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)


The Emotional Element in Quitting Smoking

Have you ever tried to quit smoking only to find your emotional stability had gone haywire, making the challenge overwhelming? Did quitting make you so irritable and grouchy that family and friends avoided you, perhaps even encouraged you to smoke again? Were feelings of anxiety and depression reasons to relapse back to smoking? If you can relate to any of these questions, know that you are not alone, and that emotional swings are common in the early stages of your quit. But they do not have to roadblock your success…quitting and staying quit is still an achievable goal! 

Grieving the Loss

You may feel sad, lonely and miss smoking your cigarettes. Smoking is like a constant companion who is there in good times and bad, guaranteed to help boost your mood. Giving up this perceived friend may cause you to feel deprived of the enjoyment of smoking. No need to worry -- the loss of this friend is replaced with more money, more time and control over your life so you can live it in the healthiest way possible! 

Anger and Mood Swings  

Recently-quit smokers often get irritable, frustrated and angry. Emotions may swing from good-natured to snappy in no time flat. Be aware that this is normal and due to nicotine withdrawal. Nicotine elevates dopamine in the brain, which makes you feel good; when you stop smoking, these levels go down and so can your mood. In the past, you may have used cigarettes as a coping tool for dealing with these emotions.  Now you will have the choice of practicing other healthier ways of managing these feelings.

Be assertive and deal with your feelings. Don’t stifle them with a smoke! Remove yourself from a situation before things get out of hand. Walk away and take a ‘time out’ to collect yourself by calling a friend and venting. Taking some slow deep breaths, or go outside for a walk if possible. Tell yourself “This too shall pass,” and it will.

Depression

Many people feel depressed when they quit smoking. Some depression is caused by nicotine addiction and the withdrawal and recovery process. You may smoke to control your moods and feelings. When you stop smoking you no longer have this mood enhancer and may feel a reversed affect. Depression of this nature is not long-lasting and may be helped along with regular exercise, a healthy diet, and the use of an NRT product. 

Many times the depression is an underlying condition that develops when you stop smoking. Nicotine and some chemicals in smoke can decrease depressive symptoms by elevating the levels of dopamine and norepinephrine (feel good neurotransmitters) in the brain and you may smoke to keep this chemistry in balance. If this is your situation, consult your doctor, as there are many helpful treatments for depression due to this nature.

Return to Normalcy

The good news is that all this emotional upheaval is temporary. It will take some time and practice to get used to the new you – the person who no longer uses cigarettes to control moods and feelings. In the meantime here are some ways you can manage these emotions:

  • Talk to your support person(s) and vent safely, or journal and write out your thoughts
  • Do deep breathing exercises, use relaxation techniques
  • Exercise, take a walk, get outdoors, breath fresh air, enjoy nature
  • Do things you truly enjoy
  • Practice your personal affirmation(s)- use positive self talk, "I love being a non-smoker!"
  • Consider using a quit-smoking medication to help minimize the emotional withdrawal symptoms

Quitting smoking is about gaining back control of your life -- emotions and all!

Keep the Quit!

Bette Q TTS-M

Should I Quit Smoking Cold Turkey?

Let's be clear about a few things before we begin. Most smokers try to quit smoking cold turkey (CT = without taking medication to manage detox symptoms). It's true. Also true? I quit smoking CT myself (from a 3-pack-per-day habit). And finally, I usually suggest that smokers try CT first, for the same reasons that most people do  -- it's the quickest, easiest way to go for someone who wants to quit. No extra $$ spent, no waiting for NRT to arrive in the mail, no "Am I doing this right?"

There's only one problem. Decades of research repeatedly demonstrate that, for most smokers during most quit attempts, cold turkey offers the lowest odds of a successful quit. The conventional wisdom of pro-CT advocates (who often ignore the conclusions and summaries of the very studies they cite) focuses on the numbers of people who quit CT, not the % of quitters who succeed. If you're planning your quit now, be wary of three common myths about cold turkey quitting.

Myth #1. Cold Turkey is the most effective way to quit.

Only 3-6 CT quitters, out of every 100, will succeed during any given quit attempt. This makes cold turkey the least effective of all treatments, even less so than medication placebos. CT successes are so low because the physical, mental and behavioral components of withdrawal can prove too much to handle, and negatively impact quitters' work and personal lives -- especially for those who aren't that motivated to quit in the first place.

This doesn't necessarily mean that you won't be able to quit using CT. Any smoker who can make their quit their top priority, and do whatever it takes to not smoke one day at a time, can quit cold turkey like I did. But in the real world of randomized, controlled studies, most quit-medications demonstrate better quit-rates than CT. (See some references below the Join button)

Myth #2. Cold Turkey is the fastest way through withdrawal.

The longest, most intense detoxifications are usually suffered by CT quitters, depending on their level of addiction. Three days is commonly referred to as make-or-break time for CT withdrawal, but CT quitters can experience mild-to-severe detox symptoms, off and on, for weeks after quitting. I know this from personal experience; each of the three times I quit CT, I went through extended detoxes, what we called the Quit Flu in those days, lasting a week to a month.

Again, this is not to say you will suffer such withdrawal if you quit cold-turkey -- that's largely determined by your current addiction/smoking level and metabolism -- only that you're more likely to. And withdrawal symptoms are the top-reported reasons for relapse.

Myth #3. The intensity of a cold turkey quit inhibits relapse. 

Though many CT quitters claim that their quit is/was so horrific that they never want to go through it again, there's no solid research demonstrating that past withdrawal experiences influence current quit-success, or that a bad past experience helps us keep the quit this time. What we often find instead is an increased resistance to the idea of quitting this time because of past difficulties, and higher rates of slips and relapses during intense detoxes.

All that being said...

Cold turkey quitting may still best the way for you to quit. If you're a middle-aged man or post-menopausal woman motivated to quit, have successfully quit before without medicinal intervention, and/or aren't being treated for depression or a bi-polar condition, your odds of quitting CT are better than average. If you're pregnant or breastfeeding, or smoke less than half a pack a day, you probably should quit smoking cold turkey (discuss this with your doctor).

However, don't assume that cold turkey means no assistance at all -- research consistently shows that behavioral support and/or assistance from healthcare professionals and other ex-smokers can make the difference between losing or keeping your quit.

But if you know or fear that severe withdrawal will negatively impact your life, or if you haven't been able to get through detox unaided in the past, don't worry. You don't have to quit cold turkey. There are more effective treatment methods available to you!

No matter how you quit, staying quit is your real priority. Good luck, visit QuitNet for help, and KTQ!

Alan Peters, CTTS-M

Note: This blog is about CT quitting for individual smokers. Public health officials sometimes promote CT treatment to large populations, because they feel that's more cost-effective than paying for, distributing, and supporting compliance with quit-medicines on a large scale.

Note: No QuitNet staff, authors, or treatment specialists receive research funding or other remuneration from pharmaceutical companies or quit-smoking medication manufacturers. Our recommendations are always based on science and evidence, and best practices.

Pharmacological interventions for smoking cessation: an overview and network meta-analysis. 
AUTHORS' CONCLUSIONS: "Higher rates of smoking cessation were associated with NRT (17.6%) and bupropion (19.1%) compared with placebo (10.6%). Varenicline (27.6%) and combination NRT (31.5%) (eg, patch plus inhaler) were most effective for achieving smoking cessation."

Nicotine replacement therapy for smoking cessation.  
AUTHORS' CONCLUSIONS: "All of the commercially available forms of NRT increase the rate of quitting by 50 to 70%, regardless of setting.  The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual."

Usage Patterns of Stop Smoking Medications in Australia, Canada, the United Kingdom, and the United States.  
AUTHORS' CONCLUSIONS: "Approximately 3–5% of smokers who make an unaided quit attempt report remaining smoke free one year following their quit attempt [1]. In the UK, an evaluation of the NHS indicated that smokers who attempted to quit using stop smoking medication and behavioral support were nearly 4 times more likely to be quit at 52 weeks than smokers who attempted to quit with no assistance [6]."


Meta-analysis of the efficacy of nicotine replacement therapy for smoking cessation: differences between men and women.
AUTHORS' CONCLUSIONS: "NRT was more effective for men than placebo at 3-month, 6-month, and 12-month follow-ups. The benefits of NRT for women were clearly evident only at the 3- and 6-month follow-ups. Giving NRT in conjunction with high-intensity non-pharmacological support was more important for women than men."

Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice Guidelines. 
U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality
AUTHORS' CONCLUSIONS: "Numerous effective medications are available for tobacco dependence, and cllinicians should encourage their use by all patients attempting to quit smoking—except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents)... Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline."

Center for Disease Control Quit Smoking Fact Sheet
AUTHORS' CONCLUSIONS: "Medications for quitting that have been found to be effective include the following: Nicotine replacement products: Over-the-counter (nicotine patch [which is also available by prescription], gum, lozenge); Prescription (nicotine patch, inhaler, nasal spray); Prescription non-nicotine medications: bupropion SR (Zyban®),6 varenicline tartrate (Chantix®)."

Your Smoking Brain on Nicotine

Ever wonder what compels you to smoke, knowing full well the health risks? Most likely the answer is nicotine, the addictive substance in cigarettes, and a cigarette is the perfect delivery system for nicotine. It takes only ten seconds from inhalation of smoke for nicotine to reach your brain, quicker than an IV drug injection! It's this speed of nicotine to the brain that makes cigarette smoking so easily and heavily addictive. Other additives in cigarettes, such as ammonia and theobromine, also play a part in maximizing this rapid delivery (and are added by tobacco companies for this reason).

Once nicotine reaches your brain, it changes the way your brain cells communicate to each other. Nicotine mimics the neurotransmitter acetylcholine by attaching to special receptors on your brain cells, stimulating the release of chemicals that make you feel good. Dopamine, a main neurotransmitter of the reward pathway in the brain, is one of the chemicals released. Dopamine helps regulate moods and gives you a feeling of pleasure and calm. It's part of what encourages you to keep going back for more tobacco smoke.

When you smoke and expose your brain to nicotine, it increases the number of nicotine receptors, which then require more nicotine for the brain to feel normal. This alteration in brain structure is what makes quitting smoking so difficult. The level of dopamine drops during the time in between smoking cigarettes. You may feel irritable, fidgety, and stressed when that happens, and craving a cigarette to make the withdrawal symptoms subside, so you can feel good again.

As long as you keep on smoking, this cycle of craving, smoking, relaxing, craving will continue. Over time, you build up a tolerance to nicotine and need to smoke more cigarettes to get the same feel good effect. This is why if you switch to a 'low' or 'light' cigarette you will inhale more deeply or smoke more of the cigarette to compensate for the lower dose of nicotine. 

Nicotine can have both a stimulating and relaxing effect on your brain. Ever been tired and taken a couple short puffs on a cigarette to perk up...or taken in a few longer drags to help feel relaxed when feeling stressed or tense? That's just another way nicotine gets you hooked in.

The changes nicotine causes in the brain makes smoking highly addictive and difficult to stop. Not only do you deal with the symptoms of nicotine withdrawal, such as irritability, anxiety, depressed mood, difficulty concentrating, and strong cravings to smoke, but you also have to contend with the behavioral and environmental triggers that crop up, like having a glass of wine, driving the car, or getting into a heated argument -- all times your brain is used to getting a jolt of nicotine and pleasure. Once you do quit smoking you need to stick with the acronym N.O.P.E -Not One Puff Ever, because even a single cigarette can risk triggering the same cravings to smoke you had before quitting. 

As overwhelming as this may sound, quitting smoking is an achievable goal that can make all the difference in leading a healthier life. Consider using a quit-medication if the uncomfortable withdrawal symptoms get in the way of a successful quit. The encouraging news is that, though it may take up to six weeks, quitting for good enables the nicotine receptors in your brain to return to normal. 

Keep Going and KTQ!

Quit Smoking and Start Living!

To a longtime smoker, smoking is more than just lighting a cigarette. It is a ritual, a reward, a past time, a close friend, a pick me up, a thought provoking moment, an ice breaker in social situations, a comfort when lonely, and something to look forward to when the alarm rings. The act of smoking is woven through every aspect of what you do. Putting down that last cigarette can leave a void so large, many quitters are at a loss as to how to move forward. The good news is, you can move forward in more ways than you ever thought possible!

Look at all those moments in your life you gave away to smoking. Not anymore! You have a whole new experience ahead of you, and a chance to fill it with everything you have been missing. Embrace the possibilities that come with change. Find your interests. Experiment, reach out, and enjoy. When the smoke clears, there is a beautiful world out there!

You can get started today by identifying the essence of your smoking moments. Answer the question 'What do I feel I am getting from this cigarette?’ for each cigarette you smoke. Chances are good that your answers will be reward, comfort, and treat/pick me up, habit, fun or relaxation. Once you know why you are smoking each cigarette you smoke, you can fill the void so you do not miss cigarettes. Let go of the old tapes playing in your mind that tell you smoking is the only option. Be open to trying new things so you can enjoy the smoke-free you. By filling the void with other behaviors, your emotional needs will be met and your routines altered to support a nonsmoking lifestyle. You will be adding much needed relaxation, reward and fun experiences to your life!

If you are not sure how to come up with ideas, think back to when you were young. Did you like being outside, inside, or in a group? Did you build things, read, bake or draw? Were you the leader of your friends, a lone bicycler, or in your room reading? Did you skate, ski, play music, play ball, go camping, hiking or love to sing? We begin our lives without limitation, and often those original interests are keys to who we really are. Writing, drawing, biking, jogging, baking, dancing, leading a meeting, starting a club, volunteering, fostering, taking lessons, taking a class and other activities can enhance your life and open new doors for you. These interests may have been long forgotten, or simply took a back burner to work, responsibility, and day to day chores. When you quit smoking, give yourself the freedom to spend that extra time and money (re)discovering things you would like to do! At the end of our lives, few look back and were glad they kept their floors mopped or the garage tidy. Times enjoyed, people loved, unique experiences, joy and special moments will be what matter most. So put down the cigarettes, get out there and live a life you enjoy and cherish. You are worth it; KTQ!

Vikki CTTS-M

Master Certified Tobacco Treatment Specialist