Is Hookah Smoking Safe?

Hookah is becoming a household word, but is hookah smoking safe? Studies indicate that it’s not: hookah smokers can be exposed to higher levels of carbon monoxide and other toxins than cigarette smokers, and hookah users are more likely to become cigarette smokers.

What is Hookah?

What is hookah – also known as water pipe or shisha? Traditional hookah has tobacco in a bowl with burning charcoal on top of it to create smoke. The chamber is filled with water, sometimes mixed with juice or rosewater to flavor the smoke. Smoke collects in the water chamber and a hookah smoker sucks on a pipe, drawing smoke through the water.

The tobacco is often sweetened with fruit or molasses, which makes the smoke pleasant smelling, and disguises the bitter smell and taste of the burning tobacco. Popular flavorings include apple, plum, coconut, mango, mint, strawberry and cola.

Who’s Smoking Hookahs?

Hookah was extensively used in ancient Persia (Iran), India, Turkey, and etc. beginning in the 1500’s. Even though use is declining in some Middle Eastern-Arab countries, it’s becoming more popular in Southeast Asia and with Western youth.

In the past year, hookahs have been used by over 12% of American adults, and over one in five high school seniors. Between 2011 and 2014, hookah use among high school students doubled. Hookahs are becoming popular, with hookah bars popping up near college campuses everywhere. 18-24 year olds are the fastest-growing group of users; in 2011, two out of five college and university students had smoked a hookah.

Not unexpectedly, along with the boom of battery charged e-products, enter the e-hookah that produces vapor. It resembles the e-cigarette and comes in both a reusable and a disposable version. These are often bright and colorful, and may be the next step in making hookah use even more widely accepted.

Health Effects

Many believe hookah is less harmful and addictive than cigarettes, and that the water filters and the fruit detoxify the harmful substances. But a hookah smoker can inhale the equivalent of 100 or more cigarettes in one session.

Cigarettes are usually smoked over the course of 5-7 minutes, with the smoker inhaling 8-12 times (about a pint of smoke). Hookah smoking sessions last much longer -- generally 20-80 minutes, with the smoker taking 50-200 puffs. A hookah smoker is thus exposed to carcinogens (like tar and heavy metals) and carbon monoxide from the tobacco and the burning charcoal for much longer periods.

One of the reasons a hookah user is able to tolerate so much smoke is that the water bowl does filter out some of the nicotine. Otherwise, users would have to stop smoking very quickly, because the high levels of nicotine would make them nauseated. The water also has the effect of cooling the smoke, masking the harshness of the tobacco. This encourages a smoker to inhale more deeply and for longer periods.

Hookah smoking is a social activity,  and the mouthpiece is often passed around among friends without being changed, risking the spread of infectious diseases. Disposable mouthpieces are available, but not often used.

Finally, a recent study of nearly 1,050 nonsmokers, aged 15 to 23, showed that after two years, 39% of those who had smoked hookahs had also started smoking cigarettes, compared with about 20% of those who had not.

Hookah Smoking is Not Safer

Hookah or shisha smoking can be more, rather than less, hazardous than smoking cigarettes, and is more likely to lead to habitual cigarette smoking. We need to snuff out the perception that it is safe, or a fun alternative to smoking cigarettes.


Ann Wendling, M.D., M.P.H.

Medical Director, Tobacco Cessation

Healthways, Inc.


References (available upon request)