease manifestations in terms of probing depth measurements. The researchers concluded that the impact of water pipe smoking was of largely the same magnitude as that of cigarette smoking.
Teen/Young Adult Hookah Concerns
Smoking hookah delivers the same chemical compounds as smoking a cigarette. In fact, one session (usually about 45 to 60 minutes) delivers approximately a hundred times the smoke as a single cigarette, with 40 times the tar and ten times the carbon monoxide.
New electronic smoking devices, such as “hookah pens”, can appeal to minors. They are colorful, come in fruit and candy flavors, and allow the smoker to be discreet in their usage around parents or other adults in school situations. Go to http://www.texashookah.com/images/disposablehookah.htm to see an example of these types of products. Read our white paper with information on the health issues surrounding Electronic Cigarettes.
A study published in the July 2012 issue of the journal Psychology of Addictive Behaviors found that 23% of freshman college female students surveyed had tried hookah smoking for the first-time in their first-year of college. Researchers at Miriam Hospital's Centers for Behavioral and Preventive Medicine in Providence, R.I. surveyed 483 female college freshman. Of the 343 who had not tried hookah smoking prior to entering college, 23% tried hookah smoking during their first year of college.
In June 2012, the Nicotine and Tobacco Research Journal published a study entitled, Waterpipe Smoking Among U.S. University Students. 105,000 students were surveyed (152 U.S. universities participated in the National College Health Assessment during 2008-2009). Researchers found that for current tobacco use, 16.8% smoked cigarettes, 8.4% smoked hookah, 7.4% smoked cigars (includes cigarillos) and 3.5% used smokeless tobacco. 51.4% of hookah smokers did not smoke cigarettes. Current hookah use was most strongly associated with younger age, male gender, White race, fraternity/sorority membership, and nonreligious institutions in large cities in the western United States. The researchers concluded that after cigarettes, waterpipe use was the most common form of tobacco use among university students. Because waterpipe use affects groups with a wide variety of individual and institutional characteristics, it should be included with other forms of tobacco in efforts related to tobacco surveillance and intervention. Read a CNN article about the study which found 1 in 3 current college students has ever smoked hookah at some point.
University at Buffalo's School of Medicine and Biomedical Sciences and School of Public Health and Health Professions reviewed 38 studies on hookah smoking in several countries, including the U.S. The study found an alarming prevalence of waterpipe smoking among middle- and high-school students in the U.S., according to lead researcher Associate professor Dr. Elie Akl. The study also found that 10% of university students in the U.S. reported waterpipe smoking. Read the study published in April 2011 in Biomedical Health Central Public Health. Read the press release.
A September 16, 2011 editorial in the Sparta Independent discusses the adverse health consequences of hookah smoking. A June 16, 2011 news story from Bergenfield, NJ reports that high school teens are attracted to smoking hookah, unaware of its health dangers.
The May 10, 2010 issue of Pediatrics (the official journal of the American Academy of Pediatrics) published a study on hookah smoking rates of young adults (ages 18-24) in Canada. Out of 871 young adults surveyed in 2007-2008, 23% had smoked a hookah in the previous year, which is almost three times higher than the 8% reported in a 2006 survey. Another finding was that younger age, male gender, speaking English, not living with parents, and higher household income, independently increased the odds of water-pipe use. Click here to read an MSNBC news article about the study, which attributed the rise in hookah smoking to numerous factors:
- Low cost
- Easy Access
- Appeal of the social interaction that accompanies use
- Commercialization by the media
- Availability of sweetened, flavored, and aromatic tobacco or maassel, which can mask the taste of tobacco
- Misperceptions of low risk to health
- Misbelief that the water filters the toxins from the smoke
- Lack of public health warnings about the dangers of water-pipe use
- Misperception that water-pipe smoking is less addictive than cigarette smoking
Additionally, researchers at Wake Forest Baptist Medical Center surveyed a cross-sectional sample of 3770 college students from eight universities in North Carolina about their smoking patterns, drug habits, and students' knowledge about the subject. Read a Science Direct news article or the full study from Drug, Alcohol, Dependence (2011) which concluded with:
"The results highlight the popularity of waterpipe tobacco smoking amount college students and underscore the need for more research to assess the public health implications of this growing trend."
A study Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States from the American Journal of Health Behavior in the Fall, 2010 had the following published results:
"Waterpipe tobacco smoking is increasing in prevalence worldwide; in the United States, 10-20% of some young adult populations are current waterpipe users. Depending on the toxicant measured, a single waterpipe session produces the equivalent of at least 1 and as many as 50 cigarettes. Misconceptions about waterpipe smoke content may lead users to underestimate health risks."
Around the globe, the health consequences and allure to teens of addictive waterpipe tobacco is known. As of January, 2012, Turkey has a Parliamentary proposal to close hookah cafes, which are currently exempt from the country's indoor smoking ban, and Denmark, a country with a high incidence of hookah smoking, is investigating a ban. A 2009 study by the National Cancer Society and Maastricht University found young people who use water pipes are three times as likely to smoke regular cigarettes. The Bacchus Network, a nonprofit focused on tobacco-free college campus policies, published a white paper, Reducing Hookah Use.
The 2008 NJ Youth Tobacco Survey published by the NJ Department of Health and Senior Services in July 2009, found that 1 out of 10 high school students reported current use of a hookah to smoke tobacco or flavored tobacco (9.7%). Middle school students were more likely to report current use of a hookah to smoke tobacco or flavored tobacco (4.1%) than smoking cigars (2.4%) and using smokeless tobacco (1.4%). (see page 11 of survey).
For the first time, survey questions in the 2010 Monitoring the Future national survey (National Results on Adolescent Drug Use, page 40) asked 12th graders about smoking small cigars and smoking tobacco using a hookah water pipe. Survey results found that more than one-fifth (23%) of 12th graders reported smoking small cigars in the past year, and 17% reported smoking tobacco in a hookah water pipe. The 2010 MTF survey encompassed about 15,100 12th-grade students in almost 400 secondary schools nationwide. Study conducted by University of Michigan, sponsored by the National Institutes of Health, Summary published on February 21, 2011 by the University of Maryland Center for Substance Abuse Research.
Laws Prohibiting Hookah Lounges
Madison County, Kentucky banned smoking inside all public places, including tobacco retail establishments, as of June 6, 2011. The amendment to their Clean Indoor Air Regulation MCHR 700.00 took effect June 6, 2011, removing Section 700.425 which had exempted retail tobacco stores. The law previously banned smoking in bars, including but not limited to, taverns, nightclubs, cocktail lounges, and cabarets. The newly amended law also broadened the definition of smoking in Section 700.025 to include or "any other lighted or heated tobacco or plant product intended for inhalation, in any manner or in any form", which covers hookah smoking. Learn more about Madison County's law. The law has a few smoking exemptions, such as private residences, except when used as a childcare, adult day care, or health care facility; no more than twenty-five percent (25%) of hotel and motel rooms rented to guests; and private functions (no public announcements) at private clubs. See FAQs from Madison County Health Department.
Some Middle Eastern countries have recently enacted legislation banning hookah and other secondhand smoke in public places. Effective July 30, 2012, Saudi Arabia's law covers government offices and most public places and bans the sale to minors under 18 years. Read this article from the Washington Post which cites the Interior Minister saying "Islam urges the preservation of public health". In February 2012, Kuwait banned smoking, including sheisha (hookah) smoking in all public places. The United Arab Emirates bans cafes and restaurants from serving shisha and other tobacco products, which are located in residential buildings and areas, under Article 11 of the Federal Law on Tobacco Control No. 15, 2009. Businesses have until December 31, 2011 to relocate or stop this service or face a penalty. Mr. Salim Adib, Manager of Public Health and Research at Health Authority Abu Dhabi (HAAD), noted that the Municipality of Abu Dhabi City has already stopped issuing licenses to cafes, and stated that shisha places should be 150 meters away from residential areas.
Recognizing the dangers and addictiveness of hookah, U.S. states and jurisdictions have passed or introduced legislation to curtail the myth that hookah smoking is not as dangerous as other smoking:
- Utah passed an amendment to their smokefree air act to include e-cigarettes and hookahs. Read a May 16, 2012 Salt Lake Tribune news article about the passage of HB245.
- Connecticut - introduced SB0415: http://www.cga.ct.gov/asp/cgabillstatus/cgabillstatus.asp?selBillType=Bill&bill_num=SB-0415
- Oregon - passed HB2726: http://www.leg.state.or.us/11reg/measpdf/hb2700.dir/hb2726.en.pdf
- San Francisco, California - The health department issued a public notice to enforce the already existing ban on hookah smoking in public places: http://www.sfdph.org/dph/files/EHSdocs/AirQuality/SmokingEnforcementAlert.pdf
- Maine - passed law effective September 2007: http://www.mainelegislature.org/legis/bills/bills_123rd/billpdfs/SP026901.pdf
- New York - prohibits sales to minors of hookah tobacco and pipes - passed 7/15/2011 - S04269A/A6037A
Applicable New Jersey Regulations & Court Decisions
In April 2007, the NJ Department of Health and Senior Services (NJDHSS) published regulations to help implement the 2006 New Jersey Smokefree Air Act (NJSFAA) (filed in the NJ Register at 39 N.J.R. 4395(b)). The Register includes public comments to the NJDHSS draft regulations, followed by NJDHSS responses, and then the 2007 Regulations. The NJDHSS' response to comments #106 and 107 discuss the health concerns with hookah smoking and secondhand hookah smoke exposure, and support the WHO's findings on the hazards of hookah smoking and exposure to secondhand hookah smoking (see page 74 of the 2007 Register). NJDHSS states:
"Thus, the Department finds that it is possible and appropriate to view the Act's broader definition of "smoking" as being purposeful within the Act, as a means to capture all kinds of smoking that can generate secondhand smoke and cause harm to nonsmokers."
This NJDHSS statement makes it clear that hookah smoking is meant to be included in the 2006 NJSFAA's definition of "smoking", and as such, hookah smoking is not allowed in public places and workplaces as defined in the 2007 NJSFAA and subsequent NJDHSS 2007 Regulations.
A hookah lounge does not meet the definition of a tobacco retail establishment to qualify for a smoking waiver. Assuming that the smoked product is to be consumed on-premises, hookah lounges meet the definition of a "cigar bar/cigar lounge" under the 2006 New Jersy Smoke-Free Air Act (SFAA). To apply for a cigar bar/lounge exemption to allow smoking inside, the establishment must have existed prior to December 31, 2004 and meet other NJSFAA requirements. See our exemptions webpage.
In November 2011, the NJ Department of Health (NJ DOH) Office of Local Public Health issued an Administrative Advisory on the operation of public places that permit hookah smoking.
Hookah and other smoking lounges do NOT meet the requirements for a tobacco retail establishment (TRE) smoking waiver, according to 39 N.J.R. 4395(b). Strict criteria need to be met for A TRE smoking waiver application to be approved by a local health department. First, a TRE is a "cash and carry" business for product purchased to be consumed off-premises, just like other retail businesses, according to the NJDHSS. In addition, the TRE can only allow smoking sample a tobacco product with the intent of purchasing more of the product for use off-premises; no food or beverage can be sold, and other criteria need to be met. Read the full list of requirements that need to be met for either of these two waivers to be issued by a local health department.
On August 5, 2010 the Appellate Division of the Superior Court of New Jersey ruled that a local health department (Township of Woodbridge) can enforce the 2006 New Jersey Smokefree Air Act against a hookah bar that allowed smoking to take place. The Appellate Division's decision found that:
- The 2006 New Jersey Smokefree Air Act's (Act) definition of smoking, "which includes any other matter that can be smoked", is not unconstitutionally overbroad nor vague
- The right to operate a particular kind of business that allows smoking on the premises, is not constitutionally protected as a fundamental right; and
- Selective enforcement of the Act did not deprive the owner of a hookah bar of his right to equal protection under the New Jersey Constitution. The hookah bar owner argued that other hookah bars existed in New Jersey, so applying the Act to his establishment was a violation of his right to equal protection.
Last update: 3/26/13